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“Would you tell me, please, which way I ought to go from here?” “That depends a good deal on where you want to get to,” said the Cat. “I don’t much care where-“ said Alice. “Then it doesn’t matter which way you go,” said the Cat. “-so long as I get SOMEWHERE,” Alice added as an explanation. “Oh, you’re sure to do that,” said the Cat, “if you only walk long enough.”
I grew up reading Alice’s Adventures in Wonderland, and you know what? There’s a lot of wisdom in its pages. This section resonates particularly, because when we think about our careers in critical care, we are all likely to walk for long enough to get somewhere – the question is, where do we want to get to?
Battle I want to be excellent
She doesn’t know where she’s going I don’t know where I am
Heisenberg - round and round, no progress
What does excellent even mean?
[Interaction - what is excellence?]
Not destination Theoretical place, like Wonderland, Changes as we explore it. Medicine is evolving, static definition will be outdated by the end of the week.
Elements that help us to navigate journey to excellence challenge us to keep thinking, growing and changing - our personal Cheshire cats.
Excellence as an individual and excellence as a team. Excellence more than just me. How we can work out where we are, where we are going, and how to get ourselves there.
At the start of any journey, we need to have some idea where we are.
Illusion of stillness Knowing where we are - a continual evaluation, key to this is reflection. Reflection allows us to look at what is under the surface. Replay and dissect the things we have said and done, squeeze out every drop of learning Understanding of the self and the situation, to inform future actions.
Tough stuff is natural Cases confront us for a number of possible reasons, we should reflect on them. We find peace, change practice, move on and heal.
Tough stuff - immediate phase - emotion driven. Ride it out. Share it with friends. Be kind to yourself. But don’t miss the analysis phase, after the storm.
But we should also reflect regularly, Toyota’s Shippai Gaku Nososume, “an invitation to the science of failure”. My juniors do this in the ED in Australia
Break down the facts of what happened, the reasoning and drivers behind the facts and future planning
Be open and honest about the emotional component.
Start with “what happened?” and follow with “how do I feel about it?” or start with “how do I feel?” and then “what happened to make me feel this way?”.
Then framework to thrash out the reasoning and driving forces.
At Sydney HEMS we use STEPS Similar acronym in our Zero Point survey - which Simon is going to talk about a little later.
At Resuscitology we use GPAS (Goal – what are we trying to achieve, Plan – how are we going to get there, Action – what do we need for the plan to work, Skills – how do we do those things)
This model moves from macro to micro, to allow us to really plan better for next time: Cliff has some examples of GPAS in action at Resus.Me
and it’s GPAS we are going to use
final challenge of reflection: consider the future, ask “what will I do differently?” or “what will I take forward from this situation?”.
The answer may be nothing – but that’s pretty unlikely.
So now we know where we are and we know our goal is excellence,
we can start to plan how we are going to get there.
But I don’t think we should make that plan alone.
Think about ourselves and our practice in the bubble of our own perceptions of our value, skills, and attitudes Dunning and Kruger, that we really have no idea whether that bubble is floating high in the sky
or part of a pigsty.
Informal peer review “coffee and cases” open forum for our staff to bring tricky cases and chat through the details.
Mentor - sounding board for the tough stuff. Choose person who knows what it’s like to work how and where you do, and who cares about you enough to be honest but kind.
Peer observation. free to drift away, Direct observation at consultant level; we both learned from. I’m hoping to have a framework to help you do this in the next few years.
What’s our action - what do we need to actually do, to enact this plan for excellence?
Identify our comfort zone – and step into the fringes. A physical place, a practice area, or a mindset. Talk about challenges of new workplaces - my experience
Move beyond, into fear. What scares you? How can you confront it? You will become less afraid, HUET fear story What’s your fear? A sick neonate? A major trauma? How can you step far beyond your comfort zone and face it?
Limits of our comfort zone -> identify the skills needed to deal with our fear.
