Establishing a Culture of Patient Safety: Improving

Communication, Building Relationships, and Using Quality

Tools

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 Establishing a Culture
of Patient Safety
Improving Communication,
Building Relationships, and
Using Quality Tools

Judith Ann Pauley and Joseph F. Pauley

ASQ Quality Press

Milwaukee, Wisconsin

H1418_Pauley.indd iii 6/14/11 3:12 PM

 American Society for Quality, Quality Press, Milwaukee 53203
© 2012 by Judith Ann Pauley and Joseph F. Pauley
All rights reserved.
Printed in the United States of America
16 15 14 13 12 11 5 4 3 2 1
Library of Congress Cataloging-in-Publication Data
Pauley, Judith A.
Establishing a culture of patient safety : improving communication, building
relationships, and using quality tools / Judith Ann Pauley and Joseph F. Pauley.
p. cm.
Includes bibliographical references and index.
ISBN 978-0-87389-819-5 (alk. paper)
1. Hospitals—Administration. 2. Medical errors—Prevention. 3. Communication
in medicine. 4. Physician and patient. 5. Medical care—Safety measures. I. Pauley,
Joseph F. II. Title.
[DNLM: 1. Hospital Administration. 2. Medical Errors—prevention & control.
3. Comprehensive Health Care—methods. 4. Models, Organizational. 5. Professional-
Patient Relations. 6. Safety Management. WX 153]

RA971.P38 2011
362.11068—dc23
2011017946
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H1418_Pauley.indd iv 6/14/11 3:12 PM

 To
Major General (ret.) Gale S. Pollock, former Acting
Surgeon General of the United States Army, for her
friendship, for sharing her leadership skills with us,
and for recognizing how the concepts of Process
Communication can improve the healthcare provided to
the army heroes wounded in battle defending our country
and to their family members who have remained behind.

And to
Dr. Taibi Kahler, the clinical psychologist who made
the discoveries on which the concepts of Process
Communication are based, for his genius, for his
friendship, and for improving our lives and the lives
of all those we come in contact with every day.

And especially to
All the healthcare professionals who provide
outstanding medical care to millions of patients every
year, especially those who have dealt patiently with
our idiosyncrasies and provided excellent medical
care and advice to us throughout our lives.

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H1418_Pauley.indd vi 6/14/11 3:12 PM
 Contents

List of Figures and Tables . . . . . . . . . . . . . . . . . . . . . . . . xi

Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xix
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxiii

Chapter 1 The Need to Improve Patient Safety . . . 1

Three Examples . . . . . . . . . . . . . . . . . . . . 11

Chapter 2 Who Are These People? . . . . . . . . . . . . . 17

Chapter 3 Interaction Styles . . . . . . . . . . . . . . . . . . 25

Chapter 4 Perceptions . . . . . . . . . . . . . . . . . . . . . . . 35
The Language of Perceptions. . . . . . . . . . 36

Chapter 5 Channels of Communication. . . . . . . . . 45

Establishing Contact . . . . . . . . . . . . . . . . 50

Chapter 6 Motivational Needs . . . . . . . . . . . . . . . . 55

Motivating the Six Personality Types . . . . 56
Personality Phase . . . . . . . . . . . . . . . . . . . 67
An Anesthetist’s Example . . . . . . . . . . . . 71
A Patient’s Example . . . . . . . . . . . . . . . . . 72

vii

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 viii Contents

Chapter 7 Using the Concepts in Treating

Patients . . . . . . . . . . . . . . . . . . . . . . . . . . 75

Chapter 8 Distress . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Workaholics . . . . . . . . . . . . . . . . . . . . . . . 83
Persisters . . . . . . . . . . . . . . . . . . . . . . . . . 86
Reactors . . . . . . . . . . . . . . . . . . . . . . . . . . 90
Dreamers . . . . . . . . . . . . . . . . . . . . . . . . . 91
Rebels. . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
Promoters . . . . . . . . . . . . . . . . . . . . . . . . . 95

