3 The Problem: Mrs. Beauchaine’s Hot Dog A 75 year old great-grandmother suffering from heart failureTold by Berkshire Medical Center not to eat hot dogs at holiday cookouts because salt content would promote dangerous fluid retentionAt 4th of July picnic, Mrs. Beauchaine ate a hot dog and was back in hospital next dayShe told girl at food table, “I’m going to have a hot dog. If I’m dead in the morning, I’ll never know”The annual Medicare cost to taxpayers of Mrs. Beauchaine’s hot dog in terms of preventable hospital readmissions: $12 billionWinslow, Ron and Jacob Goldstein, “Cutting Repeat Hospital Trips—Simple Idea, Hard to Pull Off,” Wall Street Journal, July 28, 2009.
4 What Is Our EBP Hot Dog?If we know that doing EBP will change offender and delinquent behavior, reduce recidivism and enhance public safety, why don’t we do it?Why do we still eat the same old loveable hot dog even though we know it may do us and those around us significant harm?
6 Medical Cost of Not Taking Medicine In 2003, American Pharmacists Association estimated that failure to take medicine accounted for11-20% of all hospitalizations and repeat doctor visits125,000 deaths each yearHopfield, Jessica, Robert M. Linden and Bradley J. Trevelow, “Getting Patients to take their medicine,” The McKinsey Quarterly, 2006
7 Medical Cost of Not Taking Medicine National Pharmaceutical Council’s Task Force for Compliance found thatPoor adherence to medication regimen adds $100 billion annually to US health care costsClinical research has shown adherence rates among patients of 30 to 70%Hopfield, Jessica, Robert M. Linden and Bradley J. Trevelow, “Getting Patients to take their medicine,” The McKinsey Quarterly, 2006
8 Taking Medicine and Patient Attitude McKinsey study of 811 hypertension patients revealed thatHypertension affects 65 million Americans, half of whom don’t adhere to their drug therapiesThe usual interventions—electronic reminders and easy-to-open packaging—improve only short term adherenceA one-size fits all approach failsA better understanding of patient attitudes improves adherenceHopfield, Jessica, Robert M. Linden and Bradley J. Trevelow, “Getting Patients to take their medicine,” The McKinsey Quarterly, 2006
9 Patient Attitude and Intervention “Concerned” patients are 47 to 64% adherentConcerned about risks of high blood pressureWorry about long-term risks of medicationsIntervention: information on long-term patient safety quells their fears and increases adherenceHopfield, Jessica, Robert M. Linden and Bradley J. Trevelow, “Getting Patients to take their medicine,” The McKinsey Quarterly, 2006
10 Patient Attitude and Intervention “Confident” patients are 69 to 82% adherentRarely think of high blood pressure risksConfident in ability to control healthNo concerns about taking medicinesLess reliant on physiciansIntervention: respond to rewards programs such as loyalty-type programsHopfield, Jessica, Robert M. Linden and Bradley J. Trevelow, “Getting Patients to take their medicine,” The McKinsey Quarterly, 2006
11 Patient Attitude and Intervention “Resigned” patients are 13 to 45% adherentWhile afraid of high blood pressure, do not manage health activelyToo much trouble to live a healthy lifestyleHave no routine and careless about taking medicineIntervention: provide simple reminder devicesHopfield, Jessica, Robert M. Linden and Bradley J. Trevelow, “Getting Patients to take their medicine,” The McKinsey Quarterly, 2006
12 Danger of Attitudes S.U.V.s are more dangerous than cars They confer a sense of cognitive safety that invites careless behaviorSUV drivers are more likely toNot bother with seat beltsTalk on cell phones or textNot wear seat belts which talking on cell phones or textingVanderbilt, Tom, Traffic. Why We Drive the Way We Do (And What It Says About Us. New York: Alfred A. Knopf, 2008.
