Dave's Whiteboard

A recent interview with Dr. Peter J. Pronovost dealt with safer ways to care for patients in hospitals.  Pronovost is the medical director for the Quality and Safety Research Group at Johns Hopkins Hospital in Baltimore.

The interview’s worth reading on its own merits.  I saw in it good examples of performance analysis and efforts to improve performance–with relative few attempts to train people out of non-training problems.

For example, for cardiac catheterization, Hopkins had an infection rate of 11 per 1,000 procedures.  According to Pronovost, at the time that “put us in the worst 10% of the country.”

Here’s a diagram I created to illustrate some influences on performance:

And here are points that Pronovost makes:

• Hopkins developed a checklist to standardize what to do before catheterization (wash hands, clean skin with chlorhexidine, drape the patient, etc.).  To me, this is support for item 3 above.
• Supplies, which had been stored in as many as eight places, were prepped in a cath cart–with someone assigned to make sure it was stocked and handy.  Item 2, equipment and materials.
• The hospital asked nurses to remind doctors to wash their hands–and empowered nurses to stop procedures if this didn’t happen.  Item 8 (standards) and item 9 (feedback) — and, you could argue, item 7 (consequences).

Note also that the Hopkins project defined a specific problem (a high rate of infection), analyzed likely causes, chose action based on those causes, and measured the results.

Pronovost forcefully describes another barrier to performance: workplace culture:

As at many hospitals, we had dysfunctional teamwork because of an exceedingly hierarchal culture…

…in every hospital in America, patients die because of hierarchy. The way doctors are trained, the experiential domain is seen as threatening and unimportant. Yet, a nurse or a family member may be with a patient for 12 hours in a day, while a doctor might only pop in for five minutes.

I mention this not to single out doctors but to emphasize that performance problems usually have multiple causes.  Some you can address in a straightforward fashion (rethinking where to keep the supplies).  Others, you have to keep working at.  In commercial aviation, use of preflight checklists is maintained not only by regulations but by the active support of those who use them: it’s not smarter or more efficient to try memorizing the checklist.  In fact, it’s seen as counterproductive.

(Note what the Skout Group says about workplace culture–and checklists–in terms of USAir 1549, the plane that Sullenberger and Skiles managed to set down in the Hudson River last year, with no loss of life.)

Back to the hospital: isn’t there some need for training?

I couldn’t say; Pronovost’s interview doesn’t have enough detail.  It could be that some hospital staff need training in preparing for catheterization.  If that’s the case, I suspect that inside the generalization of “preparing for catheterization,” there are distinct subtasks: identify and obtain the supplies, prep yourself, prep the patient, assist (or be assisted by) a specialist, and so on.

And perhaps there’s a meta-skill: make sure the individual assigned to this task can first demonstrate an acceptable level of skill.  In other words, something like “we expect you learned this in nursing school (or wherever); here are our standards; we’ll observe you and tell you how you did.”

I don’t know that I’d put the necessary culture change under “training.” I’m pretty sure the label is less important than the goal: having doctors (most not hospital employees) and hospital staff work together to reduce the rate of preventable infection.

Word of the day: nosocomial, meaning “occurring in a hospital.” I came across it in this 2001 CDC report, The Impact of Hospital-Acquired Bloodstream Infections.  Its low estimate for life-threatening bloodstream infections acquired in the hospital is 87,500 per year.  The low estimate of deaths from these bloodstream infections: 8,750.

(And bloodstream infections are estimated at 10% of all nosocomial infection.)

I saw this comment on Twitter:

@urbie: Flashback.. taking a text-based CBT. Owie.

I couldn’t resist retweeting…nor adding my own comment:

@dave_ferguson: RT @urbie: Flashback.. taking a text-based CBT. Owie. // Me: yeah, like going to college at the ATM screen.

This led to a side conversation with Simon Bostock about the (mostly) bad old days.  I’ve written thousands of lines of text-based CBT: long ago, I was in charge of computer-based training for Amtrak’s reservation system, and I consulted with Marriott when they launched MARSHA, their hotel system.

