VITALSMARTS™ INDUSTRY WATCH SILENCE KILLS The Seven Crucial Conversations® for Healthcare Silence Kills The Seven Crucial Conversations for Healthcare David Maxfield, Joseph Grenny, Ron McMillan, Kerry Patterson, Al Switzler NASA employs some of the smartest and most dedicated professionals in the world

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VITALSMARTS™ INDUSTRY WATCH SILENCE KILLS The Seven Crucial Conversations® for Healthcare Silence Kills The Seven Crucial Conversations for Healthcare David Maxfield, Joseph Grenny, Ron McMillan, Kerry Patterson, Al Switzler NASA employs some of the smartest and most dedicated professionals in the world. Individually they are the cream of the crop in their various science, engineering, and administrative disciplines. Their collective achievements have dramatically expanded the boundaries of our knowledge of both our universe and our world. And yet in spite of their individual dedication and collective brilliance, on February 1, 2003, seven astronauts died—perhaps unnecessarily—when the Columbia Shuttle Mission STS-107 incinerated on reentry into the earth’s atmosphere. The reason? A key contributor to the tragedy was a culture that “prevented effective communication of critical safety information and stifled professional differences of opinion.”1 People’s inability to confront risky topics allowed risks to go unaddressed—contributing to the loss of seven lives. Those who serve daily in U.S. hospitals could be described as similarly intelligent and dedicated. In the aptly titled report To Err is Human2, the Institute of Medicine acknowledges both the individual dedication and collective contributions of those who give their all to improve and save the lives of patients in our healthcare institutions. And yet, as the report points out, each year hundreds of thousands of patients are brought to harm in the course of their healing because of fundamental problems in the collective behavior of these caring professionals. These problems are not unlike those that contributed to the loss of Columbia. For example, each year one in twenty in-patients at hospitals will be given a wrong medication, 3.5 million will get an infection from someone who didn’t wash his or her hands or take other appropriate precautions3, and 195,000 will die because of mistakes made while they’re in the hospital.4 © 2005 VitalSmarts, L.C. All Rights Reserved. VitalSmarts is a trademark and Crucial Conversations is a registered trademark of VitalSmarts, L.C. 2 VitalSmarts™ SILENCE KILLS Hospitals are responding aggressively to this crisis with new technologies, qualityimprovement systems, and methods of organizing. However, though the healthcare community is taking needed action on a number of fronts, there is a deeper problem that must be resolved before acceptable levels of improvement will be attainable. As with NASA personnel, key problems that contribute to these tragic errors are often known far in advance. And yet few people talk about them. Every day, many healthcare workers stand next to colleagues and see them cut corners, make mistakes, or demonstrate serious incompetence. But only a small percentage speak up and discuss what they have seen—even though they’re standing only a few feet away. As a result, problems go on for years—contributing to avoidable errors, high turnover, decreased morale, and reduced productivity. Just as the unwitting behavior of well-intended NASA personnel served to suppress key information that might have escalated risks, many healthcare workers tend to act in ways that allow risks and problems to remain unaddressed—sometimes for years. A group of eight anesthesiologists agree a peer is dangerously incompetent, but they don’t confront him. Instead, they go to great efforts to schedule surgeries for the sickest babies at times when he is not on duty. This problem has persisted for over five years. (Focus Group of Physicians) A group of nurses describe a peer as careless and inattentive. Instead of confronting her, they double check her work—sometimes running in to patient rooms to retake a blood pressure or redo a safety check. They’ve “worked around” this nurse’s weaknesses for over a year. The nurses resent her, but never talk to her about their concerns. Nor do any of the doctors who also avoid and compensate for her. (Focus Group of Nurses) Past studies have indicated that more than 60 percent of medication errors are caused by mistakes in interpersonal communication. The Joint Commission on Accreditation of Healthcare Organizations suggests that communication is a top contributor to sentinel events.5 This study builds on these findings by exploring the specific concerns people have a hard time communicating that may contribute to avoidable errors and other chronic problems in healthcare. The study we report here suggests that there are seven crucial conversations that people in healthcare frequently fail to hold that likely add to unacceptable error