workforce
we have an all-staff training program. That looks at awareness of
what the program is, and awareness that we are trying to redefine
normal. It’s really this acknowledgement that what you think is not
normal behaviour isn’t actually normal behaviour, and we should
stop pretending it is. It makes them aware that this is a normalisation
that happens in healthcare and that we’re now drawing a line in
the sand, but it also teaches them about how, along the way, we
could teach you to speak up in a way that is respectful but still gets
your message across. That’s either for safety, for something that is
inappropriate, or for something that makes you uncomfortable.
We use a great assertiveness model called CUSS. You say: “I’m
curious about what you’re doing.” Then the next level is: “I’m
unsure about what you’re doing. I don’t think it’s quite right.” Then
it would be: “I’m seriously concerned.” And then this idea of being
able to say: “Stop.”
Anyone in the organisation can do that, and that promotes a
culture where it’s okay to be wrong, where it’s okay to say I made
you stop, I made you look. You were right, but at least I made
everyone aware that I was worried.
We had a straw poll of some of our junior doctors, and we said:
“If you were in a clinical scenario where you had consented the
patient for surgery on their right leg, you had marked the patient’s
right leg, and you saw the surgeon about to operate on the left
leg, would you say anything?”
And of the four or five junior doctors we asked, they all said they
wouldn’t say anything, which shocked even me. And the reason,
when we looked into it, was twofold. First, I might be wrong. And
then, if I’m wrong, I look stupid. I’ve sort of insulted or humiliated
the surgeon by questioning them.
It’s this idea of being okay to be wrong that we teach as part of
our all-staff awareness. And then we also say we recognise that,
at the moment, you may not be able to or feel it’s something that
you can do – to speak up in real-time – so here’s an alternative
pathway, and we teach them about the program.
Then there is the training for the triage team. We also have a role
called the Ethos Messenger, and these are the mes sengers that will
deliver conversations to their colleagues when those complaints are
at a low level.
For instance, if somebody speaks inappropriately to someone, I
can go with the chief medical officer and speak to them, and that
will have some effect. Probably about 10 per cent effectiveness. But
medicine is very tribal, and if a colleague goes and speaks to them
about that behaviour and calls them out on it, that’s a lot more
effective. So we train that role in our clinicians and non-clinicians,
because this is for everyone in our organisation.
They are the main roles, but it’s continued training. This will
lead to other things. There’ll be more things about speaking out
for safety. There’ll be more things about how you performance-
manage someone effectively. How you promote and reward
people. It’s like renovating a house. We’ve started with the carpet,
and then the walls need doing, and the way we recruit, the way we
orientate people to our organisation, the way we performance-
manage people. How we look at gender in our organisation. It’s
sort of the beginning of a long journey.
What feedback have you had from staff so far?
It’s really interesting because, if we’d had this conversation three
or four years ago, I would have been in a room full of clinicians,
particularly, and said, “Let’s all talk about behaviour,” and they
probably all would have got up and walked out. What’s been really
interesting is when the Royal Australasian College of Surgeons
report came out, and we were doing some media, we had people
call up clinicians and clinical leaders, and nursing, medical and
allied health ring up from all over our organisation and say: “What
are we doing? What are we doing? It’s time!”
And I think for me, one of the biggest tests was I had to give
a presentation on this at one of our senior medical staff grand
rounds, and the place was packed. And they were all sitting there
cross-armed, going: “Go on, convince me.” This was sort of the
acid test for me, because if this isn’t clinician-led, then it’s just
another bit of rhetoric from management. So I went through the
presentation, and at the end all the hands shot up, and I thought:
“Oh God, here we go.” And I called on the first question, and the
doctor said: “Thank God someone’s got a plan.”
So it’s been incredibly positive. We find that people are very
interested in how it will work, and what the safeguards are around
vexatious complaints has been a big one. But they’re very engaged
in the idea that there is now a path forward.
When we’ve delivered messages to people, both positive and
negative, people have recognised the value of that. We’ve had
a couple of people that haven’t taken too kindly to it, but the
evidence shows that even those people who don’t appreciate it at
the time will still reflect on their behaviour later.
We’re also finding it’s very generational. The junior doctors and
medical and nursing students coming through are not tolerant of
this anymore. They won’t stand for this kind of culture.
And what has usage been like so far?
We’ve had it in our Melbourne public hospital for about four
months now, and we’ve had about 65 reports through the
reporting tool. And of those, 40 per cent have been positive and
about 60 per cent have been negative.
And it’s really spread across the organisation. One of the
misconceptions was that this was all going to be doctors yelling
at nurses. And that’s not the case. We had some pressure to just
make this about doctors, and we resisted that, and the numbers
are bearing that out. It’s spread across the organisation as we
thought it would be, including non-clinical areas.
We’ve found that, of the negative reports we’ve had, most have
been able to be dealt with in the informal space, and mostly with
the level one peer colleague conversation. We’ve only had a
couple that have had to be escalated up to line manager level.
Also, when you log in to the reporting tool, you have an
encrypted, unique identifier, but you can choose to be identified,
especially if it is a serious HR-type complaint. And pleasingly 75
per cent of people have chosen to do just that, so we’ve only had
about 20–25 per cent anonymous reports. There are limitations,
legally, with what we can do with an anonymous report. It has to
be kept in the informal space. So that’s been really pleasing for us,
that people feel enough trust in the system to put their name to it
and trust that we’ll use that responsibility.
Also, we’ve made sure we support not only the people
delivering the messages, but the people receiving the messages.
Incorporated into the program is a welfare check. We can’t
excuse behaviour, but we have to acknowledge that it is a unique
environment and we do have lots of stresses, and sometimes
people don’t manifest that well. Sometimes life happens to people,
and there might be death, disease or divorce.
So that’s been an important part of this as well, and something
we’ve engaged heavily with our staff in saying: “This is not
punitive. This is there to help you see behaviours and to check
that you’re okay.” n
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