#198 Microskills for Change That are Big Enough to Matter, Small Enough to Win

[SPEAKER_04]: There can be like 10,000 baby alligators on you in a day and that those baby alligators show those little betrayals of purpose and that you can just take off one little baby alligator at a time.

[SPEAKER_04]: I do recognize I have never actually seen a baby alligator but then I finally did and I was like, wow, they're huge and they look fierce but just the idea that it's something that is your betrayal of purpose that's sort of latched on and how can you just get rid of one at a time because once you get rid of one then you often learn how to get rid of others. [SPEAKER_01]: So today we're talking about baby alligators.

[SPEAKER_01]: Those little betrayals of purpose, those death by thousand paper cuts. [SPEAKER_01]: Whatever you call it, it's, you know, those silly workarounds. [SPEAKER_01]: Those many phone calls it takes to get radiology to push over images. [SPEAKER_01]: Oftentimes it leaves us feeling so angry at the system.

[SPEAKER_01]: And, you know, these inefficient workflows, maybe you'll vent to the person sitting next to you, or you'll utter some curse words under your breath, or you try to go home, you don't want to think about it. [SPEAKER_01]: Your doom scroll until you feel some type of [SPEAKER_01]: dopamine, but either way, I think all of us have been there, and I'm so excited for headspace to think about this a bit more. [SPEAKER_01]: I'm Dr. Schrecher, ready?

[SPEAKER_03]: And I'm Dr. Marissa Kastro, and honestly, I've definitely been there. [SPEAKER_03]: But what do you think, Shreya? [SPEAKER_03]: What if we could actually change some of these, you know, baby alligator's? [SPEAKER_01]: Okay, it's always going to stick now. [SPEAKER_01]: Yeah, and so we talked to someone who's actually made those changes and tried to take off some of those baby alligator's one at a time.

[SPEAKER_01]: Dr. Eileen Barrett, she is someone who is so humble and gracious and until you really probe her and ask her,

[SPEAKER_01]: You wouldn't know that she's made all these changes to the system she's doing and then she's not someone out there trying to get credit You know, it she just has this superpower when it comes to quote unquote fixing broken systems and not in the way where she's trying to like over a haul of whole health care system but in a very tactical How can I make Monday less terrible way and in addition to being an internist Dr. Barrett is also the chair emirata of ACP Board of Regents and President of Amla the American Medical Women Association

[SPEAKER_01]: and I really liked Dr. Barrett's philosophy where she often thinks about it as what are the things that are big enough to matter and small enough to win, you know, the baby alligators. [SPEAKER_01]: And so let's go through some of Dr. Eileen Barrett's wins, right? [SPEAKER_01]: And throughout the episode, we'll try to really highlight one of the micro skills that she needed to make changes happen.

[SPEAKER_01]: And along the way, I'll also share one of my failure stories that I think might resonate with a lot of you.

[SPEAKER_04]: One sort of baby alligator that we got to speak about before that I felt like was very rewarding was we had a system where if you wanted to order refax them in for a patient, then you had to first call the pharmacist because the pharmacist had to check to see if the patient would be able to pay for it after they left the hospital. [SPEAKER_04]: We can have a respectful conversation about if that step is necessary because even short courses of the medication with the mortality.

[SPEAKER_04]: But he had such a long way back you should be given in the hospital right anyway, but they have that you had to call the pharmacy first to see if you could get it approved to make sure that they could get it when even if they were on it at home and just make sure they could have it after discharge. [SPEAKER_04]: And that seems on its face value, possibly something really reasonable.

[SPEAKER_01]: a classic, well-intentioned policy, right, to make sure that patients can actually pay for this extensive medication, but not so smooth of an execution, right, because what ended up happening often was a game of phone tag.

