Boston College MBA students pose the questions

I've been invited to lecture at many business schools around the country, but tonight's experience at Boston College was pleasantly unique.  Here were the instructions I received from faculy member Stephen Bookbinder:

The class requires NO preparation from you. You just show up at 7:00 pm on April 30 for about 60 to 90 minutes and the students are prepared to ask you questions about your career and your experiences as the leader of BIDMC.  They will have used publicly available information to learn about the hospital industry, BIDMC and you to prepare for the class and anything else you might like them to read.  They will prepare an interview guide in advance and they will ask questions such as: describe a great mentor, tough decisions you had to make, how you created a leadership team,  etc. They will be graded on the quality of the interaction they establish with you and their ability to make the best use of the time they have with you.  They will also have to write a short paper on what they learned and can apply in the future.

 
So I showed up properly unprepared and responded first to Janet, Leigh, and Andy (above) and then to Colin, Brian, and Patrick (below).

For me, the time flew by.  The questions were excellent.  The students had clearly prepared throughly and coordinated the topics among themselves.  (How refreshing compared to certain press conferences I have gone to!)  On that front, I am certain that their classmates gave them a good grade.  I'm hoping the students allow me to publish excerpts from their forthcoming papers so you can all share their observations in a couple of weeks.

An investment banker asks a question

This is a true story.  An investment banker friend, very astute as to the issues surrounding private equity investments but not so familiar with health care, was confused.  He laid out the scenario as he saw it and then asked me the final question.

He said: You run a private equity firm and you are awash in cash, looking to create a portfolio of interesting investments that will satisfy your funders.  You see that the US government has passed the health reform act, assuring insurance coverage to a large percentage of the population.  You wonder if you can apply private equity principles to this sector.  What are those principles?  Get into a situation in which there are not likely to be a lot of bidders; satisfy political entities and other constituencies who might be concerned about the viability of the acquired firm and therefore view you as the "white knight;" put in place a hard-driving CEO; leverage your equity component with a healthy dose of debt; focus on extracting as much cash as possible from the business; take actions to grow the top line of the firm, as well as EBIDTA, so that you will be able to present a colorable story to future investors as to the company's growth potential; and then flip the business in an IPO or to another private equity firm after a few years.

Coincidentally, you learn that a faith-based hospital chain is having financial troubles.  Among other things, the institution faces a hangover of employee pension obligations and has been forced to underfund renewal and replacement and other capital improvements.  The religious organization that owns the system is unfamiliar with the operation of  health care facilities and views the system as a financial and operational drain not central to its mission.  For reasons of control, though, it created a governance structure that gives little authority to the hospital chain's board of trustees.  Further, its CEO is keen to arrange a sale of the hospital system to a private equity firm to show that he can create a vibrant business proposition.

So your private equity firm offers to buy the property, making promises to regulators and stakeholders in the community.  Few objections are raised and the deal is approved.  The private equity firm, new to health care, gives an unprecedented level of authority and autonomy to the CEO.  He rewards your confidence by executing the key elements of the business plan.  Assets are sold for short term gain, with little concern for the downstream costs: After all, the hospital properties will be flipped in a few years anyway.  The hospital system's laboratories are sold to a private laboratory service company, in return for a long-term contract to use that company.  Real estate is sold and leased back.  The system agrees to a front-end-loaded risk-based reimbursement contract with the largest private insurer, one that calls for substantial reductions from the trend of medical expenses in future years.  Physician practices in the community are purchased at above-market prices to create an increased flow of referral business to the hospitals.

The partners of your private equity firm have some concerns, but not enough to act.  The new corporate headquarters for the hospital system seems a bit large and luxurious.  Very high prices are paid to recruit tertiary care specialists into the hospital system.  For the high acuity services that this hospital system cannot deliver, patients are being sent to the highest cost hospital in the region instead of equally competent, but lower cost, alternatives. Also, experienced senior level executives that are recruited leave soon after arriving, either being fired or choosing to take lower paid jobs elsewhere. Insiders are promoted to replace them. 

But then the money falters.  Revenues take a tumble and days in accounts receivable grow during an extended transition to a new centralized billing system that was designed to take the place of the billing systems run by each hospital.  The risk contract with the insurer starts to limit annual price increases.  Medicare and Medicaid rates are constrained by the federal and state government.  Top line revenues fall, EBIDTA falls, cash flow falls.  Finally, the private equity partners are nervous.

They turn off the spigot and impose cash constraints on the system.  Normal maintenance of building systems is deferred.  Medical equipment expenses, too, are kept to a minimum.

The private equity firm searches for a new person who will be told to fix things, and quickly.  When he arrives, he will realize that the previous decisions that were made are now starting to burden the system with unavoidable operating costs and revenue constraints.  The only place to save money is on staffing.  He must make dramatic cuts in the upper management levels but will also be forced to make other cuts in the clinical support and lower administrative staff. Band-aid capital spending will be permitted when unsafe conditions exist, but the hospitals will start to fall behind on upgrades of important medical equipment and devices.  He will be in a race against the clock.  Can he hold it together long enough to permit the investors to get a return in the flip?  Finally, he will realize that closing one of the hospitals has to be part of the answer.  Investors will be relieved when he does so, but the community and governmental constituencies that supported the initial acquisition will get worried.

