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Voices for Safer Care

Insights from the Armstrong Institute

The doughnut shop I pass on my drive to the hospital isn't the kind of place where you might expect to see outpourings of random kindness. It sits in the shadow of a raised highway, a few doors down from a bail bond business and a block away from a prison complex that resembles a medieval castle. One Sunday before Valentine’s Day, the line to get served there was long, checkered with homeless people—some of whom sleep under the highway to stay dry and protected from the wind—and more well-off people getting breakfast or bringing bagels or doughnuts to work or church.

A homeless couple stood ahead of me. Their clothes and hair were dirty, and the undersides of their fingernails were caked in dirt, as if they had just come in from gardening without gloves. They appeared very much in love—standing close, gently touching and smiling. She wanted a heart-shaped doughnut, and he wanted the same. They reached deep into every pocket counting their change, hoping to find enough.

They were a nickel short. Sheepishly, they turned to me and asked for help. I had a feeling of injustice: Here I was bringing doughnuts to doctors, nurses and staff who did not need them, yet this couple would not have breakfast without help. Not wanting to shame them, I softly told them that they could order whatever they wanted and that I would be happy to buy them breakfast.

When they ordered, the cashier looked at them judgmentally. Perhaps she had been stiffed before, or maybe she knew they did not have the money. The woman spoke up, stating that I had offered to pay. The cashier looked at me and I nodded.

That is when the cascade started. “What a great idea,” said a woman behind me, who was picking up doughnuts for Sunday school. She offered to buy breakfast for the homeless person next to her. The nurse behind her did the same, as did the police officer further back. The nurse and Sunday school teacher discussed how they were going to come back the following Sunday to do this again.

I was also moved by their generosity and handed the homeless couple more money to cover lunch and dinner and perhaps pay for a stay at a shelter. They wept, and I sat down at the table with them. They spoke excellent English, as if they had graduated college or higher. The man explained how they never intended to be that way. They hit some “rough patches” and made a couple bad decisions, he said. “We are something,” the woman told me. I told them that I believed them. My only request, I said, is that when they got back on their feet, they “pay it forward” to someone in need.

For weeks, I reflected on that day not quite understanding what exactly had happened. Then I read a New York Times article on the science of paying it forward. Cornell University sociologists Milena Tsvetkova and Michael Macy explained how we are much more likely to perform a kind act when we experience or witness one. Experiencing a small kindness is more potent than observing one, though in the case of the doughnut shop, observing proved a potent pill. They describe how chains like I observed are not rare at all. At a drive-through coffee shop in Manitoba, Canada, one customer paid for the person behind them, and the chain progressed to 226 people. At a Chick-Fil-A drive-through, there was a 67-customer cascade after one generous customer paid for the person next in line.

Of course, these remarkable phenomena all fit a pattern: random events that occur as people are waiting in some sort of line. Health care is different, of course. We can’t easily pay the doctor’s bill for the person next to us. But what if we could bottle whatever it is that makes these events happen, and use it to deliver safer, higher quality and more patient-centered care? There is a large segment of health care workers who want to do the right thing, to do things differently, but are held back for a variety of reasons. Sometimes they just want to know that there are others who are willing to move forward with them. Someone needs to takes that first step, to set off the chain reaction. Others want to know that if they lead, others will follow.

Take, as a great example, Janet Wall, a support associate on the Weinberg ICU at The Johns Hopkins Hospital. Wall has worked on the unit for 14 years and often jokes that she is “protecting her house” when she sees a behavior that is not consistent with the values that the unit is built around. If she sees anyone neglect to perform hand hygiene before entering a patient room—be it a world-renowned surgeon or a clerical worker—she will immediately remind them to do so. She’s on the unit to save lives, she proudly announces.

Anyone who has worked in health care or been a patient knows how uncomfortable it can be to ask someone else to wash their hands. But Wall took the risk to do something different and hold others accountable. And once she did, other support associates and staff began to follow. Many staff who had never before taken those kinds of risks began to speak up. This social movement has spread around the unit, and even nurses who before did not feel empowered to speak up are doing just that. Such phenomena take me back to a quote from the famed anthropologist Margaret Mead that has provided inspiration to those of us at the Armstrong Institute for Patient Safety and Quality:

Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it's the only thing that ever has.

