Book of the month: If Disney Ran Your Hospital: 9 1/2 things you would do differently by Fred Lee

Before you wonder if you're reading the wrong blog, change the word in the book's title from "Hospital" to "Simulation Centre" and please bear with me for a few more paragraphs. 

About the author

Fred Lee was a senior vice president at Florida Hospital in Orlando before becoming a cast member (as their employees are referred to) at Disney. He helped to develop and facilitate "The Disney Approach to Quality Service for the Healthcare Industry".

Who should read this book?

Lee says: "Although this book was written with hospital managers in mind it should also be appealing to staff at all levels." And he is correct, anybody with an interest in how to improve the experience of the customer/client/participant/patient would benefit from reading this book.

I haven't got time to read a whole book!

The 9 and 1/2 things are listed on the right, however they will provide little insight without reading the chapters. The 10 chapters can be read in chunks and the plain language and personal examples make this book an easy read. 

What's good about this book?

In every chapter Lee provides both the theory behind the thing you would do differently as well as practical applications. A few concepts which  Lee explores, that may influence the way you run your simulation centre are covered below.

1) "Employees leave managers, not organizations" (p.4) Lee quotes work carried out by Buckingham and Coffman for their book "First, Break All the Rules". They argue that an employee's manager has a much greater impact on aspects such as their loyalty, job satisfaction and efficiency than the culture of the company. An employee who does not get on with their manager will not stay in a post because they love the company.

2) "Selling is trying to get people to want what you have. Marketing is trying to have what people want. When you have what people want, it makes selling unnecessary" (p.5) Lee took this quote from Terrance Ryan, a healthcare marketing consultant. A mistake for a simulation centre is for the faculty to sit around and think about what courses they should run. Inevitably this new course will not be radically different from previous courses. Instead what Lee is suggesting is to run the courses that the participants want to come to, i.e. having what people want. This concept may also be applied to timing. At the SCSC we currently don't run any courses after 5pm or on weekends. However, if this is what participants want then shouldn't we be offering it? (Some  sim centres provide 24/7 access.)

3) Most participants are comparing you against the "ideal" sim centre and not another sim centre (p.10) This is part of "redefining your competition" so that you are no longer comparing yourself with other (nearby) sim centres but instead against what you would expect and want from a sim centre which existed to give participants the best possible learning experience.

4) Work on outcomes and perceptions (p.13) Lee argues that both outcomes and perceptions are important, but that outcomes are improved by teams, while perceptions are improved by individuals. At Disney every individual cast member is aware that they represent the brand and that their words and actions reflect on the brand. Lee also argues that you may have fantastic teamwork but that you must show this to participants. How would you do this in a sim centre? Ideas might include referring to the faculty on a first-name basis, wearing badges with first names easily legible, being courteous to the admin and technical staff... The importance of perceptions may also be shown & assessed in a simulation centre by running sessions which include (for example) telling a simulated patient that their operation has been cancelled as the list has run over. Events such as a cancelled op may have a massive effect on the reputation of a hospital and ensuring that these conversations are handled with care and empathy may require some training. 

5) The four Disney priorities are (in order): Safety, Courtesy, Show, Efficiency (p.28). 

Fig. 1: Columns vs Ladder

Lee discusses how a lot of hospitals have graphics showing columns supporting a roof The problem with these graphics is that they do not tell the employees which one of the columns is most important. Lee argues that we should instead have a ladder of priorities which would make it clear to employees that safety is more important than being patient-centred (for example.)

6) Lee says that we must move away from a service to an experience paradigm. Participants at the sim centre do not talk about the service they received but rather the experience they had. We should be focusing on the experience of the participant. What happens when they call or email to book onto a course? Does anyone make them feel welcome when they walk through the door? Are they treated with respect and courtesy? As for your faculty, are the classrooms set up for them, computers & projectors on, kettle on for a cup of tea?

7) Encourage a culture of dissatisfaction. Lee tells us that "being good is the enemy of being great". Your sim centre should constantly be striving for excellence both in the faculty and in the participants. One reason to strive for excellence is because "excellence is fun" (p.212).  Lee means that once you have reached "excellence" you can stop worrying so much about whether what you are doing is right. One of the reasons people are stressed at their jobs is because they feel that they cannot cope with increased acute stress from an emergency. Simulation training can help to alleviate this stress.

8) As a sim centre director/manager, how do you know you're doing a good job? One possible method is to ask your staff what they would want from an excellent director or manager. Then use this template yearly to allow the staff to feedback on your performance.

