PowerPoint, Keep it Simple

PowerPoint is an essential ingredient for many presentations. Remembering it is an ingredient and not the whole meal can be the key to successful communication. We communicate to transfer ideas, an overly complicated PowerPoint diverts attention from the presenter to the medium and reduces knowledge transfer. When it comes to PowerPoint, less is more.

Keeping It Simple:

• Pick a simple format and stick with it
• Use no more than four to seven lines per slide
• Simplify the wording of each line
• Reduce lines of text when including images
• Rarely use animation, it usually distracts the audience
• Rarely use sound, sound as well can distract the audience

Your audience can read text on the slide, you do not need to read it to them. Your verbal presentation should amplify each slide’s context adding depth and understanding.

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Blue Flag Iris (iris versicolor)

Just north of Stevens Point, Wisconsin, is the Dewey Marsh, home of mosquitoes and blue flag iris. Some consider the mosquitoe as our state bird, but most will list this iris as one of their favorite wildflowers.  Relatively common along our marshy water ways, it blooms in early summer.  

This image was obtained in the Dewey Marsh and is an HDR composed of 4 different images obtained using an off camera flash. The flash unit was moved between each image in an effort to illuminate most of the iris. The flash was brought closer to the left on the last image to provide highlight.

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Addressing the Medical Staff - Disruptive Behavior

In previous posts, I have presented an interview with one of our administrative clinicians outlining how he deals with disruptive behavior and the Principles of Partnership we have with Ministry Health Care clinicians. We also must deal with this issue at our hospitals, most of which have independent physicians.  Regardless of the setting, we have to establish the baseline for acceptable behavior. One of our hospital medical staffs formed a Respect Committee that then interviewed a number of individuals.  The interviews uncovered numerous examples of respectful behavior and a few examples showing disrespect.  The Committee then produced a PowerPoint presentation that has served as a cornerstone establishing respectful behavior.  The basic contents of the PowerPoint is listed below. Examples of respectful and disrespectful behavior has proven to be helpful on many occassions.

 

Ministry Health Care:  Values Behavior

• Treating Others with such a sincere regard that each person  feels important and worthwhile
• Recognizes others for their achievements and capabilities
• Provides honest, non-judgmental feedback to others
• Creates an environment where frustrations and concerns can be expressed without fear of repercussion    

 

Ministry Medical Group Professional Practice Standards

• We believe each patient, customer and staff member is important.  …. we strive to treat each person in a respectful nature that honors his or her importance and worth.

 

Cultural Assessment Questionnaire:

• Ministry-wide and local norms 
  • Physicians in this organization treat other staff members with respect
  • Employees Treat Each Other with Respect

 

What Additional Data Did We Want to Gather?

• Are there recognizable characteristics of “Best Practices”?
• Are there characteristics of the opposite?
• What makes staff feel that they are respected?
• What makes staff feel that they are disrespected?
• Can we show improvement in staff perception of respect over time?
• Can we change behaviors to achieve this end?

 

Respect Committee Intentions

• This is NOT a disciplinary committee
• Emphasize the POSITIVE, the IMPROVEMENT
• To be EDUCATIONAL, not punitive
• To provide TOOLS for the Medical Staff  and MMG Clinic Divisional Chairs to  improve RESPECT
• To EDUCATE all employees regarding respect issues and holding ALL WHO WORK here to the same standards
• Try to learn something about SUCCESSFUL physician/nurse and physician/employee relationships that can benefit all.

 

WHY

• IT HAS DIRECT CONSEQUENCES AFFECTING PATIENT CARE

Intimidating and verbally abusing nurses and pharmacists may lead to patient harm:  Institute for Safe Medication Practices (ISMP) Survey of Nurses and Pharmacists

• 7% involved in medication error where intimidation played a role
• 49% said history of intimidation altered the way they asked for clarification of medication orders
• 40% said at least once in past year a concern was overlooked in order to avoid confrontation

Types of Behavior :

•     Condescending language 21%
•     Impatience 19%
•     Verbal Abuse 48%
•     Threatening body language 43%

 

AMA News: Sept 2004

• Staff Less Tolerant of Rude Doctors            
• Survey of Physician Executives :
  •      One physician can taint the culture of the unit
  •      83%  problems with physician behavior involve disrespect
  •      50%  problems only reported when doctor completely out of line and serious violation occurs
  •      95%  met with disruptive physician in last two years
  •      40% said physicians who generate high amount of revenue are treated more leniently than doctors who bring in less revenue    OUCH !

