Message from the President:

It’s here! The CSHRM board proudly unveils the newly revised electronic newsletter. E-news will be delivered to CSHRM members via web-mail on an every other month basis. The newsletter will contain valuable information on education sessions, board work product, and featured articles on the latest healthcare risk management topic of interest.  It is our goal to improve communication with our members. Accessing the newsletter provides members a quick link to the CSHRM website where detailed CSHRM organization information is posted. We welcome members to contact board members for comments and questions related to CSHRM activities by accessing "board" link attached. Also, feel free to also forward E-news to non-member colleagues.

Thank you and enjoy the following information.

Pamela Brotherton-Sedano, CSHRM Board President

Networking/Education/Conference Updates:

The ASHRM 2007 Annual Conference & Exhibition is here. This year’s conference is held in the “windy city” of Chicago, Illinois with keynote speaker, Steven M. R. Covey on Wednesday October 10th and concluding Saturday October 13th  with keynote speaker, Karyn Buxman. Many CSHRM members will be attending this year’s conference to gain further insight on healthcare risk management while networking with invaluable colleagues.

CSHRM Committee Updates:

Membership Committee Update:

The membership committee has been busy adding new and renewal members to CSHRM! We now have 221 members for 2007! We are under target for membership this year so the committee has partnered with the Education Committee to offer 3 regional educational programs. The first two SB1301 and Disclosure…Doing the Right Thing the Right Way were successes. Our last and final program for 2007 is scheduled for Thursday November 01 in Sacramento and includes topics regarding End of Life, SB1301, and Managed Care’s Impact on Medical Ethics. We have great speakers and seats are still available. To reserve, email Membership Committee Chair Teresa Campbell at campbet@sutterhealth.org.

We want to take this opportunity to thank our membership for your continued support!

Audio Conference Committee Update:

CSHRM recently provided several host sites for ASHRM’s most recent audio conference held on 08/14/07 discussing the topic, 2008 National Patient Safety Goals. By providing members FREE access to the audio conference at convenient locations, members are able to network with colleagues while being provided the conference free of cost.

The next ASHRM audio conference is scheduled for November 13th titled Risk Management and Behavioral Health Issues in the Emergency Department.  The audio conference is designed to bring to light the various challenges healthcare providers encounter and offer ways to deal with behavioral health patients, particularly in the Emergency Department setting. CSHRM host sites to be announced.

Communication Committee Update:

As evidenced by the newly revised E-news publication, the Communication Committee has been hard at work to improve networking between the board and CSHRM members. The website continues to grow and provide members with information related to current events happening locally in California in addition to important ASHRM related education offerings. The committees next project will involve a member survey to obtain insight on newsletter content, website information, and more.  The Communications Committee is always interested in “article” submissions so if you or a colleague has a knack for putting healthcare risk topics to paper, please email the Communication Chair at faberd@sutterhealth.org.

Sponsorship Committee Update:

Sponsorship interest remains high for the annual conference, CSHRM continues to strive in adding value and exposure to its sponsors. Several new recognition areas are being introduced this year. The goal is to give sponsors the chance to have a forum to present their services and value to CSHRM members.

Board/Committee Contacts:

For quick board member/committee chair contact, access board link and choose applicable member to contact. We look forward to hearing from you!

Making SBAR Training Memorable and Fun
By John Ford, BA. LLB Certified Trainer

"I see and I forget, I hear and I remember, I do and I understand."
Confucius

The connection between effective communication and teamwork on the one hand, and patient safety on the other, is now well established, and indeed accepted in health care circles.  The SBAR communication tool has become a popular way to address part of the communication puzzle and is typically introduced through training programs. The challenge of dealing with resistance to the training itself, and making the delivery SBAR training relevant, is the subject of this article. It is aimed at Risk Managers and Patient Safety Officers who are responsible for coordinating, and sometimes delivering this kind of training.

Communication Basics

George Bernard Shaw once commented, “The biggest problem with communication is the illusion that it has been accomplished.” Speak to any risk manager and they will tell you that when something goes wrong, the common thread is miscommunication.