What's not good about this book?

Very little…. There is no index and the "1/2 thing" does feel a bit gimmicky. (9 1/2 things… probably sounds more interesting than 10 things….)

Final thoughts

Buy this book, read it and keep it for referring back to. Then make some of the changes Lee suggests and see if they improve your sim centre.

The success of failure

Sim centres around the world have routines for when participants first arrive. Perhaps a sign-in sheet, distribution of parking permits, directions to the nearest toilets, refreshments, etc.

Most sim centres will also have a period before embarking on scenarios which includes looking at (or setting) the learning objectives and talking about confidentiality. This period helps to create the safe learning environment which will allow the candidates to perform without fear of reprisal or ridicule.

During this "setting the scene" period I talk to the candidates about failure and say something along the lines of:

"We are all human. We all make mistakes. You will make mistakes today. That is alright. I have made some spectacular mistakes in my clinical practice which have resulted in patients being harmed. I have learned from these mistakes and am a better practitioner as a result.

We are all here to learn from one another and I'm sure you would much prefer to make a mistake here on a mannequin, who will not die or come to harm, than on a real patient."

The problem with participants... with all of us... is that we don't like failure. In fact, we actively avoid situations where failure is an option. Youtube has a plethora of "fail" clips. Cats failing to jump high or far enough seem to be a particular favourite. Although they can be humorous, perhaps the viewpoint should be that these cats are trying something, failing at it and then learning from it. And that persistence often pays off.

Perhaps there are still places where failure is not seen as failure? In this very readable Inc. article about cadets at the United States Military Academy at West Point, the author Jim Collins talks to some of them about failure. Their responses:

"It's better to fail here and have other people help you get it right than to fail in Afghanistan, where the consequences could be catastrophic"

"Here, everybody knows it's a learning experience"

Collins goes on to claim that repeated failure is built into the West Point culture. Currently our education system and our medical training system is not rewarding or encouraging of failure. Big summative tests at the end of periods of training allow you to advance (or not) to the next level. In terms of education and training, what would happen if there were a test on day 1, where everybody fails and then repeated tests throughout the year to show you how you are doing and where your strengths and weaknesses are?

In terms of the simulator I am not a believer in the idea that the participants must fail in order to learn. (This is the "they're doing really well, let's throw in an 'anaphylaxis'" school of thought.) I think if the participants shine then we can all learn from that. But perhaps we should be more positive about failure, build it into our simulation centre culture and show how failure can be a success if it makes you better. I leave you with two quotes. The first a youtube comment on one of the cat "fails" and the second from Tommy Caldwell, a rock climber who features in the above-mentioned Inc. article

"This is not a fail. This is an Epic try!" - Dio Rex

"(Failure) is making me stronger. I am not failing; I'm growing." - Tommy Caldwell

Book of the month: Crisis Management in Acute Care Settings (2nd ed) by St.Pierre, Hofinger, Buerschaper and Simon

The last two books reviewed here: "Why we make mistakes" and "Set phasers on stun" were light summer reading. "Crisis Management in Acute Care Settings" is the sort of book you need the rainy weather and darker evenings for; its 335 pages of densely packed text require concentration and persistence.

The four authors are: Michael St.Pierre (Anaesthetist, 'Oberarzt' at Erlangen University hospital), Gesine Hofinger (PhD, Cognitive Psychologist, Department of Intercultural Business Communication, Friedrich-Schiller-University, Jena), Cornelius Buerschaper (Researcher, focused on decision-making in crises, who unfortunately passed away in August 2011) and Robert Simon (Director of Center for Medical Education, Harvard Medical School)

Who should read this book?

This book is for the dedicated human factors and/or simulation devotee. Although an aim of the authors was to "formulate the text in an easy to read language" (p.ix) with a target audience of "nurses, technicians, paramedics and physicians" (p.ix) the language used is at times overly complex and the concepts require a more than basic understanding of human factors. This is not the book to give to people who have expressed an initial interest in human factors or simulation.

I haven't got time to read 335 pages...

The book is divided into four parts, so you can decide if there is one particular aspect you wish to explore:

1. Basic Principles: Error, Complexity and Human Behaviour (81 pages)
2. Individual Factors of Behaviour (111 pages)
3. The Team (81 pages)
4. The Organization (62 pages)

62 pages? That's still too much!

Every chapter finishes with an "In a nutshell" section which provides an overview of the content. It may therefore be worthwhile reading the "nutshells" and then deciding which chapters warrant a more detailed look.