 

What We Did

• Focus groups were interviewed  with representatives from Clinic and Hospital  departments with high and low respect scores. Included  nursing and  clinical staff,  administrative, and non-clinical employees.
  • Confidential
  • Qualitative
  • Individual Responses                                   
  • Highlight the most pressing and prevalent problems

 

Questions Asked

• What are some examples of times you felt very respected by physicians?  What specific behaviors caused you to feel this way?
• In general, is this behavior on the part of most or all physicians? Or is it more specific to a minority of them-but a minority who have a significant impact on others?
• What are some examples of times you felt you were not respected by a physician? What specific behaviors caused you to feel this way?
• In general, is this behavior on the part of most or all physicians? Or is it more specific to a minority of them-but a minority who have significant impact on others?
• What physician/employee situations have you heard of?
• How many times have you heard about situations versus times you actually experienced them?
• How frequently does this behavior occur?

 

Sample of Comments Regarding Positive Respect  

• MAJORITY of physicians
• Has IMPROVED over couple years
• HOSPITALIST program has decreased call issue complaints and a change for the better, hospitalists working together
• LISTENING and taking  suggestions.                                      
• INCLUDING nurses as part of a team by discussing plan of care and asking for input
• ACKNOWLEDGE skill level, opinion and judgment
• RECOGNITION for good patient care
• THANKING YOU  for asking questions, bringing patient concerns to the attention of the physician
• APOLOGIZING  when a mistake has been made
• Basic MANNERS…thank you, acknowledgement in hallways even if just say “hi”, using pleasant voice, eye contact
• ASKING rather than telling
• Creating a learning environment
• There are no “dumb” questions, no belittlement
• Performance is improved by physicians who teach
• Errors are handled non-judgmentally
• Physicians act upon being called
• Compliments in front of others and patients
• Positive outweighs the negative

Sample of Comments Regarding Disrespect

• Minority, some departments
• Dismisses what you (staff) are doing
• Expecting problem to be immediately fixed
• Complaints about other departments/doctors
• Belittling in front of patients or peers
• Inappropriate comments about other physicians to patients
• Not dealing directly with the issue
• Yelling, hanging up phone
• Taking out frustration on wrong people
• Using sarcasm or intimidation
• Requests to move patients to other areas without discussing reason
• Unavailable, not answering page
• Personal things taking precedence of work related duties
• Being told not to call for certain reasons by on-call physicians and reprimand for calling
• Unapproachable, avoid connecting
• Being asked to lie/give excuses when physician is scheduled to be in two places at once
• Taking out anger on staff for being awoke or called while on call
• Criticizing staff for not being as prepared or skilled as another unit
• Poor communication of treatment plan
• Physician behavior differs between hospital and clinic
• Heard about disrespect more than experienced it

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Disruptive Behavior

Interview with Dr. Norm Chapin

My name is Dr. Norm Chapin. I am the Medical Director for Columbia Memorial Hospital in Hudson, New York. 

How big is the hospital?  They are currently staffed for 120 beds. 

Can you describe for me some of the steps you’ve made in rising through the leadership ranks?  I graduated from my residency in 1985 and for the first 5 years from 1985-1990 I practiced clinical emergency medicine.  In 1989, I was assigned responsibilities related to EMS education and ED quality management.   In 1990, I took a directorship position of a very small Emergency  Department near Detroit, Michigan and I worked there for about a year. I realized that I had taken that position maybe a little bit sooner then I was ready. I felt like I did not have adequate administrative experience.   My wife and I were looking to move out of Detroit at the time so we moved out of Detroit in 1991.  I went back to just practicing clinical medicine and emergency medicine again. 

Then a couple of years later I was given the opportunity to assume responsibility for the Quality Management Program in the Emergency Department.   I started doing some administrative work again and in 1996 when I accepted a position as Assistant Director of an Emergency Department near where I had been working. 

At that time, how much time was split between clinical practice and administrative practice? At that time, our normal clinical commitment was 144 hours per month, 12 - 12 hour shifts and I was doing 120 hours of clinical and 24 hours a month administrative time. 

As time went on did you do anything in particular to improve your leadership abilities or management abilities?  At that time, other than having a mentor I really didn’t take any formal courses in administration and leadership. Most of my CME classes were straight clinical courses.  I was doing more teaching all the time and I was learning more about how to present data to people but it was pretty much seat of the pants learning.  I really didn’t get into any kind of formal education at that time. 

When did you get into any kind of formal education?  In 1999, I was promoted to the Chief of the Department and I joined the American College of Physician Executives and I began taking some of their courses. I took my first course from them in 2000.  I also joined the ACPE list serve and began receiving their publications.  I was initially going to get my CPE Certification through ACPE and I took approximately 50 credit hours or so toward that but never completed it. 

