Book Review-Relationship-Based Care: A Model for Transforming Practice

Healthcare isn’t sausage-making. In sausage-making, “what’s in there” doesn’t matter. It’s simply that it tastes good. In fact, most people don’t want to know about the sausage-making process. However, in healthcare, we’re talking about people, and the process matters. That’s the heart of Relationship-Based Care: A Model for Transforming Practice – an understanding that the process of delivering care is important and the best way to do that is by recognizing the importance of relationships.

Three Directions

In the healthcare system, there are three primary kinds of relationships that a provider can have. First, there’s the obvious relationship to the patient – and their family. The second relationship is with the colleagues. Healthcare is a “team sport.” No provider can work alone. Finally, there’s the relationship to one’s self.

It may seem that a relationship to self is an odd thing to add; however, the truth is that the lack of self-care and self-awareness on the part of providers leads to burnout – and poorer outcomes for the patient. (See for more on burnout causes and resolutions.) The truth is that the relationship to self is the relationship from which the other relationships initiate.

Connecting to the Mission

Every day, care providers face new patients. They present with the same kinds of conditions and the same acuity as the day before and the day before that. There are variations to be sure, but the patients keep coming. It seems like the provider isn’t having an impact. The same patient comes back with the same problem, because they didn’t heed the provider’s advice.

It can be frustrating and demoralizing to realize that you can’t save everyone – that you can’t help everyone. As each day becomes more and more of a grind, it’s possible to lose your way – and wonder why you’re pushing yourself if you’re not seeing any results. That’s when it’s important to reconnect with the mission of the organization and to our personal mission.

Simon Sinek in Start with Why explains that connecting to why we’re doing something has a powerful effect on our productivity and our ability to continue in the face of adversity. In some cases, we know why we’re doing something – our personal and organizational missions – but we’re lost, because we don’t feel like we’re accomplishing the mission. Instead, we feel as if we’re engulfed in chaos, and we’re just trying to survive.

The Healing Power of Relationships

We think we’ve got the world figured out. We believe that our technology and techniques save lives – and to some extent, that’s true. Our technology does save lives, but there’s more to it than that. Aristotle knew that there was more than one way to know the truth. There’s the science – episteme – but there’s also the art – techne. The truth is that our technology and techniques are only part of the solution. (See Theory U for more about different kinds of knowing.)

In Being Mortal, Atul Gawande recounts research that assisted living facilities with patients who were given something to care for – a plant or an animal – lived longer than those who didn’t have something to care for. Our connection to other living things is a powerful tool for health.

Florence Nightingale knew this. She believed that the role of the nurse was to help patients attain the best possible condition, so nature could act, and self-healing could occur. The icon of nursing didn’t believe it was the nurse’s role to heal but rather to create the conditions for healing to occur, and those conditions seem to be found in caring, compassionate relationships.

Transforming an Environment of Care

Jayne Felgen developed a model, I2E2, for transforming the environment of care. The model is four concepts:

  • Inspiration – How do you connect people with the things that inspire them – in other words, their mission?
  • Infrastructure – The set of practices, systems, and processes that make the inspirational vision achievable.
  • Education – The promotion of competence, confidence, and personal commitment through providing the knowledge and skills necessary to do the job.
  • Evidence – Gut feel isn’t enough. In today’s healthcare world, it’s necessary to know for sure that the work being done is making a real difference.

The model encourages the tools that we know lead to change, including creating the initial pull to drive the change forward, supporting the individual both at a systemic and educational level to help them understand they can be successful, and providing continuing support in the form of demonstratable results. (See Diffusion of Innovations for more about motivating people to change.)

The Five Cs (Conditions)

In every organization, there are barriers to change. In fact, organizations, by their very nature, are resistant to change. The network of policies and procedures are designed to form a network that provides strength around unnecessary change. However, there are conditions that make it more likely that change can occur. They are:

  • Clarity – When people know what’s happening at a deep level – both to them and to the organization at large – they can move forward with less fear. (See The Fearless Organization about the role of fear in organizations and Trust=>Vulnerability=>Intimacy, Revisited for more on the role of safety.)
  • Competency – The more people feel competent, the more willing they are to step forward into the change. (See The Psychology of Hope for how waypower impacts a person’s ability to maintain hope.)
  • Confidence – The feeling that someone knows what is being asked of them and has the skills to execute on that leads to confidence – or courage – to move forward. (See Find Your Courage for more.)
  • Collaboration – Collaboration is the ability to work together towards a common goal. That’s essential if you want to transform an organization, because in all but the smallest of organizations, there are multiple people involved whom you need to work with. (See Collaborative Intelligence for a very detailed investigation in how to make collaboration work.)
  • Commitment – Being “bought in” to a goal is critical to its success. Commitment carries the change beyond just doing it if it’s easy, and instead moves it to the world of grit, where there’s a burning desire inside the person who is willing to face adversity to accomplish the goal. (See Grit for more.)

Though the 5 Cs aren’t a rich model for organizational change, it does provide a good framework for some of the basics.

