Protecting Second Victims from Work Performed without Passion by Dev Raheja Author-Safer Hospital Care Originally Published in Confident Voices eNewsletter Feb 2011 Who is a second victim? A patient is obviously the first victim of harm. The person blamed for the harm is a second victim, such as a nurse who is the last person in a chain of harmful events in the process or a care giver who made an inadvertent mistake that should have been mitigated in the system. According to Beth Boynton's book Confident Voices, 80-97 percent nurses experience verbal abuse which is another way of blaming such second victims. The next issue is why the system problems are not recognized, and not mitigated? The reason usually is that there is very little effort invested by management in designing out the harm through robust changes in the system or planting safeguards and barriers. Blaming an individual is the easiest thing to do to avoid system accountability. In other words many managers manage risks without passion to prevent harm. How does one start out with passion and lose it? The Gallup organization defines a worker/manager without passion as a disengaged and unengaged employee. According to a Gallup pole nationally, engaged employees made up only 29% of the work force (an engaged employee is one who is willing to go the extra mile to help the organization do the right things). The remaining employees were either not-engaged (56%) or actively disengaged (15%). Not-engaged and actively disengaged employees tend to work in a substandard manner. Most important, disengaged managers are often responsible for disengaged and un-passionate safety culture. Most employees are excited when they find the job of their choice. But they lose the excitement over time. There are at least two reasons. We can call the first reason as "boiling frog phenomenon." James Kilts in his book Doing What Matters has this advice for new employees: Usually in your first day on a new job you spot a number of things that don't make sense. Some seem inefficient and ill conceived. Two weeks later wrong things seem perfectly fine because your experienced peers are OK with this stuff. You are in a pot that has been heating slowly and you don't know that you are being cooked. It is like the situation of a frog. If you put it into boiling water, it will not tolerate it. If you put it into cool water and slowly raise the temperature, the frog gets cooked before it knows what is happening. The second reason is the so-called "organizational silence." It is a result of punitive or "blame" culture in which employees choose self-censorship because they are afraid to speak up. In addition, they choose silence to fit into the norms of the organization and be a part of the group think. They are rewarded if they go along with the group in the name of team work. How can we mitigate harm in the system? Dr. James Reason, through his Swiss cheese model on harm causation, has earned high respect for explaining why a single event by a nurse or any care giver cannot cause harm. Harm is always a result of hidden hazards in the system and a trigger event such as a human error. Hazard can be prevented either by preventing the system from being vulnerable or by preventing humans from making mistakes. History tells us that we can reduce human errors but cannot eliminate them entirely. Therefore the wise choice is to work with a passion to prevent system vulnerability. But people without passion for zero harm are not ready to listen. To listen, hospitals first must create an organization that empowers employees to do the right things including reporting on abusive employees. Ritz Carlton hotel system is such an example, where employees are expected to respect each other and authorized to go out of their way to give outstanding service to customers and improve the quality of service. This strategy protects the service providers from compromising quality and safety. They create passion for ultrahigh quality. For employees to work with passion, hospitals must create meaningful work, capable and similarly committed colleagues, and respectful and respected managers who will welcome investment in safety as a business strategy instead of a necessary cost. The meaningful work includes work that can be done with normal effort. This is not the choice the nurses usually have with constant interruptions, real alarms, false alarms, sudden worsening of the patient condition, inadequate hand-offs, and a lot of wasted effort in looking for proper forms and supplies. Hospitals must evaluate the adequacy of work load with the help of industrial engineers who are trained to design a suitable work load that allows enough rest too. Rest is important for mental efficiency as well as physical efficiency. Some industrial organizations have a dedicated time for a nap after lunch. Hospitals need to decide whether they want efficiency with more people or chaos with less people. Savings from an increase in efficiency can often justify hiring more nurses. How can nurses help? What can nurses do to prevent blame on their profession? My recommendation for them would be to band together as a team, create a name like Nurses Council on System Thinking, develop system improvements( especially on how to prevent employee disrespect against a fellow employee, find a high level manager (not a dictator), who believes in listening and convince the manager, as a team, on the solutions. The solutions should include eliminating wasted time for nurses such as finding forms, walking constantly for medications stored outside the patient rooms, supplies stored in remote places, working with poor quality medical devices, looking for batteries for failed instruments, and dealing with work environmental frustrations. Examples of work environment frustrations can be: bureaucratic procedures, unresponsive physicians, unsupportive supervision, missed breaks, expediting pharmacy delays, waiting to access the automated medication dispensing systems that are often unreliable, sloppy co-workers, and frustration of seeing many mistakes being made. Management is more open to implementing right things if the whole team believes in the solution with passion. The nursing council can elect volunteer leaders, meet periodically during lunches to discuss ideas, and even invite mangers during discussions. Convince management on Primum non nocere. It stands for First, do no harm. Including the harm to nurses! About Dev Raheja A respected and sought out expert on hospital and medical device safety, author Dev Raheja draws on his 25 years of experience as a risk management and quality assurance consultant to provide hospital stakeholders with a systematic way to learn the science of safe care. He uses evidence-based safety theories and tools taken from the aerospace, nuclear, medical, and chemical industries to identify the combination of root causes that result in an adverse event. He applies analytical tools that can effectively measure hospital efficiency, establish evidence between Lean strategies and patient satisfaction. His focus is on using various types of innovation including accidental, incremental, strategic, and radical, and establish a culture conducive to high return on investment.

