Is There a Heffalump in the Room? Learning to Be a Leader, Part 1

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In Pooh’s “Huffalump” movie, Roo asks, “’Scuse me, what’s a heffalump?” Pooh, Tigger, Rabbit, Piglet, and Eeyore sing a song about the horrible qualities that they believe heffalumps possess (three heads, fiery eyes, spiked tails, etc.).

When presented with a difficult task or situation, we often find ourselves in conflict about how to deal with it. The Chinese word for conflict or crisis consists of two symbols: danger and opportunity. When we are faced with difficult moments, we must remember we have a choice. How we manage that choice often determines the outcome of the situation. In audiology, we are often faced with conflict ranging from difficult hearing aid fitting and counseling sessions to negotiating with vendors. Sometimes we have conflicts internally in our office or conflicts regarding professional issues in our membership organizations.

Conflict often makes us think of a negative experience that did not go well. We must remember, however, that conflict is not a bad thing but an opportunity for both personal and professional growth. Think about how boring meetings and conversations would be if people did not speak up and share their thoughts and ideas. If conflict is handled right, then there are benefits that you might not expect such as:
Better understanding of the issues and the opportunity to expand your awareness to the situation.
Increased trust among your team members and colleagues. People feel safe to express themselves, allowing an opportunity for growth.
Enhanced self-awareness due to being more aware of your goals and thoughts on how to be an effective leader and team member.

Handling conflict, however, does not necessarily come easily for most. Here are some key strategies that leaders use every day to help prevent and/or defuse conflict to allow for productive opportunities or engaged conversations.

When dealing with difficult moments:
Focus on the process. It is not about the people, it is about the system or process.
Go “below the line” for a collaborative approach for conflict resolution. Imagine an iceberg. You can only see the top, which is usually only 10 percent of it. To navigate the waters, you need to know what is below the sea line, the other 90 percent, to be safe.
Listen first and then ask questions for understanding. Remember restate, rephrase, and summarize when trying to gain understanding and trust.
• Create options collaboratively. Be open to ideas.
• Negotiate what options would solve the conflict.

When dealing with conflict, it is important to consider when do you take action and who should have the conversation. To answer when—the sooner the better. Addressing unprofessional behaviors, engaging with the dissatisfied patients, and/or intervening before people forget are essential to maintaining accountability, employee satisfaction and retention, and minimizing potential liabilities. To answer who—anyone in most cases. Regardless of the title, anyone should be able to talk to us and share ideas without feeling minimized or degraded. If the leaders blink or if the culture is of the mindset “it doesn’t matter, can’t change it…,” then it is important for the leadership to step in and be a role model on how to resolve conflict or better yet create a culture where conflict is considered to be an opportunity not a negative event.

To learn more about your conflict style, the Thomas-Kilmann Conflict Mode Instrument is a widely used instrument that provides helpful information on your conflict style. The conflict styles are Competitive, Collaborative, Compromising, Accommodating, and Avoiding. Different situations call for different conflict styles, so knowing what domains you typically prefer will be helpful.

I encourage you to take Roo’s direction and instead of being scared of conflict, look for the heffalump yourself and discover that often the many traits outlined are things that are not true or can be negotiated.

So, you ask, how do I negotiate these uncharted waters? Next, Leadership Realities Part II will provide you with your compass.

Tamala Selke Bradham, PhD, CCC-A, is a quality consultant in the Department of Quality, Safety, and Risk Prevention at Vanderbilt University Medical Center. She is an affiliate of ASHA Special Interest Group 9, Hearing and Hearing Disorders in Childhood.

Audiologists, You Know the Science of Hearing but Do You Know the Art of Listening? 

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As audiologists, we learn about anatomy, physiology, psychoacoustics, pathologies, technologies, and interventions. We are experts in assessing hearing sensitivity, diagnosing hearing loss, and providing audiological (re)habilitation with technologies and counseling.