[SPEAKER_04]: What ended up happening is say you're a medicine attending or a resident, and you're admitting someone from the ER, you're calling the inpatient pharmacy, which is what's listed in the chart, is who you're supposed to call when you try to order refaxement, order reorder from the home meds, and you would call that person, and they say, oh, they're not actually in the hospital, so you need to call the pharmacist in the ER.

[SPEAKER_04]: But the only thing is that the pharmacist is in the ER,

[SPEAKER_04]: you, they need to know what bed the patient's in and oftentimes you don't know which one they're in because you've already seen so many patients you sort of got rid of that or they've been moved so then you don't know where they are so then you have to go and you have to either go at log out and go into a different system to find out what room they're in or you have to go like walking around trying to find them and it absolutely has been the case that in the interim the person actually was in the elevator on the way up to the room.

[SPEAKER_04]: And then you find that person and then that person says, oh, yeah, that sounds reasonable, right? [SPEAKER_04]: And then you still can't order it and you have to wait for them to order it and hope that they remember. [SPEAKER_04]: And in my experience, I never had that they forgot, but it didn't feel very good to have it out there in ether.

[SPEAKER_04]: So what I ended up upon fighting with the idea was, again, we have to check, I'm doing air quotes, we have to check to see if they can get it after discharge. [SPEAKER_04]: Was what we just did was us, well, can we just flip the process?

[SPEAKER_04]: which is can we order it and you check if they you're going to check anyway and you're going to check to see if they can get it after discharge and if they can't get it after discharge just let us know and then we'll figure out another plan and and so we switch that and then we tracked it over the course of just a year I mean actually less than a year and it was it was over 500 phone calls that we had saved just from that and I'm not going to say that saving 500 phone calls in under a year was like it's going to change the

[SPEAKER_04]: just one example of something that we can do by just switching of something in the workflow that can decrease the frustration or the thing that feels like it's getting in the way of you taking good care of the patient. [SPEAKER_00]: Yeah, and again, I could like see someone just being like so frustrated, being like, oh my gosh, like what is this like work around on work around and work around?

[SPEAKER_00]: Yeah. [SPEAKER_00]: And mentally, how did you get yourself to [SPEAKER_00]: right that email or have that conversation, and then what was that conversation and where email about? [SPEAKER_04]: Yeah, so when I was asking the pharmacist, speaking about it, and I said, you know, I just feel so bad. [SPEAKER_04]: You get all these calls through me all the time for this medication that this person is on at home.

[SPEAKER_04]: And the patients are on at home, and I know that there are always like, oh, I don't mind. [SPEAKER_04]: And I'm like, I know. [SPEAKER_04]: I also, you have a lot of work to do also too. [SPEAKER_04]: I wonder if, who needs a cure? [SPEAKER_04]: I think I talked about this as maybe we could just switch the order because you're going to be checking any way and then in the person said like, well, yeah, I don't Yeah, that's a good idea.

[SPEAKER_04]: Why don't you email our supervisor or this is their name and I emailed my word hi in Her name here and we recently haven't had conversations about the benefit of this medication.

[SPEAKER_04]: Reflects and then as you know and I appreciate that the pharmacy is so sensitive to the patients [SPEAKER_04]: And it has ended up happening at times where that I'm hearing about and I know has happened to me is that we end up having to make multiple phone calls because the patient isn't actually physically in the hospital and by the way, it's a continuation of a home medication and I'm concerned about delays to the patient care.

[SPEAKER_04]: And I said, so I wonder if this is something that we could talk about or to consider. [SPEAKER_04]: I hope we're able to get in touch. [SPEAKER_04]: Thanks very much, take a care, since you're the Eileen Barrett Hospital Medicine. [SPEAKER_04]: The person did right back to say something like, well, internal process, something about their internal processes. [SPEAKER_04]: And I said, oh, I, you know, I trust your internal processes.