You are enrolled in a more formal program now.  How did you decide to do that?Well, between 1999 and now I had assumed additional administrative roles.  Within the hospital I was elected as Secretary and Treasurer of the Medical Staff. The Emergency Management Group that has the contract at our hospital had branched out and I had taken a leadership role in getting two new contracts for the group. I was involved in negotiations with 3rd party payers, involved in negotiating with hospital administrators about contracts, I was doing a lot of recruiting, a lot of human resources types of things and I just realized that I needed to have a better background on the business side of medicine and healthcare in general. I’ve been interested for the past 4 or 5 years and going for my masters degree I had been challenged to really find the time to do that.  I had looked at several programs that were completely self study.  There was a little bit of a deadline to them but most of them were studying on your own, taking full on-line courses with no residency periods and that just didn’t work for me because it was too easy for me to push off the deadlines and I didn’t stick with any of those and didn’t think they would be a good fit for me just knowing my own personality.

A couple of years ago I met Mike Stahl who is the Director of the Physician Executive MBA Program at the University of Tennessee.  I talked with him. I was very interested in the program. It had a good track record.  We got a new ED contract shortly after my initial contact with Mike and I became totally immersed in the start up. Last year, 2007, I met Mike again at a national emergency medicine conference and applied to the program. I t was just very good timing for me. I applied and was accepted at the MBA program. I’m not quite half way through yet but it’s going very well. 

In your current position what percent clinical are you and what percent administrative?  Right now, I am only doing about 24-30 hours a month in the Emergency Department and the rest of the time I am Administrative. 

Do you see your clinical time further decreasing or staying about that level?  Emergency Medicine is a pretty demanding specialty and I still feel comfortable clinically right now but I when I became the Director, I went to half time clinically. That was back in 1999 and there was probably only one or two months in there that I actually only worked half time.  I was always picking up shifts for people because of scheduling problems and things like that so I always felt like I maintained a pretty good comfort level with clinical medicine. In the last year my clinical time has gone down to 2 or 3 shifts a month it is getting harder for me to maintain my comfort with practicing there.  I think over the next year as my administrative role continues to evolve, I’ll probably stop clinical medicine completely.

What advice would you give to young physicians who are considering being involved in leadership activities?   I would discourage young physicians from making a decision regarding full time administrative too early in their career.  I think my first mistake was taking on an administrative role before I really matured enough as a clinician to sustain that.  I don’t think I had enough maturity to deal with physicians who have been practicing for 20 or 30 years.  I don’t think I had earned my stripes so to speak.  I also think I tried to go from a position where I had very minimal administrative responsibilities when I was a director of a department too quickly.  So I think the best advice is to go slowly, make sure that you enjoy doing the administrative things, make sure that you gain enough experiences clinically so you can really be assured that your skills and your understanding of how healthcare works either in your specific specialty or throughout a multi specialty physicians organization or a managed care organization or a hospital organization which ever your practice has placed you.  M ake sure that you really do understand the organization well before you decide to take a real significant role there.  Committee participation, involvement in medical staff affairs, participating in performance improvement projects in the organization are each excellent opportunities to gain leadership experience.

What special skills or unique insight do you think physicians bring to the leadership table than non-physicians would not?  Well, I think we really understand other physicians better than non-physicians do.  I think we also understand patients in a way than non-physicians don’t, because we have really been with them through a lot of medical crisis.  We really understand their fears and their concerns.

I think we understand what physicians and what patients expect of physicians in a way that non physicians might not understand.  I think that gives us an advantage when discussing strategic initiatives within a healthcare organization or discussing  the vision or mission of a healthcare organization.  We have a different perspective of the complexity and how difficult it is sometimes to meet patient’s expectations and needs.  There are also aspects of healthcare as a business that we don’t understand or have a very different perspective of.  I think a team where both of those perspectives are represented at the Senior Executive level ,   gives  organizations a huge advantage in   responding  to some of the pressures that they face. 

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Bog Pond

 

Water gardening has become fairly popular in central Wisconsin. We created this bog garden about five years ago.  It is roughly 30 feet in diameter and kidney bean shaped. Most of the pond is less than six inches deep with a section in the middle about 2 feet deep. The shallow sections are for bog plants that like to be very wet and the center section is for deeper water plants.  The edge is rimmed with stones that is now covered with various rock garden plants. In front of the pond is a two foot wide section within a liner extending about two feet down and poked with holes.  The dirt in this area stays very moist but not as wet as within the pond itself. 

The plants are all winter hardy and most have survived temperatures to at least -30. There always seems to be something blooming.  The pond has attracted turtles, frogs and dragonflies. We’ve tried keeping fish but the local blue herons clean us out fairly quickly.

The pond has become a true source of enjoyment for my family.  

