- Email: [email protected]
Call Me Bob:
Call Me Bob: A Safety Culture Initiative to Improve Interprofessional Teamwork Robert H. Connors, MD Patient safety is the highest goal in any health care environment. However, individual practitioner efforts are not enough; high-functioning, collaborative teams are required to achieve desired results. Traditional physician culture has emphasized physician authority and individual responsibility, leading to power gradients and often disrupting effective communication. To address this, an initiative to help remove communication barriers and promote all team members’ comfort with proactively speaking up about concerns was created in a major Midwest regional children’s hospital. This process is now part of the organization’s working culture and has the potential to enhance communication, collaboration, and safety in other health care organizations.
I
n 2007, the president of Helen DeVos Children’s Hospital (HDVCH) established a goal to become the safest children’s hospital in the country. The 234-bed children’s hospital in Grand Rapids, Michigan, is part of a major 12-hospital Midwest health care system: Spectrum Health. After several years of focused effort, significant progress was made, with an 85% decrease in serious safety events.1 The leadership team identified the key to this success: a strong focus on highfunctioning interprofessional teams that reinforced each team member’s personal safety and willingness to raise concerns to others and voluntarily report safety events, including adverse outcomes. Those years clearly demonstrated that enhanced harm prevention required all personnel to go beyond their personal commitment to “do no harm” and work together effectively. Having already seen so much progress, the results of HDVCH’s 2013 Agency for Healthcare Research and Quality (AHRQ) Safety Culture Survey were surprising and disappointing. Only 49% of the clinical staff reported feeling free to question decisions or actions of those with more authority. More than one-third reported being afraid to ask questions when something did not seem right regarding their patient. Most of the survey respondents were nurses, and the leadership team suspected that often the authority figure was a physician. They knew that traditional medical culture often reinforces the power and authority of physicians and sets up power gradients that can compromise www.nurseleader.com
teamwork and communication.2,3 They hypothesized that this dynamic was a barrier to nurses and other caregivers raising concerns about their patients’ care, thus placing the patients at increased risk for harm. The connection of hierarchy and its associated authority or power gradients in the functioning of various teams has long been a topic of interest to organizational administrators, including those in health care environments. Discussion of the pros and cons of steep gradients versus flat gradients continues.4 Strong examples from other industries have highlighted the connection between power gradients and error prevention and safety. Gaps in communication between pilots and copilots that contribute to airline accidents are frequently cited examples.5,6 KEY POINTS Interprofessional power gradients create barriers to raising safety concerns, which can endanger patients. Physicians can be successfully engaged in dropping their “doctor” title with interprofessional teammates to promote better communication and improve patient safety. It is possible to change traditional medical cultural norms in an organization dedicated to advancing patient safety. Month 2019
1
safety survey. In particular, it was expected that nurses and other staff would feel freer to question those with more authority, that is, that they would be less afraid to raise concerns about their patients. If this would help the hospital’s various teams function more effectively, in the long run, fewer harm events would occur.
In many medical situations, some hierarchy is necessary to allow clarity in decision-making authority. However, power gradients may promote dysfunction in a team when they intimidate staff or generate reluctance to speak up about a safety concern in the moment. There is often a natural human fearfulness when questioning or challenging power gradients—in this case, those related to physicians’ power. Unfortunately, traditional medical cultures have often reinforced these fears with a long history of assigning punitive individual fault to nurses and other personnel.7 When this occurs, the trust and psychological safety so important to speaking up during events and reporting adverse outcomes is damaged. Team functioning suffers. THE INITIATIVE AND ITS RATIONALE In response to HDVCH’s 2013 AHRQ survey results, it was proposed that some flattening of physicianrelated hierarchy might further increase team trust and remove barriers to speaking up. It was assumed that first, even longstanding elements of traditional medical culture could be modified by changing specific behaviors; second, HDVCH physicians would respond to a trial of change based on the expectation that it would make patients safer; and third, the physicians would at least consider, if not embrace enthusiastically, a modification of their own perceived power to facilitate better safety teams. This was the genesis of the HDVCH Call Me Bob safety culture initiative, which began in 2014. In proposing this change, the leadership team acknowledged the unique authority attached to the “doctor” title in the general culture. Dropping this title in team interactions would very likely change all teammates’ perceptions and would serve to flatten the power gradient. It was anticipated there would be some changes in the perceptions of the physicians related to their functioning in teams, as well as new nurse and staff perceptions about their doctor colleagues. These changes might influence the key characteristics of highfunctioning teams that are so important to patient safety and, if so, this would be reflected in the staff 2