[SPEAKER_04]: And don't wish to have any involvement in any of those with the exception of how it interfaces with the physician could we just switch the order because I know you're checking any way. [SPEAKER_04]: So it was a little bit of like a kind back and forth acknowledgement. [SPEAKER_04]: We may have had one phone call, um, with the person said, was they wanted to better understand the scope of the problem?

[SPEAKER_04]: So they asked at one of the pharmacy residents to like a little chart review. [SPEAKER_04]: They did find that some significant number of the patients were on it at home. [SPEAKER_04]: And so that was very persuasive to them because in a decreased the workload of their pharmacists. [SPEAKER_04]: And then they said, yeah, we can roll it out. [SPEAKER_01]: so much unpack here.

[SPEAKER_01]: I think one of my favorite parts is that she started off with, you know, I just feel so bad and get all these phone calls from me all the time for medication that patients already on at home. [SPEAKER_03]: Yeah, no for sure. [SPEAKER_03]: I have definitely called the same person many times, but I also really like that she calls out the good intention behind the policy. [SPEAKER_03]: She even wrote, I appreciate that pharmacy is sensitive to patient stability to pay.

[SPEAKER_01]: definitely. [SPEAKER_01]: And one of the things that I think is so powerful to point out too is that this wasn't like a massive effort to save 500 plus phone calls, right? [SPEAKER_01]: It was she had one phone call with the frontline pharmacist and emailed to the supervisor and then a few back and forth, right? [SPEAKER_01]: Maybe like total time of three minutes to an hour tops, right? [SPEAKER_01]: So all that time, but a whole lot of emotional intelligence and persistence.

[SPEAKER_04]: And I left a post-it note on my computer at work that would say follow up on with X-Amen. [SPEAKER_04]: So if I didn't hear back after a couple weeks, I would like circle back with the brief. [SPEAKER_04]: Hey, hope that all is well. [SPEAKER_04]: Just wondering, I know that everybody is super busy. [SPEAKER_04]: Is it something that has been able to that anybody's been able to discuss yet?

[SPEAKER_04]: Or is there any way, if it would be helpful, I'd be happy to come to an upcoming meeting. [SPEAKER_04]: You know, because you want to offer something, not just ask something in a follow-up.

[SPEAKER_04]: And then when they finally said they were going to roll it out, what they said was, the please make sure you educate the physicians that they are not, you know, that they are being careful with their, this is a really expensive medication that you're only giving it to people who absolutely need it. [SPEAKER_04]: So I said, of course, I would love to.

[SPEAKER_04]: If you feel like someone on your team wanted to come to one of our meetings to talk about it, you'd be welcome to, and they said, no, they didn't have time. [SPEAKER_04]: And I was like, that's okay. [SPEAKER_04]: I'll talk to them about it. [SPEAKER_04]: And then it was it.

[SPEAKER_01]: Yeah, I appreciate her also offering something right to come to a meeting to make it easier for the person on the other end, acknowledging how busy they are and really finding that win-win for everyone. [SPEAKER_03]: Yeah, and I also really love the post-it note reminders, but I do want to pause here because listening to Dr. Barrett, this all sounds so easy, right?

[SPEAKER_03]: Be curious, show empathy, but in reality, it's really, really hard in the moment, especially when you're advocating for patients. [SPEAKER_01]: Yeah, I have been there, and I wish I had Eileen's level of emotional intelligence. [SPEAKER_01]: I should remember a time when I was a resident and the hospital has switched over the long acting insulin that was on formulary.

[SPEAKER_01]: And there was this middle-aged patient of my non-English taking, who's doing it really well on insulin for many years. [SPEAKER_01]: And suddenly, she had multiple ED visits, her sugars were in the 360s, she had blurry vision. [SPEAKER_01]: Thankfully, no other complications, but still, my God, and you couldn't explain [SPEAKER_01]: Yeah, and nothing was really adding up.