Chapter 9 Healthcare Providers in Distress . . . . . 99

Story One . . . . . . . . . . . . . . . . . . . . . . . . . 103
Story Two . . . . . . . . . . . . . . . . . . . . . . . . . 105
Story Three. . . . . . . . . . . . . . . . . . . . . . . . 108
Story Four . . . . . . . . . . . . . . . . . . . . . . . . 112
Story Five . . . . . . . . . . . . . . . . . . . . . . . . . 114
Story Six. . . . . . . . . . . . . . . . . . . . . . . . . . 115
Story Seven . . . . . . . . . . . . . . . . . . . . . . . 118
Story Eight . . . . . . . . . . . . . . . . . . . . . . . . 119
Story Nine . . . . . . . . . . . . . . . . . . . . . . . . 121
Story Ten . . . . . . . . . . . . . . . . . . . . . . . . . 123
Story Eleven . . . . . . . . . . . . . . . . . . . . . . . 125
Story Twelve . . . . . . . . . . . . . . . . . . . . . . 127

Chapter 10 Getting Patients to Diet and

Lead Healthy Lifestyles . . . . . . . . . . . . . 131

Chapter 11 Using the Concepts in Leading

Improvement . . . . . . . . . . . . . . . . . . . . . 147
Leading Improvement in a National
Healthcare System . . . . . . . . . . . . . . . 147

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 Contents ix

Leading Innovation in a Healthcare

System Medical Education
Department. . . . . . . . . . . . . . . . . . . . . 150
Leading Improvement at a Medical
Facility . . . . . . . . . . . . . . . . . . . . . . . . 153
Leading Improvement in a Family
Clinic . . . . . . . . . . . . . . . . . . . . . . . . . 155
Leading Improvement in a Healthcare
System Education Institute . . . . . . . . 157
Leading Change to Develop a Team . . . . 158
Leading Change in a Women’s
Hospital . . . . . . . . . . . . . . . . . . . . . . . 160
Influencing Improvement in Safety
Procedures in Biomedical Research
Laboratories . . . . . . . . . . . . . . . . . . . . 164

Epilogue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171

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H1418_Pauley.indd x 6/14/11 3:12 PM
 List of Figures and Tables

Figure 1.1 Doing more with less . . . . . . . . . . . . . . . . . 12

Figure 1.2 Courtesy and helpfulness of the staff
during this visit . . . . . . . . . . . . . . . . . . . . . . 13
Figure 1.3 Overall satisfaction with visit . . . . . . . . . . . 14
Figure 2.1 Personality components of a doctor . . . . . . 20
Figure 2.2 Personality components of a nurse . . . . . . . 21
Table 3.1 Preferred interaction style of each
personality type . . . . . . . . . . . . . . . . . . . . . . 27
Table 5.1 Preferred channel of communication of
each personality type . . . . . . . . . . . . . . . . . 46
Table 5.2 Examples of communication and
miscommunication . . . . . . . . . . . . . . . . . . . 49
Table 5.3 Preferred channel and perception of
each personality type . . . . . . . . . . . . . . . . . 50
Table 6.1 Motivational needs of each personality
type . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Figure 9.1 Promoter action plan . . . . . . . . . . . . . . . . . . 105
Figure 9.2 Reactor action plan . . . . . . . . . . . . . . . . . . . 107
Figure 9.3 Persister action plan . . . . . . . . . . . . . . . . . . 112
Figure 9.4 Rebel action plan . . . . . . . . . . . . . . . . . . . . 117
Figure 9.5 Workaholic action plan . . . . . . . . . . . . . . . . 121
Figure 9.6 Dreamer action plan . . . . . . . . . . . . . . . . . . 123

xi

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H1418_Pauley.indd xii 6/14/11 3:12 PM
 Foreword

H
uman interaction can be complicated. It probably always
has been. Even in the days when communities of our
ancestors huddled together in caves for protection and
for warmth, living together in proximity for extended periods,
it was the same. As they negotiated or resolved to establish
an agreed pecking order, and as they rationed out their (often
scarce) resources, their skills in being able to relate effectively
and constructively to one another were tested—and, indeed,
the very survival of their community often depended on it. Not
to mention the challenges of keeping their youngest ones safe,
dealing with their impulsive and rebellious teenagers, and caring
for their sick and elderly. All this required sophisticated social
interaction. One would have to think that nothing has changed.
Well, almost nothing. The same bases for these intricacies
of human behaviour remain. But what is different now is the
environment in which they play out: It is much more complex
and demanding. It places much greater stress on its inhabit-
ants. The senses are bombarded with a greater range of stimuli
that require rapid and specific responses. So in many ways,
the range of skills required for effective daily functioning has
become significantly more complex. It is not so much that
the technology we use (whether it be cars or computers) has
become more complicated, but more that the array of systems
and processes with which we now have to comply has become