Month 2019
THE INITIATIVE PROCESS Prior to introducing the Call Me Bob trial, significant planning and analysis were done to confirm the importance of modifying physician-related power gradients and to assess institutional readiness. Discussions within the HDVCH leadership team confirmed the cultural imperative of addressing this challenge to advance the overall safety culture. The team acknowledged the difficulty in modifying longstanding cultural norms. However, after evaluating the timing of this intervention, the decision was made that HDVCH was ready for a pilot project. At that point, HDVCH already had a 7-year track record with specific patient safety work. Significant serious safety event (SSE) reductions had been achieved, and the hospital had previous experience with a successful hand hygiene campaign. The hospital president (the author, Robert “Bob” Connors) was a practicing physician with 24 years of service at HDVCH, 9 of which were as hospital president. A stable and trusted leadership team was in place, which included additional supportive leaders who were also practicing physicians. Previously, a “hospital in a hospital,” staff retained their enthusiasm from the opening of HDVCH as a new freestanding children’s hospital 3 years earlier. Thus, it was predicted that the physician staff, which included an approximately equal mix of employed and independent physicians, would be open to this trial. HDVCH had specifically been recruiting for team-oriented physicians for many years. After confirming the strong support of the physician executives, the concept was introduced at a standing meeting of physician clinical leaders for discussion and feedback. A majority were supportive, several were enthusiastic, but some remained unconvinced or resistant. At a second meeting a month later, a stronger voice of support emerged, and it was decided to move forward. Stage 1: Initial Implementation When it began in 2014, the project was envisioned as a formal improvement project, with process improvement colleagues engaged to help formulate a pilot project plan document. The internal communications team was also engaged to help with rollout planning. A new badge holder was supplied to each physician. It prominently displayed the physician’s preferred familiar name. The new badge holders were distributed personally by physician leaders with supportive messaging. www.nurseleader.com
The hospital president sent an e-mail memo to all staff titled “Call Me Bob” A Safety Culture Experiment. It described the initiative and explained to staff that their participation was an expectation—that “our teams are on a first-name basis here.” A second memo followed to answer frequently asked questions. One theme discussed in the second memo was the relationship of titles to respect. Another area that needed clarification related to patients and families; it was reinforced that the use of familiar names for this pilot applied only to team interactions. The initiative fostered many conversations. Nurses and other nonphysician staff often felt uncomfortable using the doctors’ first names. Some physicians were resistant to dropping the doctor title. Some female physicians were concerned that using first names might exacerbate the role confusion they already experienced related to families misidentifying them as nurses. The president met with some influential resisters. After 90 days, the leadership team felt that they were seeing value from the initiative, and they decided to extend the trial indefinitely, removing it from just pilot project status. Stage 2: Project Expansion A change in the HDVCH logo offered an opportunity for a second stage in the initiative 6 months after it began. ID badges all needed to be replaced, so the badge holders were expanded to include familiar names for all clinical staff. The president’s e-mail memo at the time emphasized the importance of teamwork to the HDVCH safety culture, listing several characteristics of high-performing teams. He encouraged everyone to participate in the Call Me Bob project. Nine months following this, a third phase of the name badge rollout included other shared services employees from the hospital system who worked in the children’s hospital. Staff from environmental and nutrition services, risk management, and care management received badges with familiar names noted. A president’s memo welcomed them to the team and reminded the whole team that Call Me Bob was about “eliminating any barriers to the great communication and teamwork that is required to keep our patients safe.” Feedback and Measurement As expected, during the first months of the rollout, there were many discussions about this project. Purposeful rounding and the support of “project champions” were used to promote the effort. Process improvement staff performed structured observations and conversations with clinical teams and reported these results. The hospital president shared 5 memos with the entire hospital team and continued conversations with physicians. Nursing leadership monitored progress with nursing staff and reinforced the connection of the work to patient safety. Over the www.nurseleader.com