Here’s a question, though: Are we experts in listening? To be an effective listener, you need to focus on the meaning of what you hear and take in to gain understanding. Have you ever taking a listening test? Have you ever given your patient a listening test?

There are many types of listening styles, and there’s also depth of listening. In reviewing the literature, I identified 27 different styles of listening and six depths of listening. I believe we use different listening styles and depths of listening based on what is happening in the moment. So, I am a client, I may, during a hearing test, be a discriminative, deep listener. Or if I am the patient learning about the new hearing aids you just fitted for me, I may be a content, full listener.

These are the four most common types of listeners.

People-oriented (empathic) listeners, who:

  • Build relationships and interpersonal connections
  • Search for common areas of interest
  • Tune into the speaker’s emotions, body language and prosody of speech
  • Ask, “Tell me all about it – what happened?”

Action-oriented (evaluative) listeners, who:

  • Prefer information that is well organized, brief and error-free.
  • Will digress when a speaker goes off on a tangent.
  • Evaluate information heard and do not take things at face value.
  • Ask, “What am I supposed to do with all this information?”

Content-oriented listeners, who:

  • Enjoy listening to complex, detailed information.
  • Ask questions to test speakers (are they credible?).
  • Focus on issues and if information is credible.
  • Ask, “Is that so?”

Time-oriented listeners, who:

  • Love “to do” lists.
  • Are overbooked, so they want messages delivered quickly and briefly.
  • Enjoy the role of keeping people on task during the meetings (the time keeper).
  • Ask, “And, what’s your point?”

If you are a people-oriented listener and your patient is a time-oriented listener, then your patient may feel that you are intrusive and not respecting their time. If you are a content-oriented listener, then be careful not to “throw the baby out with the bathwater”: When taking a patient’s history, you don’t want to ignore what could be key information because you believe there’s a lack of sufficient evidence.

And those audiologists who are action-oriented listeners may need to watch that they aren’t perceived as inpatient and not caring. Knowing your listening style can help you better understand how to adapt to various listening situations. Knowing your patient’s listening style will help you with how to deliver quality care!

There are multiple tests available to assess your dominant listening style.  Here are a few that I have used:

In establishing relationships with your patients, the importance is not so much in what you say as how you listen. Knowing hearing thresholds is only part of the evaluation. Listening to what your patient shares with you will drive your overall outcomes in patient care.

Tamala Selke Bradham, PhD, CCC-A, is associate director of quality, protocols, and risk management in the Department of Hearing and Speech Sciences at Vanderbilt University. She is an affiliate of ASHA Special Interest Group 9, Hearing and Hearing Disorders in Childhood.

Ensuring a Warm Send-Off for Your Clients

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Those of us working in hospital settings hear about discharges all day long. And we track everything about them: monthly rates, handovers, discharge summaries, patient’s perceptions of them.

In the outpatient world, discharges are just as important. When the patient leaves your office, do they know what they need to do next?

No matter the setting, we health care providers have a responsibility to ensure safety and efficiency when discharging a patient from care.

What happens when discharge isn’t done well? Patients experience adverse events due to delayed or absent communication, inaccuracies in information exchange, or ineffective planning or coordination of care between providers, as found recently in a study by Gijs Hesselink and his colleagues. In fact, at least 20 percent of patients report adverse events following discharge, and least half of these adverse events could have been prevented.

So what is your discharge or “thank you, goodbye” practice?  Here are five take-aways to consider:

