Sunday, December 02, 2012

Let's go for autonomy, mastery, and purpose

(Please read this in conjunction with the post below.)

A number of regular readers were appalled the other day when I asked for comments about an idea, that malpractice insurance should not cover cases in which surgeons failed to conduct time-outs and therefore harmed patients.

One person said:  "As Wachter and others have indicated, the balance between a just culture and individual accountability is a very difficult subject."

Another argued:

I suspect that such a measure would result in 100% of DOCUMENTATION of the use of the Universal Protocol. As we all know, this is not the same thing as the cultural commitment to the underlying ideas of respect for the patient that leads to this thoughtful pause and confirmation. I suspect, however, that rate of wrong site surgeries would not fall appreciably. Unfortunately, there is no shortcut to the culture that is committed to eliminating patient harm. In some ways, regulation of good behavior IMCO has led to the illusion that this is possible.

I had hoped that my straw-man proposal would provoke some controversy, and I think these comments join the issue perfectly. We want to create a learning organization, one that cherishes mistakes and near-misses to undercover systemic problems.  Yet, we also want to know that we can rely on personal accountability to comply with protocols that reduce variation and enhance proven standardized approaches.

My blog post set forth the classic regulatory type of solution to this problem:  Impose a "contingent motivator."  If you do A, the consequence is B.

In this TED talk, Dan Pink explains the problem with such incentives.  You can watch the whole thing, but the main point is that it has been demonstrated that contingent motivators do harm.  They tend to "narrow our focus and concentrate our minds," just the opposite of what is needed in a learning organization.  He calls this "the lazy, dangerous, and crazy industry of carrots and sticks."  Indeed, I have set forth just that kind of argument with regard to financial penalties related to rates of readmissions.

Instead, research has shown that ideas develop and organizations improve when the environment is structures to give autonomy, mastery, and purpose to people.

But wait, isn't that the problem in medicine? Doctors are taught to be individual players, relying on their judgment, experience, and good intentions in taking care of patients.  The result is a high degree of variability, producing uncertain clinical outcomes, causing preventable harm to patients, and unnecessarily costing a lot of money.

Brent James and others offer the answer, one that is ideally suited to the personalities and abilities of the people who become doctors.  He says that we want to provide mastery in the use of the scientific method in clinical process improvement.  We want to allow autonomy, but within the context of that scientific method.  Purpose will carry us the rest of the way.  When Brent received an award last year it was:

[F]or his pioneering work in applying quality improvement techniques that were originally developed by W. Edwards Deming and others, in order to help create and implement a “system” model at Intermountain, in which physicians study process and outcomes data to determine the types of care that are most effective.

I summarized the Intermountain approach here:  

1 -- Select a high priority clinical process;
2 -- Create evidence-based best practice guidelines;
3 -- Build the guidelines into the flow of clinical work;
4 -- Use the guidelines as a shared baseline, with doctors free to vary them based on individual patient needs;
5 -- Meanwhile, learn from and (over time) eliminate variation arising from the professionals, while retain variation arising from patients.

Note that this approach demands that doctors modify shared protocols on the basis of patient needs.  The aim is not to step between doctors and their patients.  This is very different from the free form of patient care that exists generally in medicine.  Notes Brent, “We pay for our personal autonomy with the lives of our patients.  This is indefensible.”  The approach used at Intermountain values variation based on the patient, not the physician.
As the Lucian Leape Institute has noted, though: 

Medical schools are not doing an adequate job of facilitating student understanding of basic knowledge and the development of skills required for the provision of safe patient care.

I am not sure we should be optimistic yet, but there is some movement on the education front.  Medstar's David Mayer likes to say, "Educate the young. (And on occasion, regulate the old.)" While that still leaves unstated how and where to "regulate the old," it puts the emphasis where it needs to be.  The current system of care has evolved over decades.  It is unlikely that we will effectively use regulation to bring about change.  Years ago, I suggested that change must come from within.  It will, when we give mastery and autonomy to rising doctors to practice their craft in a way that is consistent with their underlying purpose.


