The whole group agreed. That was amazing enough and this group never agreed on anything! But they did agree on this; that pecan pie was the best that any of them had ever tasted. How did Margie do it? Even if they did not like pecan pie, they loved her pie. Chewy, sweet but not over-the-top, crispy pecans on top, flaky crust on the bottom. That pie could right the wrongs of any dinner in a Mississippi minute!
As the senior member of the group, Elizabeth took it upon herself to request the coveted recipe. Ratcheting up her courage just a bit, Elizabeth moved in at just the right moment. Margie was alone near the sink. With the most profuse compliments attached to it, Elizabeth requested the prized recipe.
With feigned apologies, Margie assured Elizabeth that Margie’s dear Grandmother would roll over in her Kentucky grave if anyone ever shared the secret family pecan pie recipe. Margie gave that laugh — you know the one you give when it wasn’t really funny but you need to fill the awkward silence — and then walked into the living room, her and her secret recipe.
Some recipes are nothing less than sacred! They are to be safeguarded no matter the cost. I have one of those sacred recipes. I do, but I am about to break all the rules and share it with you now. This recipe has one extremely important secret ingredient. It is often overlooked and undersold, but it is THE KEY. Just before I tell you about that secret ingredient, let me share a slice of the finished product with you. After all, how do you know if you want the recipe if you never tasted the pie?
Recently, one of the hospitals which we support was successful reducing operation-related nuisance alerts from their Patient Security System (PSS). That turned out to be a huge understatement. Some of the categories of alerts caused by operational errors dropped by 90%. That is huge!
Because of an abundance of team miscues, hospital leadership became concerned about staff alert/alarm fatigue from their PSS. One of the hospital Vice Presidents brought this issue to the Nurse Managers. He called all of them to a meeting and invited one of the Trainers from IMS to meet with the leaders and answer questions on how to address the issues.
The team walked through the special monthly alarm report supplied by IMS and defined the various types of alarm types. They went on to pinpoint which type of alarms most urgently needed to be addressed. They then designed a plan with clear, specific action steps they would take to address those trouble spots. Finally, they would actively hold their staff accountable to carry out the action steps defined and correct the operational errors causing the alarms.
Over the next two months they regularly reminded staff of those simple action steps and held them accountable if they forgot or returned to old, more familiar ways. The results were outstanding! Check Tag Tightness alerts dropped a whopping 74% and Tag Loose alerts precipitously fell by 86% just by attaching and tightening the tag band better. Transport Expire alerts dropped an astounding 92% by simply finishing the process when a patient is transported somewhere. By focusing on eliminating these three alerts, this hospital purged 1,377 alerts a month. That is over 46 fewer alerts every single day. What an amazing turnaround!
Outstanding recipes usually have at least one “secret ingredient.” That special little something that delivers extra zing or an unexpected twist that makes your taste buds burst and your eyes pop; like a drop of lemon juice, a shake of cinnamon, or a splash of Worcestershire.
Now, it is important to remember here that those special ingredients are only a small part of the entire recipe. There are the common elements like flour or sugar or butter. Those regular items need to be used correctly otherwise the secret ingredient hardly matters.
The secret ingredient at this hospital is Leadership. I had heard it said that “everything rises and falls on leadership,” but I had never seen it flushed-out this clearly. The leaders took notice that the staff was struggling. They took time to define the problems and the solutions. They took action to educate and positively reinforce new behaviors by monitoring staff and keeping them accountable.
“People don’t do what you expect. They do what you inspect,” goes the old leadership adage. When leaders care enough to take time and energy to inspect work, the staff catches on and they begin to care, as well. I remember one Nurse Manager in particular; She stood up during my training session and said, “Ladies, please don’t be offended when, 30 minutes after you apply a tag, I stop by to check your work.” She understood leadership.
“Speed of the leader, speed of the team.” What matters to the leadership begins to matter to the staff.
Good leadership makes a positive difference and bad leadership can allow a team to slouch into mediocrity. When you as a leader take time, energy and steps to focus on reducing unnecessary alarms, your staff will begin to respond positively, your patients will be safer, and their stay will be more peaceful. Leadership is the key ingredient that turned this site from mediocre to blue-ribbon in just three months.
Your leadership does matter!