Protecting Second Victims

from Work Performed

without Passion

by Dev Raheja

Author-Safer Hospital Care

Originally Published in Confident Voices

eNewsletter Feb 2011

Who is a second victim?

A patient is obviously the first victim of harm. The person blamed for the harm is a second victim, such as a nurse who is the last person in a chain of harmful events in the process or a care giver who made an inadvertent mistake that should have been mitigated in the system. According to Beth Boynton's book Confident Voices, 80-97 percent nurses experience verbal abuse which is another way of blaming such second victims. The next issue is why the system problems are not recognized, and not mitigated? The reason usually is that there is very little effort invested by management in designing out the harm through robust changes in the system or planting safeguards and barriers. Blaming an individual is the easiest thing to do to avoid system accountability. In other words many managers manage risks without passion to prevent harm.

How does one start out with passion and lose it?

The Gallup organization defines a worker/manager without passion as a disengaged and unengaged employee. According to a Gallup pole nationally, engaged employees made up only 29% of the work force (an engaged employee is one who is willing to go the extra mile to help the organization do the right things). The remaining employees were either not-engaged (56%) or actively disengaged (15%). Not-engaged and actively disengaged employees tend to work in a substandard manner. Most important, disengaged managers are often responsible for disengaged and un-passionate safety culture.

Most employees are excited when they find the job of their choice. But they lose the excitement over time. There are at least two reasons. We can call the first reason as "boiling frog phenomenon." James Kilts in his book Doing What Matters has this advice for new employees: Usually in your first day on a new job you spot a number of things that don't make sense. Some seem inefficient and ill conceived. Two weeks later wrong things seem perfectly fine because your experienced peers are OK with this stuff. You are in a pot that has been heating slowly and you don't know that you are being cooked. It is like the situation of a frog. If you put it into boiling water, it will not tolerate it. If you put it into cool water and slowly raise the temperature, the frog gets cooked before it knows what is happening. The second reason is the so-called "organizational silence." It is a result of punitive or "blame" culture in which employees choose self-censorship because they are afraid to speak up. In addition, they choose silence to fit into the norms of the organization and be a part of the group think. They are rewarded if they go along with the group in the name of team work.

How can we mitigate harm in the system?

Dr. James Reason, through his Swiss cheese model on harm causation, has earned high respect for explaining why a single event by a nurse or any care giver cannot cause harm. Harm is always a result of hidden hazards in the system and a trigger event such as a human error. Hazard can be prevented either by preventing the system from being vulnerable or by preventing humans from making mistakes. History tells us that we can reduce human errors but cannot eliminate them entirely. Therefore the wise choice is to work with a passion to prevent system vulnerability.

But people without passion for zero harm are not ready to listen. To listen, hospitals first must create an organization that empowers employees to do the right things including reporting on abusive employees. Ritz Carlton hotel system is such an example, where employees are expected to respect each other and authorized to go out of their way to give outstanding service to customers and improve the quality of service. This strategy protects the service providers from compromising quality and safety. They create passion for ultrahigh quality.

For employees to work with passion, hospitals must create meaningful work, capable and similarly committed colleagues, and respectful and respected managers who will welcome investment in safety as a business strategy instead of a necessary cost. The meaningful work includes work that can be done with normal effort. This is not the choice the nurses usually have with constant interruptions, real alarms, false alarms, sudden worsening of the patient condition, inadequate hand-offs, and a lot of wasted effort in looking for proper forms and supplies. Hospitals must evaluate the adequacy of work load with the help of industrial engineers who are trained to design a suitable work load that allows enough rest too. Rest is important for mental efficiency as well as physical efficiency. Some industrial organizations have a dedicated time for a nap after lunch. Hospitals need to decide whether they want efficiency with more people or chaos with less people. Savings from an increase in efficiency can often justify hiring more nurses.

How can nurses help?

What can nurses do to prevent blame on their profession? My recommendation for them would be to band together as a team, create a name like Nurses Council on System Thinking, develop system improvements( especially on how to prevent employee disrespect against a fellow employee, find a high level manager (not a dictator), who believes in listening and convince the manager, as a team, on the solutions. The solutions should include eliminating wasted time for nurses such as finding forms, walking constantly for medications stored outside the patient rooms, supplies stored in remote places, working with poor quality medical devices, looking for batteries for failed instruments, and dealing with work environmental frustrations. Examples of work environment frustrations can be: bureaucratic procedures, unresponsive physicians, unsupportive supervision, missed breaks, expediting pharmacy delays, waiting to access the automated medication dispensing systems that are often unreliable, sloppy co-workers, and frustration of seeing many mistakes being made. Management is more open to implementing right things if the whole team believes in the solution with passion.

The nursing council can elect volunteer leaders, meet periodically during lunches to discuss ideas, and even invite mangers during discussions. Convince management on Primum non nocere. It stands for First, do no harm. Including the harm to nurses!

About Dev Raheja

A respected and sought out expert on hospital and medical device safety, author Dev Raheja draws on his 25 years of experience as a risk management and quality assurance consultant to provide hospital stakeholders with a systematic way to learn the science of safe care. He uses evidence-based safety theories and tools taken from the aerospace, nuclear, medical, and chemical industries to identify the combination of root causes that result in an adverse event. He applies analytical tools that can effectively measure hospital efficiency, establish evidence between Lean strategies and patient satisfaction. His focus is on using various types of innovation including accidental, incremental, strategic, and radical, and establish a culture conducive to high return on investment.