Storytelling’ by staff, patients brings issues to life, aids change

Technique used successfully to support safety, satisfaction, training

It’s as old as humankind itself, yet when recast through modern technology, storytelling is becoming one of the newest and most effective techniques for engendering cultural change and facilitating performance improvement in health care.

"It comes down to a question of motivation and change management," explains James A. Espinosa, MD, FACEP, FAAFP, medical director of the Overlook Hospital emergency department (ED) in Summit, NJ, and quality advisor and fellow of the Atlantic Quality Institute, for Florham Park, NJ-based Atlantic Health System (AHS), of which Overlook is one of several facilities. "That question always hangs in the air, but conventional elements of QI don’t really address the issue."

"It’s a great way to train staff," adds Karen Baldoza, MSW, project manager for the Boston-based Institute for Healthcare Improvement (IHI). "We have a very fun culture, and this reflected it very well."

The IHI has used video storytelling to create a training video, but its uses are virtually limitless. For example, the National Institutes of Health (NIH) has adapted a CD-ROM "virtual schoolhouse" developed by AHS into a core tool to be used internationally. AHS, which began its pioneering work in storytelling in 1996, has used it to help improve clinical processes, including timely delivery of medications; to teach principles of quality management (patient satisfaction, teamwork and leadership, cause and effect, patient safety); to support root cause analysis; and to partner with risk management.

Today, storytelling has become a regular feature of its ED microsystem meetings, where stories of what went well and what did not are shared openly.

Why storytelling works

Why has storytelling proven to be such a powerful tool? "Storytelling works because it really brings across more than just facts," notes Tina Maund, MS, RN, director of performance improvement, at AHS/Overlook. "On the human level, it really captures people’s interest and engenders an emotional investment."

In one application, she recalls, Overlook used it to tell the story of a process. "Our flowchart for medication administration in the OR covered two walls of our conference room," she notes. "So we videotaped to tell the story. Seeing it acted out by real people in a real environment made comprehension much easier."

"It was a way to involve the organization in something different," says Baldoza. "People wanted to work on it because it was different and creative, but it was also a teaching and training opportunity."

"Especially in process redesign, video storytelling can work with a larger group, with everyone having the same perspective since they’re all sitting around the table," adds Linda K. Kosnik, RN, MSN, CS, chief nursing officer at Overlook and fellow with the Atlantic Quality Institute. "It also validates the importance of the process by using leadership. It allows the staff to really understand what’s important to the organization; it becomes more of a personal issue."

Early experiences

What motivated AHS to begin exploring the storytelling technique? "There are a number of elements of health care QI that are imports from industry," Espinosa notes. "And they are excellent at defining problems and addressing the execution of change in terms of where we should head. But to get others to work with you requires persuasion. Increasingly, we recognized that what we saw in data persuasion was getting the data to tell a story. We had to get a wide range of people to see a similar vision. In order for it to have meaning, we had to get at what was in our heads, and you can only do that so many times verbally over and over. The theatrical element enables us to show what’s in our minds."

The first experience with storytelling in video was the "virtual schoolhouse," the core of which were videos of actual patients telling their own stories in their own words. "The virtual world looks like a building, and one room is a gallery of stories, where real people tell real stories about atypical chest pain presentations," Espinosa explains.

"The NIH kept the architecture [AHS sold it to NIH for $1], but upgraded it. They added even more diversity of people to it, and then populated the rest of the world with a lot of best-in-class’ science, but they kept the core. As we understand it, release is imminent, and it will be available to everyone through the NIH web site in time," he explains.

Over the years, AHS has found a wide variety of applications for storytelling. Here are just a few examples:

• Patient safety education: "We developed within AHS a core group of scenarios to be used for patient safety education," Maund notes.

"We tried to teach staff in areas where there were errors or the potential for errors through a mini-root cause analysis, using a video." In the evaluation forms, the response was overwhelmingly positive. "We were told that the use of videos was very effective in terms of bringing points across in analyzing safety problems and taking the learning going forward in a way that errors were prevented or situations were made safer," she reports.

After piloting the videos in small groups, the program was expanded and used in AHS’ "Megaday," which all staff must attend. "We had people who were recognizable in the clips," Maund notes. "Since some of these people held very high positions, it made it clear there was organizational support for this. Also, with these people being recognized, those watching felt very connected."

Critical thinking: New staff often lack much-needed critical thinking skills, and Kosnik sees this as one of the key challenges in safety and process redesign.

"Hardwiring is a challenge, and this is a great retention tool," she asserts. "New staff really see value in being trained to identify problems as they occur, as opposed to identifying the causes after they occur."

Redesigning medication processes: Anesthe-sia usage in the OR was one example, Kosnik reports.