To address these communication challenges, experts advocate a variety of techniques and practices. A foundational best practice is closed-loop communication. In essence, closed-loop communication requires that the listener demonstrates that he or she has understood what is being said by repeating back the gist of the information. When vital technical information is being conveyed, however, the “gist” is not good enough, and the precise message is read back for confirmation.

But how we deliver the message is just as important as demonstrating understanding. The SBAR communication tool focuses on the delivery of messages. It is an effective way to convey critical factual information about a patient’s condition during emergencies, but also for commonly challenging situations that have a direct impact on patient safety and or pose risk, such as hand-offs. 

Adult Learning Theory

Addressing gaps between desired and actual performance levels is the focus of training and human recourse development. A body of knowledge has emerged that describes how best to train adults. Malcolm Knowles, who is considered the father of adult learning theory, set forth these tenets:
•           Adults are autonomous and self-directed learners
•           Adults have accumulated a foundation of life experiences and knowledge
•           Adults are goal-oriented
•           Adults are practical, focusing on what is most useful to them in their work
•           Adults need to be shown respect

Building on the work of Knowles, Edgar Dale explored the learning modalities that work best for adult learners. As Confucius before him, he found that learning is most effective when learners are actively involved in doing something during the learning experience. When that occurs, after two weeks we remember 90% percent. By contrast, when we only read something we remember 10 percent, when we hear something we remember 20 percent, and when we see something we remember 30 percent. By using more than one sense, we increase retention. Thus, we remember 50 percent of what we hear and see, and 70 percent of what we say. Chances are you will remember this diagram better that this paragraph!

The 1990s was described and ultimately proclaimed by President George Bush as “the decade of the brain.” Powerful real-time imaging has essentially confirmed what Confucius, Knowles and Dale have been saying: learning is a personal experience and created in the mind and body of the learner. Learning is not given but constructed, and reflected in new neural pathways. It is best achieved through direct experiences.

Two common challenges to training are resistance to being in the training in the first place and making the training relevant. Both are addressed in the remainder of this article.

Training Challenges: Resistance

As Knowles noted, learners are autonomous and self-directed. One of the biggest challenges in delivering training in a work setting is overcoming the resistance of the learners to being there. Resistance is expressed in a variety of ways: “We already do this,” “I don’t have time for this,” This is just another flavor of the month”

To blame the learners is to miss the point. The task of the trainer is to address those resistance points, recognizing that resistance is typically a sign of an unmet need. Building on the work of Knowles, it is important to demonstrate to the learners the relevance of the training to the learner.

A key best practice in training is conducting informal interviews with participants prior to the training. This alerts the trainer to the resistance climate and allows the development of a strategy to address the concerns. For example, knowing that a particular department has already developed their own communication template allows the trainer to validate that, and rather than saying it must be immediately replaced with the new SBAR tool, invite participants to consider making improvements to their existing tool based on what they learn about the SBAR tool in the training.

While time is an ongoing issue in health care, for the most part arrangements are made for staff to participate while on duty. Still, it doesn’t hurt to address this concern, if only through acknowledgements: “I know you are all really busy, and that finding the time to be here today was not easy.” One of the potential benefits of using the SBAR communication tool is greater efficiency, which translates into saving time. Telling participants that in a patronizing manner will backfire, but putting it out there and asking them to be the ultimate judges is a different matter entirely.

Getting defensive around points of resistance does not help. Only time will tell if SBAR goes the way of other training fads. Bluntly asserting that it will not is probably not going to do anything to shift attitudes. Being honest and leveling with staff is always a good policy. Ultimately, the challenge for the trainer is to contextualize the communication challenges faced in health care and to point out that SBAR is but one of many communication strategies being employed, and that for effective transfer of vital information, it has no peer—at least not for now. It’s also fine to point out that something better may come along, and that should be welcomed as part of the continuous improvement process.

Training Challenges: Relevance

Knowles noted that adults have a vast body of lived experience. To discount that is fatal. In our rush to make trainings interactive, we are often surprised at the resistance to the role- play. For now, lets focus on the disconnect between the dry text of the role-play and the lived experience.

Again, this is where pre-training informal interviews can play a vital role in ensuing that any role-plays used are true to this organization’s experience. Beyond that, the challenge of the trainer is to come up with creative ways that ensure that participants practice the new skills they are learning, and do so using their own lived experiences as the reference point. For example, in conflict resolution training, it’s always best to have the participants identify a conflict situation of their own and work on that through the day.

