Cheryl Hoerr, MBA, RRT, FAARC
Yesterday was the first day in quite a while that the sun was still shining when I stepped outside the front doors of the hospital at the end of the workday. As I write this column in early April, the days are getting noticeably longer, the temperatures are consistently above the freezing mark, the flowers are just beginning to bloom…but my department is still stuck with the winter blues.
Most of you are probably acquainted with the familiar ritual of spring cleaning. For some it is the one time of the year when their home receives a thorough top-to-bottom cleaning. For those of us who have survived a long, cold, and snowy winter, the idea of throwing open the windows and airing the house out on the first warm days of spring is especially appealing.
It suddenly occurred to me that now would be a great time to gear up and get rid of those winter blues with a good departmental spring cleaning. We could definitely use some freshening up, and a thorough cleaning would ensure our department was organized and ready for the soon-to-be-here-any-day-now Joint Commission inspectors.
But…where to start?
I began by consulting the all-knowing, all-powerful experts of the Internet for some spring cleaning advice. As expected, advice specifically targeted toward respiratory services departments was nonexistent, but I did find a multitude of experts touting a variety of home spring cleaning checklists. I’ve adapted their expert advice and plan on using the information as a springboard to clean, declutter, and organize both my office and the department.
The experts recommend getting rid of clutter you don’t need prior to any cleaning attempt. It’s been my experience that most respiratory therapists are hoarders. We’ve all been in those situations where we needed a particular supply or piece of equipment and couldn’t find it, so we squirrel away bits and pieces of supplies and equipment “just in case.” This leads to secret stashes of supplies that are long expired and ancient equipment hidden in secret storage areas.
These stashes need to be eliminated, so identify the one therapist in your department who knows where all the skeletons are hidden (you know the one) and give her/him the resources to bring all that stuff out into the open. Once you know the extent of “the stuff” you’ll need to decide if you’re going to keep it, throw it away, or, if it’s usable, sell it. Your materials management department will be happy to help you with that last bit. One side benefit to clearing out the clutter is that it frees up much needed space within your department.
Speaking of much-needed space, after you declutter the department you should turn your attention to decluttering your office. As I look around my office I see samples of products we are evaluating, literature that goes along with the samples, purchased equipment that is being staged prior to implementation, back issues of magazines that are now readily available online, knick-knacks therapists have given me as gifts, assorted posters and educational packets, and miscellaneous equipment that, for unknown reasons, chose my office as a hibernation spot over the winter.
The samples and literature can be distributed, back magazine issues can be recycled, and knick-knacks can be donated to the resale shop or stored out of the way and rotated for display so as not to cause hurt feelings. The rest of “the stuff” can be disposed of or returned to where it belongs.
Another area that might be in need of decluttering and organization is your computer files; when was the last time you went through your hard drive and deleted the old and obsolete information and files? You’ll be amazed at how much a good deep clean and defrag can help the speed of your system!
The expert recommendation is to “take advantage of the natural urge that comes each spring to get rid of items that are weighing you down and begin fresh with a more streamlined lifestyle. While we may have a tendency to hoard and hold on to items in the winter, we generally are more ready to let go of clutter when spring arrives.”
Now that the clutter is gone it should be much easier to do some cleaning. Target a small area of the department for deep cleaning first; trying to tackle the entire department at once could become overwhelming. And if you start with the area most in need of attention the worst will be over at the beginning and give everyone involved a big sense of accomplishment.
If you are the one organizing the cleanup party, make sure to have enough cleaning supplies on hand: gloves, hospital-approved disinfectants and cleaners, and microfiber cloths are good, basic supplies that will go a long way in shining things up. Depending on how dusty the area is, you may want to consider supplying masks for any volunteer who may be sensitive to dust.
As is the case with most projects, this process will have a higher chance of success if you get the entire staff involved. Even if each staff member only works on the project for 15-30 minutes, that time adds up. A side benefit to getting everyone involved is that working together on something out of the ordinary has been shown to improve teamwork, and the collaboration will continue after this specific project is completed.
Music can inject some fun into the work and divert attention away from the drudgery (even the seven dwarfs whistled while they worked!), and the offer of a free meal during the cleanup may bring in extra volunteers. I would also plan on a small reward for those therapists who actually did roll up their sleeves; my therapists are all addicted to fancy coffee beverages and a gift card to the coffee bar in the medical building next door is a highly prized reward for a job well done.