13 A Model of Cognitive Performance Three levels of cognitive performanceSkills based: patterns of thought and action governed by stored patterns of preprogrammed instructions (schemata) and which are largely unconsciousRule-based: solutions to familiar problems governed by stored rules (“if x then y”)Knowledge-based: novel situations requiring conscious analytical processingRasmussen, J. and A. Jensen, “Mental Procedures in real-life tasks: a case study of electronic trouble-shooting,” Ergonomics, Vol. 17 (1974)
14 A Model of Cognitive Performance Departures from routine (a problem) lead to two types of reactionA bias to search for a pre-packaged solution (a rule) before resorting to more strenuous knowledge-based functioningA dependence on “expertise” consisting of an extensive repertoire of schemata and rules, with infrequent resort to knowledge-based functioning (reason)Leape, Lucian L., “Error in Medicine,” Journal of the American Medical Association, Vol. 272, No. 23 (December 21, 1994)
15 A Model of Cognitive Performance: Habits of Thought Biased memory: tendency to based decisions on memory, which is biased to overgeneralization and overregularization of commonplaceAvailability heuristic: tendency to use first information that comes to mindConfirmation bias: tendency to look for evidence supporting a hypothesis and ignoring contradictory evidenceOverconfidence: tendency to believe in chosen course of actionLeape, Lucian L., “Error in Medicine,” Journal of the American Medical Association, Vol. 272, No. 23 (December 21, 1994)
16 Stress and Habits of Thought Stress produces aConing of attention: a tendency to concentrate on one single source of information, the “first come, best preferred solution”Reversion: recently learned behavior patterns are replaced by older, more familiar ones, even if they are inappropriateLeape, Lucian L., “Error in Medicine,” Journal of the American Medical Association, Vol. 272, No. 23 (December 21, 1994)
17 The Error of Our Ways: The Individual When professionals do not follow evidence-based practices or procedures (when they make errors) we tend to blame the professionalWell trained professionals, such as doctors, are not supposed to make errors (rule of infallibility)When they do make errors, they must have been incompetent or negligent, or it was someone else’s faultErrors never get reported because they are result of “individual failure” and no one wants to look badLeape, Lucian L., “Error in Medicine,” Journal of the American Medical Association, Vol. 272, No. 23 (December 21, 1994)
18 The Error of Our Ways: The System In any human system errors are inevitable because of our cognitive structuresProximal causes are individualRoot causes are systemicResult from poor design, faulty maintenance (quality control), and erroneous management decisionsBad management decisions can result in unrealistic workloads, inadequate training, and demanding “production” schedules that force workers to make errorsLeape, Lucian L., “Error in Medicine,” Journal of the American Medical Association, Vol. 272, No. 23 (December 21, 1994)
19 The Error of Our Ways: Root Causes Cannot prevent errors by focusing on “unsafe” individual acts themselvesOther “errors,” unpredictable and infinitely variable, will occur if underlying causes are not correctedAddressing root causes reduces probability, not inevitability, of errorThe way in which humans think is a major root cause of errorLeape, Lucian L., “Error in Medicine,” Journal of the American Medical Association, Vol. 272, No. 23 (December 21, 1994)
21 The Error of Our Ways: Inside the Black Box In terms of case managementThe research: the more time spent dealing with the criminogenic needs of the offender, the lower the recidivism rateThe practice (in a study of 62 officers with 154 adult and juvenile offenders):Only 39.4% of identified criminogenic needs had a corresponding intervention planWhile half of adult probationers had antisocial attitudes and peers, they were discussed with offenders only 8.8% and 21.1% of the time30 of 31 youths had peer problems, but were discussed only 43.3% of timeBonta, James, Tanya Rugge, Terri-Lynne Scott, Guy Bourgon and Annie K. Yessine, “Exploring the Black Box of Community Supervision,” Journal of Offender Rehabilittion, Vol. 47, No. 3 (2008)
23 The Error of Our Ways: Wash Your Hands Washing hands is one of the most effective ways to prevent infection in a hospitalHealth-care workers are less likely to wash hands if a higher ranking person in the room did not washOnly 8.5% of medical students (future doctors) washed hands after patient contactRecommendation: incorporate hand hygiene in medical school curriculumLankford, Mary G., Teresa R. Zembower, William E. Trick, Donna M. Hacek, Gary A. Noskin and Lance R. Peterson, “Influence of Role Models and Hospital Design on Hand Hygience of Health Care Workers,” Emerging Infectious Diseases, Vol. 9, No. 2 (Feburary 2003)
25 The Error of Our Ways: The Jerk Manager The problem is widespread in private, public and non-profit organizationsOne study of 700 representative Michigan residents in the year 2000 found that 27% had experienced mistreatment in the workplaceA 2003 study of 461 nurses found that, in the month before, 91% had experienced verbal abuse, primarily by physicians, that left them feeling attacked, devalued or humiliatedThe tolerance of such “jerks” leads to MORE STRESS AND MORE COGNITIVE ERRORRobert Sutton, “Building the Civilized Workplace,” The McKinsey Quarterly, May 2007
26 Correcting the Error of Our Ways: A Five Step Plan Off the Jerk ManagerReinvent TasksRebuild learningExploit hypocrisyGet the dumb stuff out of the way
27 Correcting the Error of Our Ways: Off the Jerk Manager Firms that consistently make Fortune’s 100 Best Places to Work List:Plante and MoranEmployee manual: “The goal is a ‘jerk-free’ workplace at this accounting firm. The staff is encouraged to live by the Golden Rule.”Barclay’s CapitalCOO Rich Ricci: “We have a no-jerk rule around here. Hotshots who alienate colleagues are told to change or leave.”Southwest AirlinesHerb Kelleher, former CEO: “One of our pilot applicants was very nasty to one of receptionist, and we immediately rejected him. You can’t treat people that way and be the kind of leader we want.”Robert Sutton, “Building the Civilized Workplace,” The McKinsey Quarterly, May 2007