What's bad about this book?

There are a number of minor annoyances such as:

• Random use of italics e.g. "First, the majority of patients arrive at the ED rather unprepared..." (p.12)
• Obtuse sentences e.g. "Humans try to balance actual and nominal physiological conditions"(p.66) "The interpretation of sensory impressions tries to form them as good a good Gestalt (the law of "Praegnanz" - good form)."(p.93)
• Obtuse sentences which are also long e.g. "From an evolutionary point of view, the ability to rapidly produce workable patterns to understand of the environment seems to have been advantageous compared with a 100% scanning and consciously filtering important from unimportant information about the surroundings."(p.95) Including possibly the longest sentence I have ever read: "As complex situations are characterised by the interrelatedness of many system variables (on-scene situation, pathophysiology of the patient, main motives of the different providers and professional groups involved), there will be some goals which are in themselves justified but which are mutually exclusive - be it the parallel technical and medical rescue operation on site or the side by side of diagnostic and therapy during resuscitation of a trauma patient in the emergency room."(p.127)
• The use of distracting background pictures in diagrams which add nothing to the understanding of the text (p.90,p.188)

A more important oversight is the lack of any reference to our acute medicine and surgical colleagues whom I would consider part of the "acute care setting". With the advent of Non-Technical Skills for Surgeons (NOTSS), the development of courses looking at surgical crisis teamwork and leadership and courses for acute medical practitioners, I would like to see surgeons and acute physicians included in the third edition.

What's good about this book?

This book provides a detailed analysis of human factors and team psychology in a high stakes environment. The book also links the aforementioned with patient safety and so enriches the understanding one may have of how work in human factors/simulation can improve patient safety.

The "in a nutshell" section at the end of every chapter is a useful reminder of what has been discussed. Most chapters also have a "tips for clinical practice" section which may help to convert theory into practice and there is an extensive list of references provided for every chapter.

Most chapters are packed full of information and, once the convoluted language has been overcome (see above), they begin with a good overview of the concepts and then delve into the core of the matter, focusing on each piece in turn.
For example, Chapter 11: "The Key to Success: Teamwork" discusses and defines teamwork and teams, followed by a review of team performance. The latter is analysed by looking at the input into the team from: individual characteristics, team characteristics, characteristics of the task and characteristics of the environment. The authors then go on to discuss how teams are formed, how a "good" team performs and where teams can go wrong (communication, shared misconceptions, groupthink etc. etc.) The level of detail is extremely impressive and educational. The same detail is found other chapters such as chapter 3 which looks at the nature of error and chapter 9 which looks at stress (acute, chronic, coping mechanisms). 

There are also some great quotes such as:

• A situation does not cause emotions; your interpretation of the situation causes emotions (p.99) (with echoes of Jack Sparrow)
• "As an overall philosophy, it is wise to use good judgment to avoid situations in which superior clinical skills must be applied to ensure safety"(Attributed to Hawkins in Human Factors in Flight, 1987) (p.118)
• ...human factors should never be equated with "risk factors." Each time mindful healthcare professionals detect, diagnose, and correct a critical situation or an error before it has an opportunity to unfold, it is the human factors that prevent patient harm (p.15)
• The development of expertise requires struggle. There are no shortcuts (p.33)
• Practice does not make perfect; instead perfect practice makes perfect (p.33)
• Teamwork is not an automatic consequence of placing healthcare professionals together in the same shift or room (p.210)
• If you want to profit from a good team process in a critical situation, you need to rehearse team skills on a frequent basis. (p.216)
• You will not succeed if you do not talk! Talking is the way team members develop and maintain a shared mental model. (p.217)
• Teamwork seems to be the essential component in the pursuit of achieving high reliability in healthcare organisations. (p.324)

Final thoughts

Buy this book for your simulation centre. Set aside the time to read it. It is a great reference text and will inform your workshops, lectures, research, simulated scenarios and your clinical practice.

It's all about me, me, me: the problem with advocacy-inquiry in debriefing

The importance of the debrief

It is safe to say that those of us involved in simulation believe that the debrief is a very important part of the learning experience. Many of us (1) would say it was the most important part. A slide taken from the SCSC's faculty development (train the trainers) course helps us see why (Figure 1).

Fig. 1: Scenario and Debrief mapped onto Kolb's learning cycle

When we map the simulation activity onto Kolb's learning cycle, we can see that three-quarters of the process is supposed to occur during the debrief. The debrief is important therefore because much of the learning is supposed to take place during this period.

