Dr. El

McKnight’s Long-Term Care News frequently notes stories about rogue employees engaging in illegal and disturbing behavior and then trying to cover it up after the fact.

There are regular reports about intra-organizational systems that fail, leading to wrongful death lawsuits and other problems, such as this one about a resident who died from scabies.

Occasionally there’s an article about a whistleblower alerting the authorities about a questionable practice, resulting in repercussions for the company.

It’s very likely that there were employees who noticed that things were going awry before these stories became stories.

I know I’m not the only one who has observed that in some facilities, staff reports of potential problems are met with appreciation for the alert before rectifying the situation, while in other nursing homes, information is so often ignored that it is no longer reported. These vast differences in the culture and communication style of organizations directly impact health outcomes.

In a New York Times article last week, “A More Egalitarian Hospital Culture Is Better for Everyone,” author Pauline W. Chen, M.D. detailed efforts to alter interactions between hospital staff members, moving from an authoritarian style to a more egalitarian approach.

In authoritarian hospital cultures — those with a “do as I say” management strategy — nurses feel powerless to affect change. Patients fare worse in authoritarian environments than in egalitarian hospitals where nurses are regularly asked for input and senior management staff meet consistently with clinicians.

The article describes a program called Leadership Saves Lives, which created significant cultural changes in a relatively short time frame and improved clinical outcomes. The effort involved “guiding coalitions,” with the more successful coalitions having more diverse membership, including participants across departments as well as frontline, mid-level and top leadership and administrative staff.

Effective groups were able to elicit authentic contributions from members, who felt that their perspective was welcomed and valuable, and they found ways to handle conflict, fatigue and motivation over time.

While this particular study focused on hospitals, long-term care — with its similar interdisciplinary team approach and fragile population — might take note. Authoritarian, top-down communication makes it less likely that workers will notify supervisors about practices that could negatively affect the health of residents and could potentially lead to litigation and unfavorable press.

Teachable moments

While there’s a temptation to blame rogue workers for their mishandling of an event (and to feel relief that the situation happened elsewhere), we’d be better off viewing these events as teachable moments for any organization. A scabies death, a report of abusive staff behavior, or worker complaints about unethical billing practices across the industry could trigger self-reflection rather than relief.

Neglect or mistreatment of residents and false documentation might indicate an incomplete understanding of policies and procedures, a need for staff education about handling specific resident needs, staffing deficits or other factors.

Healthy organizations examine not only the factors that contributed to specific mishaps, but whether there were warning signs, whether and how they were communicated beforehand, and how those notified handled the information.

In “Teams, tribes and patient safety: overcoming barriers to effective teamwork in healthcare,” researchers recommend not only more democratic teams with a flattened hierarchy, but also suggest structured communication protocols and the use of a “step back” model where team leaders facilitate discussion among team members while they take an overview of a clinical or procedural situation.

In a complex healthcare system, there will always be adverse events, but strengthening communication between team members and between different levels within the organization can improve outcomes and reduce the likelihood of becoming front page news.

Eleanor Feldman Barbera, Ph.D., author of The Savvy Resident’s Guide, is an Award of Excellence winner in the Blog Content category of the APEX Awards for Publication Excellence program. She also is the Gold Medalist in the Blog-How To/Tips/Service category of the American Society of Business Publication Editors Midwest Regional competition. A speaker and consultant with over 20 years of experience as a psychologist in long-term care, she maintains her own award-winning website at MyBetterNursingHome.com.