course of the rollout, the leadership team continued to learn, advancing its own understanding around issues of respect, titles, and power gradients. The standardized tool chosen to measure the impact of this initiative was, again, the AHRQ Safety Culture Survey. This allowed a direct comparison of the baseline results generated prior to the trial with subsequent survey results. During the study, other safety-related data were collected, including SSEs, other harm events, and hospital-acquired conditions. It was anticipated that measuring the more qualitative outcomes affecting teamwork would be difficult. Exact causal effects of this intervention in the complex HDVCH environment would also be difficult to prove. However, the leadership team believed that even indirect indicators of success might sustain this voluntary initiative and enthusiasm for the trial, while promoting behavior change and spreading the initiative to other parts of the health system. INITIATIVE RESULTS In terms of qualitative findings, Call Me Bob created many valuable learning opportunities. First and foremost, it proved that the organization could implement a focused initiative to directly change and enhance the hospital’s patient safety culture. It showed that longstanding and embedded behaviors related to titles, respect, and power gradients could be addressed. The institutional and personal conversations that resulted from this initiative illuminated many challenges related to culture change and increased the organization’s understanding of important issues, opening unique opportunities for meaningful dialogue. Second, the familiar name badges contributed to an enhanced children’s hospital team identity in the majority Spectrum Health adult health care system. The use of first names by hospital leaders reinforced the focus on teamwork and was identified as unique and valuable to those being recruited to the organization. Third, the leadership team learned that individual resistance to this change occurred for a variety of reasons, and it would prevent initial full adoption in all of the hospital’s teams. This resistance was seen from physicians, nurses, and other staff, but over time, adoption of the familiar name badge increased. The results from 2 subsequent annual AHRQ surveys provided the main objective findings.8 These results showed improvement in some important areas. Although the AHRQ Safety Culture Survey examines several factors in overall culture, the leadership team chose to focus on 3 questions included under the title Communication Openness. As mentioned previously, the baseline survey was taken in 2013 before Call Me Bob began. Subsequent surveys were completed in 2015 and 2017. Over the first 4 years of the project, some improvement was seen in the participants’ answers to all 3 survey questions. Nurses and other staff who said they Month 2019
3
would speak up freely if they saw something that might negatively affect patient care increased from 76% to 82%. Staff who felt free to question the decisions or actions of those with more authority increased from 49% to 52%. Those who were not afraid to ask questions when something did not seem right increased from 61% to 66%. Most of the improvement was noted between the 2015 and 2017 surveys, after the initiative had been underway for more than a year. Process improvement staff not directly involved in the initiative made observations in 4 service areas throughout HDVCH prior to beginning the pilot project and again at 60, 120, and 240 days. These service areas included the neonatal intensive care unit, sedation services, a medical/surgical floor, and the pediatric intensive care unit. Their conversations around survey questions and observations were limited but documented increasing comfort with the initiative over time. By 240 days, the assessment was that the initiative was approaching normalization in the culture. OBSERVATIONS AND DISCUSSION It is widely held that a strong patient safety culture is key to reducing patient harm.9-12 Beyond individual commitments not to harm patients, it is paramount that care teams function well together to keep patients safe. But power gradients among team members may present barriers to open communication and bringing forward patient care concerns. This initiative was an original attempt to decrease the perceived power gap between doctors and other team members. It was designed to reinforce mutual respect, enhance psychological safety, and promote deference to appropriate expertise in the team. Organizational leadership support has been identified as being critical to the development of a safety culture.13,14 Still, even dedicated leaders may remain challenged to discern how to move toward a stronger safety culture or even to identify its essential elements.15 Any culture change can be slow and difficult. Seven years into HDVCH’s original safety culture work the leadership team realized that many staff were still reluctant to speak up and question the decisions or actions of those with more authority. Call Me Bob addressed this reluctance directly. By dropping their doctor title among their colleagues, physicians sent a message that they welcomed a different type of interaction with nurses and other team members without removing an appropriate use of hierarchy for decision making. The measured AHRQ Safety Culture Survey improvements have been modest, but significant. Perhaps more important, to date, a very low rate of SSEs has been sustained, and there has been a significant decrease in the number of hospital-acquired harm events. Because HDVCH is part of a predominantly adult system, the initiative has promoted several system 4
Month 2019