Acts of leadership and courage can be powerful forces for social change when they are aligned towards a goal. And as Wall demonstrates, you don’t need a C-suite title to set these in motion. So start a social movement in your unit or clinic. Take that first step—an uncommon act of kindness, generosity or courage. Witness or experience these acts, and then pay it forward, and watch as the world around you begins to change.

For another interesting perspective on what it takes to create a social movement, watch this clever YouTube video, “First Follower: Leadership Lessons from Dancing Guy." It shows how a shirtless, barefoot man dancing alone on a hillside became a throng in less than three minutes.


Peter Pronovost

One of the world’s leading authorities on patient safety, Peter Pronovost served a the director of the Armstrong Institute, as well as senior vice president for patient safety and quality, at Johns Hopkins Medicine from 2011 until January 2018.

7 thoughts on “The Ripple Effect”

  1. The only way we change things, is one person touching another person. It sounds so simple, yet we cant seem to figure it out here. Maybe our culture has us thinking it's all going to be about one huge thing.
    Everyone should be required to watch " it's a wonderful life " at least once a year.

  2. Debra S Slaymaker-Walker

    Thank you food sharing this. I'm someone who just started collectngfood stamps & am embarrassed. I did for pennies for gas for the car. I don't go out for food. Thankful for friends.
    Husband divorced after 32 years. Since I made more & he got the girlfriend..
    In my state he got the house, the truck that was paid...We were separated 6 1/2 years...once My had no more to give he was ready to divorce... All was signed. I had mad $300 more than him the year we separated. Signed divorced in September.. He remarried 60 days later..
    Understanding? Guess I don't... She doesn't work? Choices?
    My company closed...2010 downsizing I was first to go as training manager of 12 stores...they closed 2013.
    I am thankful in all because my Good knows my journey and He wants me ...just not sure where.l
    am to be at. I keep searching and applying. We sometimes end up in unexpected places. I used to be the NNE on the other side..paying it forward..
    Thank you for sharing!! So true! A smile, a kind word, even a jester... all positive actions are great..
    Continue to show others! A friend indeed.

  3. 2 weeks ago I lost my cell phone. It turned out that I accidentally left in in the shopping cart at babies r us (they are having a huge clearance sale). That was a Saturday night. On Monday morning I was glum at the prospect of the phone being lost or stolen instead of being misplaced and having to order a replacement. At 6:45 am I got a phone call from a woman who found my phone. She is visiting from New York and took the phone home to make sure it got to it's owner. It made my morning to say the least! I spent the night tossing and turning over my lost phone so I stopped at the Grille for some caffeine before going in to work. The woman in line in front of me didn't have enough money to cover her food so I paid the difference for her. Then the next day I was approached in a dark parking lot by a woman who said she had lost her cell phone and didn't know where to meet the person because she wasn't familiar with the area. All she wanted was to use my phone to call the person's number. My bff and all 3 of our kids were in the car. My friend was shaking her head no and giving me the evil eye but the stranger was tearing up and how could I say no when I was literally fresh from a missing phone issue myself? Even though my friend was whispering 'our kids are in the car' over and over I handed my phone over without hesitation. Turned out she needed to go across the street and meet a restaurant. She handed my phone back and I offered to drive ahead of her so she could follow me to the restaurant. When we got there she blared her horn and shouted 'thank you' at the top of her lungs.

    I may have regretted losing my phone again but I felt much better helping her get her phone back than I would have to leave her stranded "just in case".

  4. Volunteering to teach reading, voting for good leaders, rehabing a community center etc. are ways to effect change in our community. Buying low nutrition food once or twice for the homeless only makes you feel good.

  5. Pingback: “Paying It Forward” In Healthcare |

  6. Dear Peter

    I am a writer.... it sounds weird to hear that in my head... I write for a garden center on Cape Cod. Every week I try to be inspirational, hopeful, civic minded or at least funny. This morning as I drove into work I was thinking of Robin Williams and it started me on this thread of doing small acts of kindness, which lead me to call it the Ripple Affect. I decided to Google the term and was pretty disappointed by all the connections to gun violence, motivational business speakers, math terms, housing market etc...

    I went to page 4 of the Google search and found your post. Thank you.

    I am by all accounts an emotional girl and I can cry or laugh at the drop of the hat.... no I am not Bipolar, just passionate. And your piece moved me. I loved hearing what you experienced as a human, in this world of fast moving "it is all about me-ism."

    Thank you again, you touched a cord. Nan

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