The Race to the Top of the Mountain

Remember the old joke about the two men who were racing to the top of the mountain and when they got there, a third man asked them what took them so long? The guy at the top has been a rabbi, a priest, a woman, and a host of other things, depending on the point the comedian was trying to make.

I feel like that joke just became real after reading this article. Nurses, doctors, and health care researchers clamoring to the top of the mountain as they discuss how to interpret data from interventions in health care settings, and realizing that the organizational scientists have been there for some time.

I couldn’t agree more with the conclusions drawn in the article. Randomization is a great tool, but it loses power in quasi-experimental settings. Field studies trade realism for control, and while the ecological validity of a field study is very valuable, extraneous variance due to internal validity violations is always problematic.

Organizational scientists are in a unique position to help those involved in RCTs with the identification and modeling of these variance sources, both in terms of measurement AND with respect to the meaning that they provide. For example, the article states that “changes in the skill and confidence of practitioners” was observed (Results section, first paragraph). Of course, this is not surprising from a human performance perspective, but it also constitutes a history effect, which is an internal validity concern. How are these concerns being addressed? Psychologists have many ways to do so, but how well have we applied these ideas to health care practice?

I encourage health care practitioners to seek out partnerships with organizational science. We can help each other make patient experiences in care of even higher quality.

Current Topics: March 3, 2015

Occasionally I will post some links to current topics on patient safety along with some comments. This is the first of those posts.

 

 

  • Leadership rounds are discussed in this brief piece. This is not a new idea – physically connect those with decision-making power with those who are immersed in the dynamic chaos of patient care. There are many psychological benefits to this in theory, but care should be taken when implementing. There are several cultural, structural and perceptual factors that could make leaders “on the floor” seem like prowling predators rather than helpful allies.
  • Minnesota hospitals report relatively stable numbers of adverse events and iatrogenic deaths. Monitoring our systems for adverse events that are connected to “marginally safe” behavior by employees is admirable. However, as I have explained in other posts, these “year-over-year” studies are no more than rough approximations of the system that generates them. Errors are not a static category or species, and adverse events are only defined after the fact.
  • Significant names in the PS world are arguing that our efforts need to be “rebooted.” This may sound surprising, but I argue that it is a normal phase in the development of a body of knowledge. Ultimately, “patient safety” is just “safety literacy”. Expertise in any area of knowledge requires consolidation and “pruning” from time to time, and it is encouraging to see that leading voices are admitting that.
  • Is the “safety logjam” breaking? This is an insightful piece that makes a number of important points, couched in a healthy substrate of realism. “Evidence” for whether health care is safer will be extremely hard to come by, because the definition of “safe” is so fuzzy. Are airplanes safer to fly in now than 50 years ago? Yes, statistically. But the “why” of that statistic is fertile ground for what organizational psychologists call garbage can behavior – using an opaque issue to attach personal agendas that are primarily self-beneficial. Sometimes the answer is simple – safety is now valued more than it was. That alone will make a difference.

Please comment or contact me if you would like to discuss any of these points.

Bullies

In my discipline (organizational psychology), we have studied for some time the issue of “counterproductive work behaviors.” These are activities that employees generate for the purposes of harming the organization in some way. Typical examples might include theft, sabotage or abuse of breaks and lunch hours, but in other forms of the phenomenon another employee might be the target of the counterproductive behavior. Organizations often act as breeding grounds for individuals to use social power against one another in order to enhance or preserve their own statuses, and those who do not enjoy structural power in the organization may find themselves suffering at the hands of those that do.

The attached article addresses what the authors call “bullying”, which appears to be a new organizing label attached to behaviors that have been discussed in patient safety for some time. Nurses have long reported that doctors treat them poorly, pharmacists have long complained of marginalization, and administrators have long been vulnerable to perceptions among employees of mistrust, aloofness, and arbitrariness in punishments. Remedies are suggested, such as improving communication skills, decision making, and advocating for collaboration. Leadership and staffing are also identified as factors that contribute to “bullying.”

However, there are many nuances to how power differentials play out in organizations that are not addressed. For example, “bullies” in organizations are often not out to harm anyone, but to preserve  their own position and self-perception. Have hospitals considered what structural and cultural norms are in place to encourage those with power to be so hesitant and fearful about sharing it? Teaching the appropriate skills is a wonderful idea, but skills are just tools that one has to be motivated to use.

Hope you enjoy the article, and comments are welcome.