My colleague surmised that it would be around this time that regulators would begin to understand that the corporate guarantees that might stand behind the private equity firm's acquisition of the hospital system are a nullity.  The owners' resources are legally separated from those of the hospital system.  It would take years of litigation to pierce that corporate veil.  Thus, the commitments that have been made to the governmental and private constituents in the community are supported solely by the financial resources of the hospital system itself.  But that hospital system faces high debt service costs and obligations, other long-term cost commitments, and increasingly difficult revenue restrictions.

It would be around this time, he figured, that the capital markets would get wind of the fact that this hospital system cannot generate a risk-adjusted equity return that is commensurate with other industries.  An exit strategy that was predicted on a flip through an initial public offering or sale to another private equity firm would looking less and less viable

His question to me, "What would happen next?  Don't we need these hospitals to be in good condition to serve the public?"

My answer:  Assuming my friend's scenario is correct, pressure will build--from the employee unions, from the doctors, and from the legislators and municipal officials who were promised job preservation and growth in income taxes, sales taxes, and property taxes.  Behind the scenes, the dominant provider organization in the state--the only organization with sufficient cash flow to remediate the poor state of these decapitalized properties--would let the governor and others know that, because of its "concern for the public," it will "reluctantly" take over several of these distressed properties, but only "if it is asked."  The deal is struck, and the dominant provider finds itself owning facilities in several new regions in the state, broadening and enhancing its market power.

At that point, people throughout the region would sit and wonder, "Where did all the money go?"  Investors in the private equity fund would be less concerned:  They received their cash flow for several years.  Even though the exit strategy didn't work out as hoped, this hospital system investment is just a small component of a diversified portfolio managed by the private equity firm.

"Oh, " he said, shaking his head, "I was afraid of that."

Rushdie on moral courage

Salman Rushdie, who knows of such things in away most of us will never experience, asks the question in a New York Times article, "Whither Moral Courage?"  Some excerpts:

We find it easier, in these confused times, to admire physical bravery than moral courage — the courage of the life of the mind, or of public figures.

Even more strangely, we have become suspicious of those who take a stand against the abuses of power or dogma.

It was not always so. The writers and intellectuals who opposed Communism, Solzhenitsyn, Sakharov and the rest, were widely esteemed for their stand. ... As recently as 1989, the image of a man carrying two shopping bags and defying the tanks of Tiananmen Square became, almost at once, a global symbol of courage.

Then, it seems, things changed. The “Tank Man” has been largely forgotten in China, while the pro-democracy protesters, including those who died in the massacre of June 3 and 4, have been successfully redescribed by the Chinese authorities as counterrevolutionaries. The battle for redescription continues, obscuring or at least confusing our understanding of how “courageous” people should be judged.

Two years ago in Pakistan, the former governor of Punjab, Salman Taseer, defended a Christian woman, Asia Bibi, wrongly sentenced to death under the country’s draconian blasphemy law; for this he was murdered by one of his own security guards. The guard, Mumtaz Qadri, was widely praised and showered with rose petals when he appeared in court. The dead Mr. Taseer was widely criticized, and public opinion turned against him. His courage was obliterated by religious passions. The murderer was called a hero.

This new idea — that writers, scholars and artists who stand against orthodoxy or bigotry are to blame for upsetting people — is spreading fast, even to countries like India that once prided themselves on their freedoms.

America isn’t immune from this trend. ... Out-of-step intellectuals like Noam Chomsky and the deceased Edward Said have often been dismissed as crazy extremists, “anti-American" ... One may disagree with Mr. Chomsky’s critiques of America but it ought still to be possible to recognize the courage it takes to stand up and bellow them into the face of American power.

It’s a vexing time for those of us who believe in the right of artists, intellectuals and ordinary, affronted citizens to push boundaries and take risks and so, at times, to change the way we see the world. There’s nothing to be done but to go on restating the importance of this kind of courage, and to try to make sure that these oppressed individuals ... are seen for what they are: men and women standing on the front line of liberty. How to do this? Sign the petitions against their treatment, join the protests. Speak up. Every little bit counts. 

One of the best

My UK friend and colleague Isam Osman posted this note on Facebook today:

Yesterday the Sudan lost one of its great medical pioneers Prof Ahmed Abdel Aziz Yacoub FRCS , FRCP FACS. One of the first Cardiac Surgeons in Africa, he was the medical educator who established modern surgery in Sudan. He was a charismatic leader, a gifted surgeon, a loving father and staunch advocate for the poor and suffering Sudanese patient. He taught generations of doctors both the ethics and art of surgery. After retirement he went back to study, acquiring a Law degree and subsequent Phd from London University in Islamic Medical Jurisprudence. No mean feat in ones 70's! I pray that he is min ahl Jana rahimihu Allah. 

This certainly seems like a wonderful person.  As I commented, this is a good reminder that not all the "best" doctors reside in American and European academic medical centers.

I was prompted to say that because, several years ago, a local medical school here in Boston said that its purpose was "To create and nurture a community of the best people committed to leadership in alleviating human suffering caused by disease."  A worthy purpose, I thought at the time, but how pretentious to imply that it would comprise "the best people."  As Isam's note reminds us, there are devoted and committed people throughout the world.

Three days in Boston

The emotional roller-coaster in this city pervades all our lives.  Here are three pictures from this week that run the gamut.

Tuesday evening was cold and misty, and I had a chance to be a referee on a soccer field that was covered with mud.  By the end of the match these 11-year-old boys were also covered with mud.  Do you think they had fun?