  • Write it down!  Discharge instructions should be written down for patient understanding, not for compliance and insurance companies.  Don’t worry about saving the trees, give the patient the recommendations/plan of care in writing.  And, if you have it available, the patient should be able to review them at any time on your secure, web-based patient portal that you have available.
  • Share your instructions/plan of care with the patient’s medical home, therapists, and those that need to know!  Handoffs are one of the biggest problems in patient care that leads to adverse events.
  • Check for comprehension!  Having the patient repeat back what they heard is essential.  Using techniques like “Teach Back” or motivational interviewing are great ways to check for comprehension.
  • Make the discharge follow-up phone callMultiple studies show that if a simple phone call is made within 48 hours of the patient being seen or discharged from the hospital, it is a win-win for everyone involved. For outpatients, not only will you keep that person as a patient, but you will get more referrals due to having a happy customer. For hospitals, research shows reduced readmission rates and significant cost savings.
  • Own the discharge process.  When the patient leaves your practice/hospital, everyone who directly and indirectly touched that patient needs to own the process.  Does the patient know when to return?  Does the patient know who to contact if they have problems?  Will the patient tell a friend about the great experience they had?

Are you already doing these five simple things to keep patients safe?  If not, consider one of these for your next Plan-Do-Study-Act (PDSA).

For additional information about discharge planning, visit leancare.wordpress.com.

Tamala Selke Bradham, PhD, CCC-A, is associate director of quality, protocols, and risk management in the Department of Hearing and Speech Sciences at Vanderbilt University. She is an affiliate of ASHA Special Interest Group 9, Hearing and Hearing Disorders in Childhood. This post was adapted from her blog leanhcare.

 

Audiologists: Are Your e-Records Putting You At Risk for an Audit?

EHR imageMedicare is encouraging the implementation and use of electronic health records, but the way some practitioners fill out these records is under scrutiny. The U.S. Department of Health and Human Services Office of Inspector General has made cloning (inappropriate use of the copy-paste feature) and over-documentation areas of high priority for 2014.

OIG has recommended that the Centers for Medicare and Medicaid Services  evaluate EHRs for fraud vulnerabilities. If fraud is suspected, practices will be subject to fines and penalties. It is essential that audiologists use EHRs effectively and not take too many shortcuts. As we transition from paper charts to EHRs, here are a few things to know.

1.) Review all entries in your note. Avoid repeating past information.
According to CMS 1995 and 1997 documentation guidelines, “A review of systems and/or a past medical, family, and social history obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician [audiologist] reviewed and updated the previous information.” In other words, in your note, refer to a previous note that has the comprehensive history. For example, you could write, “See note dated 1/1/2014 for a comprehensive history of patient X,” and update the present concerns/reason for the visit.

2.) Make sure all your diagnoses listed are relevant for that patient’s visit.
Many EHR systems allow the copying of all diagnoses listed in the problem list, even those that have been resolved or aren’t the reason for that day’s patient visit. Be sure to only list the diagnoses that are relevant for the reason the patient is seeing you. For audiologists, the first diagnoses code should be your treating diagnosis followed by the relevant medical diagnoses. Sometimes the treating and the medical diagnoses are the same and there is only one listed.

3.) Make sure your note is individualized for that patient’s encounter.
Many EHR systems also allow you to clone a previous note. Use extreme caution with this feature. Auditors are looking for patterns in documentation. If all your notes look essentially the same across time and across the patients you serve, then they will cite you for not providing individualized care. Review every item in your note to make sure they are relevant for that patient’s visit that day.

4.) All notes should be signed by the licensed professional, correctly dated for when the services were rendered, and the time associated with the visit.
Lawyers, auditors and accreditation organizations look when the notes are completed. All notes should be started on the day services were rendered and finished within 24 hours. The note should have not only the signature of the provider but the time and date on the note. If your notes are not completed in a timely manner, then be prepared to answer, “What are you trying to hide?” or, “How many patients did you see that day? How could you remember what to write if you did your note a week later?” Any notes that are placed in the medical chart greater than 24 hours after the patient was seen is subject to concern.

5.) Avoid saving the note on the wrong date—a common mistake when a professional does not complete documentation on the day of service.
Two things to know:

  • If the note is not there on the day of service, then the patient was not seen.
  • If you dropped charges on a day of services that the patient did not have an appointment and was not seen, then this is considered fraudulent billing and you could be subject to not only losing your license to practice but also significant fines. If this happens, amend the note immediately to the correct day of service! To prevent this from happening, try to incorporate your documentation during the day or at “bedside” when you are with the patient.

