Dan:

Kathy, welcome to the show.

‍

Kathy:

Thanks, Dan. It's just great to be here and share some ideas with you.

‍

Dan:

Yeah. This is going to be fun. I know we have lots of opinions and lots of stuff, so we'll go into some of that. I'd love to hear, you always hold a bunch of roles, whether it's in academia, or in regulation, or teaching, or consulting, you do a lot of different things. Can you tell us what you've been up to lately?

‍

Kathy:

Sure. I think it's important to understand that not everybody does well in a full-time job. And I'm one of those people. I think I have to have my fingers in every pie, and that's how you can learn a lot more. And so at some point in my career, probably 25 years ago, I realized I'm not employable anymore. And so I have to take different jobs in different places and then make the best of them. It also gives you a chance as an innovator to try new things. And when somebody asks you to do something, you say, "Oh, I don't know how to do that, but I think I'd like to do that." And so what I'm doing now is work for the board of nursing, work for Ohio State in the college of nursing, and then some consulting, writing a grant for a colleague, and continuing to write about innovation and review articles.

‍

Dan:

Yeah. I love that approach and I've sort of tried to model that in my career too, is have your hand in at least three different things. That way if one of them is not fulfilling or goes away, you have other stuff to focus your energy on. You and your colleague, Tim Porter-O'Grady also have written tons of textbooks out there, which I know keep things busy and kind of codify that knowledge and information that you're gathering through all of those roles. As a nurse and in your career, when did you find that moment where you were like, "I can't be in this health system anymore. I can't work for this sort of formal employment. I need to go out and be a little bit different"?

‍

Kathy:

So interestingly enough, it was a traumatic moment that did that. In, oh gosh, late '90s, I was a vice president of nursing at a hospital here in Phoenix. And it was a two hospital system, and a person at the other system decided they wanted to run two hospitals, so they eliminated my position. And so it was very painful of course, but then I was finishing up my dissertation and then I realized then there was a lot of things about a regular job that didn't bring out the best in me. And I laugh about going to some of the standard meetings we have to go to, like a joint commission survey, a public health survey, and doing all those surveys. And I'm thinking, "Oh, my gosh."

‍

Kathy:

That became more and more painful for me. And then people started asking me to write, and then they started asking me to consult. That's how I met Tim Porter-O'Grady. Somebody was looking to learn about case management systems and I had just done that in my last job. And people at that time encouraged me to get ... They said, "Get back on the horse. Go get another job." And I didn't. I didn't because so many interesting things came around.

‍

Dan:

Yeah, that's sounds actually really familiar, personally as well. And I've definitely been in those spaces. I don't know. I keep choosing to go back to health systems and I keep getting frustrated in them. I think it's good to have that frustration to drive some things forward. But at the same time, it's really hard to navigate some of these systems who so ingrained in their old ways. And I think you're a testament to how you can actually leave those formal executive roles that everyone's trying to get to, and actually make a humongous impact outside that traditional track.

‍

Kathy:

Yeah. I think that's the thing that you find, is that everybody is dispensable, but figure out what your shtick is. What is it that you know well, what you love, and you can share with other people? And then it becomes your consulting world because that's really what you become is a consultant and a content expert in other areas. The employment processes of today are so archaic and tend to support the system, but not the people in the system.

‍

Dan:

Yeah. That's a great way to put it, very timely for where nursing is as a profession at the moment, and realizing that traditional employment of go work at the health system as a bedside nurse forever is just not set up for success right now. And it fundamentally needs to change. And nurses are voting with their feet and their time and spending it other places, or joining more flexible workforces like travel and other things. And so I'm seeing that a ton with nurse leaders and nurse executives as well. They're saying, "Hey, I'm not going back to that. I'm going to start a coaching business. I'm going to start my own organization," those type of things, and it's really exciting.

‍

Dan:

One of the things that we did, or you did, that you started at Arizona State, and then we took it over to Ohio State, was create a program for sort of those nontraditional thinkers, the Masters in Innovation program. And I was lucky enough to be in the first cohort through the ASU program. But what was the conversation that started the kind of drive to build a program like MHI?