In the context of SBAR training, it is possible to do the same thing. In conducting trainings, I have used the “American Idol” format to meet a number of key adult learning criteria, but especially the importance of relevance and interactivity. Here’s how it works:

After learning about the SBAR tool and seeing it demonstrated, participants work individually at their tables to identify a situation from their work life in which they wished they had used the SBAR tool. They then take turns sharing their own SBAR situation with their colleagues. As a group, they identify an SBAR example that they work into an impromptu skit; ideally everyone has a role to play.

For example, one is the narrator, another the patient, another the nurse, another the on-call physician, another a rapid response team member. Each table plays out the scenario for everyone. To the side, sitting on three seats are Randy, Paula and Simon. Well, not the actual TV personalities, but senior members of your staff who are familiar with the show and are in a position to give constructive feedback at the end of each skit.

After all the groups have demonstrated their SBAR skit, everyone is handed two stars with which to vote for the best group. Participants can vote for their own group, and a lot do. But in practice, a wining group always emerges; they are the recipients of small prizes.

This format is a lot of fun. Fun resonates and is memorable. The exercise builds on their actual lived experiences. Everyone practices an SBAR situation. Everyone gets lots of feedback. By the end of the exercise everyone has a good sense of what is needed in their particular context.

Conclusion

Improving communication practices is no longer a luxury. It is vital for improved patient safety. Training is clearly going to play a central role in the challenge. Ensuring that it is structured with the reality of adult learning theory in mind will go a long way toward meeting the challenge. The “American Idol” technique is a fun and familiar format that can help.

Best Practice Training Tips

• Conduct informal interviews with participants to gauge motivation, and get customization insights
• Resistance is a sign of an unmet need
• We learn best by doing!
• Multi sense learning is more effective
• Concrete personal examples are best to practice new skills (beware of abstract ‘role plays’)
• People remember fun stuff!
• Encourage participants to adapt materials to meet their real world conditions.

 
Author’s Biography

John Ford supports organizational reliability through a focus on communication, team building and conflict management. John has provided training to thousands of employees in the workplace, especially to employees in health care settings.

John is an experienced mediator, who has successfully helped individuals resolve difficult problems. He has worked with numerous groups that are struggling to get along.  He has mediated for the Equal Employment Opportunity Commission and currently serves on Lumetra’s quality of care mediation panel. 

John’s start in conflict management was over 18 years ago as a labor and employment law attorney in Namibia. Since moving to Oakland, California, he has directed a certificate program in Organizational Conflict Management at JFK University, served as managing editor of Mediate.com since 1999, and is a past President of the Association for Dispute Resolution of Northern California (ADRNC). He is the current trainer of mediation skills to members of the Northern California Human Resource Management Association.

He is a member of the Association for Conflict Resolution, ADRNC, and the California Society for Healthcare Risk Management (CSHRM).

Humor, the Best Medicine

We all to often forget to include humor in our daily lives. In healthcare, humor is a survival skill one cannot live without. Whatever your role may be in Healthcare Risk Management, CSHRM challenges you to include humor in your daily work. Whether it be reading a funny joke before starting your day or telling a colleague about the silly thing your spouse did in the grocery store, we challenge you to partake in humor. To start us off, Karyn Buxman, RN and President and Founder of Humor, a company specializing in speaking, training and coaching services discusses how humor can be the best medicine for stress management!

HUMOR AS A COST-EFFECTIVE MEANS
OF STRESS MANAGEMENT
Karyn Buxman, MSN, CSP, CPAE

U.S. workers consume 15 tons of aspirin a day. One in four workers suffers from an anxiety related illness. Soon job stress may be the #1 reason for worker's compensation. "Terminal professionalism" seems to be a sign of the times. But taking oneself too seriously can have some unpleasant side effects.

WHAT IS STRESS? Stress is the body's response to any demand or pressure. These demands are called stressors. Stressors include major life events, such as death of a loved one or divorce. They entail chronic strains such as living in an abusive relationship. Stressors also consist of occasional strains, such as getting a flat tire in heavy traffic. (Source: Fact Sheet HE-2089, 11-91, Florida Cooperative Extension Service.

