I was inspired to address this topic after receiving this blog comment:
I was struck by your statement, "The simple reality is that it takes a compassionate and supportive work environment to create a foundation for teamwork, a methodology for applying systems improvement that is simple and accessible, and quality improvement has to be returned to the frontline people with the support of leadership." Your initiative with the Peer Support program seems to be a step in the right direction toward this "compassionate and supportive work environment," but by your own description the members of that environment were not initially receptive, suggesting that at baseline there appears to be a general lack of supportiveness and dearth of compassion in place. Have you learned from your training and experience other PRACTICAL means (besides formalized Peer Support) of fostering a "compassionate and supportive work environment" that might be helpful to people in other environments who are also interested in creating better foundations for optimally functioning systems?
As I develop further as a systems-thinker I marvel at how everything is connected. This blog comment gave me an AHA! about the link between efforts to implement authentic communication around adverse events (i.e. disclosure, apology and support) and the challenge to create a compassionate and supportive work environment.
As we all know, the culture of healthcare remains very fearful and defensive around the management of adverse medical events. While many hospitals advertise robust policies for disclosure and apology in order to be in regulatory compliance, most organizations do a very poor job of implementation. In the process of communication with patients and families around these events, there is an inherent compulsion to have every contingency covered before any conversation is initiated with a patient or family (it took me five months of active engagement to organize a meeting between my patient and the hospital administration following my adverse event (see May 2 posting); it happened then only with great reluctance and trepidation).
Patients and families will tell you that they don’t expect all the answers when communication is initiated, but that they do expect updates in real time as the information becomes available. The cultural mindset to overcome on the provider side is that we want the communication to be pragmatic, comprehensive and finite (a project) while patients and families want an ongoing process of authentic communication. We want to use empathy (we don’t want to express how we feel) and patients look for sympathy (they want to know that we feel). When we communicate with such misalignment, anger and eroded trust on part of patients and families is the norm.
This same cultural mindset impedes our attempts to create a compassionate and supportive work environment. We exercise the identical pattern of poor communication with each other every day without realizing it. I had such an experience when I was doing some quality improvement consulting at a hospital. As is the case in most hospitals, there had been many previous improvement projects at this institution where leadership had failed to follow through with the recommended changes. There was a tremendous amount of anger and skepticism on part of the staff with yet another initiative when we began. However, our engagement managed to re-instill excitement into the improvement process, largely because we had empowered and supported the teams comprised primarily of frontline staff to identify and to solve the problems themselves. Respect and authentic communication set the standard. The teams worked hard and came up with some very significant system-based improvement ideas. At the end of our engagement, we submitted the teams’ recommendations to the hospital leadership for review and approval, while the teams anxiously awaited their response. While most of the suggested improvements were relatively small investments, there were some larger investments that had to be taken into deeper consideration before leadership could make a decision.
What the hospital administration decided to do was to hold off on any communication to the team participants until all the issues were resolved. Weeks passed without any communication and as would be expected, the increasingly frustrated frontline staff began to validate in their minds the usual pattern of “no follow through” by hospital leadership. Meanwhile on the administrative side, action was being taken to implement the recommendations! In spite of our repeated encouragement to leadership that they at least acknowledge the tremendous work that the teams had done and that they simply communicate some kind of a real time status report, they refused and finally requested that we leave them alone. The trust and enthusiasm that had been painstakingly developed with staff was replaced with anger and cynicism towards administration; as one of the nurses put it, “another blown opportunity for leadership to shine.” Even with the subsequent implementation of some of the recommendations the damage caused by poor communication was largely irreparable.
The parallels between the communication challenges around adverse medical events and improvement initiatives are striking. It is a vivid example of our cultural aversion to authentic communication, and the unnecessary harm that this causes to patients, families and staff. It is also a great example of the interconnectedness of systems: a poor communication process in one domain manifests everywhere else. Finally it is reflective of the principle that the only way to create sustainable change is to see a system or process in its entirety before problem solving: we have no chance of exercising authentic communication around adverse events with unless we understand and exercise authentic communication in the work environment. If we don’t treat ourselves with respect and authenticity, we don’t treat our patients with respect and authenticity.
Food for thought:
1. Authentic communication is a process, not a project
2. Authentic communication is compassionate communication (even when tough love is required)
3. Authentic communication is effective communication
4. Authentic communication has no boundaries
5. Authentic communication is a platform for change
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