It’s hard to convey the impact of the all-text, monochrome oppression of dumb terminals, back in the early 1980s.  Amtrak’s ARROW system couldn’t (or wouldn’t) display lowercase letters, so the entire screen (25 rows, 80 columns) would be in uppercase.

(My ATM remark reveals the bias own experience; actually, I haven’t seen an all-text, graphics-free ATM in quite some time.  But a mainframe screen is falling into the same category as a dial telephone or a ditto machine.)

Back then, CBT could be downright horrible. So is a good deal of contemporary digital learning; it’s just horrible in newer, flashier, noisier ways.

I recalled, during my conversation with Simon, that at the time I’d taken great pride in the training we created at Amtrak.  The reason for the pride?  We made good use of the tool.  It was what we had to work with, and a better tool  for the situation than any other realistic option.

Every technology has its advantages and its drawbacks.  If you work in a group setting, let alone an organizational one, sometimes you choose to live with the givens.  So, at Amtrak: we had over 2,000 people in over 125 locations who needed to learn to use a new reservation system, different from the one about half of them had seen before.  And we wanted the training to work for new employees–say, 400 or 500 per year–so we didn’t want to keep saying “in the old system…”

So what did we do?  This kind of thing:

• Started with a goal in mind. Specifically, we wanted to teach people how to make reservations and issue tickets using the new system.  Folderol about what kind of mainframe we had or what company made the previous system was, well, folderol.
• Strenuously avoided on-screen lectures. We worked hard to avoid over-explaining.  A frequent pattern: simple example, you-do-it problem, clear feedback for varied answers, then extension to more cases.
• “Individualized” by chunking. Most people would learn on the job, so we build courses to take less than 20 minutes.  Clear topics (“how to report train time”) made it easy for someone to decide whether to take a given course.
• Built a practice system. Probably the single most useful thing we did was to create (in collaboration with the Train Operations department) a set of “training trains.”  Any user of the Amtrak system could use a special ID to work with these in any way he wanted–make reservations, change reservations, even issue tickets (nonvalid ones–they wouldn’t print).  This allowed people to apply the general procedures from the formal CBT to the kinds of problems they encountered on the job.

Note that the training trains were not part of the CBT.  One person on my team worked with Train Ops and essentially cloned actual trains.  You had to use the training-train ID to get to them, and with that ID, you couldn’t work with actual reservations.  So it provided robust practice (you were using all the capabilities of the system) while protecting you from serious consequences for mistakes (you couldn’t cancel someone’s actual trip).

Our success was a result of combining the new tool with the best of what we knew about learning in the workplace.  All of this reminded me, as Charles Aznavour does in a different setting, that at times in the past, people weren’t wrong.

Public domain image of a dumb-terminal screen by SamuraiClinton, from WikiMedia Commons.

Collaborative Enterprise’s blog carnival this month looks at formalizing the informal–are there ways to deliberately harness social media to foster learning without losing the (presumed) value of personal connection?

Sure.

Now, I tend to slightly resist two of the implications I see here.  First, while it’s true that “training, education, and schooling are not learning,” I don’t think it follows that learning can’t occur where these are present.  And second, learning did not start happening only after the invention of internet-based social media.

I know that Harold Jarche doesn’t think that, and I’m pretty sure Frédéric Domon doesn’t, either.  I just wanted to make my thinking explicit.

I’ve been watching the Winter Olympics and thinking about how it combines individual and organizational goals.  And just as I write this, I see multiple organizations that aren’t all in a single hierarchy:

• Small, individual sport groups (German women’s bobsled)
• Related-sport groups (sliding sports)
• National teams (Germany)
• Judges, referees, and other arbiters
• Timekeepers, scorekeepers
• Coaches
• Trainers
• Volunteers
• Fans
• Reporters, writers, bloggers, and other who opine
• Local, national, international Olympic officials
• Technicians
• Security
• Sponsors
• Donors

You couldn’t ever satisfy all these groups, let alone their subgroups and individual members–but they find enough common ground to bring about an Olympics.

I see a dynamic for the competitors: each has his or her personal goal, but each had to fit into a larger structure, especially but not exclusively for team sports.  If you want to compete in Nordic combined, you agree that your performance on the jump will determine your starting place in the cross-country element.