Person not Diagnosis

Diabetes in room 3. Stroke in room 4. Breathing trouble in room 5. It’s a quick way of communicating, but it’s not a respectful way. In healthcare, we’ve got HIPAA to consider, but we can’t use that as a shield for our thoughts and words. Everyone has a story. Everyone is a real person – and they’re much more than a diagnosis.

When we dehumanize people, as referring to them by their diagnosis tends to do, we make it easier to unconsciously treat them poorly. Stanley Milgram demonstrated that, given light environmental controls and encouragement, most people are willing to administer what they believe are life-threatening shocks to others – if they’re not in the same room. (See The Lucifer Effect and Moral Disengagement for more on Milgram’s experiments and the topic of dehumanization in general.) Though we don’t want to admit it, the more we fail to think and communicate about patients as real people with real fears, hopes, and aspirations, the easier we make it to discount them – and that’s the opposite of being in a relationship with them.

Leadership as Being in a Relationship

Joseph Rost laid out in Leadership for the Twenty-First Century how he believed all leadership is done in relationships – non-coercive relationships – and how everyone is a leader. Rather than believing there are two classes of people (separating people into us vs. them), Rost believed that all of us are in relationships with others and are capable of leading. The common thread is that the relationship is accomplished for a meaningful, mutual purpose. In healthcare, the well-being of the patient is a meaningful, mutual purpose.

Sometimes in leading recovery, the patient will lead, and other times, the nurse will lead. Sometimes, in healthcare organizations, the manager will be leading, and other times the nurse will be leading. Leading is, according to Rost, centrally focused on the ability to be in a relationship.

Most nurses recognize that their relationship with their patients, the ability to be with them at their times of such great vulnerability and need, is a sacred and privileged trust. This puts them in the position to lead the patient to better health – as non-coercively as possible.

Organizational Models

Relationship-Based Care spends a great deal of time investigating structural models of organization and approaches to how to deliver the best care. From the historically highly authoritative to the more collaborative approaches, the walk-through shows the progression from a very power-based approach to one that is more collaborative and focused on mutual relationships.

The concerns are addressed about how organizations can maintain consistency of delivery when the delivery is done in a more collaborative and relationship-driven way. The fact of the matter is providing professionals with more autonomy provides for better outcomes – when that autonomy works inside of a well-defined framework.

I’m reminded of Chris Lowney’s work, Heroic Leadership, and how the Jesuits learned which things couldn’t be adapted to fit a culture they were working with – and which could. This clarity about the things that were and weren’t negotiable made it possible to operate effectively in very different environments.


Relationship-Based Care recommends reflection – and that’s important both at an individual level and at a level of process improvement. When we do institutional reflection like after-action reviews (see Lost Knowledge), more commonly seen as root cause analysis, systemic cause analysis, or morbidity and mortality meetings, we create the opportunity to learn from our mistakes and not repeat them.

Perhaps it’s worth some reflection to see if you are providing the best Relationship-Based Care.

The Impact of Clinical Nurse Specialist

In a world where health care is focused on improved outcomes and safety the Clinical Nurse Specialist (CNS) is a light in the darkness. The role of the CNS is frequently one of the least understood of all advanced practice registered nurses (APRN). APRNs include nurse practitioners, nurse anesthetist, nurse midwifes and CNS. Of the approximately 350,000 APRN in the United States the CNS population in the United States is numbered at nearly 72,000.

The CNS specialist brings together three separate spheres: the patient, nursing, and the healthcare system. They practice within these spheres to create the best opportunities for patients to have optimal outcomes and for nurses to be supported to be able to provide the level of care they desire to give by working with systems to find better ways to support process that provide the best outcomes.

This week is national CNS week. I am proud and humbled to be among the amazing CNS’ that improve healthcare every day; not only for the patients but for everyone involved in their care.

Happy CNS week!


Cinco de Mayo aka World Hand Hygiene Day

Happy Cinco de Mayo! May your hands be washed well frequently and help prevent the spread of infection. I know this is not the typical toast to go with the annual Margarita splurging day that celebrates the Mexican army’s victory over the French army at the Battle of Puebla is 1862. I promise the intent of my toast is pure and full of hope for your good health.

The 5th of May is not only Cinco de Mayo it is also World Hand Hygiene Day. It is possible that World Hand Hygiene Day may never be as eagerly or widely celebrated as the Cinco de Mayo. It is likely that the simple act of cleaning your hands at the appropriate times will save more lives and prevent more infections than any other action we can take. The battle against pathogens and the development of antibiotic resistant bacteria is literally in our hands.

When we look at the data it is apparent that there is reason to celebrate World Hand Hygiene Day and take a stand to stop the spread of infection.

Let’s look at a bit of data related to hand hygiene:

  • A large percentage of foodborne diseases are spread by hands that were not cleansed well
  • Handwashing can reduce the risk of respiratory infections by 16%
  • Up to 80% of common infections are spread by hands
  • 10% of people do not wash their hands at all after going to the toilet
  • Only 1 in 20 people wash their hands appropriately after going to the toilet
  • In the United States, some healthcare providers clean their hands less than 50% of the times they should
    • These healthcare providers may need to clean their hands 100 times per 12-hour shift
  • According to UNICEF, one in every four childhood deaths, approximately 1.4 million globally, result from diarrhea and pneumonia. Handwashing with soap and water could reduce the death rates from these diseases up to 65% (Sam Stevens, Clean the World Foundation).

