Often times when we roll out a new tool or tactic staff initially practice the new behaviors but may do so inconsistently. Rarely is the behavior fully "hardwired." Studer Group's definition of hardwired is "the process by which an organization, department, team or individual integrates a behavior or action into the daily operations to ensure it becomes a well-executed habit." We would consider a behavior hardwired when it's used at least 90 percent of the time.
When we adequately train employees and have explained why this new behavior is important, we typically see a large percentage of compliance. Explaining the "why" is an important step so staff understand exactly how the new behavior(s) will benefit them (such as saving time, reducing call lights, etc.) and how it will benefit our patients (reduced wait times, fewer readmissions, etc.). However hardwiring a new behavior can take time. If employees are not always practicing the behavior, there are four tactics that leaders can employ to validate and verify that the behaviors become hardwired.
The first is simulated skills labs. Skills labs allow leaders to identify performance gaps between what staff feel they are doing and what they are actually doing. It's important to remember that employees are not intentionally disregarding the training (if they are, you may be dealing with a low performer). They may need additional training or to see the new behavior in action to bridge the gap. Skills labs provide this opportunity.
Identify key individuals that should participate in the skills labs and be sure to include those that interact with emergency department patients regularly, such as nurses, ED technicians, emergency physicians, physician assistants, security and so on. Identify one person to play the patient, one as a family member, and a third person as the evaluator. Have individual's role play the new behavior and offer positive feedback and coaching. This affords the opportunity to address areas for improvement and point out gaps in the processes in a safe environment.
The second tactic is direct observation. Once skills labs are complete, leaders are then able to validate the new behaviors are being executed by directly observing staff over of the next 90 days. Leaders can round on their direct reports and shadow them during interactions with patients and family members. The leader can simply observe and then offer compliments or coaching directly to the staff member practicing the new behavior. Additionally, let them know you will be rounding with them again in the near future to re-evaluate the skill.
The third tactic is leader rounding on patients. Leaders also have an opportunity to gain real-time feedback directly from the patient to validate the right behavior is being performed. Rounding on patients in the emergency department can be difficult due to the high volume and turnover of patients. A good rule of thumb is for leaders to round on 25 percent of the treat-and-release patients within a 24-hour period. For example, an emergency department with an average daily volume of 100 patients per day that admits 20 patients would have a goal of rounding on 20 of the 80 remaining treat-and-release patients.
The ED medical director, charge nurse, nurse manager or ED director are various leaders that can perform this rounding. Leader Rounding on Patients provides an opportunity to ask the patients questions, but also to manage their expectations, recognize the employee, manage up all staff treating the patient, and address any service recovery issues. Within the 3 to 5 minute interaction, be purposeful with your questions and remain focused on the outcomes you are trying to achieve (learning more about the care being provided and how you will use the information afterward). You should not be administering care to the patient during your visits, unless the patient's safety is at risk. The information you capture can be logged on a Leader Rounding Log to validate that you performed the rounding and to remember the outcomes of the interaction.
The fourth and final tactic is post-visit phone calls. The purpose of conducting post-visit phone calls includes items such as validating that patients understand their medications, answering any questions about their discharge instructions, and discussing any possible side effects. They also provide us the opportunity to capture information in real-time and validate the behaviors of staff, just as with leader rounding. We can then take immediate action to fix any issues or opportunities instead of waiting to get survey results.
By utilizing these four tactics, we can validate and verify that behaviors are hardwired and being practiced at least 90 percent of the time. In doing so, we decrease variability to create a highly reliable environment for providing safe and quality patient care.
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Reference: Shupe, R. Using Skills Validation and Verification to Hardwire Staff Behaviors. J Emerg Nurs. 2013; 39 (4): 364-68.