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1 ©2008 The Bedside Project LLC The TRUST Cycle:5 Fundamentals to Control Your Collective Destiny Brian Wong, M.D., C.C.H.O. www.mybedsideproject.com.

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Presentation on theme: "1 ©2008 The Bedside Project LLC The TRUST Cycle:5 Fundamentals to Control Your Collective Destiny Brian Wong, M.D., C.C.H.O. www.mybedsideproject.com."— Presentation transcript:

1 1 ©2008 The Bedside Project LLC The TRUST Cycle:5 Fundamentals to Control Your Collective Destiny Brian Wong, M.D., C.C.H.O.

2 2 ©2008 The Bedside Project LLC Limited License for The TRUST Cycle: Permission is granted from The Bedside Project to all September 2008 Inaugural Collaborative Participants to use any and all exercises contained in this syllabus, provided: 1. They are solely for your INTERNAL use 2. You share your results with other members of this Collaborative (including The Bedside Projects website) 3. You neither re-package nor re-sell this patent pending intellectual property for your own financial gain.

3 3 ©2008 The Bedside Project LLC T. R. U. S. T. E. D. The Wind Chill Factor the influence of red over green is up to 4:1

4 4 ©2008 The Bedside Project LLC T. R. U. S. T. E. D. Get the Red Out

5 5 ©2008 The Bedside Project LLC You dont need to move EVERY physician Magic Number for most = 20 (and as few as 5)

6 6 ©2008 The Bedside Project LLC The TRUST Cycle – The Cure Common Ground Have the conversations we need to have, the way we need to have them Diagnose, THEN treat T.R.U.S.T.E.D.

7 7 ©2008 The Bedside Project LLC The conversation is the relationship… the relationship is the conversation Susan Scott Fierce Conversations

8 8 ©2008 The Bedside Project LLC Relationships succeed or fail… one conversation at a time see one, do one, teach one the way we were

9 9 ©2008 The Bedside Project LLC Having the conversations we need to have, the way we need to have them. Crucial Conversations By Patterson, Grenny, McMillan & Switzler

10 10 ©2008 The Bedside Project LLC 3 reasons why I like Crucial Conversations 1. The physiology of poor conversations 2. The link to graffiti and the Universal Attributes 3. The Dialogue Model one simple diagram

11 11 ©2008 The Bedside Project LLC SILENCE VIOLENCE WITHDRAWING AVOIDING MASKING LABELLING ATTACKING CONTROLLING SAFETY Our Pool Of Shared Meaning The Dialogue Model, page 183 Patterson, K. et al, Crucial Conversations MEOTHER

12 12 ©2008 The Bedside Project LLC SILENCE VIOLENCE WITHDRAWING AVOIDING MASKING LABELLING ATTACKING CONTROLLING SAFETY Our Pool Of Shared Meaning The Dialogue Model, page 183 Patterson, K. et al, Crucial Conversations MEOTHER

13 13 ©2008 The Bedside Project LLC WITHDRAWING AVOIDING MASKING LABELLING ATTACKING CONTROLLING PERSONAL SAFETY Our Pool Of Shared Meaning From Crucial Conversations to… safe conversations ME (Universal Attributes) Other (Universal Attributes) Best place to practice, work & get care Graffiti SILENCE Flight VIOLENCE Fight Rigid/Inflexible Poor listener Disrespectful Arrogant Intimidating Threatening Judgmental Unforgiving Rigid/Inflexible Poor listener Disrespectful Arrogant Intimidating Threatening Judgmental Unforgiving Universal Attributes T. = Team player R. = Responsive/respectful U. = Understanding S. = Safe T. = Talent E. = Execution D. = Dedication Bring out my/our best Universal Attributes Team player = T. Responsive/respectful = R. Understanding = U. Safe = S. Talent = T. Execution =E. Dedication = D. Bring out my/our best

14 14 ©2008 The Bedside Project LLC Exercise #5: Practice with UN-Safe Conversations the way we were