xiii

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 xiv Foreword

increasingly complicated. Nowhere is this more evident than in

the area of health services.
That is where this book comes in. It is true that the technology
and techniques of medicine are advancing rapidly, concomitant
with an ever-expanding knowledge base, and that this necessi-
tates high levels of cognitive and technical expertise by those who
provide medical care. Yet, this is not where the real challenge lies.
Rather, it is that these advances also demand that all healthcare
workers communicate effectively and work collaboratively, an
absolute necessity if the complex processes that have been built
up around healthcare provision are to function properly.
Why have these processes around the delivery of healthcare
become so complex? Not surprisingly, there are several reasons.
One obvious one is the explosion in knowledge and skills required
within each specialty area. This has led to an increased level of
specialization and delineation of the roles and responsibilities
of each member of the workforce. In turn, this means that, more
than ever before, health workers are dependent on those around
them for support if they are to perform their work correctly.
But there is another reason, one that relates to patient safety.
The public now expects good outcomes to be routine. Previously,
complications were assumed mainly to be related to patient fac-
tors (e.g., old age, poor healing, comorbidity, or the patient not
following the doctor’s instructions correctly) or to limitations in
available technology. It was assumed that medical staff, being
honest and having integrity, were infrequent contributors to poor
outcomes. Now—and this book highlights the importance of this
aspect—we realize that many, if not most, unexpected adverse
events are due to human factors, specifically the actions and
behaviour of those looking after the patients.
In short, medical error leads to adverse events, and adverse
events lead to poor clinical outcomes. Understanding how medi-
cal error occurs is the first stage in reducing its incidence. This
book reviews the evidence that certain types of human behaviour
contribute to errors occurring. Moreover, it also shows the degree

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 Foreword xv

to which these types of behaviour are predictable. Fortunately,

they can be recognized and dealt with, not only by health profes-
sionals reflecting on themselves but also by colleagues. Under-
standing the role of personality types and recognizing the effects
of stress and distress allow a greater degree of collegiality and
a more collaborative and supportive environment. The authors
outline the tools available to achieve this. Put simply, once we
have the tools that have been shown to improve behaviour (or
eliminate those behaviours that contribute to mistakes), we will
be on the road to providing a safer health system.
This book is a welcome addition to our libraries, as it
applies the Process Communication Model® to the health sec-
tor. We already know that human factors—primarily behaviour
affected by varying degrees of stress—contribute to medical
errors. Here we have a tome that reminds us that perhaps the
most productive way to minimize medical error is to study how
well-intentioned and committed health specialists function and
communicate. Additionally, it encourages us to adopt some
very specific tools to influence this behaviour in a way that
eliminates many of the human factors that contribute to the high
incidence of medical error that plagues our health services.

Spencer W. Beasley, MB, ChB (Otago),

MS (Melbourne), F.R.A.C.S.
Professor of Paediatric Surgery, Christchurch School of
Medicine and Health Sciences, University of Otago
Former Chair of the Board of Surgical Education and
Training, Royal Australasian College of Surgeons

T
he healthcare industry today faces many challenges.
In spite of the fact that technology has enabled
healthcare professionals to provide the highest qual-
ity of healthcare in history, raise the life expectancy of our

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 xvi Foreword

population, and find cures for illness after illness, we still

are challenged to improve patient safety and patient satis-
faction. Our challenge is daunting: improve the quality of
healthcare, and improve patient safety to a “perfect” level
in a labor-intensive business model that will remain labor
intensive and people dependent for the foreseeable future.
This people-dependent business must ensure that employee
engagement and satisfaction are also a constant focus. To
accomplish these tasks, it is essential to improve communi-
cation among all members of the healthcare team (doctors,
nurses, administrators, and patients) and to reduce their dis-
tress levels.
When working daily in situations dealing with patients who
have suffered life-threatening heart attacks or strokes or who
have been in accidents, stress is inevitable. The key is to be
able to deal with stress in positive ways, thereby turning it into
positive stress rather than negative stress (distress). This book
provides a tool that can be applied to accomplish these goals.
In an effort to improve communication and reduce the dis-
tress in our hospital, the leadership was trained in the concepts of
Process Communication. It worked. Tools that could be applied
were applied. Leaders who struggled with one another and with
certain relationships suddenly had a different lens to view not
only their statements but also the reception of their statements.
Listening improved. And we saw results. We saw improvement
in employee engagement. These concepts enhanced our ability
to deal positively with individual issues as well as hospital-wide
management issues. This resulted in a 6% improvement in
employee engagement in one year (2009) and has enabled us to
move the entire organization to the next level.
I learned a lot about myself and about communication gaps
that I unintentionally allowed; but, for the first time, I have a
tool that I can use with my children, their teachers, my wife,
my staff, patients in the hospital, and everyone with whom I
interact. The concepts have enabled me to be a better manager

