Anyone involved in quality improvement efforts knows that scientific principles are at the center of this work. But even the most evangelical quality engineer will caution that this only part of the solution. Improvement strategies and measurement tools are most effective when embedded in an organizational cultural that ensures that changes are embraced and sustained. And there is no better means of inspiring cultural change than through the simple craft of telling stories. As Donald Berwick, MD, MPP, puts it, "Measurement is important, but it’s the stories behind the numbers that are the most enduring wellspring for change."
A growing number of improvement teams are enhancing their training in quality science with storytelling. This can take several forms. Some hospitals invite patients and family members with stories to tell – both positive and negative – to speak at quality seminars or retreats; some welcome such visitors to bring their stories to board meetings; still others include patients in high-level advisory committees that drive the organization’s quality agenda.
Patient safety departments in particular value the power of stories to help spread a culture of safety throughout the organization. For example, creating reenactments of adverse events or near-misses has been shown to help raise awareness of safety risks and the individual’s role in error prevention. These reenactments can be accomplished at various levels of sophistication, through ad-hoc live skits or a more formal video program.
One of the leaders in the art of storytelling is Atlantic Health Systems (AHS), a multi-campus provider organization in northern and central New Jersey. AHS is comprised of three hospitals that cover 11 counties and some of the most densely populated regions of the US. Since the mid-1990s, the organization’s quality leaders have experimented with techniques ranging from film clips that convey a safety principle to full-scale video reenactments of common adverse events involving dozens of staff as actors.
Senior leaders were in part inspired to pursue storytelling by seeing the Off-Broadway play "Charlie Victor Romeo," which was featured at IHI’s National Forum in 2000. The show recreates the final minutes in the cockpit before several true aviation disasters. Written from actual "black box" recorders recovered from the crash sites, the play has since become a standard training tool for of thousands of pilots and flight crews in both commercial airlines and the US Army and Air Force.
Jack Scharf, Vice President of Quality Outcomes for AHS, describes how he and his colleagues were "struck by the almost eerie similarities" between these plane crashes and medical disasters. For example, the confusion and chaos when things go wrong, the effects of excess noise and distractions, the pervasive miscommunications among staff, conflicting roles and demands, and so forth. Such process failures, Scharf realized, were the same ones that increase patient risk in health care settings.
Scharf says the group was also struck by how effective such a low-tech tool could be. They saw how simple recreations of cockpit events using two or three actors interacting behind mock control panels could be so powerful. He felt the stories "not only educated us about ‘what happened’ but also touched us, inspired us to take action, to find ways of preventing disasters from happening."
In this spirit, AHS’s Overlook Hospital quality team has incorporated video storytelling as a standard tool in patient safety training. One recent initiative is "No Harm Intended: Preventing Medical Errors," a 67-minute video depicting four reenactments of medical errors in a typical hospital. The scenarios are fictional, but they are loosely based on reported incidents at AHS – and common enough to touch a cord in any clinician viewer.
One vignette shows a blood-labeling error. A technician mixes up vials taken from two female patients in the same room. As a result, the patients are given each other’s blood during transfusions the same day, causing dangerous adverse reactions for both. In another scene, a CT scan order is lost during a rushed hand-off in the hallway. The lapse leads to a delayed diagnosis of possible spleen damage in a high school football player injured in a game, which in turn necessitates a surgical intervention.
After each vignette, the video switches to a discussion of the scene by a panel of experts, including AHS front line clinicians and consultants with expertise in systems safety. It is in this phase, says James Espinosa, MD, Chairman of Overlook’s Department of Emergency Medicine and early pioneer of AHS’s video efforts, that the real lessons are learned.
Dr. Espinosa believes strongly that "the safety lives in the dialogue, the discussion and analysis that can only take place by interrupting the story – turning on the lights and talking to each other." The panel discussion in the video illustrates this. It allows the experts to briefly analyze each incident and highlight both individual lapses and deeper systemic breakdowns.
The main focus is on the latter issues, which tend to be less visible, more complex, and harder to tackle, and often lead to more serious consequences. These are malfunctions in areas such as staffing, training, processes, planning, and oversight. In reviewing each incident, the panel dissects the system causal factors to the underlying sources. They ask, "Should that really have been her responsibility?" or "Why wasn’t the family involved in that process?" or "Where was the feedback confirming that hand-off?"
Overlook Hospital’s Nursing Officer, Lisa Kosnik, RN, agrees that a key benefit of video storytelling is the ability to stop and "pick apart the story and ask, ‘What could we do to improve this piece of the process or that?’" Her colleague Tina Maund, RN, Overlook’s Director of Performance Improvement, adds that "seeing and hearing the story" as it unfolds makes the analysis of the medical errors "not just an intellectual exercise but a much deeper experience."
Scharf encourages quality teams to involve senior leaders in storytelling projects. He himself appears in the "No Harm Intended" video as a middle-aged limo driver suffering from excessive pain following a bone marrow transplant. He says being visible in these kinds of ways sends a powerful message about leadership’s commitment to safety and willingness to lead by example.
Scharf says: "We all make mistakes. It is in telling the stories, sharing the parables, that we break the code of silence and secrecy surrounding medical errors." Such humility and optimism about the rewards of using stories to enhance quality training is a strategy innovators will continue to embrace. Because, no matter how powerful our data manipulation tools become, sometimes there is nothing more compelling than a story. In Don Berwick’s words, if in the rush to analyze the numbers we "skimp past the stories and the lessons they teach us, we’ll miss the humanity."