conversations. Although many adult service areas have not embraced the initiative, some visible physician leaders of adult services have adopted the use of familiar names, and the adult women’s service line has begun a similar initiative. In any complex care system, it is impossible to draw strong conclusions about the effect of 1 intervention. However, this initiative contributed to measurable improvement in responses in the AHRQ culture survey. Although cause and effect cannot be proven, there were no other major organizational changes within the children’s hospital during these 4 years that one might expect to directly influence the survey results. The initiative has sustained itself for 4 years and is now a unique element of the HDVCH organizational culture. It has been incorporated into orientation and continues to promote conversations about respect and teamwork. We are not aware of other hospital-wide initiatives of this type, but believe this work can be successfully spread to other health care organizations. The main institutional opportunity costs are the time and attention dedicated to the initiative by an organization’s leadership. A thorough preparation for institutional readiness must include an assessment of the readiness of physicians and physician leaders; their strong, consistent support is essential for any initiative of this type. Nurses and other nonphysician leaders must also be prepared and then actively participate in any project like this. At HDVCH, interest was generally high, but not universal, among nonphysicians as Call Me Bob was implemented. This initiative proved to be very useful in advancing the overall safety culture. It provided a reason for team members to have significant conversations about respect and power gradients—conversations that had been largely absent in the past. The leadership team continues to strongly believe that the highest functioning of care teams cannot be achieved without modification of longestablished physician-related power gradients.16,17 Resistance among some physicians is to be expected. Done properly however, all team members, including doctors, will realize that their real power to prevent patient harm will be enhanced by modifications like these. Next steps will focus even more on those team members who continue to be reluctant to speak up around those in authority.18,19 Although it would be ideal for all team members to individually speak up in every situation, the leadership team understands that this is not currently achievable. In addition to continuing Call Me Bob, a program designed to provide enhanced collegial assistance in speaking up is being developed. Our commitment remains the same: to enhance patient safety in everything we do. CONCLUSION The Call Me Bob initiative was designed as one effort to keep patients in a major children’s hospital safe from www.nurseleader.com
harm by reducing power gradients and removing communication barriers among physicians, nurses, and other team members. Following implementation, AHRQ standardized safety culture survey scores showed improvement. We believe that, with correct implementation, this process has the potential to enhance communication and collaboration and promote safety in other health care organizations. REFERENCES 1. Peterson TH, Teman SF, Connors RH. A safety culture transformation: its effects at a children’s hospital. J Patient Saf. 2012;8(3):125-130. 2. Barzallo Salazar MJ, Minkoff H, Bayya J, et al. Influence of surgeon behavior on trainee willingness to speak up: A randomized controlled trial. J Am Coll Surg. 2014;219(5):10011007. 3. Nembhard IM, Edmondson AC. Making it safe: The effects of leader inclusiveness and professional status on psychological safety and improvement efforts in health care teams. J Organ Behav. 2006;27(7):941-966. 4. Anderson C, Brown CE. The functions and dysfunctions of hierarchy. Res Organ Behav. 2010;30:55-89. 5. d’Agincourt-Canning L, Kissoon N, Singal M, Pitfield AF. Culture, communication and safety: lessons from the airline industry. Indian J Pediatr. 2011;78(6):703-708. 6. Alkov RA, Borowsky MS, Williamson DW, Yacavone DW. The effect of trans-cockpit authority gradient on Navy/Marine helicopter mishaps. Aviat Space Environ Med. 1992;63(8):659-661. 7. Leape L, Berwick D, Clancy C, et al. Transforming healthcare: a safety imperative. Qual Saf Health Care. 2009;18(6):424-428. 8. Alswat K, Abdalla RAM, Titi MA, et al. Improving patient safety culture in Saudi Arabia (2012-2015): Trending, improvement and benchmarking. BMC Health Serv Res. 2017;17(1):516. 9. Steyrer J, Schiffinger M, Huber C, Valentin A, Strunk G. Attitude is everything? The impact of workload, safety climate, and safety tools on medical errors: a study of intensive care units. Health Care Manage Rev. 2013;38(4):306-316. 10. Clancy CM. New research highlights the role of patient safety culture and safer care. J Nurs Care Qual. 2011;26(3):193-196. 11. Okuyama A, Wagner C, Bijnen B. Speaking up for patient safety by hospital-based health care professionals: a literature review. BMC Health Serv Res. 2014;14:61. 12. Singer S, Lin S, Falwell A, Gaba D, Baker L. Relationship of safety climate and safety performance in hospitals. Health Serv Res. 2009;44(2 Pt 2):399-421.
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13. Kunzle B, Kolbe M, Grote G. Ensuring patient safety through effective leadership behaviour: a literature review. Saf Sci. 2010;48(1):1-17. 14. The Joint Commission Department of Corporate Communications. The essential role of leadership in developing a safety culture. Sentinel Event Alert. 2017;57:1-8. 15. Sammer CE, Lykens K, Singh KP, Mains DA, Lackan NA. What is patient safety culture? A review of the literature. J Nurs Scholarsh. 2010;42(2):156-165. 16. Cosby KS, Croskerry P. Profiles in patient safety: authority gradients in medical error. Acad Emerg Med. 2004;11(12):1341-1345. 17. Bleakley A. Common body of care: the ethics and politics of teamwork in the operation theater are inseparable. J Med Philos. 2006;31(3):305-322. 18. Nacioglu A. As a critical behavior to improve quality and patient safety in health care: Speaking up! Saf Health. 2016;2(10):1-25. 19. Martinez W, Etchegaray JM, Thomas EJ, et al. ‘Speaking up’ about patient safety concerns and unprofessional behavior among residents: validation of two scales. BMJ Qual Saf. 2015;24(11):671-680.
Robert H. Connors, MD, is President at Helen DeVos Children’s Hospital in Grand Rapids, Michigan. He can be reached at [email protected].