rates. The nationwide study was conducted by VitalSmarts in partnership with the American Association of Critical-Care Nurses. This study suggests that improvement in these seven crucial conversations could not only contribute to significant reductions in errors, but also to improvements in quality of care, reduction in nursing turnover, and marked improvement in productivity. In addition, we will offer healthcare leaders a simple method for measuring their current performance in these seven crucial conversations, as well as an action plan for making measurable improvement in this key competency. © 2005 VitalSmarts, L.C. All Rights Reserved. VitalSmarts is a trademark and Crucial Conversations is a registered trademark of VitalSmarts, L.C. 3 VitalSmarts™ SILENCE KILLS The Study Researchers conducted dozens of focus groups, interviews, and workplace observations, and then collected survey data from more than 1,700 respondents, including 1,143 nurses, 106 physicians, 266 clinical-care staff, and 175 administrators during 2004. Their research sites included thirteen urban, suburban, and rural hospitals from across the U.S. These included a mix of teaching, general, and pediatric hospitals. Although this is a modest sample, the findings fit together in a significant and compelling way. The study identified the categories of conversations that are especially difficult and, at the same time, especially essential for people in healthcare to master. The study showed that the quality of these crucial conversations relates strongly with medical errors, patient safety, quality of care, staff commitment, employee satisfaction, discretionary effort, and turnover. We grouped these concerns into seven areas: Broken Rules, Mistakes, Lack of Support, Incompetence, Poor Teamwork, Disrespect, and Micromanagement. More than half of the healthcare workers surveyed in this study had occasionally witnessed broken rules, mistakes, lack of support, incompetence, poor teamwork, disrespect, and micromanagement. Many had seen some of their colleagues cutting corners, making mistakes, and demonstrating serious incompetence. However, even though they had these concerns, fewer than one in ten fully discussed their concerns with the coworker. Furthermore, most healthcare workers neither believe it’s possible nor even their responsibility to call attention to these issues. About half of respondents say the concerns have persisted for a year or more. And a significant number of those who have witnessed these persistent problems report injurious consequences. For example, one in five physicians say they have seen harm come to patients as a result of these concerns, and 23 percent of nurses say they are considering leaving their units because of these concerns. On the positive side, this study shows that healthcare workers who are confident in their ability to raise these crucial concerns observe better patient outcomes, work harder, are more satisfied, and are more committed to staying. About 10 percent of the healthcare workers surveyed fall into this category. While additional confirming research is needed, the implication is that if more healthcare workers could learn to do what this influential 10 percent seem to be able to do systematically, the result would be significantly fewer errors, higher productivity, and lower turnover. © 2005 VitalSmarts, L.C. All Rights Reserved. VitalSmarts is a trademark and Crucial Conversations is a registered trademark of VitalSmarts, L.C. 4 VitalSmarts™ SILENCE KILLS Prevalence of the Seven Most Crucial Concerns Participants were asked to indicate the percentage of their coworkers with whom they had each of the seven crucial concerns. They had to indicate that at least 10 percent of their coworkers were in violation to be categorized as “seeing the concern.” It is important to point out that respondents consistently report that the vast majority of healthcare workers do not exhibit the problems described below. And yet the vast majority of healthcare workers do see some number who not only exhibit the problems, but also continue to do so for long periods of time without being held accountable. 1. Broken Rules: 84 percent of physicians and 62 percent of nurses and other clinicalcare providers see some number of their coworkers taking shortcuts that could be dangerous to patients. This concern was focused on a relatively small number of their colleagues. The median was 10 percent, meaning that they were comfortable with 90 percent of their colleagues’ ability. “A phlebotomist in a neonatal unit would slip on her gloves and immediately tear the tip of the index finger off her glove, so she could feel the baby’s vein better and wouldn’t miss. I talked to her about it twice. Finally I said, ‘If I ever see you tear the finger out of another glove I will write you up for a willful violation.’ Now she follows the rules.” (Nurse Manager) 2. Mistakes: 92 percent of physicians and 65 percent of nurses and other clinical-care providers work with some people who have trouble following directions; 88 percent of physicians and 48 percent of nurses and other clinical-care providers see some colleagues show poor clinical judgment when making assessments, doing triage, diagnosing, suggesting treatment, or getting help. Again, these respondents are pointing to a relatively small minority of their colleagues—the median was again just 10 percent. “Some docs can make incorrect orders. We let it slide—especially if it is a jerk . . . For example, one physician prescribed a drug that you should give three times a day, but he said to give it twice a day. I let it go, because it was just a pain pill. It wasn’t going to make the child any sicker.” (Pharmacist.) 3. Lack of Support: 53 percent of nurses and other clinical-care providers report that 10 percent or more of their colleagues are reluctant to help, impatient, or refuse to answer their questions. 83 percent have a teammate who complains when asked to pitch in and help. On the positive side, 76 percent say that half or more of their colleagues give them emotional support when they are down, and 64 percent say that half or more of their colleagues pick up a share of their work when they need help. It’s clear that most people provide support. The problem is with a small minority who don’t. “Some people here are burnt out. They’ve lost the excitement or have some personal issue in their life . . . People have to cover for them, pick up their slack. People get mad at them, isolate them, don’t offer to help them, shy away from them. If they need extra help, they don’t get it. They don’t call or ask for it.” (Nurse) © 2005 VitalSmarts, L.C. All Rights Reserved. VitalSmarts is a trademark and Crucial Conversations is a registered trademark of VitalSmarts, L.C. 5 VitalSmarts™ SILENCE KILLS 4. Incompetence: 81 percent of physicians and 53 percent of nurses and other clinicalcare providers have concerns about the competency of some nurse or other clinicalcare provider they work with; 68 percent of physicians and 34 percent of nurses and other clinical-care providers have concerns about the competency of at least one physician they work with. “There is a cardiologist who everybody feels is incompetent. He makes himself very accessible to general practitioners, so he gets a lot of referrals, but those of us who have to work with him—the thoracic surgeons, the anesthesiologists, the other cardiologists—would never put someone under his care.” (Physician) 5. Poor Teamwork: 88 percent of nurses and other clinical-care providers have one or more teammate who gossips or is part of a clique that divides the team. 55 percent have a teammate who tries to look good at others’ expense. “We have a nurse who is like your eccentric aunt—she’s a bully. She makes unreasonable demands like, ‘I won’t take any more patients today.’ She gets away with it. She’s a very good nurse, but she’s ornery and a bully. She doesn’t do her fair share. It ticks all of us off. We’ve lost a couple of good nurses here because they were sick of putting up with her and our supervisor won’t deal with her.” (Nurse) 6. Disrespect: 77 percent of nurses and other clinical-care providers work with some who are condescending, insulting, or rude. 33 percent work with a few who are verbally abusive—yell, shout, swear, or name call. “A group of physicians went right into the patient’s room without gowns or masks or gloves. This was a patient who was supposed to be in isolation. We didn’t confront them because that cardio surgeon has a reputation. He belittles nurses by saying things like, ‘Do they have any nurses on this unit who aren’t stupid?’ If you question him, he starts yelling, and turns it into a war.” (Nurse) 7. Micromanagement: 52 percent of nurses and other clinical-care providers work with some number of people who abuse their authority—pull rank, bully, threaten, or force their point of view on them. “We have a charge nurse who . . . pages us to come to the desk so she can tell us what to do . . . She will come into the room where we have a sick patient and she’ll take over . . . She’ll say, ‘Do it because I say so.’ Sometimes when she bosses me around I feel less inclined to correct her when she’s wrong about how to treat the child. I’m sure I’ve gone along with something I shouldn’t have because I resent her. But basically, I’ve started looking at other hospitals for a job.” (Nurse) © 2005 VitalSmarts, L.C. All Rights Reserved. VitalSmarts is a trademark and Crucial Conversations is a registered trademark of VitalSmarts, L.C. 6 VitalSmarts™ SILENCE KILLS The Impact of these Crucial Conversations Most healthcare respondents are happy in their careers and believe their organizations do good work. And yet most respondents report that a number of their colleagues create problems that are common, frequent, persistent, and dangerous. And, most important, the data show these problems are rarely addressed. The study focused in detail on