CLK said...

Just one thought about the wrong site/wrong procedure/wrong patient issue. I understand the desire to have a "process" that would decrease the incidence, however this should be one of those never situations. This isn't about signing a check list or incentive A if you do B. This is about being doing the job correctly. When a patient signs on the line they are in essence saying I am giving you my body, my life and I and my family are trusting you to do X. Yes there is the possibility of complications. However, when the wrong site/procedure/patient event comes up then it becomes negligence and criminal. When a surgeon goes through training they are taught at least the basics. They would never consider doing surgery without an incision or with a fork and spoon would they? In my opinion it is the ultimate failure and signal of incompetence to make a contract with a patient, take them to surgery, render them unable to communicate and then not take the simplest precaution of making sure you have the right site/procedure/patient. This goes for every member of the surgical team. This isn't about a checklist this is about conscientiousness and responsibility.

I apologize if this seems to be an off topic rant, but as long as this type of discussion even hints at an acceptance or excuse for the wrong site/procedure/patient there will never be a good process. I have actual clinical experience in the process and cannot imagine a situation where a professional would be allowed to approach a patient again without some serious retraining.

There is a place for considered processes, checklists if you will however the wrong site/procedure/patient situation is not it.

Anonymous said...

I think Dr. Mayer has it perfectly - educate the young, but while they are still in their training we are still killing people. Therefore in the meantime, we must regulate us old folks who are not getting with the picture. So the dilemma remains; it'l just that we can be optimistic that it's a temporary dilemma (maybe?)


Anonymous said...

I'd like to address CLK's comment, the principle of which I agree with, but IMO it demonstrates an incomplete understanding of how medical errors occur. As a former hospital lab and blood bank director, I was frequently reminded of the old song "50 ways to leave your lover" - in that there are at least 500 ways to screw up any given procedure in a hospital. Some of them you literally cannot imagine. The same sense of outrage CLK exhibits in wrong site surgeries can be applied to wrong patient blood transfusions, wrong drug administrations, etc. Yet there are myriad ways in which these errors occur - and it's most important to understand that usually, it's a chain of small errors by multiple people which all line up in the famous swiss cheese analogy to cause harm.

As an example, I read about one wrong kidney removal where the left/right switch occurred as a transcription error early on in the diagnostic process, and then was simply copied on all the paperwork for the ensuing weeks leading up to the surgery, thus leading to a chain of consistent, yet wrong, 'documentation'. One could imagine where the imaging study might have been put up backwards in the OR also, given that the technician might have thought he already 'knew' which kidney it was. One error leads to another.

It's not nearly as simple as a surgeon simply being egregiously and unacceptably sloppy.

nonlocal MD

CLK said...

To nonlocal MD,

I agree with your blood transfusion/drug administrations error assessment. There are a multitude of points where the documentation, especially when there is hand writing or data input. I guess with the wrong site/procedure issue I would still expect that the physician/surgeon would know the patient well enough to catch the error. I am aware of the many ways to make errors and that one slip can be significantly magnified if it goes through a series of providers, and don't intend to be obstinately blind to the possibilities and opportunities for errors. I have always worked in pre-post operative, endoscopy, autologous blood draw, recovery room and ICU and am well acquainted with the checking and double checking that the staff goes through to prevent errors and know that they sometimes still happen. However, the surgeon is the head of the team and I don't think he/she has as much wiggle room in the wrong/site/procedure/patient area.

e-Patient Dave said...

I've heard of this talk for years, but nobody ever said WHY it's important, so I never watched it. "The Surprising Science of Motivation" is a pretty weak title for this talk! So thanks for pointing out what matters in it.

Now I'd say it's a MUST watch for anyone addressing these issues. I knew about "the candle problem" but now I get it about this point, at 6:40:

"Rewards by their very nature narrow our focus."