Effective hand hygiene takes less than 20 seconds and is truly an action that saves lives and changes the world. We spend millions of dollars looking for ways to keep humans safe from infection. The first line of defense is found in appropriate hand hygiene. Doing the right thing takes a small time commitment combined with the awareness of when it is important to perform hand hygiene.

There are very specific times when washing your hands is imperative:

  • After going to the toilet
  • Before eating or preparing food
  • Before and after taking care of someone who is ill
  • Before and after treating a cut or injury
  • After changing diapers
  • After blowing your nose, coughing, or sneezing
  • After touching animals, their food or waste
  • After touching garbage

There are five simple steps to washing your hands:

  1. Wet your hands
  2. Lather your hands with soap
  3. Scrub your hands for at least 20 seconds
  4. Rinse your hands
  5. Dry your hands

If soap and water is not available, you can use an alcohol-based hand sanitizer to clean your hands. It is important to remember that alcohol-based hand sanitizers are not as effective if your hands are visibly dirty or greasy. When using alcohol-based hand sanitizer be sure to follow these steps:

  1. Apply the product
  2. Rub your hands together
  3. Rub the product all over your hands and fingers until they are dry

Researchers in London estimate that if everyone routinely washed their hands, a million deaths a year could be prevented. Think about that, if it was your loved one that was still alive because we all washed our hands. We can’t live forever, but we shouldn’t die because someone didn’t wash their hands. Each time you wash your hands you could be saving a life, what could be more important than that. May you wash your hands well and frequently and have a very healthy Cinco de Mayo.

#HandHygiene #HealthForAll

Patent Issued: Dressing with Moisture Indicator

It was over four years ago on a trip to visit our son that we started a journey to create a way to help protect patients from developing life-threatening blood stream infections. The journey has been long, but today is the day that the US Patent and Trademark office issues our patent for a dressing with moisture indicator. We wanted to take this opportunity to explain why this is so desperately needed and why it works.

The Healthcare Associated Infection Problem

Central line-associated blood stream infections (CLABSI) are a special class of healthcare-associated infections (HAIs) and one that is particularly life threatening, because it can lead to sepsis. Each year in the US, roughly 100,000 people die of HAIs. That’s comparable to a commercial airliner crashing every single day, killing everyone on board. There has been a great deal of energy focused on reducing this problem, but still too many people are admitted to hospitals, have a central line inserted, and get sicker because of CLABSI or some other HAI. Some of those that develop a CLABSI die from this preventable infection.

The Story

It was 1:30 AM, and we were driving through western Pennsylvania when Terri exclaimed, because a young patient had developed a CLABSI and by the bacteria and the notes in the chart, she knew what happened. The patient had vomited on their central line’s dressing, and the parents, trying to be helpful, wiped it off. The problem is the moisture and the bacteria that naturally occur in the stomach were now on the dressing. Bacteria need two things to be able to replicate. They need food, and they need mobility. There’s food for bacteria nearly everywhere. The moisture from the stomach and from the washcloth made it easy for the bacteria to get to food and replicate.

Eventually, the bacteria penetrated the dressing, and the IV led them straight to the blood stream, where they could spread out and infect everywhere in the body.

The Dressing’s Role

IVs are used to deliver fluids and medicines to patients. Central lines are inserted into major blood vessels, so that greater volumes, multiple medications, and nutrition can be quickly infused without the complications of peripheral IVs. This is great when you need to be able to diffuse medicine quickly, but it makes them particularly vulnerable to bacteria getting the benefit of the same distribution. The IV dressing is designed to protect the insertion site of the IV from becoming contaminated with bacteria and serving as a direct pathway to the circulatory system.

Dressings, however, must be semipermeable. That is, they need to let the natural moisture emitted by our skin as small amounts of sweat escape to prevent reservoirs of liquid from forming under the dressing. This semipermeable nature means that it’s possible for external contaminants to make it through. The dressing creates a protective barrier but not an absolute one.

As a result, the CDC (and everyone else) says that dressings should be clean, dry, and intact. Cleanliness is an easy visual observation. While the exact standard for what constitutes clean and dirty can be argued, it’s easy to assess the degree of cleanliness by observation. Assessing whether the dressing is intact is slightly more invasive, as it requires that the nurse or provider lift the IV to see whether there are gaps between the dressing and the skin. However, dryness presents a particular challenge.

Assessing Dry

On the surface, assessing dryness – or wetness – of a dressing should be easy: just touch it. Except nurses and providers – for everyone’s protection – should always wear gloves when touching a patient’s dressing. You can’t tell if something is wet through gloves. It’s possible to assess cold-wetness, because it will feel colder; but because the fluids will be at body temperature, it’s very difficult to determine if a dressing is wet through gloves.