Divide this into body and mind, which is (of course) an artificial division because they are interlinked.
Alice ate cookies and they made her smaller. Logic to focusing on the big stuff we might be overlooking. For me it’s ultrasound, and I just need to get myself together and make an effort to get better and more confident – by spending some time upskilling, it’ll make it a far smaller deficit
But small stuff too, that might make a big difference. My must-dos Marginal gains?
Who are you in your department - in the context of your story? Who am I? Write your own mantra
Self - kind and competent Work - privileged, up for this Colleagues - fortunate, they have come to do a good job today
I think if you take yourself through this process, you can start to develop a plan for excellence with some meaningful steps we can actually work on
Don’t work in isolation Recognise how teams contribute to excellence. Parallel track
Audit Set standards then measure yourselves Sydney HEMS has KPIs around prehospital intubation, and around scene times.
Again, we know we are aiming for our goal of excellence, so
we can start to plan how we are going to get there.
Clinical governance - how it is going to move towards excellence. JR CGD. Accessible Sydney HEMS, dial in options
M&M sessions - powerful and valuable learning, takes time and effort to extract. Not just bad without good A&A – at Sydney HEMS as part of our governance processes.
Be open De-anonymise? Curiosity and compassion
Research -how fits into global picture. Good quality primary research is hard work, but teams see tremendous benefits.
Meaningful and lasting change Consider culture: Nebulous term, critical to the way our teams function what we do and the way we do things. Determines our ability to enact change.
Sydney HEMS: regularly and explicitly sharing our core values. Language matters. 1. Daily brief 2. Risk assessment before clinical 3. 4 to say GO
Culture beyond safety But safety culture - good example of embedding shared values can shape decision-making. What is the culture like in the places you work? What are your core values; how are they shared? How are they expressed?
What skills do we need in order to shape our team’s culture, and to help our team embody it?
Training our teams in clinical skills Free up the bandwidth to address behaviours, to embody our organisational culture and make the changes we want them too.
Teach big stuff: life, limb and sight-saving procedures. They are rare, but confronting, Formal simulation - “currency” requirements. Degree of automaticity, offload bandwidth, available to manage the non-technical skills
Teach common stuff: the bread-and-butter of what you do. Big gains with small improvements in the stuff you do a lot – Decision-making, communication and teamworking alongside clinical skills. In-situ simulation - St George story. Embedding challenges
Easy to be The Boss. Role-model perpetual learning. Sharing uncertainty, errors, failures - flatten departmental hierarchies Colleagues to speak up, “what am I missing?” - permission to save your ass.
It’s hard, because we doubt ourselves regularly Overcome that by convincing everyone else Not fooling anyone. Do our teams a disservice this way. Stay curious and keep learning, openly. Thanks to St E’s team!
Lucky to have had the opportunities led me to reflect on these dimensions of what we do, Don’t have to move halfway across the world in search of personal and organisational excellence.
Excellence relative – different things to different people. No magical unicorn department where everything is perfect. None of my 9 workplaces, not me!
When our goal is excellence
reflect, to know where you are.
Peer review, to know where you are going.
Identify your comfort zone, then get out of there!
Reframe your physical skillset looking at the big and small stuff.
Reframe your mindset
When it comes to excellence for your team
Audit, to know where you are.
Examine M&M and A&A, alongside research, to shape where you are going.
Examine your culture and own it.
and role modelling to effect meaningful and lasting change.
Growth mindset: striving for continual improvement, for consistency in excellence more meaningful aim than any single big win, just as excellence is a journey, not a destination. Joy in working here. Push yourself and organisation from where you are right now –
But - hard How to move forward? Important that you…
have support - one person from inside your organisation one from outside
for times you need someone to point out you’re trying to play croquet with a flamingo and a hedgehog.
Find your people. Those who will sit down over tea and work out riddles with you. Opportunity here! Your organisation: chat during the coffee break No-one here from the place you work: whole room of enthusiastic people who can be your outside champions and your source of support…