In improving healthcare - especially the horrid problems with error rates that we've been talking about here - we're still left with what to do with people who simply will not start using best practices that work. Your thoughts?

Again, thanks for drawing the importance of this to my attention.

(btw, one thing that creeps me out about the video: In the sidebar I read that he was Al Gore's speech writer, and once I knew that, I saw Al Gore's facial expressions and gestures all over him. I don't know who taught whom, but it was creepy to see one person's face in another one's body!)

Joe Hess said...

I cannot think of any person trained in the medical field that would not want to eliminate medical errors. When you talk to medical staff many of them will tell you that they know its important and they know what they need to do to improve outcomes but yet errors still happen. There is a difference between "knowing" and "KNOWING" I mean really "KNOWING!" A comparison I've used recently.

Consider the following: the difference between being a native speaker of a language and learning a second language. The native speaker truly understands "KNOWS" the words that are used, while the second language person does "know" the words but doesn't "KNOW" the words as the native speaker. The person can feel confident since they "know" the language and make out ok, but in order for them to master the language and move from “know to KNOW” there has to be a reason to make this transition. Some people will make this transition on their own but many will need a reason. In health care this reason is often in the form of a Leadership action. Leadership action is often, if you do X then Y happens.

Leadership needs to understand how to transition from “knowing to KNOWING” It starts with them paying attention and listening, creating a just culture, that everyone understands and accepts.

Anonymous said...

Wow, Dave, you must really know Al Gore well - don't think I could recognize his gestures, etc!

As for what should we do with people who simply 'won't' use best practices, Paul and I have butted heads before over whether the CEO or the medical staff is ultimately responsible for these issues. As a former practice partner of mine used to say, 'everybody's business is nobody's business' - meaning that if there is no defined leader/responsible person, then nothing gets done.

I am fairly immovable in my belief that under our current system of organization, and perhaps even more so with ACO's, the organization's CEO must be held responsible for his/her hospital establishing safety policies and enforcing them. Whether one says that's in collaboration with the medical staff, or whether s/he provides the cover for enforcement by medical chiefs of staff, or whatever, the buck must stop in one place and like it or not, the C suite is where the power lies. I am not excusing physicians from responsibility, simply saying we must designate a consistent leader, and that should be the CEO. I don't know of any team in any setting where smooth performance ensues without a leader.

Therefore, while education of staff and medical staff is paramount to promote understanding, at some point, as CLK says, the expectation must be made clear and carried through. Perhaps the thought leaders should be concentrating their efforts more on CEO's in addition to physicians and the front line staff who, by Paul's report in his previous post, are already asking him how they can get their leaders on board.


Anonymous said...

As an agent of change--who also happens to be an expert in some medical areas--I think one of the greatest challenges occurs when there is thoughtful disagreement on best/safest practices. For example, 10 years ago endocrinologists would argue (and advocate) for tight glycemic control in Type 2 diabetics. I was a thougtful dissenter who argued repeatedly that this is not supported by evidence and introduces harm. I was right with my appraisal of the evidence, but by not supporting a standardized practice I was introducing harm. I am still conflicted how to resolve this paradox.

Paul Levy said...

Excellent point, as it is in the nature of scientific inquiry in general. We will just have to live with some ambiguities of the sort you mention.

I'm guessing though, that while there are examples of the sort you mention, in many more cases we can be more sure of the efficacy of clinical protocols. Certainly, that would be the case with avoiding infections and the like.

Anonymous said...

This link reminded me that one group who does reliably respond to incentives are CEO's. Perhaps their compensation should be much more closely tied to quality and safety measures over the long term, as indicated here:


Anonymous said...

AS a future medical student starting school in Fall '13, I'm interested in a lot of what you write about quality improvement. Can you post a case study to make the 5-step approach you outlined more concrete. I am not sure what " the team assembled and designed a protocol based on the literature of the day, but then they applied Lean principles to the use of the protocol" means.

Thank you for your consideration!