Because dryness is so hard to do, it’s not always done well. In truth, it’s not assessed as often as it should be based on research and healthcare system standards. This is the fundamental problem we solved. We found a way to make dressings tell you visually when moisture is present. The result is assessing dryness is as easy as assessing whether the dressing is clean.

Information Overload

We contributed a chapter to the American Nurses Association book Information Overload. It explains what nurses already know: they’re overloaded. They’re expected to document hundreds of observations per hour, and, for each observation, they may have to make multiple assessments – as is the case for dressings. There’s simply no time to do all that must be done to provide good care for their patients and properly document what is happening.

We recognized that, if we couldn’t make the assessment easy, we’d have no chance of changing behavior and helping nurses change dressings appropriately.


The industry has been moving down a path of using antimicrobials to combat infections. The idea is that, if you use something like chlorhexidine gluconate (CHG) in a dressing, you’ll kill the bacteria and eliminate the need to change the dressing. CHG-based dressings are better than non-CHG-based dressings for those patients that can tolerate it well; however, it creates a secondary set of issues. We have a limited number of chemicals (and metals) that we know to have antimicrobial properties. As a result, we use them frequently when timely cleaning isn’t practical or even possible.

Research indicates that some microbes are becoming resistant to the antimicrobial properties. In short, the antimicrobials are gradually becoming ineffective as the microbes adapt. At some point, we’ll overuse CHG and the other antimicrobials, and they’ll become completely ineffective. We see this already with multi-drug resistant organisms (MDROs) like Methicillin-resistant Staphylococcus aureus (MRSA) and carbapenem-resistant Enterobacteriaceae (CRE). We’ve killed the susceptible versions of the bacteria and the resulting bacteria replicates free of competition from its variants.

It’s not a question of if strategies using CHG will become ineffective – it’s a question of when. No one can predict when CHG will stop being sufficiently effective to continue its use, but the day is coming.

Unstoppable Humans

The good news is that humans are unstoppable. We’ve done amazing things as a species. This is particularly true when we make it easy to do the right thing. Evolutionary scientists have studied and modeled what has given us the power to be the dominant life form on the planet. Some of this has to do with our capacity to work together, but equally important is our capacity to adapt and to adopt behaviors that help us to protect ourselves and our communities. Caring for patients will never be easy, no matter how much we try to make it so. Having a dressing that signifies the need to be changed due to moisture helps make patient care easier. Making appropriate care easier improves the care we are able to provide and the outcomes for patients everywhere.

Conflict Resolution and Infection Prevention

Conflict is a natural part of life. We learn to resolve conflict so that we can be a part of the human condition that is designed to be social – so that we can be in relationship with others despite the conflict. In the emotionally-laden environment of healthcare, conflict consumes significant time and energy for the IP. In this brief conversation, we’ll explain the foundations of conflict resolution. Effective conflict resolution and communication skills can transform organizational culture and leadership and improve efficiency, reduce preventable errors and adverse events, and improve staff and patient satisfaction.

Rob and I are presenting Conflict Resolution for the Infection Preventionist: Improving Collaboration and Patient Outcomes at the national APIC convention in Minneapolis on Tuesday, June 13th. APIC is always an exciting conference to present at and attend. As infection preventionist there are so many opportunities to improve patient outcomes. The magic comes when you can improve patient outcomes and not add burden to the rest of the healthcare team. This transformation requires compromise to find ways to deliver the level of care that creates the best outcomes for patients in a sustainable and time effective manner.

Together we can eliminate healthcare associated infections.

Happy National EMS Week!

This week has been set aside to show our appreciation for all EMS providers who step into a problem with knowledge, compassion, and respect for those they care for.

Many years ago, I started my journey in healthcare as an emergency medical technician (EMT). It was not long before I entered nursing school with the goal of becoming an emergency room nurse. Some 35 years later, I still have a soft spot in my heart for EMS and emergency room nurses.

Our eldest son is a paramedic. I hear his stories and recognize the impact he has on the people he cares for. He provides care in the unexpected, emergent world we all hope to never experience. When we do experience it, the event is a potentially life-changing moment. Having someone willing to step in and provide the care you require is life giving.

When we teach about therapeutic boundaries, we discuss the care continuum of empathy, compassion, and altruism. Empathy is the ability to understand what someone is feeling. This is an important skill but is not enough to provide the level of care we require in healthcare. Compassion is a step further: it is an understanding of how someone feels and a strong desire to alleviate their suffering. At the far end of the continuum is altruism. The willingness to help another at a risk to oneself. We tell most healthcare providers that compassion is the place where you want to operate from; altruism is a step too far for most of us. For those who are part of the EMS team, it is normal to operate from altruism. The risk is calculated: the team has prepared and trained to limit their risk, but each rescue has a risk that is willingly accepted to provide for those in need.

Even though we only celebrate EMS week once a year, we are all thankful for every EMS provider and offer you our thanks and prayers.

Nurse’s Week Gift

Some of the nurses were talking about how nice it was that many restaurants had Nurse’s Week specials. It is wonderful to have people acknowledge the special work we do as nurses and to celebrate this with us each year.