[SPEAKER_01]: We ruled out things, we had her come back multiple times, tried different doses, and she just kept saying, like, look, I really need to go back to the other insulin that I was on. [SPEAKER_01]: And I mean, I'm humble. [SPEAKER_01]: I couldn't physiologically explain why her body was not responding to this type of long acting versus the other type. [SPEAKER_01]: But I said, look, I'll do what I can. [SPEAKER_01]: You know, I filled out the non-formular forms that I needed to.

[SPEAKER_01]: I think I was on my CC rotation, and so I got my day off. [SPEAKER_01]: I mean, she was sending me so many patient portal messages, she was so distressed about it, so I was like, okay, she will, I will take care of this. [SPEAKER_01]: I went and delivered to the pharmacy and hoping that this was going to be it. [SPEAKER_01]: Unfortunately, the pharmacy's just straight up looked at the difference, I've no, like, I just don't remember that.

[SPEAKER_01]: No, and I, [SPEAKER_01]: Lost it, Marisa. [SPEAKER_01]: I literally blew up at him. [SPEAKER_01]: I was so angry. [SPEAKER_01]: I was like, gosh, these people are just falling protocols. [SPEAKER_01]: They don't know how patients are suffering. [SPEAKER_01]: And then like, most of all, I was like, you guys don't understand, like, you're not seeing the patient and you guys are not the face of the system. [SPEAKER_01]: We are, um, and it just did not go well.

[SPEAKER_03]: Sure, I have that sound so tough. [SPEAKER_03]: I'm honestly [SPEAKER_01]: Yeah, I mean, well, don't be right. [SPEAKER_01]: I was not my best self, right? [SPEAKER_01]: Like I walked out of those doors. [SPEAKER_01]: I actually started crying and I'm not someone who cries, but I was so upset at myself raising my voice and probably one of my lowest moments in residency.

[SPEAKER_01]: And I think after listening to Dr. Barrett's stories and the micro skills that she uses, I, you know, I do wonder like,

[SPEAKER_01]: with the narrative have been different had I recruited this pharmacist to like actually the problem solved when you write what I've said hey okay if it's a no here then can you help me think about all their hospital clinics where the insulin she needs is on formulae right like instead I just took that no at face value I shut down and I made that pharmacist a bad guy in my head right and

[SPEAKER_01]: Honestly, to step back and something that Dr. Barrett does so well, she really recognizes that that person answering the phone or collecting the non-firmly forms are just a messenger, right? [SPEAKER_01]: They're just following a protocol that they didn't create, and who knows, they might be just as frustrated. [SPEAKER_03]: Right, and with all of that being said, I think that's why Dr. Bertha approach sometimes feels almost radical.

[SPEAKER_03]: She sees an inefficient process and taps into problem solving skills and does not lose her cool. [SPEAKER_01]: Guess I had to ask her, you know, how does she get from being enraged to actually being effective? [SPEAKER_04]: I think the first part of how do we overcome our emotions? [SPEAKER_04]: That's hard. [SPEAKER_04]: I do, and that can be incredibly difficult and at times, I have done that with more and less grace.

[SPEAKER_04]: I think that in general, if I try to think of something as a system story, or as part of a system story, then it becomes easier to consider addressing it. [SPEAKER_04]: True story, I think one of the reasons why I have an easy time thinking of things as part of a system is because when I was in college, I had a job where I worked on an assembly line.

[SPEAKER_04]: Like, truly, when people say, like, oh, this medicine is like an assembly line, I don't like now I worked in a factory on an assembly line and it made me think think about what can be automated and what wasn't and also and what can be just how things can be done a little bit differently, because it's safer when there's some degree of standardization, right? [SPEAKER_04]: So I think I might have that disposition. [SPEAKER_04]: I do think that it's harder now than it was.

[SPEAKER_04]: I do think that also because I've been able to get some of these successes over the years, then it becomes easier to see how getting these changes. [SPEAKER_04]: So I think anyone who wants to think how do I first get over my emotions. [SPEAKER_04]: I do think I strongly believe people can only give what they have. [SPEAKER_04]: Like that is I think that that should be on a billboard in general. [SPEAKER_04]: People can only give what they have.