On Wednesday morning the Copley "T" stop (part of our local transit system) was reopened for the first time since the Boston Marathon bombing.  There was silence in Copley Square as people dropped by the makeshift memorial that had been set up in honor of people killed and harmed by the bomb blasts just a few yards away.  This part of the memorial made me gasp.

On Thursday, 2000 people went to the World Trade Center in South Boston to take their oaths of U.S. citizenship.  I peered through the glass doors as they raised their hands and swore allegience to their new country.  The judge presiding said, "Don't ever believe that you are less of a US citizen than people born here."

First, assume a ladder.

One day I was with a prominent health care economist here in Boston. I brought up the issue of the market imperfections and the upward cost pressures that have been created in this city by the presence of a dominant provider group and a dominant insurance company.  His dismissive reply, "Just get the pricing right (with global payments) and everything will be fine."

I was reminded of the story of the engineer and the economist who, walking through a remote forest, fell into a very deep hole with vertical sides.  The engineer said, "We'll die down here.  No one can hear us calling for help, and it is impossible to climb out."

The economist said, "On the contrary, there is no problem.  First, assume a ladder."

Our healthcare expert likewise fell into the trap of assuming too much.  Proper pricing certainly can help solve problems of supply and demand, but not when the structure of the market is so perverse as to prevent normal pricing factors from working.  If there is a ladder, it is broken.

The Office of the Attorney General in Massachusetts today issued an important report.  Entitled "Examination of Health Care Cost Trends and Cost Drivers," the report might help policy-makers refrain from "assuming a ladder," from basing their conclusions on hopes rather than realities.  But only if they read and listen.  What follows are quotes from the OAG report.  I was intrigued to find some similarities to points made on this blog for the past several years.  This is certainly not because I asserted them, but rather because the OAG expert staff analysis reached those points based on the facts, not on assumptions.  Here goes:

We examine market developments and their implications for three categories of market participants: Purchasers (Part I of the Report), Health Plans (Part II), and Providers (Part III). The conduct and choices of these market participants directly impact health care spending levels in Massachusetts. Our principal findings in each of these categories are:

I. Purchasers/Consumers
A. Purchasers have increasingly moved to tiered and limited network products.
B. Purchasers have increasingly moved to PPO products, including self-insured PPO products, and away from fully-insured HMO products.
C. Purchasers have increasingly moved to high-deductible products (in general, defined in this Report as products with an annual individual deductible of $1,000 or more).
D. Purchaser enrollment trends have significant implications for health plans designing products and for providers managing risk contracts. 

II. Health Plans
A. Health plans continue to pay providers widely different amounts to care for patients of comparable health.
B. Variation in provider total medical expenses (“TME”) exists across Massachusetts and within separate geographic areas.
C. Growth in prices of medical services, not utilization, is still the primary cost driver for each of the major commercial health plans in Massachusetts.
D. The design of health plan products affects risk selection (which types of consumers tend to purchase which types of products), total medical spending, and care management.

III. Providers
A. Providers are taking on increased performance risk under extremely complex contracts that lack consistency in incenting providers to coordinate care, manage costs, and successfully take on risk.
B. Providers are taking on increased insurance risk without consistent mitigation by health plans. That is, contracts between health plans and providers vary widely with respect to protecting against extraordinary claims and adjusting for the health status of the provider’s patient population.
C. Providers are aligning in ways that are not explained by care coordination or risk contracting requirements, though those reasons are often cited. Provider consolidation and alignments have significant market implications that should be measured and monitored, particularly where consolidation may reduce access to lower-cost options for consumers and undermine efforts to promote value-based decisions by purchasers.

Give us our damn data!

Addendum on May 15, 2001.  I have found that I was in error regarding CHIA and the all-payer claims database.  Please see the comment by Commissioner Áron Boros on this post, which is reprinted in its entirety on a new post dated today.  My apologies to him and his agency.

ePatient Dave has created a worldwide call for patient to have access to their own clinical data.  His mantra is "Give me my damn data!" and there are calls to hear his rap whenever and wherever he travels.  Here it is, for those of you out of the loop:



Dave's plea is to allow patients and doctors to engage in a partnership of patient care.  He owes his life to his doctor, Danny Sands, and others who encouraged this.

Dave's call for action at the individual level has a societal analog.  What better place than Massachusetts, which took the lead on universal coverage, to adopt it?  But the state bureaucracy has not  followed through.

In 2010, the Legislature and Governor Patrick enacted a bill, Chapter 288, that required the collection of an “all payer claims database” by the Division of Health Care Finance and Policy.  As the name suggests, this database contains every health care transaction between insurers and providers in the state.  The numbers and patterns in this database explain more about our existing health care delivery system than has ever been assembled in one place.

The existence of this database offers the potential for all parties to study the actual transactions taking place in the Massachusetts health care system.  It permits testing of hypotheses with regard to payment models, clinical affiliations, and a variety of other pertinent matters with regard to the state's health care policy agenda.  Because Massachusetts took the national lead with regard to health care reform, it also offers potential value to the country as a whole.

A previous DHCFP commissioner asserted that the dataset would “allow a broad understanding of health care spending and utilization across organizations, population demographics, and geography.” Both that commissioner and the next one failed to act:  All that value remained trapped and hidden from view, burdened by unreasonable regulations regarding access.

I have to conclude that political forces from powerful interested parties, including those who benefit from the current payment system, kept the data under wraps.