This year, I want to offer all nurses a different gift. Each of us became a nurse for different reasons, and our practices differ dramatically. One commonality I see among nurses is the gift of compassion, not just the “I want to take care of you” style of compassion. It is the “by the book” definition of compassion I see over and over again. According to Merriam-Webster, compassion is defined as the sympathetic consciousness of others’ distress together with a desire to alleviate it. This depth of compassion is seen in nurses around the world every day. This compassion is what gives nurses that sense of accomplishment at the end of a hard day, knowing that they made a difference in someone’s life. To be able to truly alleviate someone else’s pain and distress is an incredible gift. If I had to guess, compassion is the basis that makes nurses the most trusted of professions.

While it is normal to see nurses show compassion to their patients every day, it is rare to see these same nurses be compassionate with themselves. Too frequently, we think that taking time for ourselves or doing something just for ourselves is selfish or unnecessary and should not be valued. Nurses in general, myself included, are not steeped in the tradition that it is necessary to care for yourself.

Rick and Forrest Hanson (authors of Resilient: How to Grow an Unshakable Core of Calm, Strength, and Happiness) tell us that compassion for yourself is fundamental. By being more compassionate with ourselves, we learn to recognize our own distress and work to alleviate it. This self-compassion feeds our souls; it helps us to find and keep the joy that life has in store for us. In the end, self-compassion gives us the strength to be compassionate to others. Being compassionate with ourselves not only helps us to be more compassionate towards other, it can help reduce compassion fatigue.

We are starting to see more encouragement for nurses to care for themselves. The ANA’s Healthy Nurse, Healthy Nation encourages nurses to take better care of themselves and be good role models for society. The first step in caring for ourselves is to develop self-compassion.

This Nurse’s Week, I ask you to be compassionate with yourself. If you can’t see a way to do this for yourself, do it for your patients, family, and friends. As we experience self-compassion, we will be better prepared to encourage one another; the ripples of compassion will grow to include not only ourselves and our patients, but also our families, friends, and co-workers.

Happy Nurse’s Week to an amazing group of people, I am honored to be a nurse with you.

Washing Hands

Cinco de Mayo

Cinco de Mayo; what does this date make you think about? Many people will think about their favorite Mexican food or beverage. History tells us that May 5th is set aside to commemorate the Mexican Army’s unlikely victory over the French Empire at the Battle of Puebla on May 5, 1062. Cinco de Mayo is not Mexican Independence Day as many believe.

Cinco de Mayo has special significance this year: May 5th is World Hand Hygiene Day! The World Health Organization (WHO) has declared May 5th as World Hand Hygiene Day to encourage patients and family members to join healthcare professionals in the practice of appropriate hand hygiene. According to the WHO, hundreds of millions of patients are affected by healthcare-associated infections (HAIs) every year. More than half of these infections could be prevented if caregivers properly cleaned their hands at key moments in patient care. Everyone has a role in encouraging each other to clean their hands.

Imagine an entire day across the globe to celebrate and remember the importance of hand hygiene. If only we were celebrating the incredible job that we as a species do at effective and timely hand hygiene. Recent data shows that on average, healthcare providers clean their hands less than half the times that they should. Alas, it appears that it is our failure to clean our hands that leads to this observation of World Hand Hygiene Day.

Too often, we only consider the importance of healthcare workers cleaning their hands at the appropriate time to prevent the spread of HAIs. The Joint Commission has stated that hand hygiene is the most important intervention for preventing HAIs. We know one out of every twenty hospitalized patients has an HAI; appropriate hand washing is the solution we somehow cannot succeed at. Hand washing in healthcare is a life-saving activity, but it is not the only place that hand washing is crucial. All of us need to clean our hands at the appropriate times, not only to protect ourselves but to protect our loved ones and society as well.

If you work in healthcare, you know there are five moments (according to the WHO) that you need to wash your hands:

  • Before patient contact
  • Before aseptic tasks
  • After body fluid exposure risk
  • After patient contact
  • After contact with patient surroundings

If you are a patient or have a loved one in the hospital or other healthcare facility, there are key times for you to wash your hands as well. These moments are not as widely broadcast but are essential in the prevention of HAIs. The CDC list patient/family hand hygiene moments as:

  • After using the restroom (use soap and water)
  • Before eating (use soap and water)
  • After touching bedrails, bedside tables, remote controls, or phone
  • Before touching your eyes, nose, or mouth
  • After touching doorknobs
  • After blowing your nose or sneezing
  • Before and after changing bandages

Hand washing, also known as hand hygiene, has two separate methods. First, washing your hands with soap and water; second is the use of an alcohol-based hand sanitizer. If the hand sanitizer contains at least 60% alcohol, alcohol-based hand sanitizers are more effective and less drying to your hands than using soap and water. This is true except after using the bathroom, times when your hands are visibly soiled, or when caring for a patient with C. difficile. At these times, soap and water is the best option because the C. difficile spores are not removed by alcohol-based hand sanitizers.