Once the area is sparkling clean take some time to evaluate the space and the workflow it must accommodate. You may want to consider the benefit of rearranging things so that they are easier to find, instead of simply putting things back in the previous arrangement. Label the items in their new locations so that therapists can find supplies and equipment easily. Improving the organization of any work area eliminates all kinds of waste, including: searching waste, waste due to difficulty in using and returning items, motion waste, excess inventory waste, and unsafe conditions waste.
Yes, I was tricky…I was hoping you wouldn’t notice the “5S” lean methodology until it was too late! Did it work?
Tim Buckley, MSc, RRT, FAARC, System Director, Respiratory Care, Sleep Medicine and Critical Care, Summa Health, Akron, OH
Most respiratory therapists understand that lung cancer is often a fatal disease. But most of us have only seen lung cancer when dealing with the extreme shortness of breath associated with end stage disease. Unfortunately, as professionals, we realize that there is little we can do for those end stage patients other than make them comfortable and provide palliative care.
In 2014 it was estimated that there were over 224,000 new cases of lung cancer diagnosed in the U.S. During that same time period over 159,000 deaths were attributed to lung cancer.1 According to the National Cancer Institute, lung cancer comprises about 13.5% of newly diagnosed cancer in the U.S.1 In 2014, it was expected to account for 27.9% of deaths from cancer, making it one of the deadliest forms of cancer, with a five year survival rate of only 16.8%.
Survival is largely associated with the stage at which the cancer is diagnosed. Only 5% of lung cancers are diagnosed when the tumor is localized and has not spread to the lymph nodes. Fifty-seven percent of lung cancers are diagnosed when the disease has already spread to distant organs. At that point, the survival rate is only 4%. But if diagnosed early and in the localized stage, the survival rate increases to 57%.1
An important goal of lung cancer care is to increase the diagnosis of early-stage lung cancer to improve patient outcomes. The consensus is that by diagnosing lung cancer early and treating it promptly we will get better results. Medicare has recently approved the use of low dose CT screening for lung nodules in selected groups of Medicare patients.2 Most other insurers were already paying for this screening, but we expect that they will all restate their guidelines to match Medicare in the future. These screenings may identify a number of early stage lung cancers that can be treated, but they may also produce a large number of false positives that will require further testing.
Another large group of patients for whom lung cancer may be found early are those who have “incidental findings” on x-rays or scans done for another reason. For example, someone has a chest x-ray for a broken collar bone and it “incidentally” finds a suspicious lung nodule that needs to be tested further to rule out lung cancer. Over three months in 2009 one group looked at 600 CT scans done in the emergency department. Sixteen of those scans showed a reportable lung nodule.3
As our institution continued to see an increase in the volume of lung nodule patients from various sources, we felt that a “navigator” would be helpful to guide patients through the complex process of follow-up to determine if the lung nodule was just something that needed to be monitored or required further testing and work-up. This presented an opportunity for one of our RTs to step up and develop a role as an RT lung nodule navigator.
When we proposed filling this role with a respiratory therapist we were asked, “what would an RT bring to this role?” Our answer was, first of all, this is a disease of the organ in which we are experts. Second, this disease is strongly associated with a smoking history, and frequently these patients have comorbid conditions such as COPD, asthma, and congestive heart failure. These are all diseases that we are very familiar with.
When we put an RT into this role, she had to quickly gain knowledge in the area of lung cancer. In spite of our expertise with the lungs, most RTs have little background and knowledge about lung cancer. In addition to learning about the disease, the RT had to learn about the diagnostic process, how patients move through this process, and where the current bottlenecks exist. The RT navigator needed to be familiar with scheduling scans, tests, labs, and PFTs.
Lung cancer, like many other cancers, has consensus guidelines that recommend treatment based on the stage of the cancer.4 While the physicians stage the cancer, our RT navigator had to become familiar with these guidelines, how they help determine the care plan, and what they mean so that she could explain them to patients and their families.