Note: The author thanks Jonda Arbogast, executive assistant to the president of Helen DeVos Children’s Hospital, for her assistance with this paper. The author also thanks Beyond Words, Inc., for its help with the editing and preparation of the manuscript. The author maintained control over the direction and content of this article during its development. Although Beyond Words, Inc., supplied professional editing services, this does not indicate its endorsement of, agreement with, or responsibility for the content of the article. Conflicts of Interest: The author has no conflicts of interest to declare. This research did not receive any specific grant from funding agencies in the public, commercial, or notfor-profit sectors. 1541-4612/2019/$ See front matter Copyright 2019 Published by Elsevier. https://doi.org/10.1016/j.mnl.2019.10.001
Month 2019
5
I
n 2007, the president of Helen DeVos Children’s Hospital (HDVCH) established a goal to become the safest children’s hospital in the country. The 234-bed children’s hospital in Grand Rapids, Michigan, is part of a major 12-hospital Midwest health care system: Spectrum Health. After several years of focused effort, significant progress was made, with an 85% decrease in serious safety events.1 The leadership team identified the key to this success: a strong focus on highfunctioning interprofessional teams that reinforced each team member’s personal safety and willingness to raise concerns to others and voluntarily report safety events, including adverse outcomes. Those years clearly demonstrated that enhanced harm prevention required all personnel to go beyond their personal commitment to “do no harm” and work together effectively. Having already seen so much progress, the results of HDVCH’s 2013 Agency for Healthcare Research and Quality (AHRQ) Safety Culture Survey were surprising and disappointing. Only 49% of the clinical staff reported feeling free to question decisions or actions of those with more authority. More than one-third reported being afraid to ask questions when something did not seem right regarding their patient. Most of the survey respondents were nurses, and the leadership team suspected that often the authority figure was a physician. They knew that traditional medical culture often reinforces the power and authority of physicians and sets up power gradients that can compromise www.nurseleader.com
teamwork and communication.2,3 They hypothesized that this dynamic was a barrier to nurses and other caregivers raising concerns about their patients’ care, thus placing the patients at increased risk for harm. The connection of hierarchy and its associated authority or power gradients in the functioning of various teams has long been a topic of interest to organizational administrators, including those in health care environments. Discussion of the pros and cons of steep gradients versus flat gradients continues.4 Strong examples from other industries have highlighted the connection between power gradients and error prevention and safety. Gaps in communication between pilots and copilots that contribute to airline accidents are frequently cited examples.5,6 KEY POINTS Interprofessional power gradients create barriers to raising safety concerns, which can endanger patients. Physicians can be successfully engaged in dropping their “doctor” title with interprofessional teammates to promote better communication and improve patient safety. It is possible to change traditional medical cultural norms in an organization dedicated to advancing patient safety. Month 2019
1
safety survey. In particular, it was expected that nurses and other staff would feel freer to question those with more authority, that is, that they would be less afraid to raise concerns about their patients. If this would help the hospital’s various teams function more effectively, in the long run, fewer harm events would occur.
In many medical situations, some hierarchy is necessary to allow clarity in decision-making authority. However, power gradients may promote dysfunction in a team when they intimidate staff or generate reluctance to speak up about a safety concern in the moment. There is often a natural human fearfulness when questioning or challenging power gradients—in this case, those related to physicians’ power. Unfortunately, traditional medical cultures have often reinforced these fears with a long history of assigning punitive individual fault to nurses and other personnel.7 When this occurs, the trust and psychological safety so important to speaking up during events and reporting adverse outcomes is damaged. Team functioning suffers. THE INITIATIVE AND ITS RATIONALE In response to HDVCH’s 2013 AHRQ survey results, it was proposed that some flattening of physicianrelated hierarchy might further increase team trust and remove barriers to speaking up. It was assumed that first, even longstanding elements of traditional medical culture could be modified by changing specific behaviors; second, HDVCH physicians would respond to a trial of change based on the expectation that it would make patients safer; and third, the physicians would at least consider, if not embrace enthusiastically, a modification of their own perceived power to facilitate better safety teams. This was the genesis of the HDVCH Call Me Bob safety culture initiative, which began in 2014. In proposing this change, the leadership team acknowledged the unique authority attached to the “doctor” title in the general culture. Dropping this title in team interactions would very likely change all teammates’ perceptions and would serve to flatten the power gradient. It was anticipated there would be some changes in the perceptions of the physicians related to their functioning in teams, as well as new nurse and staff perceptions about their doctor colleagues. These changes might influence the key characteristics of highfunctioning teams that are so important to patient safety and, if so, this would be reflected in the staff 2
Month 2019