When completing hand hygiene with soap and water or alcohol-based hand sanitizers, be sure to clean your fingertips, thumbs and between your fingers. Hand sanitizer should be used in a quantity to keep your hands wet for 20 seconds. Hand washing should include take at least 20 seconds as well, with 15 seconds spent rubbing hands together.

Whether you are a healthcare provider or a healthcare consumer, you can impact HAIs through appropriate hand washing. It is time to wash out HAIs and improve all our lives.

Happy World Handwashing Day!!!!

SBIR STTR America's Seed Fund

Why the Small Business Innovation Research and Small Business Technology Transfer Grant Programs are Irreparably Broken

Innovation is at the heart of America. It’s called “American ingenuity,” and the very systems that are designed to grow it are crushing it. Subsumed by academia to work on worthless projects and stripped of all relative value, the programs that were set aside by the government to encourage the one area of the economy where most innovations come from are being used to fund side projects of professors rather than support and encourage real innovation. It’s a way to support salaries and augment the income of professors.

In this post, I’m going to reveal the painful process that we tried to go through to get a grant and the ludicrous responses that we got – ludicrous until you understand what the system is designed to do and how no one has stood up to change the status quo. In the process, I’m going to reveal our ideas with the full understanding that someone can decide to copy it and do it without us all on the hope that someone will realize the power of the idea and help us find a way to fund it.

To be fair, I recognize that there will be some who will say that this is just another sour grapes post. We didn’t get funded, so we’re going to complain about the system. However, what you need to know is that the post was germinated before we knew whether we would be funded or not. More importantly, the structure of the problem was revealed through a coach – a long-time veteran of the process – before our grant began and was reinforced by another former member of our state’s team for helping businesses get funded. This is a deep-seated problem that insiders can’t expose, because they’re too into the system to publicly share their concerns. To expose the rotten underbelly of the system, I need help you see the system from our point of view.

Our story

AvailTek LLC has two owners. Terri Bogue and Robert Bogue. Terri is a clinical nurse specialist with a specialty in helping healthcare systems prevent healthcare-associated infections (HAIs). She has a national practice consulting with organizations to help them reduce their infection risk.

Speaking about myself in the third person for a moment, Robert, on the other hand, has written over 25 books, numerous courses, and too many articles to count. He’s been a technologist who has done software development, networking, and application-level solutions development for decades. He’s spent the last 14 years as a Microsoft MVP – an award that’s reserved for select individuals who share their passion for technology with the global community. He’s traveled the world speaking and teaching about software development.

If you were going to put together a two-person team for creating educational technology to help reduce healthcare infections, you’d be hard-pressed to find a team that’s more able to execute. The expertise you can’t find in one person you can find in a team that are partners in every sense of the word.

Further, with 12 years in business, we’ve demonstrated staying power. We’re not doing what we’re doing on a lark, or because we can’t find jobs and need something to do so we don’t have to tell our friends that we’re unemployed or looking for work. This is a conscious – and often difficult – choice for us.

However, the very things that make us good at business and creating solutions are the very things that make it impossible to get a project funded. Even if we could literally save ten thousand – or more – people from dying from HAIs, and we can demonstrate costs savings in excess of a worker’s salary each year, it’s not enough in the minds of the academics who preside over the process of awarding funding.

Grant Structure

Most folks have never had the displeasure of writing for a grant proposal. It’s a displeasure, because it’s expected to be academic writing with strict page limits, citation requirements, and the general requirement to try to make the whole work sound more difficult to understand than it needs to be. I’ll focus my attention on the Small Business Innovation Research (SBIR) program here, because that’s the program we applied to; however, the Small Business Technology Transfer (STTR) is similar, only having the additional explicit requirement to have an academic institution as a part of the application process.

Writing for the grant was an exercise in trying to fit the important pieces into cramped confines, and at the same time writing in a precise way that made it clear exactly what we were talking about. Other areas didn’t have page limits, or were so much larger than was needed that we felt bad, because we couldn’t fill the pages. Our citations list was pages long. We knew no one would ever read even a fraction of our citations, but they were there, because you could get extra space in the main areas if you didn’t have to explain things too deeply.

In our case, the key to the solution was in our ability to train environmental services workers on how to clean hospital rooms effectively. We’d leverage augmented reality in the rooms they clean, watch their performance, and nudge them into better behaviors. Expressing that in the structure wasn’t easy – even for a seasoned writer – mostly because of the writing requirements.


Imagine for a moment if you had to cite a reference to everything – or every other thing – that you said. What if every time you said anything material, you had to find a research paper that validated your statement? That’s what writing is like for the grant. You can’t make assumptions or generalizations. It’s like the old quote, “In God we trust, all others bring data.” Of course, what they don’t say is that research in general isn’t always correct. In fact, much of the research printed in journals couldn’t be replicated by anyone else.

However, citations are what’s expected in academia. You’re supposed to cite your references. In the real world, citations are rare. They’re the occasional pointer to help the reader understand in more depth, if they choose to. They’re clarifications.

In the end, the need to cite everything makes it easier for academics – because it’s what they’re used to – and harder for innovators, who are frequently without good access to journal articles. Even with the connections that we have, finding all the research wasn’t easy.