‍

Kathy:

Thanks, Dan, because I think at that point and time, it was in the early 2000s I think when we started, so there was the old fashioned nursing administration masters that was out there. And then the people at the college said, "We don't have a whole lot of enrollment in the nursing administration program. We probably should stop it. We should end it because we've saturated the market." And my response was, "Oh, my gosh. We haven't saturated the market. We haven't touched it for leadership in healthcare," because our leadership was so transactional and so ineffective. And so then Bern Melnyk invited Tim and I to come in and brainstorm at Arizona State University about what would be the perfect education program for nurse leaders.

‍

Kathy:

And so when we got into those discussions, what we did was say, "There's three things that are wrong right now." One of them was innovators are usually exhausted because we want to do everything, so we've got to figure out how to do a better balance. Then the second thing was we didn't learn how to work in teams with other disciplines. So we were all just nurses working by ourselves and not collaborating with physicians, therapists, and social workers, and other people. And so that was not right. And so then the other thing was we didn't know how to innovate. And so those things are what kind of formed the beginning discussion. And from there, we created courses. We created nine courses to support and help people develop.

‍

Kathy:

We have this one, I love this one, the individual and innovation. And it's: How do you understand yourself? And how do you give yourself permission to not always be on? Because I think a lot of us who are high energy pushers, we always want to be on. And we forget to go to the beach, or the golf course, or something like that, and turn our phones off. And so that was that course. And then we did a leadership course, a culture course, an innovation course. We wanted people to learn innovation theory. We didn't want them just to have anecdotal approaches to doing things differently. We wanted them to get in there and know it.

‍

Dan:

Yeah. And I think that's the key that you and I have also tried to hit home across our different platforms too, is at the time, a lot of leaders focused on sort of the Toyota Production Systems or Lean Six Sigma sort of methodology, which definitely is a great methodology for change. But it's really focused on performance improvement. And then when people were doing innovation, it was that cool, shiny technology, or that post it note party that they got a bunch of ideas and they take a picture of it, and then it'd go nowhere, and those type of things.

‍

Dan:

And what I really learned, and I remember just sitting there on I think it was Sundays during our immersions, we'd have the Sunday sermon by Tim Porter-O'Grady and it just blew our minds. But there's science behind leadership, there's science behind innovation. And it's the obligation of people in formal leadership roles or those trying to influence others to practice those evidence based things and not just throw stuff at the wall and see what sticks. That's not what innovation is. And so I think that science of change is something that's just severely missing across every healthcare system at the moment.

‍

Kathy:

I couldn't agree more with you because I think it's the shiny object, or we got a new idea, we read a new article, or we went to a conference and heard somebody talk about something fancy. But the flip side of that too is someone told me a long time ago that the MBA that we know today is going to be the blue collar degree of tomorrow because it puts everybody in widgets and lockstep. And we don't manage from a complexity science perspective where we let things happen. And so how do you teach healthcare experts to let things happen when they're focused on safety? And so that's what this whole program did was say, "Here's where you drive down and you can't compromise related to safety. Here's where you must compromise because the system isn't working."

‍

Dan:

Yeah. And we've seen how leading in linear ways has impacted our health system with the recent Vanderbilt case with the nurse and those systems that are in place, but there's no flexibility. There's no understanding of the complex nature of the environment, and it leads to error, which now is potentially setting precedent for future things. There's the workforce, the nurses through COVID, being locked into all these archaic charting methodologies and care and ratios and these type of things that just could not flex in the face of a complex problem.

‍

Dan:

And I think leaders are uncomfortable in that space. But once you go through a program like MHI, and you learn the science of change innovation and people and organizational culture, there's tools and tactics that you can use to navigate those things. And it doesn't have to be as scary as it looks. You don't have to grab command and control in order to run an organization, but you have to have the toolset to understand that. What are some of those key tool sets that conceptually high level ... I know we're not going to go into super detail, but what are some of those key concepts that leaders leading in a complex system need to understand?