RESPONSE TO STRESS: Stress requires the body to make adjustments physically, psychologically, socially and even spiritually to maintain the necessary balance for survival. Too much stress (distress) can manifest itself in a number of ways.

Psychologically, one who is experiencing stress may undergo increased anxiety and tension. Stress is also manifested in such ways as moodiness, irritability, inability to concentrate, crying, changes in eating patterns, changes in sleeping patterns, decreased libido, worrying, mood swings, frustration, nervousness, and depression. He or she may exhibit a negative attitude, low productivity, confusion, lack of creativity, lethargy, forgetfulness or boredom.

Socially, stress may be exhibited by isolating oneself from others, loneliness, or fewer contacts with friends. Communication may be hampered due to preoccupation with stressful events or impeded by negative mood swings, such as lashing out at others, nagging or clamming up.

The physiology of stress affects all major body systems. Breathing tends to be more rapid but shallow, not allowing for full air exchange deep in the lungs. The heart rate quickens and is accompanied by an increase in blood pressure. The person may experience a feeling of their heart "racing" or "jumping out of the chest." The circulatory system exhibits vasoconstriction with the blood supply being shifted to muscles and major organs. "Cold hands" are often an excellent indicator of one's stress level.
During stressful events, an increase in epinephrine is seen via the sympathetic nervous system. The immune system becomes depressed resulting in an increased susceptibility to viral and bacterial infections. These can range from a minor cold to a major illness.

During a stressful experience, muscles become tense, preparing for the "Fight or Flight" response. A person may develop headaches or a variety of muscle aches, clenching of the jaws or grinding of the teeth, tight neck, shoulder and back muscles and clenched fists. As for the digestive system, the person may encounter a variety of symptoms ranging from cold sores around the mouth to nausea, vomiting and/or diarrhea.

Nearly everyone is aware of the rising costs of health care in this country. These increasing costs are an escalating burden on employers. The Wellness Councils of America found that the average cost of providing medical benefits for one employee in the United States in 1992 was approximately $4000. By the year 2000, this estimate will balloon to nearly $12,000 per employee. These rising health care costs are cutting into the corporate bottom line. It is estimated that nearly 50 percent of corporate profits are devoured by employee health care costs. (Source: Healthy, Wealthy and Wise--Fundamentals of Workplace Health Promotion, Wellness Councils of America, Omaha, Nebraska, 1993)

Wellness and health promotion at the worksite has seen significant growth in recent years. Recent and long-term studies have shown that worksite health promotion programs have made an impact on significant decreases in health care costs. The good news is that humor is a cost effective and simple way to ward off many of the detrimental effects of stress.

WHAT IS HUMOR? Humor is that which lends itself to laughing, smiling, or amusement. It is considered a positive emotion and may be used synonymously with a sense of joy. It has characteristics that make it a viable coping mechanism. That which appeals to one person's sense of humor may be offensive to others. Everyone's sense of humor is unique.

According to Dr. Vera Robinson, author of Humor and the Health Professions, there are three functions of humor: psychological, social, and communication. Psychologically, humor acts as a major healthy coping mechanism, relieving anxiety and tension. It serves as an outlet for hostility and anger, provides a healthy escape from reality, and lightens heaviness related to critical illness, trauma, disfigurement, and death. When employees are working on a job that is repetitive, humor can increase length of time on task by reducing tension and boredom. And studies show that humor doesn't detract from tasks requiring increased concentration. Granted things can sometimes get out of hand. Therefore, it's important to also have a high performance norm and high expectations of the staff.

Socially, humor lessens the hierarchy between individuals, establishes rapport, and decreases social distance. Humor solidifies a group. Victor Borge once said, "Laughter is the shortest distance between two people." Workers that can share a laugh develop rapport. Much office humor is "inside" humor or "you had to be there" humor. While this kind of humor can make folks feel like part of the gang, it can also make others feel excluded. Be careful that this humor is used constructively, and not to shut out others.
As for communication, humor helps convey information. It opens the door for communication by allowing one to bring up a secretly serious subject to see how it will be received while providing an 'out' such as "I was only joking." Humor gains and holds the listener's attention. Over 80% of conflict results from problems with communication. Humor can help establish rapport and neutralize emotionally charged interpersonal events.