Iteration and Adaptation

While citations are annoying, they’re not structurally incorrect, they’re just a barrier that must be overcome. On the other hand, the idea that you have it all figured out, and you know exactly how you’re going to perform the innovation is structurally wrong. Edison didn’t know exactly how to create a lightbulb when he started; no one did. He had a goal and some ideas but no specific path to reach the objective. That’s the point of innovation: a solid direction – a tack – but not an answer on exactly how to do something. After all, if you knew everything there was to know, you wouldn’t need a grant to help refine the idea into the sharp point of a solution.

In the end, this was the undoing of our proposal. I refused to write the proposal like we knew exactly what we were doing. I wrote that we knew the structure of the idea and the science behind why it would work. The problem was I wasn’t willing to spell out in detail exactly how we were going to teach.

This seems reasonable on the surface, that they might resist someone without a finely-defined approach. However, it leaves out the awareness that we cannot plan into innovation. You cannot know what you don’t know until you know it. The point of the exercise is to learn and adapt and create something that works in reality – not on some drawing board somewhere. However, the feedback we got was that we didn’t have a specific plan for how we were going to do everything.

The Feedback

It would be funny if it wasn’t so tragic. Each round of the process you get feedback from a few reviewers. These are the folks who presumably read your proposal and were qualified to respond to it. However, the comments were so bad as to be laughable. They requested that we explicitly detail out what we’re going to do – while at the same time maintaining the strict page limits. But those weren’t the comments that were the most troubling.

The point of the grant program is to create innovation. It’s in the name. However, under the category of innovation, in the weakness section, one reviewer literally wrote the sentence, “This has never been done before.” Clearly the reviewer wasn’t able to understand the word “innovation.” How can you have innovation that has been done before? It’s in the definition of the word.

There were comments that the business was small and only included Terri and I as full-time employees. (That’s not technically correct, but let’s not let that get in the way.) The point of a small business grant is to help small businesses. The Bureau of Labor statistics has 74% of all businesses having fewer than 10 employees. 54% of those businesses have fewer than five. Why would you be comment (in the negative category) that there are only two employees? Doesn’t that miss the point – again?

Other comments included things like claiming that we had pasted in a fake arm in our mock-up of the user interface. Little did they know this was literally Terri’s arm with a glove and a microfiber cloth – not some clipart. The reviewer clearly made an incorrect assumption.

Then there was the thinly-veiled attempt to explain that we weren’t academic enough. Terri has a Master’s degree and I have a Bachelor of Science. Neither of us have a Doctorate. One of the comments called for us to have an “educational methodologist.” I’ve been doing education for decades and have delivered all types of educational programs. Never once have I heard someone call for an educational methodologist. I’ve done instructional design. I’ve taught cognitive load and adult learning concepts. The friends we have who are in academia said that the role doesn’t exist. It’s just a way to say that you didn’t have a PhD in education or psychology on the team – without saying it.

The Timing

The program is about innovation. A few times a year (roughly quarterly) there are submission deadlines. You submit your proposal and they get back to you. The problem is that they take longer than a quarter to get back to you. Consider that most proposals require at least one revision – certainly those proposals from people who’ve never done the process before. That is, those who are innovating and not continuing to be frequent fliers to the system will probably need to do a revision. The review process extends from one deadline beyond the next one. So, you have to expect to spend a few months building the proposal, more than three months waiting on the first response, then wait until the next cycle and submit again to wait three months for that review cycle. For those of you doing the temporal math in your head, it’s over a year. To get funding on an innovation you must wait more than a year.

Small Business

While our small business has been in business for a dozen years, most small businesses fail in only one or two. Perhaps there are no innovations from people who start businesses that fail. However, my belief is that businesses succeed in no small part due to luck. While Pasteur said, “Chance favors the prepared,” there’s certainly something to be said for not having bad luck. Think about the businesses that leased their office space starting in late August of 2001 in the World Trade Center. Full of hope they were going to change the world, until the world changed, and they were at the epicenter.

The process is so bureaucratic and fossilized that it is unable to understand that most small businesses can’t wait a year or 18 months to know if there’s some funding at the end of the rainbow. On the other hand, if it’s not really a business at all but is instead a way for a professor to make some money on the side, well, there’s all the time in the world.

What to Do

The solutions to the problem are simple. Instead of a review board made up of academics, replace them – all of them. Innovation doesn’t come from the “professional” scholars. It comes from the tinkerers and the amateurs who are burning with a passion to make the world better.

The first group of people who could be on the review board are the service core of retired executives (SCORE) that the Small Business Administration uses. While they’ll have the corporate bias of saying no, they won’t be looking for a way to get their projects funded next time. The point is that they’re retired, and they’re looking to give back.

The core of the review board should be entrepreneurs who have innovated. Whether the market ultimately accepted the innovation or not, those people who were able to deliver on the innovation should be evaluating those most likely to succeed. It’s not about what the market will accept. It’s about the innovator’s ability to deliver.