The stewardship of the database is now in the hands of a newly formed state agency.  This one is not part of the administration.  It is independent.  Here's the background from the Governor's website:

In August 2012, Governor Patrick signed landmark legislation that launches the next phase of health care reform. Implementing the reforms in the legislation, which takes effect Nov. 5, will result in nearly $200 billion in savings over the next 15 years by moving to alternative payments, increasing transparency, addressing market power, promoting wellness, enacting malpractice reform and supporting health information technology. Implementation will include a number of state agencies, along with cooperation from providers and insurers, non-profit organizations, and input from and information delivered to the public.

An important part of the bill was to establish the Center for Health Information and Analysis as the successor agency to the Division of Health Care Finance and Policy:

CHIA is an independent state agency that collects health care cost and quality information and provides objective analysis of this data to assist in the formulation of health care policy.  CHIA maintains a number of the Division’s responsibilities, including the compiling of the state’s annual cost trends reports, managing the state health data repository, and monitoring the financial stability of hospitals and health plans.

Months ago, David Stephenson and I suggested:

Massachusetts universities and NGOs have the largest collection of health care researchers in the world.  It is time to make this database open and free of charge to those researchers.  Let them create hypotheses and test them — using real numbers.  Allow insurance companies and hospital systems, too, to view treatment patterns and finances to evaluate new policies and models of clinical care.  All this can be done safely and appropriately, because the law contains strict privacy safeguards.

The law, “to promote cost containment, transparency and efficiency in the provision of quality health insurance,” is a good one, but only if the data is really liberated. It must be automatically available to those who need it, when and where they need it, in forms they can use, and with freedom to use as they choose, while simultaneously protecting security and privacy.

Among the other states — Kansas, Maine, Maryland, Minnesota, New Hampshire, Oregon, Tennessee, Utah, and Vermont — that have created similar data bases, we know of none that have taken this approach to freeing the numbers to enable the information to be used for the greater good.  Instead, most states have a governing board or advisory committee that administers or provides recommendations on the reports to be generated from the databases.  That kind of government is a hold-over from the centralized control of another era, a form of government that inconsistent with a world of web 3.0.  

It is within the authority and power of the Executive Director and the Board of  CHIA to "give us our damn data!"  It is time.  Do they have the spine to stand up to those who wish to keep it hidden?

Giving Voice

A tweet on Twitter from @gillian_salt led me first to this delightful video of a flash mob in Birmingham, UK, singing a piece about "Giving Voice."  Intrigued, I went from that to a website of the Royal College of Speech and Language Therapists, where things were explained to those in the UK and also to us "in the colonies:"

With the financial climate hitting all areas of the economy the RCSLT realised the services essential to people who need support with communicating and swallowing could be under threat and that the profession would be heading for a difficult period. As a result, we set in motion our Giving Voice campaign.

Giving Voice will help us and speech and language therapy services demonstrate SLTs’ unique value to national and local decision makers, while showing evidence of their efficiency and value for money. Please click on each link below to find out more.

The RCSLT believes:

• Speech and language therapists are specialists who enable people to develop or regain vital communication and swallowing skills.
• Problems with speech and language imprison the individual and severely limit their participation in family life, the community, education and the world of work.
• Tackling communication and swallowing problems reduces avoidable costs and waste in the NHS, local authorities, the criminal justice system and the wider economy.
• Urgent changes are needed to support timely access to speech and language therapy for those who need it.

I can certainly sympathize with this campaign. Speech and language therapists are often unrecognized champions of healing in hospitals and rehabilitation facilities.  I have seen the magnificent results that can be achieved through their technical skills, patience, and empathy.  I hope the RCSLT is successful in convincing the body politic in the UK to provide proper support to this mission.

How a blog held off the most powerful union in America

I've published a new book that might be of interest to those of you who care about the power of social media in preserving democratic values.  The story is about how I used this blog to fend off a corporate campaign by the Service Employees International Union between 2006 and 2010.  By denigrating our hospital, the SEIU was trying to put pressure on our Board and management to agree to process that would have shortchanged our employees' right to a free and open debate about the question of union organizing.  By using this blog to expose the corporate campaign playbook, the public and our staff were able to see through the union's tactics, and the effectiveness of the corporate campaign was nullified.

I was honored when David P. Boyd, Professor of Management at Northeastern University, agreed to write a foreword for the book.  Here are some excerpts:

In this book, Paul Levy offers a compelling historical narrative of labor-management relationships over a tumultuous five-year period. While the story itself is riveting and the stakes compelling, it is more than simple case narrative; rather it is a morality play about an attempt at power dominance which, if realized, would have foreclosed employee engagement. Through such tactics as “neutrality agreements” and “card checks,” a powerful union sought to become hostage-taker of a hospital’s financial and reputational halo. Levy knew such an approach would usurp the primary goal of the hospital to preserve and enhance patient care. It would also deny employees the right to debate and determine the environmental parameters within which they worked. Thus the principles in play were no less than institutional purpose and individual prerogative.

To safeguard the sanctity of these principles, a communications strategy became key; Quite novel as a weapon in 2006, this social medium offered several advantages. 

The result was victory for the hospital whose fundamental aspirations never fell victim to an external force.... The book remains more, though, than a treatise on unions and those they seek to organize. Rather it is a passionate plea that process be predicated on mutual respect. By shortcutting process, any group will nullify the ethical validity of its intended outcome.