‍

Kathy:

So I would say first of all, they need to understand how to listen better, and listen and hear what people are saying. Now that's not a complexity principle, but if you listen then you can get all the information because things happen, depending on where people are. And so if there's 10 of us in a room, in five minutes, we're all in different places. And something different happened, and when there was no map for us. The same thing happens every day in healthcare with every patient, with every provider that we all move in different places. And so can you accept that, what is emerging? And then can you make sense of it? And then can you also course correct? Because they're not intentional errors or failures, things happen.

‍

Kathy:

I see failure as what happens all the time. And how do we love failure better? Errors, we have to get rid of. I mean, error is when people do things over and over and over again wrong, and have negative outcomes. So you've got to get rid of errors. But failure, you have to love, and that's a complexity reality.

‍

Dan:

Yeah, love failure, communicate, listen, see the signposts. We've written some papers on the idea of the attractor or this sort of magnetic force of energy where people spend their time and spend their energy. And by listening and being in the culture, you see those things. And it's often unwritten rules that are governing most decision making. And so whether you're dictating it or not, or you have a meeting about it or not, things are happening behind the scenes. And as a leader, it's important to have your ear to the ground and to know what's going on there.

‍

Dan:

One of the things that I'd love to kind of go down, which is this idea of failure and errors, and so one of your roles was as president of the Arizona Board of Nursing. And I think automatically people are probably cringing like, "Oh, God. Error and failure in the face of a board of nursing, that's the dirtiest place to be." So can you tell me just from your perspective as being a board president, how did you approach some of those cases that came before you that from one lens could be the person or that individual did the error, but really, what was your approach to understanding system failure, personal error, those type of things, the patterns of behavior?

‍

Kathy:

That's a lifelong journey to understand what's going on in the system. What I try to understand is that when a case came before the board, and you had someone who was committing error, after error, after error, had been counseled, had been educated, and couldn't get it, or similar to that would be substance use disorders. They're drinking, they're doing drugs, and they can't get it. Then you need to take some discipline. Discipline is about stopping practice or partially stopping practice. So how do I know that there was no evidence of trying to do better? Now the ones that will break your heart is when somebody does something really horrible, or gives the wrong med, or puts the wrong dressing on somebody, puts on the wrong patient, first time they ever did an error, and it's like, "Whoa."

‍

Kathy:

So we don't even open those one time error cases, I mean, unless somebody maybe dies or something. But we don't open them because that should be taken care of in an organization. That's a human resource issue. That's not a violation of the Nurse Practice Act, where we look for patterns of poor behavior, unacceptable behavior. One of the things I think got us in trouble was root causes analysis. We were looking for someplace to put a pin in. We wanted to nail somebody or something. I think people thought about a just culture then, but the reality with a lot of errors or failures is that the system is to blame, so you can't put a pin in anybody.

‍

Kathy:

This is the one thing I always loved is if you did something, you didn't put the side rails up, or you gave the wrong med, or you hollered at somebody inappropriately, you were just really unprofessional, and before you came to the board, if you went and got counseling, or you had some coursework to remediate yourself before you ever got to the board, there are times where the complaint would be dismissed. Why not? What are we trying to do? And so that was the good thing I think too. And I think the whole regulatory system begs for evidence. And so we give a decree of censure, put people on probation or different levels of discipline. There's not a lot of evidence to say, "Did it really matter?" Did the person get better? Did the behavior go away? And so we're working on that now. We're trying to study that to figure out. What's the right thing to do to get somebody back on path?

