Transcript Getting Corrections Professionals to Take Their EBP Medicine

Getting Corrections
Professionals to Take Their
EBP Medicine
APPA Summer Institute
August 2010
Frank Domurad
The Carey Group, Inc.
[email protected]
GREEN WORKSHOP
For Handouts: send e-mail to
[email protected]
The Problem: Mrs.
Beauchaine’s Hot Dog
 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
 At 4th of July picnic, Mrs. Beauchaine ate a hot dog and
was back in hospital next day
 She 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 billion
Winslow, Ron and Jacob Goldstein, “Cutting Repeat Hospital Trips—Simple Idea,
Hard to Pull Off,” Wall Street Journal, July 28, 2009.
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?
Cross Your Arms
Medical Cost of Not Taking
Medicine
 In 2003, American Pharmacists
Association estimated that failure to take
medicine accounted for
 11-20% of all hospitalizations and repeat
doctor visits
 125,000 deaths each year
Hopfield, Jessica, Robert M. Linden and Bradley J. Trevelow, “Getting Patients to take their
medicine,” The McKinsey Quarterly, 2006
Medical Cost of Not Taking
Medicine
 National Pharmaceutical Council’s Task
Force for Compliance found that
 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%
Hopfield, Jessica, Robert M. Linden and Bradley J. Trevelow, “Getting Patients to take their
medicine,” The McKinsey Quarterly, 2006
Taking Medicine and Patient
Attitude
 McKinsey study of 811 hypertension patients
revealed that
 Hypertension affects 65 million Americans, half of
whom don’t adhere to their drug therapies
 The usual interventions—electronic reminders and
easy-to-open packaging—improve only short term
adherence
 A one-size fits all approach fails
 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
Patient Attitude and
Intervention
 “Concerned” patients are 47 to 64%
adherent
 Concerned about risks of high blood
pressure
 Worry about long-term risks of medications
 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
Patient Attitude and
Intervention
 “Confident” patients are 69 to 82%
adherent
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Rarely think of high blood pressure risks
Confident in ability to control health
No concerns about taking medicines
Less reliant on physicians
Intervention: respond to rewards programs
such as loyalty-type programs
Hopfield, Jessica, Robert M. Linden and Bradley J. Trevelow, “Getting Patients
to take their medicine,” The McKinsey Quarterly, 2006
Patient Attitude and
Intervention
 “Resigned” patients are 13 to 45%
adherent
 While afraid of high blood pressure, do not
manage health actively
 Too much trouble to live a healthy lifestyle
 Have no routine and careless about taking
medicine
 Intervention: provide simple reminder
devices
Hopfield, Jessica, Robert M. Linden and Bradley J. Trevelow, “Getting Patients
to take their medicine,” The McKinsey Quarterly, 2006
Danger of Attitudes
 S.U.V.s are more dangerous than cars
 They confer a sense of cognitive safety
that invites careless behavior
 SUV drivers are more likely to
 Not bother with seat belts
 Talk on cell phones or text
 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.
A Model 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
 Rule-based: solutions to familiar problems
governed by stored rules (“if x then y”)
 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)
A Model of Cognitive
Performance
 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 dependence on “expertise” consisting of
an extensive repertoire of schemata and
rules, with infrequent resort to knowledgebased functioning (reason)
Leape, Lucian L., “Error in Medicine,” Journal of the American Medical
Association, Vol. 272, No. 23 (December 21, 1994)
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
 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
 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)
Stress and Habits of Thought
 Stress produces a
 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
Leape, Lucian L., “Error in Medicine,” Journal of the American Medical
Association, Vol. 272, No. 23 (December 21, 1994)
The Error of Our Ways: The
Individual
 When professionals do not follow evidencebased 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)
 When they do make errors, they must have been
incompetent or negligent, or it was someone else’s
fault
 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)
The Error of Our Ways: The
System
 In any human system errors are inevitable
because of our cognitive structures
 Proximal causes are individual
 Root causes are systemic
 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
Leape, Lucian L., “Error in Medicine,” Journal of the American Medical
Association, Vol. 272, No. 23 (December 21, 1994)
The Error of Our Ways:
Root Causes
 Cannot prevent errors by focusing on “unsafe”
individual acts themselves
 Other “errors,” unpredictable and infinitely
variable, will occur if underlying causes are not
corrected
 Addressing root causes reduces probability, not
inevitability, of error
 The way in which humans think is a major root
cause of error
Leape, Lucian L., “Error in Medicine,” Journal of the American Medical
Association, Vol. 272, No. 23 (December 21, 1994)
What Are Common Line Staff
EBP “Errors”?