The book is available on Amazon and in electronic form on all platforms.  While you are waiting for the book to arrive, you can go to this site if you would like to see a full compendium of my blog posts with regard to the SEIU corporate campaign.

An Epic voyage

Several months ago, I wrote a blog post comparing customers’ experience with Epic with the Stockholm Syndrome.

I reminded people of the syndrome:

Stockholm syndrome, or capture-bonding, is a psychological phenomenon in which hostages express empathy and have positive feelings towards their captors, sometimes to the point of defending them. These feelings are generally considered irrational in light of the danger or risk endured by the victims, who essentially mistake a lack of abuse from their captors for an act of kindness.

Then, I noted: 

What is striking about this company is the degree to which the CEO has made it clear that she is not interested in providing the capability for her system to be integrated into other medical record systems.  The company also "owns" its clients in that it determines when system upgrades are necessary and when changes in functionality will be introduced.  And yet, large hospitals sign up for the system, rationalizing that it is the best. 

I quoted an article by Kenneth Mandl and Zak Kohane in the New England Journal of Medicine:
 

We believe that EHR vendors propagate the myth that health IT is qualitatively different from industrial and consumer products in order to protect their prices and market share and block new entrants. In reality, diverse functionality needn't reside within single EHR systems, and there's a clear path toward better, safer, cheaper, and nimbler tools for managing health care's complex tasks.

A year ago, Forbes noted, "By next year 40% of the U.S. population--127 million patients--will have their medical information stored in an Epic digital record." 

It is this last point that we must now address, as I hear from my colleagues in the EHR world—no, not Epic’s competitors-- that Epic engages in practices that well help cement that market share for years to come.

They tell me, for example, there is the “good install credit.” If your enterprise chooses to have a significant portion of its IT staff trained and certified by Epic to conduct part of the system’s installation, you get a significant discount on the installation costs. On the one hand, training and using internal staff rather than outside consultants can be viewed as a good thing. On the other hand, what better way to assure future product loyalty than by indoctrinating a hospital’s internal IT force in the ways and means of this system?

Another technique they report to me is the limitation set on “certified consultants.” If you are a third-party consultant who would like to be certified as an Epic consultant, you have to promise not to work on other systems.

As a country we get nervous when any company in any sector has a market share in the range of 40% because we know that companies will use their market dominance to limit consumer options and hold back technological advancement.

In the 1980’s, we saw an antitrust case filed against the AT&T and its Bell System based on such concerns. AT&T, for example, engaged in an “installed base migration strategy,” a pricing policy that caused large business users to adopt its next generation of office-based telephone switching equipment, whether or not the users needed the new functionality. The pricing power was extraordinary. We also saw the company systematically prohibit the use of telephones and other premises-based terminal equipment provided by other manufacturers, claiming that it would damage the telephone network. You also had no choice of long distance carriers, and you paid for each call by the minute.

The situation was so pervasive that comedienne Lily Tomlin could easily generate laugh lines in her routine about Ernestine, the telephone operator, by saying, “We don't care, we don't have to...we're the phone company.”

Ultimately, the antitrust officials in the government stepped in, and the Bell System was broken up into its component parts. Competition was permitted in each segment. Anyone could install inside wire in their home or business. Anyone could manufacture and sell telephone sets. You had a choice of long distance carriers. Consumer choice expanded. Functionality increased to respond to market demand. Pricing plans changed. Value increased.

I see some analogies in the EHR environment. I hear that high-end specialty IT application companies—e.g., the best of breed emergency department system vendors—find it extremely difficult to make sales inroads in hospital systems that employ Epic, as compared to other enterprise systems. These are the folks that are developing the cutting edge applications to improve decision support, quality of documentation, and interoperability. They are the analogs to the terminal equipment, switching, and long distance companies that were squeezed out during the Bell System’s dominance.

Can we afford to delay the introduction of such systems in a health care system that is desperate for better quality and safety, greater efficiency, and higher value? While Epic does not have the market share once enjoyed by the Bell System, there is a special consideration here. We need to consider whether it is appropriate that an EHR company that is making its money in great measure on contracts paid directly or indirectly by federal funds should be able to engage in practices that support long-term market dominance.

The joy of Division 4

Our regional youth soccer league places teams into one of four divisions, ranked from 1 to 4.  Division 1 contains the very best players, the ones who vie to be state champions, and it goes down from there.  By the time you get to Division 4, you find the kids who have the lowest level of individual skills, the least ability to execute plays requiring two or more members of the team acting in concert, and the poorest physical conditioning.

For a referee, officiating a Division 1 game is a physical and mental challenge.  The play is fast and furious; the teams are often evenly matched, so the official is required to move up and down the full length of the field many times; the kids exercise creative plays that are interesting to watch; and the players are likely to engage in intentional fouls of the other team, trying to do so when you have turned your attention to another part of the field.  Those of us who have refereed for many years view these high level games as fun, because they keep us on our toes and requires many judgment calls as the game progresses, all in real time.

In contrast, refereeing a Division 4 game can be as exciting as watching paint dry.  You seldom need to run to keep up with the play, whether or not one team dominates the game.  The fouls that occur are usually inadvertent, the result of clumsiness, not intent.  Goals seldom occur, as the kids have trouble making consecutive passes.

I was thinking of this today as I officiated a Division 4 boys game.  It was so boring that I was having trouble keeping my concentration, and then I realized I was not exercising a proper duty of care in my position as the lead official on the team.  I simply wasn't being fair to the 22 players on the field.  They were playing hard, but I was not.