There are also physiological effects related to humor and laughter. For example, laughter increases respiratory activity and oxygen exchange. During "belly laughter," air is inhaled deep into the lungs and forced out at high speeds. Smokers or those with respiratory conditions frequently experience coughing after laughter, continuing the good air exchange.

As for the cardiovascular system, laughter stimulates one's heart rate and blood pressure followed by a relaxation phase that is accompanied by a decrease in both heart rate and blood pressure. According to Dr. William Fry, a leading researcher in the field of psychoneuroimmunology, laughter provides an excellent cardiovascular workout, which requires no special equipment and no limit to the number of times in which it can be used. (Source: "Physiology of Laughter" in Humor and Aging.) Laughter also produces vasodilatation, putting color and warmth into the face and hands.

In the immune system there is an increase in Immunoglobulin A, which fights upper respiratory tract insults and infections. There is also an increased spontaneous lymphocyte blastogenesis resulting in an increase in the number and activity of natural killer cells, which attack viral infected cells and some types of cancer cells and tumors. An increase in activated T cells (lymphocytes) is seen, as well as an increase in gamma interferon; an increase in Immunoglobulin G and Complement C. (Source: Humor & Health Journal 5, (5), "PNI Research Summary" p.6)

Other systems also demonstrate changes during humor and laughter. Muscles experience a stimulation phase followed by a relaxation phase that results in decreased muscle tension, often resulting in diminished pain. In the sympathetic nervous system there is an increase in the production of catecholamines resulting in increased levels of alertness and memory, enhancing learning and creativity. There is also a measurable decrease in stress hormones such as epinephrine and dopamine. Laughter stimulates both hemispheres of the brain at the same time, coordinating all the senses and producing a unique level of consciousness and a high level of brain processing. Internal organs are massaged resulting in increased peristalsis and improved digestion. Tears of laughter (and grief) provide an exocrine response, carrying away toxins found in cells under stress.

CONSTRUCTIVE AND DESTRUCTIVE HUMOR: While nothing is black and white, humor can basically be categorized by that which is constructive and that which is destructive. Destructive humor lowers self-esteem, belittles others, excludes others, creates tension, stimulates laughter at someone, perpetuates a stereotype, creates barriers, creates defensiveness, closes off creative thought, and focuses on negatives. Constructive humor raises self-esteem, is supportive, includes people, reduces tension, stimulates laughter with others, confronts stereotypic ideas, breaks down barriers, relaxes people, stimulates new ideas, and creates energy and a positive atmosphere. When promoting humor as a means of stress management, the emphasis should be on constructive humor.

Because everyone's sense of humor is highly individualized, one does risk offending others when using humor. However, there are some basic guidelines to help reduce the risk. Dr. Christian Hageseth, author of The Laughing Place, suggests that there are four components to effective, positive humor: relationship, rapport, setting, and timing. When using humor with others, do they understand who you are and what relationship you have with them; such as employee/boss, teacher/student, parent/child/, staff/customer? Do they have a sense of rapport or a feeling of safety with you? As for setting, it's important to remember that anyone who can hear, see, or experience the humor is part of the setting, regardless of whether or not that person was an intended member of the audience. Timing is twofold. First there is the timing of humor in relationship to an event. At the peak of a crisis, humor will fall flat. While most humor is in some way associated with some type of pain, some time will have to elapse before it is found to be funny. The amount of time necessary is unique to each experience. Timing is also important in the communication of a humorous joke or story. The more it is practiced, the easier timing becomes.

TAKING ACTION:

Set the tone: If you're in a position of leadership, give the staff permission to have fun. "Walk your talk." Be willing to overcome the fear of foolishness. Don't be afraid to look a little silly: a goofy hat, tie, button, socks, etc.

