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Getting Corrections Professionals to Take Their EBP Medicine APPA Summer Institute August 2010 Frank Domurad The Carey Group, Inc.

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Presentation on theme: "Getting Corrections Professionals to Take Their EBP Medicine APPA Summer Institute August 2010 Frank Domurad The Carey Group, Inc."— Presentation transcript:

1 Getting Corrections Professionals to Take Their EBP Medicine APPA Summer Institute August 2010 Frank Domurad The Carey Group, Inc.

2 GREEN WORKSHOP For Handouts: send to

3 The Problem: Mrs. Beauchaines Hot Dog A 75 year old great-grandmother suffering from heart failure A 75 year old great-grandmother suffering from heart failure Told by Berkshire Medical Center not to eat hot dogs at holiday cookouts because salt content would promote dangerous fluid retention Told by Berkshire Medical Center not to eat hot dogs at holiday cookouts because salt content would promote dangerous fluid retention At 4 th of July picnic, Mrs. Beauchaine ate a hot dog and was back in hospital next day At 4 th of July picnic, Mrs. Beauchaine ate a hot dog and was back in hospital next day She told girl at food table, Im going to have a hot dog. If Im dead in the morning, Ill never know She told girl at food table, Im going to have a hot dog. If Im dead in the morning, Ill never know The annual Medicare cost to taxpayers of Mrs. Beauchaines hot dog in terms of preventable hospital readmissions: $12 billion The annual Medicare cost to taxpayers of Mrs. Beauchaines hot dog in terms of preventable hospital readmissions: $12 billion Winslow, Ron and Jacob Goldstein, Cutting Repeat Hospital TripsSimple 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 dont we do it? If we know that doing EBP will change offender and delinquent behavior, reduce recidivism and enhance public safety, why dont 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? 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?

5 Cross Your Arms

6 Medical Cost of Not Taking Medicine In 2003, American Pharmacists Association estimated that failure to take medicine accounted for In 2003, American Pharmacists Association estimated that failure to take medicine accounted for 11-20% of all hospitalizations and repeat doctor visits 11-20% of all hospitalizations and repeat doctor visits 125,000 deaths each year 125,000 deaths each year Hopfield, 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 Councils Task Force for Compliance found that National Pharmaceutical Councils Task Force for Compliance found that Poor adherence to medication regimen adds $100 billion annually to US health care costs Poor adherence to medication regimen adds $100 billion annually to US health care costs Clinical research has shown adherence rates among patients of 30 to 70% Clinical 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 that McKinsey study of 811 hypertension patients revealed that Hypertension affects 65 million Americans, half of whom dont adhere to their drug therapies Hypertension affects 65 million Americans, half of whom dont adhere to their drug therapies The usual interventionselectronic reminders and easy-to-open packagingimprove only short term adherence The usual interventionselectronic reminders and easy-to-open packagingimprove only short term adherence A one-size fits all approach fails A one-size fits all approach fails A better understanding of patient attitudes improves adherence A better understanding of patient attitudes improves adherence Hopfield, 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% adherent Concerned patients are 47 to 64% adherent Concerned about risks of high blood pressure Concerned about risks of high blood pressure Worry about long-term risks of medications Worry about long-term risks of medications Intervention: information on long-term patient safety quells their fears and increases adherence Intervention: information on long-term patient safety quells their fears and increases adherence Hopfield, Jessica, Robert M. Linden and Bradley J. Trevelow, Getting Patients to take their medicine, The McKinsey Quarterly, 2006

10 Confident patients are 69 to 82% adherent Confident patients are 69 to 82% adherent Rarely think of high blood pressure risks Rarely think of high blood pressure risks Confident in ability to control health Confident in ability to control health No concerns about taking medicines No concerns about taking medicines Less reliant on physicians Less reliant on physicians Intervention: respond to rewards programs such as loyalty-type programs Intervention: respond to rewards programs such as loyalty-type programs Patient Attitude and Intervention Hopfield, Jessica, Robert M. Linden and Bradley J. Trevelow, Getting Patients to take their medicine, The McKinsey Quarterly, 2006