So, I looked for things to notice about the boys and about the game, hoping to do a better job maintaining my interest.  The first thing I noticed was that the boys were nice to each other.  They all knew they were not terrific players, and so when someone made a good play, the others praised him.  When someone muffed a play, there was no criticism.  Quite the contrary.  You'd hear, "Good try, Joe," or "We'll get it next time, Sam."  Even when the error was egregious, one that would make me squirm in embarrassment for the child.

The next thing I noticed was that these were really intelligent kids.  The structure and vocabulary they used reflected the best students of their age level (13- and 14-year-olds).  They employed the sardonic--and often self-deprecating--humor that is characteristic of intelligent children who are good at science and math.  Perhaps you've heard it.  It is the humor that is displayed by people with enough confidence to realize that mistakes are to be learned from.  Interestingly, too, the boys were able to analyze the game situation and comment on it and know what should have been happening, even if they were unable to execute it.

Finally, the boys were having fun.  There were smiles.  There was laughter.

So, I finally realized that I was surrounded by the kids we would have affectionately called nerds.  I know the group well because I was one of them growing up and went to a college (MIT) that was full of them.  To stereotype, they are great at academics, not particularly great at athletics, and a bit socially inept, except when among themselves.  But, to recap, they were having fun.  They were thinking and learning the whole time.  They were behaving like good and supportive members of a team.

I felt abashed that I had allowed myself to become bored in their presence, that I wasn't giving their game the attention it deserved, that I had allowed my performance to wane.  I became revived and realized that their game was an important as any Division 1 game I had officiated.  I understood that it was filled with joy and that, if I did my job right, I could experience the joy myself.

This is where nurses and doctors differ

Tamara Schalken, chair of the hospital nursing advisory board at Jeroen Bosch Ziekenhuis, recently presented at TEDx in Nijmegen.  In eight cogent minutes, she explained the difference in skills and perspective between a great physician specialist and a super nurse.  Watch it here.  If you can't see the video, click here.

Health care is a service industry? Really!

Brian Powers, Amol S. Navathe, and Sachin H. Jain offer a thoughtful and interesting approach to the question of patient-centeredness in a recent blog post on the Harvard Business Review page, learning from service industries.  Here's the lede:

Current approaches to patient-centered care are based on aggregated preferences rather than individualized needs. Researchers and health systems deploy focus groups and surveys to assess general patient preferences in an effort to determine "what patients want." But patients are a diverse group with diverse needs. Characterizing general beliefs and preferences alienates those whose needs and preferences do not align with the majority. The result has been a monolithic view of patients and their needs — a framework that prevents the delivery of truly patient-centered care.

The authors call current efforts "well intentioned" but stemming from "a misguided focus on the needs of the average patient."  They point to other service industries that have gotten clever at segmenting their customer groups, learning about particular aspects of service that are relatively more important for those segments.

Customer segmentation is ubiquitous across service and consumer product industries, but its application to health care has lagged. As health-care-delivery systems expand and more data is stored in electronic databases, there exists the potential to prospectively segment patients according to their needs and preferences.

Why does the health care segment lag in this approach?

One reason is providers have been reluctant to see health care as a service industry. Only by accepting the reality that it is one can providers learn from the successes of others in the field. And there is plenty to learn.

One commenter notes with approval:

The patient sitting in front of a doctor is no longer "his" or "hers" patient. It is an individual with his own needs. Meaning the center of attention is no longer the doctor and his expertise but the patient.  More precise[ly] the demand[s] of the patient. Which [are] not the same as by the doctor perceived demand[s].
 
Or, as I would put it, "patient-driven care."

A true and great MD

Dr. Richard Wolfe, chief of emergency medicine at BIDMC, after attempting to revive the injured first Boston Marathon bombing suspect: "You have to put their interest first. It doesn’t matter if it’s a perpetrator or the president.’’

Smart Patients helps organize smart patients

In 1995, Gilles Frydman, founded the Association of Cancer Online Resources (ACOR), which evolved into the world’s largest collection of online cancer communities. These communities are remarkable, not only as support groups, but as repositories for the latest and best information about each disease.  Why? Because the participants care deeply about the topic. For them, knowing and sharing as much as possible can literally be a matter of life and death.

Now Gilles and Roni Zeiger, M.D., former Chief Health Strategist at Google, have created Smart Patients, an online community for cancer patients and caregivers.  Beyond patients helping patients, though, this will be patients helping corporations and organizations in the health care field. They note:  "Smart Patients’ business model is to conduct occasional voluntary surveys and share anonymous insights from patients with partners in the healthcare industry to help them provide better care and incorporate the patient perspective into the design of future clinical trials. The site has no advertising or marketing."

Here's more from their press release issued today:

Smart Patients is launching with several partners who will help seed the community. One of the company’s early partners is The Bonnie J. Addario Lung Cancer Foundation, based in San Carlos, California. “We are honored to be partnering with Smart Patients. It is a perfect fit with our philosophy that educated and empowered patients live longer,” said Bonnie Addario, Founder and Chair of the Foundation.

Cancer Commons, a nonprofit, open science initiative linking cancer patients, physicians, and scientists in Rapid Learning Communities, is also partnering with Smart Patients. “It's critical to bring patient data as well as patient wisdom to our research teams, to accelerate the development of personalized cancer therapies. We're excited to work with Smart Patients to close that loop,” said Sarah Greene, Executive Director of Cancer Commons. Smart Patients will tap into the knowledge of networked patients to help speed the development of needed cancer treatments.