28 Correcting the Error of Our Ways: Reinvent Tasks According to D.A. Norman four systemic steps will minimize errorTasks should be simplified to minimize load on weakest aspects of cognition (short-term memory, vigilance, prolonged attention)Power of constraints should be exploited“Forcing functions” should make it impossible to act without meeting a preconditionStandardize procedures thereby reinforcing the pattern recognition that humans do wellOperations should be easily reversible or difficult to perform when not reversibleNorman, D.A., To Err Is Human. New York: Basic Books Inc. Publishers, 1984
29 Correcting the Error of Our Ways: Rebuild Learning Bulk of our EBP learning focuses on knowledge-based cognitive performanceIgnores skill- and rule-based cognitive performance (schemata and rules)Tends to believe that one type of cognitive intervention fits allCreates cognitive situations that may enhance rather than diminish “errors”
30 Correcting the Error of Our Ways: Exploit Hypocrisy No one likes being a hypocriteResearchers have found that people who try to convince others to do something different and then are reminded that they are being hypocritical in not doing it themselves, change their own behaviorHumans care intensely how they are perceived and don’t want to be seen as hypocrites by persons around themTechnique has proven much more effective than education in encouraging people to practice safe sex, use sun screen to prevent skin cancer, and go to fitness centers prevent heart disease and diabetesVedantam, Shankar, “Preach What You Plan To Practice,” The Washington Post, January 6, 2009
31 Correcting the Error of Our Ways: Exploit Hypocrisy In the 1980s at University of Santa Cruz, AIDS was a death sentencePsychologist Elliot Abramson tried to get students to use condoms byEducating them (usage went from 17 to 19%)Make their use “sexy” with Romeo and Juliet films (usage soared to 60% only to drop to 20% after two months)Exploited hypocrisy by having students make video on importance of condom use, then asking them individually if they used condoms (usage among hypocrites were to 65-70% and stayed there)Vedantam, Shankar, “Preach What You Plan To Practice,” The Washington Post, January 6, 2009
32 Correcting the Error of Our Ways: Exploit Hypocrisy Two caveats to using this techniqueIt only works when people are convinced about the importance of the issueDo corrections professionals thing that protecting the safety of the public is important?Alert people to their hypocrisy in a subtle and supportive mannerIf people feel publicly humiliated, they will respond by minimizing the importance of the issueVedantam, Shankar, “Preach What You Plan To Practice,” The Washington Post, January 6, 2009
33 Correcting the Error of Our Ways: Get the Dumb Stuff Out of the Way Human factor in change process demands that we create the opportunity for normal human beings to implement and practice risk-reductionSimplicity leads to avoidance of error and prevents harmCheck lists “get the dumb stuff out of the way, the routines your brain shouldn’t have to occupy itself with…and lets it rise above to focus on the hard stuff.”They force us to retool our skills-based and rules-based cognitions so we can focus our effort on knowledge-based cognitionsGawande, Atul, The Checklist Manifesto. How To Get Things Right. New York: Henry Holt and Company, 2009
34 Correcting the Error of Our Ways: Get the Dumb Stuff Out of the Way Surgery checklists could save lives, study revealsTom Blackwell, National Post Published: Wednesday, January 14, 2009
35 Correcting the Error of Our Ways: Get the Dumb Stuff Out of the Way Good checklists arePreciseShortEasy to use even in difficult situationsDo not try to spell out everythingProvide reminders of only the most critical and important stepsPracticalGawande, Atul, The Checklist Manifesto. How To Get Things Right. New York: Henry Holt and Company, 2009
36 Correcting the Error of Our Ways: Get the Dumb Stuff Out of the Way Divide into three groups: managers, supervisors, line staffDevelop a good EBP checklist for a supervising officer to use before seeing an offender in the office?
37 Correcting the Error of Our Ways: Get the Dumb Stuff Out of the Way World Health Organization Surgical Safety ChecklistHas the patient confirmed his/her identity, site, procedure, and consent?Is the site marked?Is the anesthesia machine and medication check complete?Is the pulse oximeter on the patient and functioning?Does the patient have aKnown allergy?Difficult airway or aspiration risk?Risk of >500ml blood loss (7ml/kg in children)?<
38 Correcting the Error of Our Ways: Get the Dumb Stuff Out of the Way Bad checklists areVague and impreciseToo longHard to useImpracticalMade by desk jockeys with no awareness of situation in which they are to be deployedGawande, Atul, The Checklist Manifesto. How To Get Things Right. New York: Henry Holt and Company, 2009
39 Correcting the Error of Our Ways: Get the Dumb Stuff Out of the Way Checklist for Crime Scene PhotographersChecklist for digital SLR cameraAre batteries in the camera?Is the media loaded?Is the camera turned on?Is the ISO set (camera settings)?Is the shooting mode selected?Is the white balance set?Is the shutter speed set?Plus 120 more items
40 So Why Don’t We Take Our EBP Medicine? Taking our EBP medicineReduces community harm and increases public safetyChallenges our brains to create new neural pathways, prevents brain atrophy, and may reduce risk of dementia or Alzheimer’sMay help us lose and keep off weight by doing something different every day (we don’t know why)So why don’t we take our EBP medicine and persist in eating the old hot dog?Rae-Dupree, Janet, “Can You Become a Creature of New Habits?”, New York Times, Business Section, May 4, 2008.