[SPEAKER_04]: So they have to, they have to, ideally have a mindfulness practice beginning their sleep that they feel cherished, that they feel valued. [SPEAKER_03]: People can only give what they have. [SPEAKER_03]: And that makes me think about your story Shria. [SPEAKER_03]: I wonder what your interaction might have been like if you were on Q3 Call Rotation and the CCU. [SPEAKER_01]: Yeah, fair, fair.

[SPEAKER_01]: I think I've got to say, like, I've matured a ton since then, but I've really also appreciate Eileen calling out that, you know, these small wins to get other small wins. [SPEAKER_01]: So each time you can draw upon those skills in a better way with each rep you go through. [SPEAKER_03]: Exactly.

[SPEAKER_03]: And speaking of reps with the small wins, let's internalize these skills even more with our last story. [SPEAKER_03]: When [SPEAKER_04]: Yeah, it worked at a hospital where one day there was a decision and then without anybody knowing like it was just suddenly one day someone wouldn't take the hospitalists for blowers when I heard about that I was I was like cheap for hospitals program but that I just asked for the policy.

[SPEAKER_04]: right like I was surprised and you wait when always says I was surprised this happened last night I was surprised to hear this not so much wrong but I was surprised to hear this I wonder if I get and this is news to us when I checked with other colleagues um is there a policy who has such policy recently been changed in most cases what you find out that email is the policy didn't change and that one random person was just wrong right like they're coming from another hospital and in this case said oh yeah that is the policy and I'm like oh go go go

[SPEAKER_04]: Just so I can best understand how did we arrive on that and I'm a little bit surprised and they said oh well because it is a requirement they said do the federal government But also because we do know that there should be computers everywhere shouldn't a matter where you are you should be able to put in You should be able to put in order plus it's for patient safety [SPEAKER_03]: a small but key step of being curious, asking for the policy, and then how do we arrive to this?

[SPEAKER_01]: Right. [SPEAKER_01]: Yeah, and she didn't just jump into, no, that's wrong, or going into a rant about how defeating it feels that so much of our cognitive space is taken up by orders that inter-professional colleagues can take full ownership of, right? [SPEAKER_01]: Like, happen flushes, de-accessing ports. [SPEAKER_01]: That's really like their territory, right? [SPEAKER_01]: Or putting in wound consults or nutrition consults.

[SPEAKER_01]: Like, [SPEAKER_01]: I wouldn't say no, or say pharmacy needs the medication change because we don't have it in our formularity. [SPEAKER_01]: It just feels so defeating to be an order monkey for everyone's minds. [SPEAKER_03]: Oh, it does for sure. [SPEAKER_03]: And I think another thing to call out is that Dr. Barrett always communicates with generosity. [SPEAKER_03]: She doesn't put people on the defensive.

[SPEAKER_04]: So it was like, hi, I'm so glad that we were able to talk about this. [SPEAKER_04]: I wondered if we can follow up. [SPEAKER_04]: I was able, it looks as though that the federal requirement on CPOE maybe it is recently changed. [SPEAKER_04]: You know, that's, you give somebody the out, right? [SPEAKER_04]: And the wonder if we're able to achieve that. [SPEAKER_04]: And I wonder if we could talk about these other issues.

[SPEAKER_04]: And the person said, well, you know what you would have to do this after come before like the nursing counsel. [SPEAKER_04]: And I said, okay. [SPEAKER_04]: So, um, and in my case, and I present to there, and what was interesting about being able to present to them was that I talked about what mattered to them. [SPEAKER_04]: So as I started to, like, say things, and I just noticed who was started to involuntarily not their head.