"You tape the process with a small group. Then, larger groups watch. You stop the video at various points so you can evaluate and see redesign opportunities," she explains. "Then, we re-video the new process and see if we can find holes in it."

Maund notes that a similar process was used with blood specimen labeling. "We had to script the tech to limit interruptions. Using video, the group started critiquing the new process, so by the time we finished, we had a much better new process."

Live stories: In this technique, actual patients, family members, or staff are brought in to tell their story to a group. "This allows us to get a firsthand perspective," Kosnik explains.

"These can be positive or negative stories. We also try to look at things that went well [positive inquiry] to make sure they go well again," she says.

Benchmarking is spreading

The NIH and IHI programs are just two early examples of organizations that will be learning from and benchmarking AHS’s experiences.

"We’ve used video clips both in regional conversations in our system as well as in major presentations, such as the IHI Forum, for the last several years," Espinosa reports.

"We presented at the Partnerships for Patient Safety program in Washington, DC, under the auspices of the Veterans Health Administration (VHA), the American Hospital Association, and other associations. It’s been of interest because it gives senior leaders something actionable they can do the next day in patient safety, patient satisfaction, and clinical areas," he says.

The IHI training video was a prime example. "Linda, Tina, and I went up there, met with them, and presented the process," Espinosa recalls.

"Their interest was to put together vignettes that had to do with their new standard operating procedures and cultural expectations around conferences. They did a treatment in the form of a debrief, where people talk about conferences, what could have been learned or done differently. Suddenly, you’re in the speaker’s head; you see what happened," he says.

"One of our VPs sat in on that meeting," adds Baldoza. "She thought, This is what we should be doing.’"

The video uses the stop-action technique particularly well, Espinosa notes. "On the screen, it actually says, Stop Here.’ It encourages a conversation to occur, for opinions to be expressed."

Real-world problems are outlined, such as how to support a speaker who has audio-visual (AV) problems. "It’s really about conscious customer service, but also how any new [standard operating procedure] can be frozen and then disseminated," Espinosa says. "But it’s not done as you normally think it would be: Here it is, do this.’ Instead, it addresses the why. What is the heart of this? If you give me meaning, I can do it."

Baldoza, who headed the project for IHI, explains that she pulled people from all different parts of the organization. "We wanted everyone to be involved. All of a sudden, we found these unique talents; we didn’t know that one person had worked for MTV, for example." Like the folks at AHS, Baldoza says she also found that involvement of senior leadership was key.

IHI intentionally picked small problems as their focus, Baldoza explains. "We do a lot of meeting planning, and strange things come up — problems with AV, with the hotel. This gives someone new the ability to see what this might look like, and how they might problem solve."

Baldoza still uses the training video. "We always show it to new people," she says.

It is not hard, or necessarily expensive, to benchmark the experiences at AHS or elsewhere. "It was surprisingly low-cost, and we learned a lot; it was much easier than I thought it would be," Baldoza reports.

"We can give people a plan on what steps to take," says Espinosa. "Leaders just need to know what it is they want to address."

"This can be done in a very low-tech manner," Kosnik adds. "We found that you can just get a room, use the same camera you would use to tape a birthday party, and get extraordinary results."

Espinosa cautions that storytelling is not a panacea to solve all an organization’s problems. "Storytelling is like the wing of a bird; it has to be linked to process change," he asserts.

"We have anecdotal evidence that it has been indispensable in our journey, but it’s very hard to study scientifically. After all, once you do the storytelling, you have an intervention, and everything is different," Espinosa adds.

Nevertheless, Maund says, "We have found that this is a tool that truly captured people’s interest and supports their investment of energy and real commitment to working going forward. Aside from just stating the facts, you really have that humanistic component. People respond in a way that is absolutely absent in the traditional approach." n

Need More Information?

For more information, contact:

  • Karen Baldoza, MSW, Project Manager, Institute for Healthcare Improvement, 375 Longwood Ave., 4th Floor, Boston, MA 02215. Telephone: (617) 754-4800. Fax: (617) 754-4848. Internet:
  • James Espinosa, MD, FACEP, FAAFP, Chairman, Emergency Department, Overlook Hospital, 99 Beauvoir Ave., P.O. Box 220, Summit, NJ 07902-0229. Telephone: (908) 522-5310.
  • Linda K. Kosnick, RN, MS, CS, Chief Nursing Officer, Overlook Hospital, 99 Beauvoir Ave., P.O. Box 220, Summit, NJ 07902-0229. Telephone: (908) 522-5310.
  • Tina Maund, RN, MS, Director of Performance Improvement, Overlook Hospital, 99 Beauvoir Ave., P.O. Box 220, Summit, NJ 07902-0229. Telephone: (908) 522-5310.