Why It Won’t Happen

So, while it’s simple, it won’t happen, and here’s why. The measurement criteria for success is the number of papers published. For that, you need academia. When you measure success by the wrong criteria – the creation of more research instead of by innovations making it to market – you necessarily get the wrong result. You get what you measure. You get papers, not innovation. You get academic rigor instead of entrepreneurial improvisation.

So, the system is fundamentally broken. It simply can’t produce what it’s designed to produce. You can’t get innovation in a system designed to prevent it from happening, which measures results based on papers instead of products.

A Word on STTR

STTR is even more challenged in some ways, because it presupposes that there is innovation happening inside of academia that needs to be transferred into the commercial markets. My observation is that this happens automatically, whether or not it’s incentivized externally. The university wants to make licensing revenue on the ideas and so will encourage the use of the intellectual property.

STTR follows the same rough process, with different page limits, but I can only assume with the same crazy (or crazy-making) approach. The tragic humor is that the system designed to get innovations to market is overseen by people who have spent their lives in academia and don’t really know how to get things to market.

Our Idea

If you’re interested in partnering on what we’re working on, send me a note. I’m happy to share what we’re going to do in more detail.

Sick Man in Office

Personal Bioterrorism – Going to Work with the Flu 

Every day, thousands of bioterrorists go into work.  They are normal people like you and me, but they are also harboring a biological contaminant that kills up to 650,00 people.  Despite this threat, little is being done to stop these bioterrorists and protect our health. 

As the prevalence of the flu increases, we have come to expect hospitals to implement flu restrictions for visitors.  This may mean that people younger than 18 years old or anyone other than immediate family members are not allowed to visit patients in hospitals.  This restriction is implemented to help reduce the risk of the flu for patients, visitors, and staff.  These restrictions can be bothersome, but in general, they have become an expected part of the flu season. 

The flu, also known as influenza, is a respiratory illness caused by one of the multiple and ever-changing influenza viruses.  These viruses infect the nose, throat, and lungs, making them very different from stomach illness we all grew up calling “the flu.” 

Influenza has a season that is unpredictable and varies by year and geographic location.  It typically starts in late fall and continues through winter, although sometimes it can continue through the spring.  The flu is not just a bad cold, the flu can result in hospitalizations and even death.  According to the World Health Organization, up to 650,000 people die of respiratory diseases linked to seasonal flu each year. 

The flu is spread by tiny droplets that spray when people cough, sneeze or talk.  These droplets can land in the mouth or nose of nearby people, causing them to develop the flu themselves.  Less commonly, you can contract the flu by touching an object or surface that the flu virus has landed on and then touching your own mouth, nose, or eyes.  The flu is contagious beginning one day before symptoms develop and up to seven days after becoming sick.  The period of greatest risk of spreading the flu is the first three to four days after symptoms begin.  Once exposed to the flu, symptoms begin within one to four days if you are susceptible to the specific influenza virus. 

One way we can protect ourselves from the bioterrorists is by getting a flu vaccination.  While the vaccination will not guarantee you will not get the flu, it does mean that, if you get the flu, it should be less severe than it would be had you not been immunized.  Remember, the flu can cause hospitalizations and death for a significant number of people. 

At this point, you should be wondering how the flu relates to bioterrorism.  Bioterrorism is the deliberate release of viruses, bacteria, toxins or other harmful agents to cause illness or death in people, animals, or plants.  When you have the flu, you are releasing the influenza virus with every cough, sneeze, and possibly every word you speak.  Many of us continue to work, shop, and interact with others when we have the flu.  Some of this feels like a necessity; we are expected to show up to work, we have important meetings, we may not have the time available to take off work, we need to keep our jobs.  This is all true; however, showing up to work or meetings or other events places everyone you interact with at risk to contract the flu.  Knowing that we are contagious each time we interact with others we put them at risk of illness, thus the idea of working with the flu as bioterrorism. 

The second way we can protect ourselves from the flu is by encouraging our friends, coworkers, and family members that caring for their health and those they come in contact with is more important than the work they do.  Too frequently we are taught that not missing a commitment or a day of work/school is imperative.  This has led to all of us taking medication to treat the symptoms of the flu so that we can do the things we need to do without feeling as ill.  While we may feel better when we take these medications, they do nothing to reduce the risk of spreading the flu.  While we are told that work and attendance is extremely important, we also are told that we need to be compassionate and caring to our fellow man.  Somehow these two beliefs come into conflict when we are sick.  We feel compelled to work, and we do not want to make others sick.  How do we balance these issues? 

Staying home and taking care of yourself when you are sick is the best thing you can do for yourself and those you come in contact with.  This gives your body the time and rest it needs to recover and prevents the spread of the flu.  What about the stress of missing work?  Some employers have started allowing extended sick time when employees have the flu.  While this is not widespread currently, it definitely is a benefit to the employee, the company, and society.  Requiring or even encouraging people to work with the flu supports bioterrorism in your own community.  We must find ways to support one another and our society. 

The flu can be a very serious illness.  Preventing the spread stops the bioterrorism that is rampant in America today.