Our RT lung nodule navigator spends much of her time educating patients and their family members about the disease and the importance of prompt testing. She also spends a portion of her time helping to schedule tests ordered by the physician, making sure results are sent to the appropriate physician, and ensuring physician appointments are scheduled. She often has to troubleshoot roadblocks too, like delays in testing when an MRI is down. Our navigator knows more about how to obtain transportation for patients without access to a car or public transportation than most clinicians will ever have to know.
At our system, each week we conduct a multidisciplinary conference to recommend patient care plans based on the National Comprehensive Cancer Network Guidelines.5 The RT lung navigator is a key participant in these conferences, usually voicing the concerns of the patient or family and assessing the likelihood of compliance with testing and treatments. Some of this is clinical but much is experience based. Her skills in teaching, assessing, and providing diagnostic and clinical care are all at the forefront during these conferences. The RT is on an equal footing with the physicians, nurses, and other team members.
Since 2013, we have been working with our Cancer Center to support the Lung Nodule Program. This program is designed to increase the early detection of lung cancer and speed the diagnosis and treatment to improve outcomes. The need for a navigator became apparent as the patient volume increased. The role was traditionally a nurse’s role, which had been developed in various cancer programs and proven to be successful.4 We challenged that thinking and developed a job description for a respiratory therapist to develop and fill this role. We have proven that a motivated and competent RT has the skills and background to be a successful navigator.
A recent article in Respiratory Care describes the role of a respiratory navigator with several key bullet points6—
We used this as a model as we developed the role of the RT lung nodule navigator. The goal of the navigator is to move more of our patients from the low survival group to the group of those who can successfully survive lung cancer through early diagnosis, rapid treatment, and effective support. This is truly a new role for RTs that can be duplicated elsewhere.
The use of an RT as a navigator is cost effective and an appropriate use of our skills and background. As we move from fee-for-service to population health management and value-based care, this type of position is a natural fit for RTs.
John S. Rinck, MM, RRT-NPS, CPFT, Adjunct Faculty, Graduate and Professional Studies, Spring Arbor University, Traverse City, MI
Some decisions never come easy; ones that do are rare. Managers face a multitude of daily decisions that demand time and attention. Information overload is the norm, yet the expectation is to make spontaneous, often high risk but sound decisions. Even the most seasoned managers experience delays or suboptimal choices under these conditions.
Fortunately, decision making is a skill that can be learned and should improve with experience. Theoretical models may be helpful and focus on willful choice, reality-based, or combinations of the two coupled with quantitative, qualitative, descriptive, or prescriptive considerations.1 Decision models address “what” and “how” without venturing to explain “why.” The more challenging task is to understand what boundaries, shortcomings, or blind spots affect the decisions we make.
Here are a few functionally concrete observations drawn from recent research grounded in common sense that managers should be mindful of before making decisions.
Bad decisions can be attributed to any number of causes: failed processes, groupthink, bad chemistry, ineffective leadership, or managerial bias.2 Who the manager knows affects the quality of his decisions. One company found that 60% of the time spent on decision making was spent with colleagues identified as advice providers who fell into two groups: those who “wanted to know” and those who “needed to know.”2 Much time was wasted on those who wanted to know as opposed to those who needed to know.
Rarely are the negative effects of collaboration discussed, but when overdone, the more-is-better approach negatively affects decisions by failing to get the right people involved.2 In this study, managers fell into the trap of relying on individuals they were familiar with to the exclusion of other expert perspectives. Overconfident managers tended to discount alternative viewpoints and opinions when making decisions.2
Managers can take action to prevent these errors by reducing interactions within their network to those who “need to know” and by utilizing a smaller network to improve accountability and avoid paralysis by consensus.2
Rapidly changing conditions potentially expose managers to blurred roles and misunderstood decision rights.2 For example, reorganization coupled with changing responsibilities creates uncertainty about “who decides what,” driving managers to seek approval from the top, which leads to bottlenecks. When decision rights are unclear, tens of thousands of dollars in labor costs are potentially generated over days or weeks while waiting for answers. In one specific case, one decision cost $60,000 in staff hours spread over 25 people because decision rights were not clear.2
Cultural traps also exist. Overly bureaucratic cultures create performance barriers managers should be aware of.2 When networks are overly hierarchal, decisions get pushed up the ladder, ending up in the C-suite on a senior leader’s desk. The senior leader who is working at her limits frequently keeps decision makers waiting for answers, becoming an unintentional decision-blocker. Leadership training can mitigate this situation by focusing attention on individual accountability, conflict resolution, and adherence to assigned roles at all levels within the organization.2
What’s more, bureaucracy, with its complex regulations and default rules, restricts creativity, decision options, and individual preference. Defaults truncate decision making to a direction the organization requires that either cuts costs or promotes efficiency.3 Creative decision making may involve higher costs in terms of time to learn options, but it promotes learning in ways not allowed by default rules.