[SPEAKER_04]: When I mentioned, say, for example, the part about you lose your progress note because you have to go into right and order and you've lost all of your work and I saw like half the room did this. [SPEAKER_04]: You can find your says yes. [SPEAKER_04]: Yes, and then I thought, okay, that's the thing I'm going to lean into more here. [SPEAKER_04]: to talk about that. [SPEAKER_04]: And then when we're just very heavily talk about the thing that seemed to matter with them.

[SPEAKER_04]: And then when we talked about patient safety and I talked about like, oh, I can see that people couldn't, couldn't have known. [SPEAKER_04]: Like you don't say you didn't know, but you couldn't have known that what we have the experience of when someone is at the bedside and they can't leave because a person is critical.

[SPEAKER_04]: And then you have like two people in the back of [SPEAKER_04]: It creates conflict, and it leaves the nurses in the lurch because you have to leave to go put in an order, and it leaves the patient in the lurch, right? [SPEAKER_04]: So you're not overplaying that you're hanging your colleague out to drive, but you are acknowledging that this introduces conflict. [SPEAKER_04]: And you're like, I have to leave to go enter the metamusul order.

[SPEAKER_04]: You know, even though we're starting pressures here and talked in like more story form, and then, and what are the questions and what are the concerns that you have? [SPEAKER_04]: And then it helps people see without you having to disagree with them because you're trying not to disagree, what you try to do is be more persuasive because, you know, as you know, people, like we don't persuade each other, things people persuade themselves.

[SPEAKER_04]: So you make them the hero and let them persuade themselves. [SPEAKER_04]: And that's the case, what they did was that they changed the rule and they said, okay, we can absolutely allow, and the nurse was really happy about this too. [SPEAKER_04]: We can allow for blurters, but has to be because it's important. [SPEAKER_01]: Right. [SPEAKER_01]: So, so you spoke about what matter to them and how people convince themselves that, yes, purple orders are still needed.

[SPEAKER_04]: I, um, and with the caveat that sometimes that it, I've had a lot of successes with it, sometimes I've had failures also too, right? [SPEAKER_04]: I feel like some of the ways how, ooh, one of them is I try not to use the word I feel. [SPEAKER_04]: It is an objective scientific fact that the patients are waiting for days for an echo, that is not about my feel, right? [SPEAKER_04]: That is at that not about my feeling.

[SPEAKER_04]: I personally try very hard, um, [SPEAKER_04]: to not have a rant in a meeting. [SPEAKER_04]: And I usually encourage people to try not to. [SPEAKER_04]: There can be a real role in it. [SPEAKER_04]: What's hard about rants is that they are received very differently based on the major. [SPEAKER_04]: And particularly that it is gendered and racialized. [SPEAKER_04]: And it is received through an age prison as well.

[SPEAKER_04]: And this ridiculous belief that somehow are really queer colleagues, or less dedicated than people who trained. [SPEAKER_04]: great some time ago is just just so patently false, but so I'm very sensitive to that those dynamics some people can have those like implicit biases, right? [SPEAKER_04]: I think it's really important to consider short storytelling.

[SPEAKER_04]: I hurt my own, I try to be pretty dispassionate so that the story tells itself and that could include a quote from a patient or even paraphrase from a patient or an ideally if you have one paraphrase from a nurse.

[SPEAKER_04]: So like one example I had when I was talking about something that was going on was I said, and it was incredibly difficult that when I let the patient, when I let the nurse know that the patient wanted a bath, and that I didn't want to put the pressure on the nurse because I know their day is really difficult.

[SPEAKER_04]: But that when I just said, I just want to let you know that they let me know that they wanted a bath, and that the nurse just [SPEAKER_04]: Like, deeply side and their shoulders, like, slump forward, and they said, what I would do to have time to be able to give my patients a bath. [SPEAKER_04]: And I did the same thing with my body language because I cared about her expressing the problem.