Set the environment: Humorous posters, memos, and signs can lighten the surroundings. Bulletin boards displaying cartoons, jokes, and funny notes don't take a big investment but can provide an abundance of entertainment. Create a positive working atmosphere at the desks with toys such as Legos, Nerf guns, Silly Putty, Koosh balls and hula-hoops. Add some comic activities or theme days to the calendar. Encourage everyone to be involved: management, various departments, volunteers, patients and family members. A M.A.S.H. day where everyone dresses up like the characters on the favorite television show by the same name, or a western theme where everyone dons cowboy boots and bandannas can lighten the atmosphere for staff and clients. A little competition between floors or departments might increase interest.

Set the pace: If you agree that humor in the workplace is a valuable idea, don't delay taking action. No one is suggesting that management or staff attempts to be a stand-up comic or laugh constantly. What is suggested is that attempts are made to use humor routinely (see sidebar for additional ideas). Whatever forms of humor are chosen, it's important to practice them on a regular basis. When humor happens by accident, there is much to gain. But there are too many benefits to let humor happen strictly by chance-- make humor happen by choice, today.

GETTING STARTED!

Studies confirm that you gain many more benefits by being an active participant in humor rather than a passive observer. Here's some ideas that will put humor to work for you!

• Make a list of things that are fun for you and do one item daily
• See a movie of your choice (via theater or video, but popcorn either way)
• Have a marshmallow fight (you can eat the left over ammunition)
• Participate in a massage train (if you make a circle, no one gets left out)
• Take a joke break (these can be programmed into your computer)
• Practice standing ovations for yourself and co-workers
• Read something for enjoyment
• Write a silly limerick
• Send a humorous card (earn bonus points if for no special occasion)
• Leave a humorous message on your own answering machine
• Keep a humor file at your desk and refer to it daily
• Wear a funny button or pin
• Lighten up your work environment (cartoons/props/photos/toys/etc.)
• Can the Muzak for something fun and upbeat
• Plan a theme day (dress down day/wild west/beach day/etc.)
• Eat fun food (Snickers bars, Ho Hos, Cracker Jacks, etc.)
• Try your hand at juggling (scarves are the easiest to learn)
• Sing silly songs
• Buy your very own humorous prop, like a magic wand or goofy glasses
• Share your most embarrassing moment
• Start your day with 20 seconds of laughter (fake it till you make it)
• Hold a cartoon caption contest
• Have a good laugh-- at yourself

FUNCTIONS OF HUMOR

PSYCHOLOGICAL: Acts as a major coping mechanism; relieves anxiety and tension, serves as outlet for hostility and anger, provides healthy escape from reality, and lightens heaviness related to critical illness, trauma, disfigurement, and death.

SOCIAL: Lessens the hierarchy between individuals, establishes rapport, and decreases social distance.

COMMUNICATION: Helps convey information; opens the door for communication by allowing one to bring up a secretly serious subject to see how it will be received while providing an 'out' such as "I was only joking."

PHYSIOLOGY OF LAUGHTER

RESPIRATORY SYSTEM: Increases respiratory activity and oxygen exchange.

CARDIOVASCULAR SYSTEM: Stimulates heart rate and blood pressure followed by a relaxation phase; vasodilatation.

SYMPATHETIC NERVOUS SYSTEM: Increases production of catecholamines resulting in increased levels of alertness and memory, enhances learning and creativity.

IMMUNE SYSTEM: Immunoglobulin A found in significantly increased levels of saliva with stimulation of humor and laughter, increased spontaneous lymphocyte blastogenesis, a natural killer cell activity.

MUSCLE SYSTEM: Stimulates muscles and relaxes muscle tension, often resulting in diminished pain.

BRAIN: Laughter stimulates both hemispheres at the same time, coordinating all the senses and producing a unique level of consciousness and a high level of brain processing.

DIGESTIVE TRACT: Internal organs massaged resulting in increased peristalsis, improved digestion.
TEARS (of laughter and grief): Provides exocrine response, carrying away toxins found in cells under stress.

Karyn Buxman is an award winning speaker, author and professional nurse. For 15 years, she has been speaking to audiences about the application of humor in a work setting. More recently, she has combined her work with the Six Advisors Such in order to effect even greater change in the arenas of business and personal growth. Karyn is President and Founder of Humor; a company that specializes in the needs of businesses and associations who are seeking speaking, training and coaching services. Contact her at info@humor or by visiting. www.humorx.com