Since we’re talking athletic competition, psychomotor skill comes into play, and “training” (in the sense of focused attention, demonstration, feedback) plays a major role.  You do learn as you train–by which I mean, not only do you build the muscle memory and automatic physical behavior, but you also refine and deepen awareness and the potential to respond to outside stimuli.

Another thought came to mind when I was getting annoyed by local-news people focusing relentlessly on medal count: so-and-so “had to settle for silver” (because she was favored to win gold, but didn’t); someone else “won a stupendous bronze” (because he performed much better than expected).

Those phrases got me thinking about how, if you work within a large organization, you need to find ways to align your personal goals with the organization’s in a way that’s authentic for you and helpful to the organization.  In part, it’s the old concept of the king’s shilling: if you’re accepting the paycheck, you’re granting the organization’s right to set and pursue its goals and to ask you to help achieve them.

When you can’t ethically do that, it’s time to get out.

Another point of view emerged when I was reading an obituary for jockey and mystery author Dick Francis, who died this week.  He wome some 350 races in a nine-year career, and rode as jockey for the Queen Mother’s horse in the 1956 Grand National–where his horse, in the lead and 50 yards from the finish, suddenly collapsed.  In his autobiography, Francis wrote:

I heard one man say to another a little while ago [4 or 5 years after the race], “Who did you say that was?  Dick Francis?  Oh, yes–he’s the man who didn’t win the National.”

I’m sure Francis would have love to win it, just as every Olympian would love to win the gold.  But individuals and even organizations often need to reframe their goals, to redefine what success means.

In the workplace, I think that means organizations have to work harder at finding ways to match their goals with those of individuals within the organization.  I once worked across the hall from an ambitious young guy.  He had some “rules for success” on his wall, including “love the business.”

Me, I didn’t love the business–and I can think of at least one boss who’d agree.  But often I did love helping the customer perform better, and that didn’t mean beating him to death with PowerPoint.  It sometimes meant working with him to apply performance-improvement strategies while calling them “transfer of training,” because at the time helping that transfer occur was a lot more important than fretting about jargon.

CC-licensed photo: Olympic colors by kk+ / Kris Krüg.

Harold Jarche posted a great set of slides on complexity, the web, and business.  I’ll get out of the way and let him explain:

The New York Times reports on an analysis of 32 million user passwords.  Someone stole them from RockYou, which helps people use sites like Facebook and MySpace; the list was posted online.  As one researcher commented, a list this size is “the mother lode” for examining user habits.

Imperva, a data security firm, has published highlights of its  analysis of the passwords.   The chart on the right is taken from Imperva’s analysis.

Remember, the group was roughly 32,000,000 — which means that nearly 1% (290,731 individuals) used “123456″ for their password.

If you add up all the “123-” variations in the top 10, you have 488,878 people who chose consecutive numbers starting with 1 as a password.

The Times article notes that 20% of the account holders–6.4 million people–used only 5,000 different passwords.  (Number 5,000 in terms of popularity was “tigger123.”  That’ll keep the hackers away.)

I’m writing this on Thursday night, following a #lrnchat discussion on workgroups with little connectivity or tech-savvy.  Granted, the RockYou account holders probably had personal rather than workplace goals in mind.  At the same time, I’ll argue that their password selections reflect some of their own tech-savvy… or at least their actual performance, regardless of any theoretical savvy.

Which means that “strong password training” probably won’t solve on-the-job security shortcomings.  People might still use weak passwords because:

• They don’t have an easy way to generate strong ones (like this one that includes a mnemonic).
• They have too many different passwords to recall.
• Nothing bad happens immediately after they choose a weak password.

In a work setting, imagine combining the third and first points: a system or website tells you (politely but candidly) that your password isn’t secure, then offers you help in creating one that is.  The result probably won’t be “abc123″ or “qwerty.”  A more practical problem is that the result’s going to be hard to remember, which increases the likelihood that someone will want to write the password down.

I suspect that even the “tech-savvy” are tempted to cycle through maybe five or six pet passwords, in the same way that a lot of people list “regular backups” as part of their digital religion while rarely engaging in the practice.