THE INITIATIVE PROCESS Prior to introducing the Call Me Bob trial, significant planning and analysis were done to confirm the importance of modifying physician-related power gradients and to assess institutional readiness. Discussions within the HDVCH leadership team confirmed the cultural imperative of addressing this challenge to advance the overall safety culture. The team acknowledged the difficulty in modifying longstanding cultural norms. However, after evaluating the timing of this intervention, the decision was made that HDVCH was ready for a pilot project. At that point, HDVCH already had a 7-year track record with specific patient safety work. Significant serious safety event (SSE) reductions had been achieved, and the hospital had previous experience with a successful hand hygiene campaign. The hospital president (the author, Robert “Bob” Connors) was a practicing physician with 24 years of service at HDVCH, 9 of which were as hospital president. A stable and trusted leadership team was in place, which included additional supportive leaders who were also practicing physicians. Previously, a “hospital in a hospital,” staff retained their enthusiasm from the opening of HDVCH as a new freestanding children’s hospital 3 years earlier. Thus, it was predicted that the physician staff, which included an approximately equal mix of employed and independent physicians, would be open to this trial. HDVCH had specifically been recruiting for team-oriented physicians for many years. After confirming the strong support of the physician executives, the concept was introduced at a standing meeting of physician clinical leaders for discussion and feedback. A majority were supportive, several were enthusiastic, but some remained unconvinced or resistant. At a second meeting a month later, a stronger voice of support emerged, and it was decided to move forward. Stage 1: Initial Implementation When it began in 2014, the project was envisioned as a formal improvement project, with process improvement colleagues engaged to help formulate a pilot project plan document. The internal communications team was also engaged to help with rollout planning. A new badge holder was supplied to each physician. It prominently displayed the physician’s preferred familiar name. The new badge holders were distributed personally by physician leaders with supportive messaging. www.nurseleader.com
The hospital president sent an e-mail memo to all staff titled “Call Me Bob” A Safety Culture Experiment. It described the initiative and explained to staff that their participation was an expectation—that “our teams are on a first-name basis here.” A second memo followed to answer frequently asked questions. One theme discussed in the second memo was the relationship of titles to respect. Another area that needed clarification related to patients and families; it was reinforced that the use of familiar names for this pilot applied only to team interactions. The initiative fostered many conversations. Nurses and other nonphysician staff often felt uncomfortable using the doctors’ first names. Some physicians were resistant to dropping the doctor title. Some female physicians were concerned that using first names might exacerbate the role confusion they already experienced related to families misidentifying them as nurses. The president met with some influential resisters. After 90 days, the leadership team felt that they were seeing value from the initiative, and they decided to extend the trial indefinitely, removing it from just pilot project status. Stage 2: Project Expansion A change in the HDVCH logo offered an opportunity for a second stage in the initiative 6 months after it began. ID badges all needed to be replaced, so the badge holders were expanded to include familiar names for all clinical staff. The president’s e-mail memo at the time emphasized the importance of teamwork to the HDVCH safety culture, listing several characteristics of high-performing teams. He encouraged everyone to participate in the Call Me Bob project. Nine months following this, a third phase of the name badge rollout included other shared services employees from the hospital system who worked in the children’s hospital. Staff from environmental and nutrition services, risk management, and care management received badges with familiar names noted. A president’s memo welcomed them to the team and reminded the whole team that Call Me Bob was about “eliminating any barriers to the great communication and teamwork that is required to keep our patients safe.” Feedback and Measurement As expected, during the first months of the rollout, there were many discussions about this project. Purposeful rounding and the support of “project champions” were used to promote the effort. Process improvement staff performed structured observations and conversations with clinical teams and reported these results. The hospital president shared 5 memos with the entire hospital team and continued conversations with physicians. Nursing leadership monitored progress with nursing staff and reinforced the connection of the work to patient safety. Over the www.nurseleader.com
course of the rollout, the leadership team continued to learn, advancing its own understanding around issues of respect, titles, and power gradients. The standardized tool chosen to measure the impact of this initiative was, again, the AHRQ Safety Culture Survey. This allowed a direct comparison of the baseline results generated prior to the trial with subsequent survey results. During the study, other safety-related data were collected, including SSEs, other harm events, and hospital-acquired conditions. It was anticipated that measuring the more qualitative outcomes affecting teamwork would be difficult. Exact causal effects of this intervention in the complex HDVCH environment would also be difficult to prove. However, the leadership team believed that even indirect indicators of success might sustain this voluntary initiative and enthusiasm for the trial, while promoting behavior change and spreading the initiative to other parts of the health system. INITIATIVE