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Mistakes Are Good

Communicating can be frightening, especially if you worry too much about making a mistake.  Of course you strive to be accurate, but you will eventually make a mistake.  It is good when a mistake is pointed out to you because:

At least one person heard your message

The issue was important to them

You engaged them

They cared enough to point out an error

Thank people who point out mistakes and empower them to become involved in the improvement process.  Restat your mistake and what the correction will be and ask if you got it right.  Make sure to follow through and correct your mistake.  In future presentations you can even thank the individual for how they influenced the process. 

 

Spring Greens

For a several week period in late spring, Wisconsin is filled with a wonderful mix of greens as vegetation emerge from a long winter. Grasses and spring wildflowers emerge first and tend to have the darkest greens while trees bud later resulting in softer lighter greens. The contrast of the greens in the image above was accentuated by an early morning sun brightening the trees but not yet reaching the forest floor. A hint of a footpath seems to add to the magic of this image.

The image was obtained near the Wisconsin River just outside of Stevens Point, Wisconsin along West River Drive.

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Life Expectancy is Now 78

A government report has announced U.S. life expectancy has now surpassed 78 years.  Good news.  The report suggests the main reason for the rise is less flu deaths and a reduction in the death rate of chronic diseases. If we have the best health care system in the world, why is our rising life expectancy still less than what is experienced in 30 other countries?  Answer: health care only makes a small contribution to life expectancy.  

Experts estimate our health care system only has a direct effect on about 10% of the factors causing death. While our average life expectancy is not world class, your chance of surviving cancer, a heart attack or any catastrophic life threatening event is best in the good old U.S of A.  

Our health care system has developed partly due to economic reality. We have desired high quality acute care and have paid for it preferentially as compared to preventive, wellness, primary or even office based chronic care. In my neck of the woods, health care reimbursement policies have resulted in free standing surgical centers, orthopedic centers, cancer centers and MRI centers while primary care is often thought of as a loss leader feeding providers of highly reimbursed procedures.

The upcoming Presidential election will include a health care debate. My intent behind today’s post is not to provide the answers to the debate, but is to make a few observations which may well lead us to the answers. 

1. Our health care organizations make a lot of money when patients are admitted to the hospital or the various outpatient procedure oriented facilities.
2. Our health care organizations loose money when patients receive care and live a lifestyle allowing them to stay away from hospitals and outpatient procedures.
3. Our communities will spend less money on health care with the same results by increasing or establishing reimbursement for services that keep patients out of the hospital.
4. If we are interested in improving life expectancy, you will get a good bang for buck by concentrating on improving lifestyle behavior that impacts health.

 

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Crepuscular Rays Over Lime Lake

Beams of light radiating from the sun become visible when shadows are formed and light is scattered by particulates in the atmosphere. These crepuscular rays can be seen forming at three distinct cloud banks above Lime Lake in eastern Portage County, Wisconsin.  If conditions are just right, the rays can be seen traveling the entire sky to the opposite horizon.  

Lime Lake is one of the few lakes in Portage County draining initially to the east.  A remnant of our glacial past, it was formed by a huge block of ice left behind by the retreating glacier.  The ice chunk depressed the ground underneath forming a depression that would become Lime Lake. The image was captured from the western ridge overlooking the lake.  Drainage for the lake exits through the gap seen in the distance.

This image is an HDR and was constructed from five separate images. The images were captured using a static aperture but variable shutter speed resulting in a full f-stop between images. Images were combined using Photoshop CS3 and a Photomatix tone mapping plug-in.

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e-iatrogenesis

I recently had the opportunity to listen to a presentation by Joan Ash, PhD, MLS, MBA; Associate Professor of Medical Informatics and Clinical Epidemiology at Oregon Health and Science University in Portland, Oregon.  She has been part of a long term effort investigating computerized physician order entry (CPOE).  You can review the result of the work done by this team at http://cpoe.org. If you are considering CPOE, the website is well worth the effort of review.  If you know the experiences of others, you will be better prepared to minimize or mitigate the inevitable surprises of implementation.

Dr. Ash and her team have found asking users about their surprises rather than the unintended consequences of CPOE will result in a richer discussion.  She has also discovered that if you want to know how a process is working, go to the source and observe it.  Observing and asking questions results in far more accurate data than sitting in an office and reviewing the results of surveys.

I did learn of one specific example of a CPOE surprise that was new to me:

 

 http://www.timesonline.co.uk/tol/news/uk/health/article753765.ece

It seems as if there were no complaints from patients who had received Viagra in error.  Perhaps their thoughts of smoking were transformed into something else.

Please do not consider all surprises to be negative.  When we implemented electronic Rxs in my outpatient office, patients could actually read and interpret our prescriptions.  They became empowered in the process, read the Rxs,  pointed out address errors, asked for greater quantities  and even asked for more refills.

Any new useful technology solves old problems but introduces new ones.  A term has been recently coined, e-iatrogenesis, to label any patient harm caused at least in part by the application of health information technology.  

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