‍

Dan:

Yeah. I think that's a great point to kind of highlight, which is it's about the pattern of behavior, not the one time thing. And if you show a dedication to trying to figure it out, what went wrong, and to help yourself and help the system evolve, those are all professional behaviors that are expected of clinicians in a healthcare world where error will happen in some point. And if you can work to remediate it, that's much better than stressing about losing your license and those type of things. Now and we don't have to go into it, but there have been some things lately where it was an error and one time thing. And now there's these massive punishments, but that wasn't necessarily the Board of Nursing doing that. But it is that sort of pattern behavior, and that goes back to the complexity pieces as well, which is the way you understand organizations isn't by the single act, it's by the patterns of behaviors across groups. And that gives you that lens to view what's happening within an organization?

‍

Kathy:

And so that is point on. Is there a pattern? So if you do one horrible thing, and it's your first and only horrible thing you've ever done in nursing, let's take a look at a just culture perspective. Were there any system influences that got in the way? Are there any things about the staffing that got in the way? Were you overworked, overtired? You have to ask those questions. The outcome of an error is not how you make a regulatory discipline action. The outcome happens. It's going to happen no matter what. But did you violate the Nurse Practice Act or your professional requirements consistently?

‍

Kathy:

In any of these high profile cases, you want to know if there's a pattern. And you want to know if there's remediation. The board can't regulate systems, but that doesn't stop one from asking, "What did the system do?" And I think we should.

‍

Dan:

Yeah. And we have to understand all the contributing pieces and to what degree it was intentional, personal, a violation versus factors that were beyond people's control and those type of things. 

‍

Kathy:

Well, and I think too, Dan, that there are so many workarounds in practice, healthcare practice, that have just it's like the normalization of deviance. We've been doing them, and those workarounds have the potential to either make work really easy or really bad. And we have to be calling out workarounds and to say, "Do we make this part of practice? Or do we figure out how to stop this?" It happens everywhere.

‍

Dan:

It happens everywhere, yep. And I know there's some new technologies and things that the board's working on to help kind of track these things and share them faster. And that was a big complaint from the systems as well. Nurses can move very quickly between states and things with censure on their license and it wouldn't be discovered for multiple months and things, and so I know there's some work there. But what are some of the future innovations that may be needed or are happening in the regulation space?

‍

Kathy:

So I think we have to look at how we triage cases. I think we have to think a little bit more long-term about: Is this really something that should be investigated? Or is there a way to do a non disciplinary intervention? I think we have to look at that. I think we have to use our technology better in the portability of nurses from state to state. I mean, we're getting better with the compact, but now the next part is advanced practice nurses to have their compact. I think we have maybe two or three states in that. I think we have to do that.

‍

Kathy:

I think we have to have some common simulation scenarios for competency. I think we have to figure out what's that basic competency of a nurse beyond a test. How do we get the cognitive and the effective behaviors in our assessments? And how do we do that? And I think we also should not relicense people, but reexamine them for competence in the field that they're in. So I think those are some things.

‍

Kathy:

I think some basic things too, Dan, that have been ... These have bugged me for a long time, is routine vital signs. We take so many blood ... I'll bet 95% of the blood pressures we take, we never do anything about. And so maybe if we could just cut the frequency of blood pressures and if we could look at patients, and if they're looking bad, then take their blood pressure. I mean, I think about: How much time does that take to do these vital signs? And are we doing it so the nurse goes and looks at the patient? Or can we give the nurse time to think and be there for the right reason? I think we have to get pretty creative and innovative how to assess that, the routine vital signs, and how we do that.

‍

Kathy:

And I think our challenge is: How do we get very, very, very busy practitioners to ask why? Why, why, why are you doing that? And then what's the value from it? And so how do we integrate that into the role of the nurse? If we were going to add competencies or add requirements for a nurse, I'd like to see every nurse accountable for at least one significant improvement in nursing every year. I mean, that's part of your professional role.

‍

Dan:

Yeah, I love that. I think I agree. We write about that in the Leadership in Nursing Practice book of your professional obligation to improve the profession over time, generate the evidence, and create those changes. And you think the other piece to that is the future is really: What are those tasks like vital signs that nurses don't even need to do, that we could actually replace? I mean, there's beds now that will take vital signs every three minutes without anyone touching the patient. And it's not about taking the vital signs. It's not a nursing action. It's interpreting it in the context of care. And so how do we bring nurses to that point of interpreting information? Not gathering and hunting down pieces of information, but really spending their time interpreting it and making decisions that allow for care to move forward, or interventions to happen, or patients to go home, or teach families, or the stuff that require the nursing brain.