[SPEAKER_04]: And I showed that care without it being I feel I think I want is let allow the anecdote to tell the story. [SPEAKER_04]: Sometimes an anecdote more clearly tells the story than otherwise. [SPEAKER_04]: So sometimes it's nice to have afterward. [SPEAKER_04]: So I'm really concerned about our staffing levels and how our nurses are doing and the extra and how we can look to see to decrease what we're asking of them.

[SPEAKER_04]: I know that this doesn't fix it, but these are some of the things that I think could be opportunities to do so. [SPEAKER_03]: Yeah, and you offer solutions. [SPEAKER_03]: And then offer solutions. [SPEAKER_01]: Just a quick word from a sponsor with a new year here. [SPEAKER_01]: I've been trying to reset a few things, nothing extreme, just a little shift to feel better at home. [SPEAKER_01]: And one of the biggest upgrades has been Careaway Cookware.

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[SPEAKER_04]: and what do I want to see to come result from that meeting. [SPEAKER_04]: And that often is an intonatly wedded to my way, but just to know that having some degree of strategy is going to be more successful than none. [SPEAKER_04]: Because I want to always be open to that someone could go in there with a much bigger problem than I've identified and with a much better solution than one that I've identified. [SPEAKER_04]: So try to think about like, what is the North Star?

[SPEAKER_04]: What am I looking to get out of it? [SPEAKER_04]: Who are my allies? [SPEAKER_04]: Who can we speak to about how can we do have the pre-meeting, essentially? [SPEAKER_04]: what is the tenor of the room? [SPEAKER_04]: I write down bullet points about what I think I want to say. [SPEAKER_04]: And also, if someone has said something that lands with me or that supports a case for something that I think we need, give them credit for it in the room.

[SPEAKER_04]: So I'll say, just like I hear Dr. Travedi's point was a really good one that I wanted to amplify. [SPEAKER_04]: And then just choose like seven words from that, because I don't want to give someone some big one, so we'll look really great. [SPEAKER_04]: But like try to [SPEAKER_04]: try to find the common themes that we've already heard as I'm presenting what is the idea of what a solution could be.

[SPEAKER_04]: I also try to think about when I am speaking about trying to like create some sort of a change then I think about what is the skills that we get to be a better public speaker and one of them is how we create presence and just like how when we're talking with patients how we just pause and then just go slower because when you start to go [SPEAKER_04]: people often they notice the change in your cadence and they know usually something important is coming.

[SPEAKER_04]: And so often to that I try to be mindful of how I'm sitting, we're speaking right now and I've just crossed my arms, but I actually very deliberately try to keep my arms open often. [SPEAKER_04]: And when the person who is speaking is [SPEAKER_04]: listening, like you almost want to be their safe harbor, so that they see that you are their ally. [SPEAKER_04]: So when they're talking about what they did to nod and to thank them.

[SPEAKER_04]: Yeah, um, because there are people also to write. [SPEAKER_04]: So it's it treats them like a human being. [SPEAKER_04]: It also helps them see that you can be that you are the ally and that we're on the same side, which is like we want a health care system that works for the patients and also for the physicians. [SPEAKER_01]: So much good stuff here. [SPEAKER_01]: I love these stories and maybe it more said you and I can summarize.

[SPEAKER_01]: You know, the next time we find ourselves frustrated on our fifth phone call, our fifth form for something. [SPEAKER_01]: When you're sure in time, maybe instead of just like venting the person next to us, maybe our first move before we send off an email with a rant or saying something out loud that we might regret to reframe, right?

[SPEAKER_01]: And Dr. Barrett does this very deliberately. [SPEAKER_01]: She shifts from a venting mode to a systems mode. [SPEAKER_01]: Exactly. [SPEAKER_03]: This isn't a people problem. [SPEAKER_01]: Yeah, yeah, she doesn't think about, oh, Pharmacy is blocking me or nursing won't help. [SPEAKER_01]: It becomes, okay, where is a processed missequence? [SPEAKER_01]: And she assumes good intent, right? [SPEAKER_01]: And she acknowledges that out loud.