In 2007, Fanning and Gaba wrote an article entitled "The Role of Debriefing in Simulation-Based Learning". They explain how adult learners do not find "linear teaching models" (i.e. didactic teaching) very effective and instead benefit from active participation (i.e. experiential learning as shown in Kolb's learning cycle above). The role of the teacher is to facilitate the learners' progress around the cycle (hence "facilitator") through a debrief of the events which occurred in the simulated scenario. This role is an important one, as Fanning and Gaba state:

"Data from surveys of participants indicates that the perceived skills of the debriefer have the highest independent correlation to the perceived overall quality of the simulation experience." (2, p.118)

Dismukes and Smith identify three levels of facilitation (3):

1. High level facilitation: participants more or less debrief themselves
2. Intermediate level facilitation: somewhere between high and low
3. Low level facilitation: facilitator directs the entire debrief

Fanning and Gaba state that we should use the highest level possible and, in their paper, go on to list some of the debriefing styles (e.g. funnelling, framing) and techniques (e.g. plus-delta, target-focused) which are used.

Debriefing with good judgment (Advocacy-inquiry)

In conversations with some facilitators at simulation-focused conferences I have been struck by their belief that "debriefing with good judgment" is the "one, true" debriefing style. After all, who does not want to debrief with good judgment?
In their two (similar) papers Rudolph et al discuss the theory and practice of debriefing with good judgment (4,5). Drawing on "a 35-year research program in the behavioral sciences on how to improve professional effectiveness through 'reflective practice'" they cite three elements in their approach:

1. Uncovering the participant's knowledge, assumptions and feelings (internal frames) allows the facilitator to "reframe" and improve future actions and behaviour
2. The facilitator has a stance of "genuine curiosity" about the participant's internal frames
3. The facilitator uses the "advocacy-inquiry" conversational technique to bring his/her judgment and the participant's frames to light.

The first 2 elements are not controversial, but the third gives me some concern. Rudolph et al define advocacy as:

"A type of speech that includes an objective observation about and subjective judgment of the trainees’ actions" (4, p.49)

To illustrate what they mean, they provide the following worked example:

I have highlighted the problem (as I see it) with the worked example below:

It's "me, me, me" and then "I, I, I". For a facilitated debrief there seems far too much focus on the facilitator. Here's my alternative to the above debrief:

Debriefer: So, how was that?
A group member: I was a bit confused by what was happening.
Debriefer: Really? In what way?
A group member: I wasn't sure who was in charge or what I was supposed to do.
Debriefer: Okay, did anybody else feel that way?
Group: Several members agree.
Debriefer: Did the confusion have any effect on how you dealt with the patient?
etc. etc.

The above is still too facilitator-driven but at least removes the facilitator as the pivot around which the conversation flows. The advocacy-inquiry technique seems to be at best an intermediate-level facilitation and at worst a low-level facilitation where the participants rely on the facilitator to discuss what he/she thought were the important points.

Should we get rid of "debriefing with good judgment"? No. Much of what Rudolph et al discuss is valid. They are correct to say that there is no "non-judgmental" debriefing. Being "genuinely curious"is also extremely important. However, I would argue that one can be genuinely curious without focusing the conversation on the facilitator.

Is there a place for "advocacy-inquiry"? Yes. Fanning and Gaba state "the debriefing techniques employed need to take individual learning styles into consideration" (2, p.117) High-level facilitation should be used whenever possible, then perhaps stepping down to advocacy-inquiry if the participants need more direction.

In their paper, Rudolph et al follow the debriefer/trainees conversation above with the debriefer saying:

I think that question needs to come much earlier.



References:
1) Issenberg SB, McGaghie WC, Petrusa ER, et al: Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Medical Teacher 2005;27:10–28.
2) Fanning RM and Gaba DM: The role of debriefing in simulation‐based learning. Simulation in Healthcare 2007;2(2):115-125. (Article available for free here.)
3) Dismukes R, Smith G: Facilitation and debriefing in aviation training and operations. Aldershot; UK: Ashgate, 2000
4) Rudolph JW, Simon R, Dufresne R, et al: There’s no such thing as “Nonjudgmental” debriefing: A theory and method for debriefing with good judgment. Simul Healthcare 2006;1:49–55.
5) Rudolph JW, Simon R, Rivard P, et al: Debriefing with Good Judgment: Combining Rigorous Feedback with Genuine Inquiry. Anesthiol Clin 2007;25:361-376. (Article available for free here.)