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 Foreword xvii

because I now listen for clues to indicate how to interact suc-

cessfully with the person in front of me at any given moment.
In addition, senior leaders in the hospital now individualize the
way they communicate with their employees on the issues fac-
ing them. They are able to respond to each person in the way
that makes the most sense to each individual.
For example, those who perceive the world through their
emotions want to know that their bosses care about them and
are willing to listen to them and allow them to discuss their
feelings. Those who perceive the world through thoughts don’t
care about that. They come to meetings with their list of things
they want to discuss, and they want to run through the list of
topics. They want their managers to respond in the same way,
and on time. Understanding this, the members of the leader-
ship team are able to respond accordingly. As a result we are
training the physician leaders, nursing leaders, and other staff
members in the concepts in order to improve communication
with our patients and enable us to work more effectively across
the various business units. We believe this will improve our
quality and service metrics and will have the ultimate result of
benefiting us financially.
This book describes these concepts succinctly. It contains
true stories that exemplify how healthcare professionals have
used the concepts to improve patient safety by helping staff
members get their motivational needs met daily. In this way
they keep themselves out of distress, significantly reducing the
number of preventable medical errors. The book also describes
how healthcare providers can increase patient satisfaction by
communicating with patients in their preferred mode and by
helping patients get their motivational needs met during their
hospital stay and in visits to clinics and doctors’ offices.
Healthcare professionals have known for years that people
can avoid the onset of many of the leading causes of premature
death—for example, heart attacks, stroke, and diabetes—if they
lead healthy lifestyles, exercise, and lose weight. Nearly every

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 xviii Foreword

healthcare professional has tried unsuccessfully to persuade

his or her patients to adopt a healthy lifestyle and is frustrated by
the fact that people refuse to do it. Chapter 10 contains specific
strategies, individualized for each of the six personality types,
that healthcare providers can use to accomplish this.
This book is a welcome addition to the medical literature
because it outlines the concepts of a tool that provides the ulti-
mate safety. Listen to what people say and how they say it.
Respond not only with empathy but with words and phrases
that resonate with your listener.

Hugh Tappan
CEO, Wesley Medical Center
Wichita, Kansas

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 Acknowledgments

W
e are deeply indebted to all those who have con-
tributed to this book. We especially want to thank
Dr. Taibi Kahler, whose genius resulted in many of
the discoveries that led to the concepts described in this book.
The power of the concepts of Dr. Kahler’s Process Communi-
cation Model® has enabled executives to lead their organiza-
tions more profitably; managers to operate their organizations
more effectively; healthcare professionals to reduce human
error, thereby improving patient safety and both patient and
staff satisfaction; and educators to individualize the way they
teach so that they reach and motivate every student, thereby
reducing disruptive behaviors in the classroom and improving
student academic achievement. In addition, Dr. Kahler’s Pro-
cess Therapy Model™ has enabled psychiatrists and psycholo-
gists to greatly reduce the treatment time of their patients
and speed up their recovery.
For more than 40 years, Dr. Kahler’s discoveries have
enriched the lives of people in all walks of life. We have
enjoyed our association with him for more than 25 years. He
has changed our lives, and his Process Communication Model®
has enabled us to be more effective leaders in every organiza-
tion we have headed. More important, the concepts of Process
Communication have enabled us to improve the lives of all