Smart Patients is working with Oncosec Medical to incorporate patient input into the design of upcoming clinical trials of Oncosec’s skin cancer treatments. “We’re excited to learn from the Smart Patients community. We believe that by incorporating patient feedback into the design process of our clinical programs, we will improve the speed and efficiency of our trials,” said Punit Dhillon, CEO of OncoSec.

Another partner, WorldOne Interactive, has assembled the leading engagement platform for physicians, including Sermo, the largest online physician community in the United States. “Partnering with Smart Patients aligns with our mission to support the physician decision journey and improve patient outcomes. Oncologists, in particular, are interested in patient experiences and clinical outcomes. Providing physicians the opportunity to hear and learn from a robust network of patients having educated discussions on clinical trials and the latest science is a powerful educational tool," said Jake Coniglio, SVP Global Strategy & Corporate Development.

WIHI - -Live from London

April 18, 2013: Patients See What We Don’t – Engaging Patients in Safety – Live from London and the International Forum on Quality and Safety

(Special Time: 1:15 – 2:15 PM ET / 6:15 – 7:15 PM BST)

Featuring:
Susan Hrisos, Senior Research Associate, Institute of Health & Society, Newcastle University (UK)
Jane O’Hara, MSc, PhD, Senior Research Fellow, Yorkshire Quality & Safety Research Group, Bradford Institute for Health Research
Martin Hatlie, JD, CEO, Project Patient Care; President, Partnership for Patient Safety; Co-founder, Consumers Advancing Patient Safety

It’s easy enough to say patients need to be engaged in all levels of their care, including being aware of best practices and anything that could inadvertently result in harm. But what does this actually look like day-to-day, especially in the high-stakes, busy environment of today’s highly complex hospitals? And what good does it do for patients and families to notice and speak up about things if there’s no one on the receiving end trained to respect and act upon the information?

With at least a decade’s worth of ideas and initiatives on patient engagement with patient safety as a backdrop, new research on what is and isn’t working in the UK — with broad application to the US and elsewhere — will be in the spotlight on the April 18 WIHI entitled Patients See What We Don’t – Engaging Patients in Safety – Live from London and the International Forum on Quality and Safety. The new analysis is being presented at the IHI-BMJ International Forum on Quality and Safety in Healthcare by leading researchers at Newcastle University and the Bradford Institute for Health Research in England. WIHI listeners will get the first peek at the findings, thanks to Susan Hrisos and Dr. Jane O’Hara, whose work headlines a workshop session in London the very next day. They’ll be joined by Martin Hatlie, one of the leading voices and experts on patient engagement in the US, who is eager to comment on the research and describe new models for effective patient/provider collaboration around safety that are emerging in the states.

Patient engagement in patient safety is here to stay. The only question is how this vital part of improvement can be more effective, and what skills patients and providers alike need to work together for the same goal.

We’re live from London on April 18 at a special time — don’t miss this upcoming WIHI! Click here to enroll.

National Stop Snoring Week

@britishsnoring. The British Snoring & Sleep Apnoea Association has an excellent website.  Check it out here, in anticipation of National Stop Snoring Week (April 22-26).

Flexibility in Engineering Design -- Free Webinar

MIT SDM Systems Thinking Webinar Series

Richard de Neufville, Ph.D., Dr. h.c.
Professor of Engineering Systems and of Civil and Environmental Engineering
Date: April 22, 2013
Time: Noon - 1 p.m. EDT
Free and open to all
Register

About the Presentation

Designed for those concerned with acquiring and implementing new products and systems, such as owners, managers, developers and engineers, this webinar will explain the concept of flexibility in engineering design, using non-technical language and many practical examples.
Professor de Neufville will cover:

• the problems with predetermined forecasts and requirement sets;
• the benefits of flexibility in engineering design and its role in developing products that can adapt to a wide range of uncertainties;
• how flexibility in engineering design delivers value by reducing or eliminating downside risks, increasing access to upside opportunities, and ultimately producing overall win-win solutions and developmental strategies;
• specific ways successful companies apply flexibility in engineering design, and;
• a framework and next steps for applying flexibility in engineering design in your organization.

We invite you to join us!

About the Speaker

Richard de Neufville, Ph.D. and Dr. h.c., is a leader in the field of systems planning and design and author of "Flexibility in Engineering Design," the first book in the new engineering systems series published by MIT Press. He has also published six other texts and currently teaches several MIT courses in this field that are directed generally to engineering systems, with a focus on product design, real estate, urban development, and airport systems design. Prof. de Neufville is currently involved in developing a wide range of flexibility analysis applications, including design of offshore oil platforms, civil engineering infrastructure, automobile plants and parts, and electrical power systems.

Halsey Burgund brings us Patient Translations

I introduced Halsey Burgund to many of you back in January, when he was working on a new piece of public art called ROUND: Cambridge.  This was an "exhibit" that comprised recordings made by people as they wandered around the city, tied to particular locations.  I thought it was very creative and said,

Now, imagine a hospital that allowed people to do the same thing.  Think about what we would hear from patients about the quality and safety of care being delivered, or physical features of our buildings, or whatever.  But we have to want to listen.

Well, Halsey has done that one step better.  He writes:

Just wanted to let you know that since we last spoke, I have had a flurry of activity on a project that I have long been interested in pursuing on health.  Obviously, I thought you might find it interesting.  I am collecting voices of people talking about their experiences as a patient and with health issues in general and creating an evolving musical piece using those voices.