15 15 ©2008 The Bedside Project LLC Consider this universal situation, Part I Dr. Black is Mr. Greenbottoms regular physician Mr. Greenbottom is referred to the ED at 5 pm Friday afternoon by Dr. Blacks nurse. The office is closing and Dr. Black has just signed out for the weekend. Mr. Greenbottom has congestive heart failure, diabetes, and peripheral vascular disease. His leg hurts and is cold and dusky. Dr. White is the primary care physician on call for Dr. Black; Dr. Gray is on call for vascular surgery until 6 pm; Dr. Silver comes on call at 6 pm. Dr. Gold is the hospitalist on call until 6 pm; Dr. Bronze comes on call at 6 pm. After an evaluation by Dr. Ruby, the emergency physician, a call is placed to secure admission and care for Mr. Greenbottom. The time is 5:45 pm.

16 16 ©2008 The Bedside Project LLC Exercise #11: universal situation, Part I Form groups of 4-6 people: Role #1: 2 of you are role-playing the ER physician Role #2: 2 of you are the doctor who has been called Both of you are slammed Imagine for a minute this is a conversation that does not go well (e.g. it is laden with your personal graffiti) Role-play the conversation; you have up to 2 minutes Play it to the hilt

17 17 ©2008 The Bedside Project LLC Consider this universal situation, Part I Dr. Black is Mr. Greenbottoms regular physician Mr. Greenbottom is referred to the ED at 5 pm Friday afternoon by Dr. Blacks nurse. The office is closing and Dr. Black has just signed out for the weekend. Mr. Greenbottom has congestive heart failure, diabetes, and peripheral vascular disease. His leg hurts and is cold and dusky. Dr. White is the primary care physician on call for Dr. Black; Dr. Gray is on call for vascular surgery until 6 pm; Dr. Silver comes on call at 6 pm. Dr. Gold is the hospitalist on call until 6 pm; Dr. Bronze comes on call at 6 pm. After an evaluation by Dr. Ruby, the emergency physician, a call is placed to secure admission and care for Mr. Greenbottom. The time is 5:45 pm.

18 18 ©2008 The Bedside Project LLC Discussion 1. Was it real? 2. How did it feel? 3. Were we on one team, or two tribes? 4. Did we give and get respect? 5. Did we listen to understand our counterpart? 6. Did we make it safe for each other? 7. Were we building TRUST with each other? 8. Was it productive or efficient? 9. Were we innovative or creative? 10. Did we help solve the problem?

19 19 ©2008 The Bedside Project LLC Exercise #6: Practice with Safe Conversations Now, lets go to the movies!

20 20 ©2008 The Bedside Project LLC Scene set up: Wednesday morning, July 1, 1863 About 25 miles south of Gettysburg, PA Col. Joshua Chamberlain, of the 20 th Maine Regiment has been ordered to receive the 2 nd Maine Regiment These 120 men mistakenly signed 3 year papers and were told they had one more year to serve Rather than fight, all 120 have decided to disengage As Col. Chamberlain receives this group of men, he is authorized to use whatever force necessary to keep them in line; including shooting them We will pause the movie at each of 5 different moments of truth Now, lets watch…

21 21 ©2008 The Bedside Project LLC Worksheet for 5 Moments of Truth from Gettysburg Obnoxious response (Graffiti) Stimulus or Moment of Truth Healthy response (T.R.U.S.T.E.D.)

22 22 ©2008 The Bedside Project LLC Worksheet for 5 Moments of Truth from Gettysburg Obnoxious response (Graffiti) Stimulus or Moment of Truth Healthy response (T.R.U.S.T.E.D.) I just have to shoot ONE of them. 1. you want to shoot them, go right ahead BANG dont we all get in line 2. Colonel, weve got grievances None of your business Ill be asking the questions here 3. how many engagements have you been in? Were DONE.4. the courier, sir Im not going to… YOU are. 5. you cant shoot them, youll never go back to Maine if you do

23 23 ©2008 The Bedside Project LLC Worksheet for 5 Moments of Truth from Gettysburg Obnoxious response (Graffiti) Stimulus or Moment of Truth Healthy response (T.R.U.S.T.E.D.) I just have to shoot ONE of them. 1. you want to shoot them, go right ahead That wont be necessary. I said, You are relieved. BANG dont we all get in line 2. Colonel, weve got grievances Go eat first, then Ill come listen to you. Fine, come along with me. None of your business Ill be asking the questions here 3. how many engagements have you been in? We sure could use men with a lot of experience. Not that many. Were DONE.4. the courier, sir Please tell the courier to wait until Im finished here. Dont go away. Im not going to… YOU are. 5. you cant shoot them, youll never go back to Maine if you do Im not going to. I know that, I wonder if they do.