6.) Develop a policy on the use of cloning, the copy-paste feature, and over-documentation in EHR technology. CMS has been charged with reviewing your policy if your site is selected for audit. OIG reported that only a third of practices audited had a policy. Be prepared!

Documentation should not be considered additional work but an extension to your patient care activities. Finally, remember our ultimate goal is to provide the best possible care that is timely and based on evidence-based practices. Having timely and accurate information in your note, and nothing else, will help provide the best possible care to your patients. The consequences are too serious to do anything less.

For additional information about documentation, visit leancare.wordpress.com.

Tamala Selke Bradham, PhD, CCC-A, is associate director of quality, protocols, and risk management in the Department of Hearing and Speech Sciences at Vanderbilt University. She is an affiliate of ASHA Special Interest Group 9, Hearing and Hearing Disorders in Childhood.

 

 

The Top 10 Take-aways for CSD Work With Families

familyportraitAccording to my dusty hardcover Webster’s dictionary, a family is defined as: All the people living in the same house; household, 2) a social unit consisting of parents and the children they rear…” (Neufeldt, V, 1988). Since this was dated, I thought I should go to The Free Encyclopedia – Wikipedia. They define family as: “In human context, a family is a group of people affiliated by consanguinity, affinity, or co-residence. In most societies it is the principal institution of the socialization of children…”

In our profession, we have had to make a mind shift from client-based services to the child to family-centered services focused on collaborating with and supporting the family. In this partnership, all people involved acknowledge that each possesses unique skills and knowledge, and they demonstrate trust and respect for one another. Professionals recognize the decision making power of the parent.

Why is family-centered care important? Outcomes! For a child to reach his or her fullest potential, it is essential to have appropriate resources, qualified professionals and family involvement. In family partnerships, families receive support not only from professionals, but from other families with similar circumstances and from the community at large.

Here are the top 10 take-aways for the next time you work with a family:

10) Time. As a professional everything is fast paced. After all time is money — and you serve a lot of people. For a parent, however, time is very slow; they are constantly waiting.

9) Don’t make assumptions or generalizations. Every family is unique with very specific needs. Present all options…don’t be biased in what you say.

8) Don’t label families—or each other.

7) Don’t make inappropriate comments about your profession. Talking negatively about your workplace or another professional reflects poorly on you. The average “wronged” customer will tell 25 others about the bad experience. Don’t reinforce negative experiences.

6) Be confident but not arrogant.

5) Communicate! Communicate! And communicate some more! You cannot overstate anything. Monitor your tone of voice, body language, rate of speech, and be mindful of professional jargon.

4) Listen! Listen! And listen some more! Show the family you are listening (body language). Provide feedback, defer judgment, and don’t try to rescue—empathize.

3) Acknowledge the parent’s efforts and strengths. No matter how small it is — acknowledge something positive.

2) Keep in mind the lack of consistency in our field. Families will see a variety of specialists, and each will provide an opinion about what the parents should do. “This method is better because”…or “You should try this.” The various opinions can be confusing and overwhelming for the family. Be respectful of one another.

1) Respect and patience. Remember parents are people too!

To learn more about family support and family-centered practices, check out the transcript of an “Ask the Expert” online chat about these services, held April 30 by ASHA Special Interest Group  9, Hearing and Hearing Disorders in Childhood.

Tamala Selke Bradham, PhD, CCC-A, is coordinator of ASHA Special Interest Group 9, Hearing and Hearing Disorders in Childhood. She is also associate director of quality, protocols, and risk management in the Department of Hearing and Speech Sciences at Vanderbilt University. She and Joni Alberg, PhD, executive director of BEGINNINGS for Parents of Children Who Are Deaf or Hard of Hearing, Inc., in Raleigh, N.C., answered questions during the SIG 9 online chat.