The TRUST Cycle™: “5 Fundamentals to Control Your Collective Destiny” Brian Wong, M.D., C.C.H.O. www.mybedsideproject.com Let’s start with the title… TRUST really IS everything. I will establish that mistrust is the root cause of all of our problems in healthcare and that trust is the only enduring, comprehensive solution Most healthcare professionals (especially doctors and nurses, but also including therapists, social workers, pharmacists, other staff and those who choose administration) choose healthcare as a career to help people… to help them get better… to actually save lives… this presentation will establish that in order to help those in healthcare save more lives, it will be necessary for each of us to change our own lives… our own way of thinking, our own responses to the environment, our very own attitudes, behaviors and conversations… if successful, we can save even more lives (including avoiding preventable harm)… and these techniques work from “bedside to board room” Yes, I agree, that changing lives is a TALL ORDER… yet, the best feedback I have gotten from my best presentations have been when audience members come up to me and thank me for “changing their lives”… it happens to about 2-5 people each time… my goal is to intentionally increase that percentage each time I do this CCHO stands for: Chief Cat Herding Officer; leading physicians has been likened to herding cats… I then show a video clip of cowboys herding cats ©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: They are solely for your INTERNAL use You share your results with other members of this Collaborative (including The Bedside Project’s website) You neither re-package nor re-sell this patent pending intellectual property for your own financial gain. ©2008 The Bedside Project LLC

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

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

“You don’t need to move EVERY physician” “Magic Number” for most = 20 (and as few as 5) ©2008 The Bedside Project LLC

The TRUST Cycle – “The Cure” “Have the conversations we need to have, the way we need to have them” “Common Ground” The TRUST Cycle was originally inspired by The Water Cycle… something from 5th grade science class…. Simple, timeless, classic, immutable and powerful. A simple cycle for a “renewable natural resource”… sustaining not just human life, but all life on our planet… Evaporation, condensation, precipitation and run-off… no one part more important than another… all occurring in balance and in sequence globally We see Trust as a “renewable natural resource” in healthcare… capable of regenerating itself and sustaining everyone in it It begins with the acronym T.R.U.S.T. which I will explain in a moment… this is foundational to the other 3 which follow in sequence: establishing common ground, conversational capacity (especially having robust conversations with the utmost personal safety) and “seeing the whole elephant” (Diagnose, then treat).. If we can understand and master this simple cycle, any healthcare organization can create and increase trust locally… and we believe this can be done on a much broader scale across the country… to the greatest benefit to our patients, our professional fulfillment and our organizational performance “Diagnose, THEN treat” “T.R.U.S.T.E.D.” ©2008 The Bedside Project LLC

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

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

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

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

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

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

From “Crucial Conversations” to… “safe conversations” “Flight” Rigid/Inflexible Poor listener Disrespectful Arrogant Intimidating Threatening Judgmental Unforgiving SILENCE Rigid/Inflexible Poor listener Disrespectful Arrogant Intimidating Threatening Judgmental Unforgiving WITHDRAWING AVOIDING MASKING “Graffiti” ME (“Universal Attributes”) PERSONAL SAFETY Other (“Universal Attributes”) Our Pool Of Shared Meaning Best place to practice, work & get care “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 LABELLING ATTACKING CONTROLLING “Graffiti” VIOLENCE “Fight” ©2008 The Bedside Project LLC

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

Consider this “universal situation,” Part I Dr. Black is Mr. Greenbottom’s regular physician Mr. Greenbottom is referred to the ED at 5 pm Friday afternoon by Dr. Black’s 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. ©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” ©2008 The Bedside Project LLC

Consider this “universal situation,” Part I Dr. Black is Mr. Greenbottom’s regular physician Mr. Greenbottom is referred to the ED at 5 pm Friday afternoon by Dr. Black’s 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. ©2008 The Bedside Project LLC

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

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

©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 20th Maine Regiment has been ordered to receive the 2nd 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, let’s watch… ©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.”) 1. 2. 3. 4. 5. ©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” “don’t we all” “get in line” 2. “Colonel, we’ve got grievances” “None of your business” “I’ll be asking the questions here” 3. “how many engagements have you been in?” “We’re DONE.” 4. “the courier, sir” “I’m not going to… YOU are.” 5. “you can’t shoot them, you’ll never go back to Maine if you do” ©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 won’t be necessary.” “I said, ‘You are relieved.’” “BANG” “don’t we all” “get in line” 2. “Colonel, we’ve got grievances” “Go eat first, then I’ll come listen to you.” “Fine, come along with me.” “None of your business” “I’ll 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.” “We’re DONE.” 4. “the courier, sir” “Please tell the courier to wait until I’m finished here.” “Don’t go away.” “I’m not going to… YOU are.” 5. “you can’t shoot them, you’ll never go back to Maine if you do” “I’m not going to.” “I know that, I wonder if they do.” ©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 ©2008 The Bedside Project LLC

Report back: “Now what do I say to them?” Show them respect Hear their grievances Common goals Nobody’s shooting anybody We need you Why did they join in the first place We’re all from Maine; we don’t quit; give them a purpose Bond against the south Stay focused on the big picture Provide perspective and context If we don’t do this, someone will do this for us ©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, we’re 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 (I’ll personally be very grateful) Give them space (walk away; let them talk) T. R. U. S. ©2008 The Bedside Project LLC