RESULTS In terms of qualitative findings, Call Me Bob created many valuable learning opportunities. First and foremost, it proved that the organization could implement a focused initiative to directly change and enhance the hospital’s patient safety culture. It showed that longstanding and embedded behaviors related to titles, respect, and power gradients could be addressed. The institutional and personal conversations that resulted from this initiative illuminated many challenges related to culture change and increased the organization’s understanding of important issues, opening unique opportunities for meaningful dialogue. Second, the familiar name badges contributed to an enhanced children’s hospital team identity in the majority Spectrum Health adult health care system. The use of first names by hospital leaders reinforced the focus on teamwork and was identified as unique and valuable to those being recruited to the organization. Third, the leadership team learned that individual resistance to this change occurred for a variety of reasons, and it would prevent initial full adoption in all of the hospital’s teams. This resistance was seen from physicians, nurses, and other staff, but over time, adoption of the familiar name badge increased. The results from 2 subsequent annual AHRQ surveys provided the main objective findings.8 These results showed improvement in some important areas. Although the AHRQ Safety Culture Survey examines several factors in overall culture, the leadership team chose to focus on 3 questions included under the title Communication Openness. As mentioned previously, the baseline survey was taken in 2013 before Call Me Bob began. Subsequent surveys were completed in 2015 and 2017. Over the first 4 years of the project, some improvement was seen in the participants’ answers to all 3 survey questions. Nurses and other staff who said they Month 2019
3
would speak up freely if they saw something that might negatively affect patient care increased from 76% to 82%. Staff who felt free to question the decisions or actions of those with more authority increased from 49% to 52%. Those who were not afraid to ask questions when something did not seem right increased from 61% to 66%. Most of the improvement was noted between the 2015 and 2017 surveys, after the initiative had been underway for more than a year. Process improvement staff not directly involved in the initiative made observations in 4 service areas throughout HDVCH prior to beginning the pilot project and again at 60, 120, and 240 days. These service areas included the neonatal intensive care unit, sedation services, a medical/surgical floor, and the pediatric intensive care unit. Their conversations around survey questions and observations were limited but documented increasing comfort with the initiative over time. By 240 days, the assessment was that the initiative was approaching normalization in the culture. OBSERVATIONS AND DISCUSSION It is widely held that a strong patient safety culture is key to reducing patient harm.9-12 Beyond individual commitments not to harm patients, it is paramount that care teams function well together to keep patients safe. But power gradients among team members may present barriers to open communication and bringing forward patient care concerns. This initiative was an original attempt to decrease the perceived power gap between doctors and other team members. It was designed to reinforce mutual respect, enhance psychological safety, and promote deference to appropriate expertise in the team. Organizational leadership support has been identified as being critical to the development of a safety culture.13,14 Still, even dedicated leaders may remain challenged to discern how to move toward a stronger safety culture or even to identify its essential elements.15 Any culture change can be slow and difficult. Seven years into HDVCH’s original safety culture work the leadership team realized that many staff were still reluctant to speak up and question the decisions or actions of those with more authority. Call Me Bob addressed this reluctance directly. By dropping their doctor title among their colleagues, physicians sent a message that they welcomed a different type of interaction with nurses and other team members without removing an appropriate use of hierarchy for decision making. The measured AHRQ Safety Culture Survey improvements have been modest, but significant. Perhaps more important, to date, a very low rate of SSEs has been sustained, and there has been a significant decrease in the number of hospital-acquired harm events. Because HDVCH is part of a predominantly adult system, the initiative has promoted several system 4
Month 2019
conversations. Although many adult service areas have not embraced the initiative, some visible physician leaders of adult services have adopted the use of familiar names, and the adult women’s service line has begun a similar initiative. In any complex care system, it is impossible to draw strong conclusions about the effect of 1 intervention. However, this initiative contributed to measurable improvement in responses in the AHRQ culture survey. Although cause and effect cannot be proven, there were no other major organizational changes within the children’s hospital during these 4 years that one might expect to directly influence the survey results. The initiative has sustained itself for 4 years and is now a unique element of the HDVCH organizational culture. It has been incorporated into orientation and continues to promote conversations about respect and teamwork. We are not aware of other hospital-wide initiatives of this type, but believe this work can be successfully spread to other health care organizations. The main institutional opportunity costs are the time and attention dedicated to the initiative by an organization’s leadership. A thorough preparation for institutional readiness must include an assessment of the readiness of physicians and physician leaders; their strong, consistent support is essential for any initiative