11 Resigned patients are 13 to 45% adherent Resigned patients are 13 to 45% adherent While afraid of high blood pressure, do not manage health actively While afraid of high blood pressure, do not manage health actively Too much trouble to live a healthy lifestyle Too much trouble to live a healthy lifestyle Have no routine and careless about taking medicine Have no routine and careless about taking medicine Intervention: provide simple reminder devices Intervention: provide simple reminder devices Patient Attitude and Intervention Hopfield, 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 S.U.V.s are more dangerous than cars They confer a sense of cognitive safety that invites careless behavior They confer a sense of cognitive safety that invites careless behavior SUV drivers are more likely to SUV drivers are more likely to Not bother with seat belts Not bother with seat belts Talk on cell phones or text Talk on cell phones or text Not wear seat belts which talking on cell phones or texting Not wear seat belts which talking on cell phones or texting Vanderbilt, 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 performance Three levels of cognitive performance Skills based: patterns of thought and action governed by stored patterns of preprogrammed instructions (schemata) and which are largely unconscious Skills based: patterns of thought and action governed by stored patterns of preprogrammed instructions (schemata) and which are largely unconscious Rule-based: solutions to familiar problems governed by stored rules (if x then y) Rule-based: solutions to familiar problems governed by stored rules (if x then y) Knowledge-based: novel situations requiring conscious analytical processing Knowledge-based: novel situations requiring conscious analytical processing Rasmussen, J. and A. Jensen, Mental Procedures in real-life tasks: a case study of electronic trouble-shooting, Ergonomics, Vol. 17 (1974)

14 Departures from routine (a problem) lead to two types of reaction Departures from routine (a problem) lead to two types of reaction A bias to search for a pre-packaged solution (a rule) before resorting to more strenuous knowledge-based functioning A bias to search for a pre-packaged solution (a rule) before resorting to more strenuous knowledge-based functioning A dependence on expertise consisting of an extensive repertoire of schemata and rules, with infrequent resort to knowledge- based functioning (reason) A dependence on expertise consisting of an extensive repertoire of schemata and rules, with infrequent resort to knowledge- based functioning (reason) A Model of Cognitive Performance 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 commonplace Biased memory: tendency to based decisions on memory, which is biased to overgeneralization and overregularization of commonplace Availability heuristic: tendency to use first information that comes to mind Availability heuristic: tendency to use first information that comes to mind Confirmation bias: tendency to look for evidence supporting a hypothesis and ignoring contradictory evidence Confirmation bias: tendency to look for evidence supporting a hypothesis and ignoring contradictory evidence Overconfidence: tendency to believe in chosen course of action Overconfidence: tendency to believe in chosen course of action Leape, 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 a Stress produces a Coning of attention: a tendency to concentrate on one single source of information, the first come, best preferred solution Coning 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 inappropriate Reversion: recently learned behavior patterns are replaced by older, more familiar ones, even if they are inappropriate Leape, 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 professional When professionals do not follow evidence- based practices or procedures (when they make errors) we tend to blame the professional Well trained professionals, such as doctors, are not supposed to make errors (rule of infallibility) Well 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 elses fault When they do make errors, they must have been incompetent or negligent, or it was someone elses fault Errors never get reported because they are result of individual failure and no one wants to look bad Errors never get reported because they are result of individual failure and no one wants to look bad Leape, 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 structures In any human system errors are inevitable because of our cognitive structures Proximal causes are individual Proximal causes are individual Root causes are systemic Root causes are systemic Result from poor design, faulty maintenance (quality control), and erroneous management decisions Result from poor design, faulty maintenance (quality control), and erroneous management decisions Bad management decisions can result in unrealistic workloads, inadequate training, and demanding production schedules that force workers to make errors Bad management decisions can result in unrealistic workloads, inadequate training, and demanding production schedules that force workers to make errors Leape, Lucian L., Error in Medicine, Journal of the American Medical Association, Vol. 272, No. 23 (December 21, 1994)

19 Cannot prevent errors by focusing on unsafe individual acts themselves Cannot prevent errors by focusing on unsafe individual acts themselves Other errors, unpredictable and infinitely variable, will occur if underlying causes are not corrected Other errors, unpredictable and infinitely variable, will occur if underlying causes are not corrected Addressing root causes reduces probability, not inevitability, of error Addressing root causes reduces probability, not inevitability, of error The way in which humans think is a major root cause of error The way in which humans think is a major root cause of error The Error of Our Ways: Root Causes Leape, Lucian L., Error in Medicine, Journal of the American Medical Association, Vol. 272, No. 23 (December 21, 1994)

20 What Are Common Line Staff EBP Errors?

21 The Error of Our Ways: Inside the Black Box In terms of case management The research: the more time spent dealing with the criminogenic needs of the offender, the lower the recidivism rate The research: the more time spent dealing with the criminogenic needs of the offender, the lower the recidivism rate The practice (in a study of 62 officers with 154 adult and juvenile offenders): The practice (in a study of 62 officers with 154 adult and juvenile offenders): Only 39.4% of identified criminogenic needs had a corresponding intervention plan Only 39.4% of identified criminogenic needs had a corresponding intervention plan While half of adult probationers had antisocial attitudes and peers, they were discussed with offenders only 8.8% and 21.1% of the time While half of adult probationers had antisocial attitudes and peers, they were discussed with offenders only 8.8% and 21.1% of the time 30 of 31 youths had peer problems, but were discussed only 43.3% of time 30 of 31 youths had peer problems, but were discussed only 43.3% of time Bonta, 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)