[SPEAKER_03]: Yeah, and that part really does matter. [SPEAKER_03]: The, I appreciate that this policy was meant to protect patients, naming that that one sentence alone can change the temperature of a whole conversation.

[SPEAKER_01]: right and then she notices her language right she doesn't lead with blame she leads with oh I was surprised to hear that so it's a flag not an accusation and once she's regulated herself the next step is how she opens a conversation and this is where a lot of us do go wrong [SPEAKER_03]: She continues to lead with curiosity. [SPEAKER_03]: She says, can you help me understand the policy has it changed?

[SPEAKER_03]: And then acknowledges the original goal, which is often cost, safety, compliance, before talking about the unintended consequences. [SPEAKER_03]: And honestly, that keeps people from getting defensive. [SPEAKER_01]: Yeah, and then it comes to a real superpower, right? [SPEAKER_01]: She thinks about the smallest change to actually matters, right? [SPEAKER_01]: The big enough to matter, small enough to win. [SPEAKER_03]: She's not trying to overhaul pharmacy policy.

[SPEAKER_03]: She's just trying to flip one step in a work flow. [SPEAKER_01]: Yeah, and with a refax mean, she did a simplest one. [SPEAKER_01]: She let the clinician order a verse in the pharmacy check-aportability afterwards. [SPEAKER_01]: Same goal, difference sequence. [SPEAKER_03]: And with that one flip, she saved over 500 phone calls. [SPEAKER_03]: That's huge leverage for a tiny change. [SPEAKER_03]: And she even offers to do downstream work.

[SPEAKER_03]: Education roll out, explaining the change to others, so the burden doesn't fall on the other team. [SPEAKER_01]: So now let's talk about persistence, because most good ideas don't die from opposition, but die from silence. [SPEAKER_01]: Dr. Barrett follows up, right? [SPEAKER_01]: She does and she does so gently, short check-ins, assuming people are busy and offering help instead of pressure.

[SPEAKER_03]: And I love the post-it note system, nothing fancy, just a way to remind yourself to circle back without doing. [SPEAKER_01]: And then she just support work before she enters the room and really is thoughtful about what is happening in the room. [SPEAKER_01]: She notices who nods, she notices what a story is land, and what pain points are shared. [SPEAKER_01]: And another big one that I'm definitely going to take away is facts over a rant, right?

[SPEAKER_01]: Of wanting those I feel statements and keeping things objective and leading with objective stories. [SPEAKER_03]: and finally, a point on presence. [SPEAKER_03]: Dr. Bert slows down before he points, open-possuring, pausing, she's regulating the emotional climate of the room and not just making an argument. [SPEAKER_01]: Yeah, and then underneath all, that is a metastale that Dr. Barrett named so clearly.

[SPEAKER_01]: If he can only give what they have, [SPEAKER_01]: Exactly, you cannot do this work when you're completely depleted. [SPEAKER_01]: So, it's a small win second-health-built confidence and confidence can build capacity and capacity makes the next change possible.

[SPEAKER_01]: So maybe one of the things that resonates with me is you don't need a lot of authority to make change or maybe even a lot of time which sometimes is what gets me what you need is regulated curiosity, strategic empathy, and small, well-chosen moves. [SPEAKER_03]: exactly and things that are big enough to matter and small enough to win. [SPEAKER_01]: Awesome, thanks so much for joining us.

[SPEAKER_01]: Let us know if this resonated, if you have any small wins that you'd love to share, any other mechers skills that you used, they all kind of help all of us, especially in this day and age where it feels like there's so much going on in the world, nothing matters. [SPEAKER_01]: It's hard to know even some news where to start, but the everyday workflows are still kind of very real and I'm sure there's a lot of work in progress that [SPEAKER_01]: Thank you so much.

[SPEAKER_01]: Take care.