xix

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 xx Acknowledgments

those with whom we interact every day and have enabled us to

positively impact professionals, leaders, teachers, students,
and educators throughout the country.
We also are indebted to the many people who shared stories
with us detailing the ways they have used the concepts. We
especially want to thank the doctors, nurses, and other health-
care professionals who described how they use the concepts to
treat patients, to reduce conflict and promote teamwork within
their facilities, and to improve patient safety and patient and
staff satisfaction. We also want to thank the patients who shared
their stories—both positive and negative—with us. Some of
those who provided stories are named in the book. Others are
not, at their request. All the stories are true.
We especially are grateful to Andrea and Werner Naef,
directors of Kahler Communications Oceania, and Dr. Brad
Spencer, CEO of Spencer, Schenk, Capers, for introducing us
to some of their clients and persuading them to provide stories
for the book. We also want to thank Nate Regier, PhD, found-
ing member partner of Next Element Consulting, for introduc-
ing us to Dr. Hugh Tappan, who wrote one of the forewords
in this book. We greatly appreciate and are indebted to Dr.
Janet Hranicky, founder and president of the American Health
Institute, for sharing with us the results of her more than
30 years of research with cancer patients.
We want to thank all the doctors, nurses, and physical and
occupational therapists who have taken such excellent care of
us throughout our lives. They have provided outstanding care
and medical advice and have kept us alive and ambulatory so
that we could continue to train professionals and others in the
concepts contained in this book. They literally saved the life
of one of the authors, Joe, when his femoral artery ruptured.
Finally, we want to thank Matt Meinholz of the ASQ Qual-
ity Press for his foresight in recognizing the value of this book

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 Acknowledgments xxi

and for encouraging us to write it. We also want to thank the

other ASQ staff members who worked with us. We especially
are indebted to the staff of Kinetic Publishing Services, LLC,
for editing and typesetting the book. This is a better book
because of their expertise, suggestions, and corrections.
To all of them we say a sincere and heartfelt thank you.
This book would not have been possible without their help.

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H1418_Pauley.indd xxii 6/14/11 3:12 PM
 Introduction

E
stablishing a Culture of Patient Safety: Improving Com-
munication, Building Relationships, and Using Quality
Tools aims to provide a road map to help healthcare
professionals establish a culture of patient safety in their
facilities and practices, provide high-quality healthcare, and
increase patient and staff satisfaction by improving commu-
nication among staff members and between medical staff and
patients, by describing what each of six types of people will do
in distress, by providing strategies that will allow healthcare
professionals to deal more effectively with staff members and
patients in distress, and by showing healthcare professionals
how to keep themselves out of distress by getting their motiva-
tional needs met positively every day.
The concepts described in this book are based on science
and have withstood more than 40 years of scrutiny and scien-
tific inquiry. They originally were used as a clinical model to
help patients help themselves, and, indeed, they still are used
in this manner. The originator of the concepts, Dr. Taibi Kahler,
is an internationally recognized clinical psychologist who was
awarded the 1977 Eric Berne Memorial Scientific Award for
the clinical application of a discovery he made in 1971. That
discovery enabled clinicians to greatly reduce the treatment
time of patients by lessening their resistance as a result of
miscommunication between them and their doctors.

xxiii

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 xxiv Introduction

Dr. Terrance McGuire, the consulting psychiatrist for the

NASA space program for more than 40 years, was so impressed
by Dr. Kahler that he invited him to participate in the 1978
round of astronaut selection interviews. Dr. Kahler’s involve-
ment with the space program led him to turn the concepts into a
behavioral model. When CEOs heard about the concepts, they
asked Dr. Kahler to translate the model into management and
leadership terms. He did, and in 1981 he developed a com-
mercial model that is being used in healthcare facilities, cor-
porations, nonprofit organizations, and other organizations
around the world to help increase employee productivity, job
satisfaction, morale, and corporate profitability. In healthcare
facilities, these concepts have enabled healthcare professionals
to greatly reduce accidents (including accidental deaths),
improve patient safety and satisfaction, and improve staff satis-
faction and retention. Since 1986 the model also has been used
in education to help teachers individualize instruction so that
they reach and teach every student more effectively.
The concepts are universal; that is, they apply in every
culture. They have proved to be effective everywhere they are
used—in the United States, Canada, Europe, Asia, Austra-
lia, New Zealand, Africa, Latin America, and the Caribbean.
Included in the book are stories from several healthcare pro-
fessionals and healthcare organizations in the United States,
Canada, Europe, and New Zealand. Many healthcare profes-
sionals have told the authors that being able to apply these con-
cepts to their patients and their colleagues has enabled them
to establish positive relationships with all their patients and to
deal more effectively with patients and caregivers in distress.
Former president William Clinton told the authors in 1997 that
he considered Dr. Kahler to be a genius. President Clinton
used the concepts in his speeches, and Dr. Kahler served as a
psycho-demographer during Clinton’s presidency.
But improving patient safety and satisfaction is only one
aspect of improving the quality of healthcare. To improve

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