three of the seven crucial conversations: incompetence, poor teamwork, and disrespect. In these three areas the study mapped the frequency, duration, and impacts of people’s concerns. It also measured whether and how these concerns were addressed. Incompetence The survey asked about a variety of competency issues, ranging from “poor clinical judgment” to “making decisions beyond their competency level” to “missing basic skills.” Respondents indicated whether they had coworkers who are incompetent in these areas. Next, respondents were asked to think of the coworker with the worst competency problem, and to rate how often this person does something dangerous, how long the problem has gone on, and how the person’s competency has impacted patient health and safety. The data in tables 1-a and 1-b reveal the scope of the problem. Most healthcare workers have serious concerns about the competence of some of their coworkers. In fairness, a person’s perceptions of another’s competence can sometimes be just a difference of judgment—and nowhere more than in a field as complex and often ambiguous as healthcare. And yet the prevalence of the perceptions, along with strong anecdotal data from focus group interviews, suggest that real problems exist. Many cite a coworker who does something dangerous as often as every month. Nearly half report the problem has continued for a year or more. Some have witnessed the person causing harm to patients. And yet only a small percentage discuss their concerns with the person. The data show it is much tougher to confront a physician than to confront a nurse or other clinical-care provider. Interestingly, the data also show physicians are about as unlikely to confront nurses and other clinical-care providers as they are to confront physicians, even though their clinical authority would seem to make it an easier discussion. © 2005 VitalSmarts, L.C. All Rights Reserved. VitalSmarts is a trademark and Crucial Conversations is a registered trademark of VitalSmarts, L.C. 7 VitalSmarts™ SILENCE KILLS Nurses and Other Clinical Care Providers’ Concerns about Incompetence 53% are concerned about a peer’s competence. This peer does something dangerous at least once a month. 27% 12% have spoken with this peer and shared their full concerns. The problem with this peer has gone on for a year or more. 48% A patient has been harmed by this person’s actions during the last year. 7% 34% are concerned about a physician’s competence. This physician does something dangerous at least once a month. 19% Less than 1% have spoken with this physician and shared their full concerns. The problem with this physician has gone on for a year or more. 54% A patient has been harmed by this physician’s actions during the last year. 8% Table 1-a Physicians’ Concerns about Incompetence This person does something dangerous at least once a month. 15% The problem with this person has gone on for a year or more. 46% 8% have spoken with this person and shared their full concerns. A patient has been harmed by this person’s actions during the last year. 9% 68% are concerned about a physician’s competence. This physician does something dangerous at least once a month. 21% Less than 1% have spoken with this physician and shared their full concerns. The problem with this physician has gone on for a year or more. 66% A patient has been harmed by this physician’s actions during the last year. 19% 81% are concerned about a nurse’s or other clinical-care provider’s competence. Table 1-b © 2005 VitalSmarts, L.C. All Rights Reserved. VitalSmarts is a trademark and Crucial Conversations is a registered trademark of VitalSmarts, L.C. 8 VitalSmarts™ SILENCE KILLS Poor Teamwork The survey examined a variety of teamwork concerns, ranging from “gossiping” to “making themselves look good at your expense” to “not doing their fair share of the work.” Respondents indicated whether they had coworkers who demonstrated poor teamwork in these areas. Next, respondents were asked to think of the coworker whose poor teamwork has the most negative impact, and to rate how often this person does something that undermines the team, how long the problem has gone on, and how the person’s poor teamwork has impacted patient care and employee morale. The data in Table 2 show a widespread problem. Three-quarters of the healthcare workers surveyed are concerned about a teamwork issue, and more than two-thirds say this problem has gone on for over a year. A smaller—yet significant—number (one-fifth) say the teamwork issue is so severe they can’t trust that patients are getting the right level of care, and even more are seriously considering leaving their jobs because of the teamwork issue. And yet relatively few ever discuss their concerns with the person involved. Nurses and Other Clinical Care Providers’ Concerns about Poor Teamwork 75% are concerned about a peer’s poor teamwork. 16% have spoken with this peer and shared their full concerns. This peer does somethin...