24 24 ©2008 The Bedside Project LLC Exercise #7: Moment of Truth #6: now what do I say to them? Take out a piece of paper As an individual, jot down a few key things you would do or say to a group of mutineers in order to re-engage them and pick up the rifle Share this with your table Arrive at a table consensus for one or two key points you would do or say together Report back in 5 minutes

25 25 ©2008 The Bedside Project LLC Report back: Now what do I say to them? Show them respect Hear their grievances Common goals Nobodys shooting anybody We need you Why did they join in the first place Were all from Maine; we dont quit; give them a purpose Bond against the south Stay focused on the big picture Provide perspective and context If we dont do this, someone will do this for us

26 26 ©2008 The Bedside Project LLC Moment of Truth #6: now what do I say to them? ONE team (America is free ground; in the end, were fighting for each other) 2-way communication (listen AND give them information) We all have VALUE… you and me. Set the boundaries AND the consequences (you can have your muskets back; you have a choice; nothing more will be said) Make it safe (dismiss the guards, feed them, listen) Make it personal (Ill personally be very grateful) Give them space (walk away; let them talk) T. R. U. S.

27 27 ©2008 The Bedside Project LLC Lets rewind the tape… The concept of a Mulligan Can I have a do-over?

28 28 ©2008 The Bedside Project LLC Exercise #8b: Practice with "Safe Conversations" Form groups of 4: Role #1: 2 of you are role-playing the ED physician Role #2: 2 of you are the doctor who has been called Both of you are slammed Imagine for a minute that between stimulus and response the ED physician chooses a different response (i.e. one pair becomes a T.R.U.S.T.E.D. Colleague) The other group will resist but will not be impossible; they can change, if they hear what they need to hear Role-play the conversation; you have up to 2 minutes Play it to the hilt

29 29 ©2008 The Bedside Project LLC Consider this universal situation, Part II Dr. Black is Mr. Greenbottoms regular physician Mr. Greenbottom is referred to the ED at 5 pm Friday afternoon by Dr. Blacks nurse. The office is closing and Dr. Black has just signed out for the weekend. Mr. Greenbottom has congestive heart failure, diabetes, and peripheral vascular disease. His leg hurts and is cold and dusky. Dr. White is the primary care physician on call for Dr. Black; Dr. Gray is on call for vascular surgery until 6 pm; Dr. Silver comes on call at 6 pm. Dr. Gold is the hospitalist on call until 6 pm; Dr. Bronze comes on call at 6 pm. After an evaluation by Dr. Ruby, the emergency physician, a call is placed to secure admission and care for Mr. Greenbottom. The time is 5:45 pm.

30 30 ©2008 The Bedside Project LLC Discussion 1. Was it real? 2. How did it feel? 3. Were we on one team, or two tribes? 4. Did we give and get respect? 5. Did we listen to understand our counterpart? 6. Did we make it safe for each other? 7. Were we building TRUST with each other? 8. Was it productive or efficient? 9. Were we innovative or creative? 10. Did we help solve the problem?

31 31 ©2008 The Bedside Project LLC Exercise #10: Creating a script for my own conversation Mulligans Complete the grid on the following page as an individual In groups of 3, practice one of your Mulligans with each other in the following roles: Person A: sender (selects the topic) Person B: receiver Person C: observer of the conversation Start by being a receiver of your own message first (role reversal) Then send your message back (as intended) Observers, please provide some quick feedback to your partners each time Continue the sequence until everyone at your table has been a sender, a receiver and an observer at least once

32 32 ©2008 The Bedside Project LLC Mulligans for Our Difficult Conversations & Relationships: Between stimulus and response we have a choice… Unsafe response Graffiti (what Ive said or done in the past that didnt work) Stimulus or Moment of Truth (what others have said or done to me in the past) Safe response (T.R.U.S.T.E.D) (what I can say or do differently in the future)

33 33 ©2008 The Bedside Project LLC Exercise #10 debrief and discussion

34 34 ©2008 The Bedside Project LLC Fierce Conversations often do take time. The problem is, anything else takes longer. The value of a Mulligan

35 35 ©2008 The Bedside Project LLC The TRUST Cycle – The Cure Common Ground Have the conversations we need to have, the way we need to have them Diagnose, THEN treat T.R.U.S.T.E.D.