of this type. Nurses and other nonphysician leaders must also be prepared and then actively participate in any project like this. At HDVCH, interest was generally high, but not universal, among nonphysicians as Call Me Bob was implemented. This initiative proved to be very useful in advancing the overall safety culture. It provided a reason for team members to have significant conversations about respect and power gradients—conversations that had been largely absent in the past. The leadership team continues to strongly believe that the highest functioning of care teams cannot be achieved without modification of longestablished physician-related power gradients.16,17 Resistance among some physicians is to be expected. Done properly however, all team members, including doctors, will realize that their real power to prevent patient harm will be enhanced by modifications like these. Next steps will focus even more on those team members who continue to be reluctant to speak up around those in authority.18,19 Although it would be ideal for all team members to individually speak up in every situation, the leadership team understands that this is not currently achievable. In addition to continuing Call Me Bob, a program designed to provide enhanced collegial assistance in speaking up is being developed. Our commitment remains the same: to enhance patient safety in everything we do. CONCLUSION The Call Me Bob initiative was designed as one effort to keep patients in a major children’s hospital safe from www.nurseleader.com
harm by reducing power gradients and removing communication barriers among physicians, nurses, and other team members. Following implementation, AHRQ standardized safety culture survey scores showed improvement. We believe that, with correct implementation, this process has the potential to enhance communication and collaboration and promote safety in other health care organizations. REFERENCES 1. Peterson TH, Teman SF, Connors RH. A safety culture transformation: its effects at a children’s hospital. J Patient Saf. 2012;8(3):125-130. 2. Barzallo Salazar MJ, Minkoff H, Bayya J, et al. Influence of surgeon behavior on trainee willingness to speak up: A randomized controlled trial. J Am Coll Surg. 2014;219(5):10011007. 3. Nembhard IM, Edmondson AC. Making it safe: The effects of leader inclusiveness and professional status on psychological safety and improvement efforts in health care teams. J Organ Behav. 2006;27(7):941-966. 4. Anderson C, Brown CE. The functions and dysfunctions of hierarchy. Res Organ Behav. 2010;30:55-89. 5. d’Agincourt-Canning L, Kissoon N, Singal M, Pitfield AF. Culture, communication and safety: lessons from the airline industry. Indian J Pediatr. 2011;78(6):703-708. 6. Alkov RA, Borowsky MS, Williamson DW, Yacavone DW. The effect of trans-cockpit authority gradient on Navy/Marine helicopter mishaps. Aviat Space Environ Med. 1992;63(8):659-661. 7. Leape L, Berwick D, Clancy C, et al. Transforming healthcare: a safety imperative. Qual Saf Health Care. 2009;18(6):424-428. 8. Alswat K, Abdalla RAM, Titi MA, et al. Improving patient safety culture in Saudi Arabia (2012-2015): Trending, improvement and benchmarking. BMC Health Serv Res. 2017;17(1):516. 9. Steyrer J, Schiffinger M, Huber C, Valentin A, Strunk G. Attitude is everything? The impact of workload, safety climate, and safety tools on medical errors: a study of intensive care units. Health Care Manage Rev. 2013;38(4):306-316. 10. Clancy CM. New research highlights the role of patient safety culture and safer care. J Nurs Care Qual. 2011;26(3):193-196. 11. Okuyama A, Wagner C, Bijnen B. Speaking up for patient safety by hospital-based health care professionals: a literature review. BMC Health Serv Res. 2014;14:61. 12. Singer S, Lin S, Falwell A, Gaba D, Baker L. Relationship of safety climate and safety performance in hospitals. Health Serv Res. 2009;44(2 Pt 2):399-421.
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13. Kunzle B, Kolbe M, Grote G. Ensuring patient safety through effective leadership behaviour: a literature review. Saf Sci. 2010;48(1):1-17. 14. The Joint Commission Department of Corporate Communications. The essential role of leadership in developing a safety culture. Sentinel Event Alert. 2017;57:1-8. 15. Sammer CE, Lykens K, Singh KP, Mains DA, Lackan NA. What is patient safety culture? A review of the literature. J Nurs Scholarsh. 2010;42(2):156-165. 16. Cosby KS, Croskerry P. Profiles in patient safety: authority gradients in medical error. Acad Emerg Med. 2004;11(12):1341-1345. 17. Bleakley A. Common body of care: the ethics and politics of teamwork in the operation theater are inseparable. J Med Philos. 2006;31(3):305-322. 18. Nacioglu A. As a critical behavior to improve quality and patient safety in health care: Speaking up! Saf Health. 2016;2(10):1-25. 19. Martinez W, Etchegaray JM, Thomas EJ, et al. ‘Speaking up’ about patient safety concerns and unprofessional behavior among residents: validation of two scales. BMJ Qual Saf. 2015;24(11):671-680.
Robert H. Connors, MD, is President at Helen DeVos Children’s Hospital in Grand Rapids, Michigan. He can be reached at [email protected].
Note: The author thanks Jonda Arbogast, executive assistant to the president of Helen DeVos Children’s Hospital, for her assistance with this paper. The author also thanks Beyond Words, Inc., for its help with the editing and preparation of the manuscript. The author maintained control over the direction and content of this article during its development. Although Beyond Words, Inc., supplied professional editing services, this does not indicate its endorsement of, agreement with, or responsibility for the content of the article. Conflicts of Interest: The author has no conflicts of interest to declare. This research did not receive any specific grant from funding agencies in the public, commercial, or notfor-profit sectors. 1541-4612/2019/$ See front matter Copyright 2019 Published by Elsevier. https://doi.org/10.1016/j.mnl.2019.10.001
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