The concept of a “Mulligan” “Can I have a do-over?” Let’s rewind the tape… The concept of a “Mulligan” “Can I have a do-over?” ©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” ©2008 The Bedside Project LLC

Consider this universal situation, Part II Dr. Black is Mr. Greenbottom’s regular physician Mr. Greenbottom is referred to the ED at 5 pm Friday afternoon by Dr. Black’s 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. ©2008 The Bedside Project LLC

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

“Mulligans” for Our Difficult Conversations & Relationships: “Between stimulus and response we have a choice…” “Unsafe” response “Graffiti” (what I’ve said or done in the past that didn’t 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) 1. 2. 3. ©2008 The Bedside Project LLC

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

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

The TRUST Cycle – “The Cure” “Have the conversations we need to have, the way we need to have them” “Common Ground” The TRUST Cycle was originally inspired by The Water Cycle… something from 5th grade science class…. Simple, timeless, classic, immutable and powerful. A simple cycle for a “renewable natural resource”… sustaining not just human life, but all life on our planet… Evaporation, condensation, precipitation and run-off… no one part more important than another… all occurring in balance and in sequence globally We see Trust as a “renewable natural resource” in healthcare… capable of regenerating itself and sustaining everyone in it It begins with the acronym T.R.U.S.T. which I will explain in a moment… this is foundational to the other 3 which follow in sequence: establishing common ground, conversational capacity (especially having robust conversations with the utmost personal safety) and “seeing the whole elephant” (Diagnose, then treat).. If we can understand and master this simple cycle, any healthcare organization can create and increase trust locally… and we believe this can be done on a much broader scale across the country… to the greatest benefit to our patients, our professional fulfillment and our organizational performance “Diagnose, THEN treat” “T.R.U.S.T.E.D.” ©2008 The Bedside Project LLC

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

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

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

©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 I’d known that I would have done something completely different Pushback from staff (“we can’t take that patient”) Bed availability Delays in discharge ©2008 The Bedside Project LLC

Parrish PI Example #1 (September 2007): Reduce waiting time on direct admissions from doctor’s 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) ©2008 The Bedside Project LLC

But wait… there’s more… When we don’t 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 don’t care if our “work around” creates problems for someone else But we get furious, when somebody else’s “work around” creates problems for us Which is why we couldn’t trust them, in the first place And the cycle repeats itself AND GROWS ©2008 The Bedside Project LLC

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

©2008 The Bedside Project LLC Report back: MY (OUR) workarounds (done 8/7/08; Skagit Valley Hospital) Do it myself Use of E-mail 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 I’m a stakeholder) Purchasing technology to fix flawed processes ©2008 The Bedside Project LLC

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

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

The TRUST Cycle™ “see one, do one, teach one” “Have the conversations we need to have, the way we need to have them” “see one, do one, teach one” Over and over again… “Common Ground” The TRUST Cycle was originally inspired by The Water Cycle… something from 5th grade science class…. Simple, timeless, classic, immutable and powerful. A simple cycle for a “renewable natural resource”… sustaining not just human life, but all life on our planet… Evaporation, condensation, precipitation and run-off… no one part more important than another… all occurring in balance and in sequence globally We see Trust as a “renewable natural resource” in healthcare… capable of regenerating itself and sustaining everyone in it It begins with the acronym T.R.U.S.T. which I will explain in a moment… this is foundational to the other 3 which follow in sequence: establishing common ground, conversational capacity (especially having robust conversations with the utmost personal safety) and “seeing the whole elephant” (Diagnose, then treat).. If we can understand and master this simple cycle, any healthcare organization can create and increase trust locally… and we believe this can be done on a much broader scale across the country… to the greatest benefit to our patients, our professional fulfillment and our organizational performance “Diagnose, THEN treat” “T.R.U.S.T.E.D.” ©2008 The Bedside Project LLC

The Universal Attributes “The Oath of The Healer” 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. ©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 Let’s start with the title… TRUST really IS everything. I will establish that mistrust is the root cause of all of our problems in healthcare and that trust is the only enduring, comprehensive solution Most healthcare professionals (especially doctors and nurses, but also including therapists, social workers, pharmacists, other staff and those who choose administration) choose healthcare as a career to help people… to help them get better… to actually save lives… this presentation will establish that in order to help those in healthcare save more lives, it will be necessary for each of us to change our own lives… our own way of thinking, our own responses to the environment, our very own attitudes, behaviors and conversations… if successful, we can save even more lives (including avoiding preventable harm)… and these techniques work from “bedside to board room” Yes, I agree, that changing lives is a TALL ORDER… yet, the best feedback I have gotten from my best presentations have been when audience members come up to me and thank me for “changing their lives”… it happens to about 2-5 people each time… my goal is to intentionally increase that percentage each time I do this CCHO stands for: Chief Cat Herding Officer; leading physicians has been likened to herding cats… I then show a video clip of cowboys herding cats ©2008 The Bedside Project LLC