22 What Are Common Supervisory EBP Errors?

23 Washing hands is one of the most effective ways to prevent infection in a hospital Washing hands is one of the most effective ways to prevent infection in a hospital Health-care workers are less likely to wash hands if a higher ranking person in the room did not wash Health-care workers are less likely to wash hands if a higher ranking person in the room did not wash Only 8.5% of medical students (future doctors) washed hands after patient contact Only 8.5% of medical students (future doctors) washed hands after patient contact Recommendation: incorporate hand hygiene in medical school curriculum Recommendation: incorporate hand hygiene in medical school curriculum The Error of Our Ways: Wash Your Hands Lankford, 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)

24 What Are Common Managerial EBP Errors?

25 The problem is widespread in private, public and non-profit organizations The problem is widespread in private, public and non-profit organizations One study of 700 representative Michigan residents in the year 2000 found that 27% had experienced mistreatment in the workplace One study of 700 representative Michigan residents in the year 2000 found that 27% had experienced mistreatment in the workplace A 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 humiliated A 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 humiliated The tolerance of such jerks leads to MORE STRESS AND MORE COGNITIVE ERROR The tolerance of such jerks leads to MORE STRESS AND MORE COGNITIVE ERROR Robert Sutton, Building the Civilized Workplace, The McKinsey Quarterly, May 2007 The Error of Our Ways: The Jerk Manager

26 Off the Jerk Manager Off the Jerk Manager Reinvent Tasks Reinvent Tasks Rebuild learning Rebuild learning Exploit hypocrisy Exploit hypocrisy Get the dumb stuff out of the way Get the dumb stuff out of the way Correcting the Error of Our Ways: A Five Step Plan

27 Firms that consistently make Fortunes 100 Best Places to Work List: Plante and Moran Plante and Moran Employee manual: The goal is a jerk-free workplace at this accounting firm. The staff is encouraged to live by the Golden Rule. Employee manual: The goal is a jerk-free workplace at this accounting firm. The staff is encouraged to live by the Golden Rule. Barclays Capital Barclays Capital COO Rich Ricci: We have a no-jerk rule around here. Hotshots who alienate colleagues are told to change or leave. COO Rich Ricci: We have a no-jerk rule around here. Hotshots who alienate colleagues are told to change or leave. Southwest Airlines Southwest Airlines Herb Kelleher, former CEO: One of our pilot applicants was very nasty to one of receptionist, and we immediately rejected him. You cant treat people that way and be the kind of leader we want. Herb Kelleher, former CEO: One of our pilot applicants was very nasty to one of receptionist, and we immediately rejected him. You cant treat people that way and be the kind of leader we want. Robert Sutton, Building the Civilized Workplace, The McKinsey Quarterly, May 2007 Correcting the Error of Our Ways: Off the Jerk Manager

28 Correcting the Error of Our Ways: Reinvent Tasks According to D.A. Norman four systemic steps will minimize error Tasks should be simplified to minimize load on weakest aspects of cognition (short-term memory, vigilance, prolonged attention) Tasks should be simplified to minimize load on weakest aspects of cognition (short-term memory, vigilance, prolonged attention) Power of constraints should be exploited Power of constraints should be exploited Forcing functions should make it impossible to act without meeting a precondition Forcing functions should make it impossible to act without meeting a precondition Standardize procedures thereby reinforcing the pattern recognition that humans do well Standardize procedures thereby reinforcing the pattern recognition that humans do well Operations should be easily reversible or difficult to perform when not reversible Operations should be easily reversible or difficult to perform when not reversible Norman, D.A., To Err Is Human. New York: Basic Books Inc. Publishers, 1984

29 Bulk of our EBP learning focuses on knowledge-based cognitive performance Bulk of our EBP learning focuses on knowledge-based cognitive performance Ignores skill- and rule-based cognitive performance (schemata and rules) Ignores skill- and rule-based cognitive performance (schemata and rules) Tends to believe that one type of cognitive intervention fits all Tends to believe that one type of cognitive intervention fits all Creates cognitive situations that may enhance rather than diminish errors Creates cognitive situations that may enhance rather than diminish errors Correcting the Error of Our Ways: Rebuild Learning

30 No one likes being a hypocrite No one likes being a hypocrite Researchers 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 behavior Researchers 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 behavior Humans care intensely how they are perceived and dont want to be seen as hypocrites by persons around them Humans care intensely how they are perceived and dont want to be seen as hypocrites by persons around them Technique 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 diabetes Technique 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 diabetes Correcting the Error of Our Ways: Exploit Hypocrisy Vedantam, Shankar, Preach What You Plan To Practice, The Washington Post, January 6, 2009