‍

Dan:

I think those are key because lately we had kind of a discussion about vital signs and things. And one piece of the vital sign thing is that because they're not entered correctly usually, sometimes everyone has 16 respirations all the time. We don't always have the most accurate data. But that data triggers all of these scores, the MEWS score, the LACE score, all these things that can be predictive of patient mortality or patient care deteriorating, those type of things. And so we have to have that data somehow. But I don't think going around wheeling those stupid carts around every three hours is the way to do it. So I think that's where we need innovation with nurses. How do we take some of these old workflows, these things that we've done forever, and just say, "Number one, why do I need to do it frequently?" And maybe there's a good rationale for frequent vital signs. But how we're doing it isn't the right way to do it either. And so I think always questioning your practice is a key piece of that.

‍

Kathy:

I think that is so important. There's another thing from the pandemic that has annoyed me. I'm not really an annoyed person, but this annoyed me. Why did we shut out families from the patients when we know from a research perspective that they facilitate health and healing? Why did we allow that? And what were we really trying to do? I'd like us to go back and revisit that and say, "What would be a better way to do it in the future?" If we ever had a pandemic again, families need to be there. One or two people, they need to be there. And how do we do that and still protect everybody from spread of disease? So those kinds of questions are out there, and that's where we need people to think differently.

‍

Dan:

Yeah. I think nurses have realized that they have to think differently, and they can think differently on their feet as well. The adaptations that happened in the moment with the pandemic in the care areas I think is a testament to how quickly nurses can MacGyver their way out of problems, and I think we need to own that a little bit more. I think there's an opportunity for us to formalize workarounds and not go backwards too. The things that we were able to institute and deploy that really worked in the pandemic. I was in a call the other day. We're going to go back to pre pandemic charting. And I'm like, "Why? What's the point of that? We did fine with exception or whatever the change was." And it took a burden off the nurses. Why are we going back? We provided plenty of great care without having to check every box.

‍

Dan:

So I think we've got to think as leaders. What are we going to move forward? What are we not going to go back to? But we're coming to the end of our time here, Kathy. And we talked about a lot of great stuff. But one of the things we like to do is hand off a piece of information, or that one nugget that our leaders and nurses can take away from the episode. So being innovators, looking for patterns, living in complex systems, what advice would you have for nurses as they emerge from the pandemic and go and create the health systems and the roles of the future that really are going to speak to their heart?

‍

Kathy:

So I would ask every single nurse to question: When is the presence of your body needed? And when can you be virtual? Because I think it's a new day out there. We don't want to go too virtual. We can't go completely virtual because there's some value to being in person. But in your own space, where should you be? Really, where should you be to give the best value to the healthcare system and to yourself? I think that's the big thing for me. What did we learn so much from telemedicine, and how many more things we could do that we already knew about? But now that we've been through it for almost two years of limited contact, where's the right space? I would say think about that a lot.

‍

Dan:

Yeah. No, I love that. And part of that is getting out of the room charge and quantifying the value of the nurse too, with the care continuum outside of being in a physical location as well, which I think is the challenge of our profession for the very immediate future. So Kathy, thank you so much for being on the show. This was awesome. I loved where it all went and how we wove in innovation and regulation, which often are not synonymous. But you're a rare breed in being able to bring those together I think. So I just really appreciate your time. If people want to learn more about your work, or get in touch with you, where can they find you?

‍

Kathy:

They can just email me, km@kathymalloch.com. I'm a good responder. I'll do that. So I'd love to have any dialogue we can have. And Dan, I so appreciate you taking the lead and pushing the walls and doing your very best to make healthcare and nursing better, so thank you to you too.

‍