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Quality Conversations for Staff and Families. Quality Week at WIH October 23, 2013 Marcia W. VanVleet, MD, MPH. or perhaps…. Silence Kills. Disclosure. I have no financial interest in the material presented. I am no way an expert when it comes to conversations,

I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
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quality conversations for staff and families

Quality Conversations for Staff and Families

Quality Week at WIH

October 23, 2013

Marcia W. VanVleet, MD, MPH

or perhaps

or perhaps…

Silence Kills

  • I have no financial interest

in the material presented.

  • I am no way an expert when it comes to conversations,

but I am open to feedback

and commit that I will keep trying.



By the end of this presentation the participant will be able to:

  • Identify examples of conversations that are crucial for patient safety
  • Explain how medical literacy can effect the quality of our conversations
so what do we see now
So What Do We See Now?

Harm Nationwide….

  • 1/20 are given the wrong med
  • 3.5 million infections from someone who didn’t wash their hands
  • 195,000 will die from a mistake in a hospital
crossing the quality chasm a new health system for the 21 st century
Crossing the Quality Chasm: A New Health System for the 21st Century

IOM Report (2001)

U.S. health care system does not provide CONSISTENT, high-quality medical care to all people.

communication model for use with every person every time

Communication Model for use with EVERY PERSON, EVERY TIME


AAcknowledge everyone in the room

I Introduce yourself, your role

D Duration – tell how long it will take

E Explain the purpose of your visit

T Teach back & Thank them for their time

what is quality
What is Quality?

IOM’s Definition of Quality

“The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”


iom s 6 aims apply to conversations
IOM’s 6 Aims…Apply to Conversations

As explained by Dr. Donald Berwick …

  • Safe:be as safe for patients in health care facilities as in their homes;
  • Effective:science and evidence behind health care should be applied and serve as the standard in the delivery of care;
  • Efficient:should be cost effective, and waste should be removed from the system;
  • Timely:no waits or delays in receiving care and service;
  • Patient centered:revolve around the patient, respect patient preferences, and put the patient in control;
  • Equitable:Unequal treatment should be a fact of the past; disparities in care should be eradicated.


joint commission s report 2005
Joint Commission’s Report(2005)
  • Pursue Patient Safety Initiatives that Prevent Medical Injury
  • Promote Open Communication Between Patients and Practitioners
  • Create an Injury Compensation System that it Patient-Centered and Serves the Common Good


wall of silence
“Wall of Silence”

“In addition to the fear of litigation, the wall of

silence is amplified by the fears of physicians

and health care organizations about the loss of

reputation, accreditation or licensure, and

income. The wall of silence severely undermines

efforts to create a culture of safety within

health care organizations and across the

health care system.

Indeed, patients will not be safe until caregivers feel safe to talk about

and act on medical error.”


the silent treatment study
The Silent Treatment study
  • 6,500 nurses and nurse managers
  • United States during 2010
  • All research participants were
    • American Association of Critical-Care Nurses (AACN)
    • Association of periOperative Registered Nurses (AORN)
  • Two research instruments:
    • a Story Collector
    • Traditional Survey

by David Maxfield, Joseph Grenny, Ramón Lavandero, and Linda Groah

the silent treatment results examples of conversations that are crucial
The Silent Treatment Results: Examples of Conversations that Are Crucial
  • Dangerous shortcuts:
    • Common:
      • 84 % work with people who take shortcuts
    • Dangerous:
      • 26% say these shortcuts have actually harmed patients
    • Un-discussed:
      • 31 % have shared with the colleague


the silent treatment results examples of conversations that are crucial1
The Silent Treatment Results: Examples of Conversations that Are Crucial
  • Incompetence:
    • Common:
      • 82% say colleague is missing basic skills
    • Dangerous:
      • 19% say has harmed patients
    • Un-discussed:
      • 21% have spoken to the colleague


the silent treatment results examples of conversations that are crucial2
The Silent Treatment Results: Examples of Conversations that Are Crucial
  • Disrespect:
    • Common:
      • 85% say they work with disrespectful people
    • Causes Problems:
      • 46% undercuts respect for professional opinion
      • 19% makes them unable to get others to listen
      • 20% considering leaving their job/profession
    • Un-discussed:
      • 24% have confronted the colleague


2 types of communication breakdowns chris argyris
2 Types of Communication Breakdowns (Chris Argyris)

Honest Mistakes

  • Poor handwriting
  • Accents
  • Competing tasks
  • “Human equivalent of gravity” James Reason



  • “Knows” strongly or suspects
  • Calculated decision not to speak up
  • Undermine the safety tools


  • CPOE,
  • Checklists,
  • SBAR Hand off protocols


knowing is not enough we must apply willing is not enough we must do

“Knowing is not enough; we must apply. Willing is not enough; we must do.”