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 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
 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
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)
What Are Common
Supervisory EBP “Errors”?
The Error of Our Ways:
Wash Your Hands
 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
 Only 8.5% of medical students (future doctors)
washed hands after patient contact
 Recommendation: incorporate hand hygiene in
medical school curriculum
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)
What Are Common
Managerial EBP “Errors”?
The Error of Our Ways: The
Jerk Manager
 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
 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
Robert Sutton, “Building the Civilized Workplace,” The McKinsey Quarterly, May 2007
Correcting the Error of
Our Ways: A Five Step
Plan
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Off the Jerk Manager
Reinvent Tasks
Rebuild learning
Exploit hypocrisy
Get the dumb stuff out of the way
Correcting the Error of Our
Ways: Off the Jerk Manager
Firms that consistently make Fortune’s 100 Best Places to Work
List:
 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.”
 Barclay’s Capital
 COO Rich Ricci: “We have a no-jerk rule around here.
Hotshots who alienate colleagues are told to change or
leave.”
 Southwest Airlines
 Herb 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
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)
 Power of constraints should be exploited
“Forcing functions” should make it impossible to act without
meeting a precondition
 Standardize procedures thereby reinforcing the
pattern recognition that humans do well
 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
Correcting the Error of
Our Ways: Rebuild
Learning
 Bulk of our EBP learning focuses on
knowledge-based cognitive performance
 Ignores skill- and rule-based cognitive
performance (schemata and rules)
 Tends to believe that one type of
cognitive intervention fits all
 Creates cognitive situations that may
enhance rather than diminish “errors”
Correcting the Error of
Our Ways: Exploit
Hypocrisy
 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
 Humans care intensely how they are perceived and
don’t 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
Vedantam, Shankar, “Preach What You Plan To Practice,” The Washington
Post, January 6, 2009
Correcting the Error of
Our Ways: Exploit
Hypocrisy
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%)
 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
Correcting the Error of
Our Ways: Exploit
Hypocrisy
 Two caveats to using this technique
 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?
 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
Vedantam, Shankar, “Preach What You Plan To Practice,” The Washington
Post, January 6, 2009
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
 Simplicity leads to avoidance of error and prevents
harm
 Check 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 rulesbased 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
Correcting the Error of Our Ways:
Get the Dumb Stuff Out of the Way
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
Good checklists are
Precise
Short
Easy to use even in difficult situations
Do not try to spell out everything
Provide reminders of only the most critical
and important steps
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
 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?
Correcting the Error of Our Ways:
Get the Dumb Stuff Out of the Way
 World Health Organization Surgical Safety
Checklist
 Has 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 a
 Known allergy?
 Difficult airway or aspiration risk?
 Risk of >500ml blood loss (7ml/kg in children)?
<http://www.who.int/patientsafety/safesurgery/en>
Correcting the Error of Our Ways:
Get the Dumb Stuff Out of the Way
Bad checklists are
Vague and imprecise
Too long
Hard to use
Impractical
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
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
So Why Don’t We Take Our EBP
Medicine?
 Taking our EBP medicine
 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 Alzheimer’s
 May 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.
Cross Your Arms--Again