Another trap that can challenge a manager after he has made a decision occurs when employees seek out individuals higher up in the hierarchy to voice objections to the decision that was made.2 Formal relationships and the need for team building are not to blame here, rather the culture and employee behavior comprise the root problems. Unfortunately, managers frequently misinterpret the situation by working to enhance collaboration—in this case a symptom of a bureaucratic culture.2 The effect of this employee end-run is to overturn decisions that have already been made, which is detrimental to the entire process.2
Researchers describe psychological distancing (filtration and exclusion of less vital details) as a cognitive tool allowing managers to sharpen their decision making focus.3 This active mental practice is particularly useful in situations involving information overload.3
This skill involves two behavioral tools that optimize performance: exploration (attention and control in new situations), and exploitation (optimizing performance in current situations).3 These two behaviors actually affect different regions of the brain that control different cognitive activities. Superior decision making relies on the manager’s ability to sequence exploitation with exploration and to recognize when to use each as he distills information into current and future tasks.
Creation of an organic department culture is a significant action the manager can take that enhances the decision making process. Psychological distancing functions best when cultural freedom allows innovators on staff and managers alike to act, fail, discuss, and try again.4
Trust plays a large role in decision-making. Trust is the manager’s willingness to take risks or become vulnerable to another person when there is potential for loss or misunderstanding.5 Trusted advice reduces transaction costs, improves decisions, reduces stress, and garners resources.5
Eight profiles of “advice-givers” have been described: Trusted Partner (best interests at heart), Harsh Truth Teller (what needs to be said), Moral Compass (sense of right/wrong), Loyal Supporter (similar views), Star Player (superior ability), Average Joe (moderate level of ability, integrity), Dealmaker (gets things done but clashes with values), and Cheerleader (unconditional support). Most often, managers are focused on the need for raw information, actionable advice, strategy, and emotional support.5 Each need requires different levels of trust.
The potential to improve decisions emerges when the manager learns how to match the need for advice with one of the eight advice-givers described above.5 The manager as trust seeker perceives the qualities of her network contacts (ability, benevolence, integrity) and draws from them to fit the need.5 “One-size-fits-all” is a common pitfall and does not work. In one survey, managers said what they wanted most was trusted partners, harsh truth tellers, loyal supporters, and moral compasses.5 Star players (ability alone) were underrepresented, with dealmakers and cheerleaders non-represented.5
Employees perceive managers who seek advice as either competent or incompetent; who the manager asks makes a difference. Employees who were asked for advice by their manager held the manager to be more competent.5 However, if the manager sought input from someone lacking expertise, the perception of manager competence was undermined.3 Advice givers must be chosen carefully and assessed in terms of the trust profile, and managers should resist indiscriminate reliance on fixed, inner circle friendships.
Decision-making involving competition for limited resources is a frequent challenge. Navigating this situation is handled best by asking clarifying questions. Doing so enables the manager to assess the issues to be decided on while looking for a spectrum of opportunity.6 Building bridges in the decision-making process involves being able to look for possible trade-offs that go beyond turf protection and “their gain is our loss” thinking.6 Asking key questions promotes managerial understanding of all positions and interests. Ask, listen, and then collect new information before making the decision. The “trading zone” is where conflicting ideas merge into shared ideas.7 Most commonly referred to as fact finding, it is collaborative and brings together different interests so that information can be gathered, analyzed, and interpreted.7
Being able to make a “now” decision without sacrificing current or future performance takes skill, understanding, insight, and experience.4 The importance of manager’s network, environment, trust, and awareness of the details cannot be minimized. Awareness of the details surrounding the decision is most helpful at any level. The availability of emerging research, with recently published tools and resources, promises to expand our understanding as to why we decide the way we do.
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