Johann Wolfgang von Goethe (1749-1832)

crucial conversations
Crucial Conversations
  • Definition:
  • Dialogue: the free flow of meaning

between two or more people.

  • “Pool of shared meaning”

Crucial Conversations, 2012.

how do we know it s a crucial conversation
How Do We Know it’s a Crucial Conversation?
  • Our Physical response
    • Fright or flight, dry eyes, tight stomach
  • Our Emotional response
    • Fear, scared, hurt, angry
  • Our Behavioral response
    • “Out of body experience”
outcomes of crucial conversations
Outcomes of Crucial Conversations
  • Good outcomes
  • Bad outcomes
    • Silence
    • Violence

“Understand this, my dear brothers and sisters: You must all be quick to listen, slow to speak, and slow to get angry.”

~ James 1:19, NLT

how do we create a safe culture
How do We Create a Safe Culture?

Mutual Purpose

Do others believe I care about their goals?

Do they trust my motives?

Mutual Respect

Do others believe I respect them?

If safety is lost…



Create a mutual purpose

Crucial Conversations, 2012.

A+ Service Recovery…

(AcAp)2 or VAFT

Acknowledge: Validate after they vent, then summarize (you teach back to them)

Apologize…without the but

Act: Fix it

Appreciate: Thank you

medical health literacy

Medical/Health Literacy

What if we Don’t Speak the Same Language?

issues that effect communication
Issues that Effect Communication
  • Language
  • Hearing
  • Vision
  • Education
  • Fear/Anxiety
health literacy
Health Literacy
  • Defined by IOM as "the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.“
  • “Health literacy is not simply the ability to read. It requires a complex group of reading, listening, analytical, and decision-making skills, and the ability to apply these skills to health situations.”


required skills aka literacy
Required Skills (AKA Literacy)
  • Visually literate (understand graphs or other visual information)
  • Computer literate (operate a computer)
  • Information literate (obtain and apply relevant information)
  • Numerically or computationally literate (calculate or reason numerically)


national assessment of adult literacy naal 2003
National Assessment of Adult Literacy (NAAL 2003)
  • Proficient 12%
  • Intermediate 52%
  • Basic 22%
  • Below Basic 14%
    • 5% are not literate in English

80 Million Adults


medical literacy outcomes
Medical Literacy Outcomes
  • Lower Rates of:
    • Utilization of preventative care:
      • flu shots, mammograms
  • Higher rates of:
    • Mortality for seniors*
    • Med errors (take, interpret labels/messages)
    • Self ratings of “Poor Health”
    • ER visits and hospitalizations

AHRQ Pub No. 11-E006-1, March 2011

iom s 10 attributes
IOM’s 10 Attributes


checklist for improving the usability of health information
Checklist for Improving the Usability of Health Information
  • Identify the intended users
  • Use pre- and post-tests
  • Limit the number of messages
  • Use plain language
  • Practice respect
  • Focus on behavior
  • Check for understanding
  • Supplement with pictures
  • Use a medically trained interpreter or translator


an example from wih
An Example from WIH
  • Series of 3 Patients in a week seen at the WIH Follow-up Clinic
  • Each with issues related to feeding and the mixing of formula
  • Started asking patients what they were doing…
directions for mixing formula


Directions for Mixing Formula


what helped the exceptional conversationalists
What helped the “Exceptional Conversationalists”?
  • When issue not urgent, collect the facts/test
  • Assumed the best, and spoke up
  • Explained their positive intent, to help caregiver and patient
  • Took special effort to make it safe for the caregiver (avoid creating defensiveness)
  • Used facts and data, actual situation
  • Avoided negative stories or accusations
  • Diffused or deflected the anger or emotions (keep in check)

Crucial Conversations, 2012.

Speak UP!

Hold Accountable and…

Ask for Help.

Vital Smarts Webinar, The 4 Culture Viruses in Healthcare, April 24 2013.

some people make cutting remarks but the words of the wise bring healing

“Some people make cutting remarks, but the words of the wise bring healing.”

~ Proverbs 12:18, NLT

comments suggestions questions

Comments, Suggestions, Questions?

[email protected]

Phone: 274-1122 x 47470

Pager: 452-0091