36 36 ©2008 The Bedside Project LLC Using The TRUST Cycle to address the ED Call Coverage problem NEW Section

37 37 ©2008 The Bedside Project LLC The Five Blind Men and the Elephant Physicians Pharmacists Nurses Board Members Executives

38 38 ©2008 The Bedside Project LLC something important to everybody is better than the biggest thing from the loudest voice

39 39 ©2008 The Bedside Project LLC Example of prioritization: the barriers that drive us crazy in throughput Scheduling of patients (for appointments, procedures and direct admissions) Unnecessary delays in the OR Lack of the information needed in the ER If Id known that I would have done something completely different Pushback from staff (we cant take that patient) Bed availability Delays in discharge

40 40 ©2008 The Bedside Project LLC Parrish PI Example #1 (September 2007): Reduce waiting time on direct admissions from doctors offices to the hospital: Baseline data: average door to floor time = 36 minutes 4 physicians actively involved After 60 days: average door to floor time = 4 minutes (including transport time and waiting for the elevator)

41 41 ©2008 The Bedside Project LLC But wait… theres more… When we dont trust each other… We avoid contact with each other… We do it ourselves in order to avoid working with others We work around the problems in front of us We dont care if our work around creates problems for someone else But we get furious, when somebody elses work around creates problems for us Which is why we couldnt trust them, in the first place And the cycle repeats itself AND GROWS

42 42 ©2008 The Bedside Project LLC 4 types of workarounds 1. People avoidance: working to avoid people 2. Task avoidance: working NOT to work 3. Situation avoidance: working to avoid situations 4. Individual heroism:forget it, just give it to ME 5. Some or ALL OF THE ABOVE

43 43 ©2008 The Bedside Project LLC Report back: MY (OUR) workarounds (done 8/7/08; Skagit Valley Hospital) Do it myself Use of in place of crucial conversations Go to the person who will help us Not with the ones who need to be involved Ignore it and it will go away Doing it faster (rushing through it) Complaining from the sidelines (esp. when Im a stakeholder) Purchasing technology to fix flawed processes

44 44 ©2008 The Bedside Project LLC Even the most perfect process can be undone by one simple workaround Safe conversations, followed by process improvement

45 45 ©2008 The Bedside Project LLC Processes Workarounds Workarounds Dominate "Good" Processes Dominate Universal Attributes Dominate Personal Graffiti Dominates + Workarounds + Universal Attributes + Good Processes + Universal Attributes + Workarounds + Personal Graffiti + Good Processes + Personal Graffiti Good Processes Must REPLACE Workarounds (as Universal Attributes Must REPLACE Personal Graffiti)

46 46 ©2008 The Bedside Project LLC The TRUST Cycle Common Ground Have the conversations we need to have, the way we need to have them Diagnose, THEN treat T.R.U.S.T.E.D. see one, do one, teach one Over and over again…

47 47 ©2008 The Bedside Project LLC The Universal Attributes T.= Team player (make others better) R.= Responsive and respectful U.= Understanding (listen & learn w/o judgment) S.= Safe (easy to approach; I invite other opinions) T.= Talent (skill, knowledge, judgment, proficiency) E.= Execution (get things done; get results) D.= Dedication and devotion (work ethic) I pledge to become a T.R.U.S.T.E.D. Colleague; every conversation, every time, with everybody; to the very best of my ability; and to be open to feedback, (positive and corrective); from any of my peers and colleagues; …beginning today. The Oath of The Healer

48 48 ©2008 The Bedside Project LLC The TRUST Cycle:5 Fundamentals to control your collective destiny Brian Wong, M.D., C.C.H.O.


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