31 In the 1980s at University of Santa Cruz, AIDS was a death sentence Psychologist Elliot Abramson tried to get students to use condoms by Educating them (usage went from 17 to 19%) Educating 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) 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) 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) Correcting the Error of Our Ways: Exploit Hypocrisy Vedantam, Shankar, Preach What You Plan To Practice, The Washington Post, January 6, 2009

32 Two caveats to using this technique Two caveats to using this technique It only works when people are convinced about the importance of the issue It only works when people are convinced about the importance of the issue Do corrections professionals thing that protecting the safety of the public is important? Do corrections professionals thing that protecting the safety of the public is important? Alert people to their hypocrisy in a subtle and supportive manner Alert people to their hypocrisy in a subtle and supportive manner If people feel publicly humiliated, they will respond by minimizing the importance of the issue If people feel publicly humiliated, they will respond by minimizing the importance of the issue Correcting the Error of Our Ways: Exploit Hypocrisy Vedantam, 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-reduction Human factor in change process demands that we create the opportunity for normal human beings to implement and practice risk-reduction Simplicity leads to avoidance of error and prevents harm Simplicity leads to avoidance of error and prevents harm Check lists get the dumb stuff out of the way, the routines your brain shouldnt have to occupy itself with…and lets it rise above to focus on the hard stuff. Check lists get the dumb stuff out of the way, the routines your brain shouldnt 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 cognitions They force us to retool our skills-based and rules- based cognitions so we can focus our effort on knowledge-based cognitions Gawande, Atul, The Checklist Manifesto. How To Get Things Right. New York: Henry Holt and Company, 2009

34 Surgery checklists could save lives, study reveals Tom Blackwell, National Post Published: Wednesday, January 14, 2009 Correcting the Error of Our Ways: Get the Dumb Stuff Out of the Way

35 Good checklists are Precise Precise Short Short Easy to use even in difficult situations Easy to use even in difficult situations Do not try to spell out everything Do not try to spell out everything Provide reminders of only the most critical and important steps Provide reminders of only the most critical and important steps Practical Practical Gawande, Atul, The Checklist Manifesto. How To Get Things Right. New York: Henry Holt and Company, 2009 Correcting the Error of Our Ways: Get the Dumb Stuff Out of the Way

36 Divide into three groups: managers, supervisors, line staff Divide into three groups: managers, supervisors, line staff Develop a good EBP checklist for a supervising officer to use before seeing an offender in the office? Develop a good EBP checklist for a supervising officer to use before seeing an offender in the office? Correcting the Error of Our Ways: Get the Dumb Stuff Out of the Way

37 World Health Organization Surgical Safety Checklist World Health Organization Surgical Safety Checklist Has the patient confirmed his/her identity, site, procedure, and consent? Has the patient confirmed his/her identity, site, procedure, and consent? Is the site marked? Is the site marked? Is the anesthesia machine and medication check complete? Is the anesthesia machine and medication check complete? Is the pulse oximeter on the patient and functioning? Is the pulse oximeter on the patient and functioning? Does the patient have a Does the patient have a Known allergy? Known allergy? Difficult airway or aspiration risk? Difficult airway or aspiration risk? Risk of >500ml blood loss (7ml/kg in children)? Risk of >500ml blood loss (7ml/kg in children)? Correcting the Error of Our Ways: Get the Dumb Stuff Out of the Way

38 Bad checklists are Vague and imprecise Vague and imprecise Too long Too long Hard to use Hard to use Impractical Impractical Made by desk jockeys with no awareness of situation in which they are to be deployed Made by desk jockeys with no awareness of situation in which they are to be deployed Gawande, Atul, The Checklist Manifesto. How To Get Things Right. New York: Henry Holt and Company, 2009 Correcting the Error of Our Ways: Get the Dumb Stuff Out of the Way

39 Checklist for Crime Scene Photographers Checklist for digital SLR camera Are 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 Correcting the Error of Our Ways: Get the Dumb Stuff Out of the Way

40 Taking our EBP medicine Taking our EBP medicine Reduces community harm and increases public safety Reduces community harm and increases public safety Challenges our brains to create new neural pathways, prevents brain atrophy, and may reduce risk of dementia or Alzheimers Challenges our brains to create new neural pathways, prevents brain atrophy, and may reduce risk of dementia or Alzheimers May help us lose and keep off weight by doing something different every day (we dont know why) May help us lose and keep off weight by doing something different every day (we dont know why) So why dont we take our EBP medicine and persist in eating the old hot dog? So why dont 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, So Why Dont We Take Our EBP Medicine?

41 Cross Your Arms--Again


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