The project, called Patient Translations, was commissioned originally for the Healthcare Experience Design conference in Boston (http://healthcareexperiencedesign.com/) late last month and will be traveling to TEDMED in DC (tedmed.com) next week.  It's a collaboration with a visual artist, Kelly Sherman, who is using the same raw material of spoken voices to create a visual component to the artwork.

In any case, if you are curious, more info is at patienttranslations.com and you can get the free app on your iPhone if you want to listen or contribute.

 

Here's a screen shot of part of the website:

 

$2.2 billion in revenue, but training is not our job

I don't really want to write so much about the problems of robotic surgery, but when I hear a quote like this from the main manufacturer of the equipment, I can't let it go without commentary:

Intuitive has no duty to train doctors on the da Vinci system under Washington law, the company has said in its court filings.

Here's the context, in this latest story from Bloomberg:

Intuitive Surgical Inc. (ISRG), a maker of surgical robots used in more than 300,000 U.S. operations last year, faces its first trial over claims it marketed the devices to doctors without providing adequate training. 

A state court jury in Port Orchard, Washington, is scheduled to hear opening arguments tomorrow afternoon about whether Intuitive properly trained a physician who, in his first unassisted surgery using the company’s da Vinci surgical system, removed the prostate gland of a patient who later died. 

The lawsuit is one of at least a dozen filed against Intuitive since 2011 alleging injuries tied to the robot-surgery systems. Intuitive’s robots, which cost about $1.5 million each, are used in 1,371 U.S. hospitals, the company has said. The robots and related products generated most of the company’s $2.2 billion revenue in 2012.  

Kitsap County Superior Court Judge Jay Roof last month rejected Intuitive’s bid to throw out the suit and scheduled the trial to conclude in May. The judge found the state’s product- liability laws require medical-device makers to properly train physicians who buy their products. 

Now look how the company and the doctor end up on opposite sides of the case.

According to court filings, [Doctor] Bildsten said Intuitive’s training didn’t inform him of the need to create the watertight seal or warn of the risk of abdomen inflation. After reading Food and Drug Administration documents about the “learning curve to obtain basic competency” with the da Vinci system, Bildsten said, “I believe I likely would not have agreed to begin training on the robot had I been given this information,” according to the filing. 

Bildsten said Intuitive told him he could achieve “basic competency” after two assisted surgeries, and that the company did not tell him that consultants paid by Intuitive reported that such proficiency couldn’t be reached “until twenty or more operations were complete,” according to the filing.

Intuitive has argued in court documents that lawyers for Taylor’s family are attempting to create a “totally new cause of action” against medical device manufacturers -- the “duty to train” -- under the Washington Product Liability Law. 

Under the state law, Intuitive had no duty to train Bildsten or warn him of the risk of the surgery, according to the filing. 

“Dr. Bildsten, a board-certified, licensed surgeon was responsible for making sure he could perform the surgery he chose to perform and to do so safely,” Intuitive argues in the filing.

If you are a surgeon using this equipment, I bet the interplay gives you a warm and fuzzy feeling.

I wonder which medical malpractice insurance company is watching this, wondering why they didn't engage in risk mitigation procedures as part of their underwriting process.

Meanwhile, back on Wall Street:

Investors are so far unconcerned with what the trial result might mean for Intuitive, said Andrew S. Zamfotis, an analyst at evaDimensions in New York. The company is “practically printing money with these robots,” and for shareholders the trial “hasn’t moved the needle yet,” he said in a phone interview.

Sadness in Boston

Thanks to so many friends and colleagues who have inquired about our well-being.  All is fine in our household except for a sense of overwhelming sadness for those killed and hurt by a mean and crazy person or persons, and for the loss of innocence and joy for what the Boston Marathon has been to this community.  We will never be able to stand along the race route in the future with the same sense of happiness. We will still go, of course, in solidarity and purpose--and to show that life goes on--but it will be different.

Robotic surgery: New medical malpractice underwriting risk

If I am a medical malpractice insurance company, should I be concerned about a new underwriting risk?

The question is prompted by a recent story in the Denver Post.  The lede:

The Colorado medical board has charged Dr. Warren Kortz with 14 counts of unprofessional conduct after a series of failed procedures with Porter Adventist Hospital's robotic surgery arm, as federal officials launch a wider review of the highly touted procedures. 

The state alleges that from 2008 to 2010, Kortz cut and tore blood vessels, left sponges and other instruments inside patients after closing, injured patients through improper padding and positioning, subjected some to overly long surgeries, and had to abort kidney donations because of mistakes.

Now, one surgeon does not an actuarial trend make.  The article notes:

The U.S. Food and Drug Administration said it is stepping up interviews of surgeons about the devices after a new series of mishap reports, although the agency said it has not yet identified a trend. Hospitals spend more than $1 million on each of the da Vinci-brand surgery units and are under pressure to keep them busy.

The lack of a trend, however, does not protect doctors and hospitals from malpractice cases.  If I were a plaintiff's attorney, here's the way I would frame the medical malpractice argument to a judge and jury:

A hospital and its doctors decide to purchase and employ a surgical robot, notwithstanding a lack of peer-reviewed evidence as to its clinical efficacy vis-à-vis other forms of laparoscopic or open surgery.

There is evidence that the hospital has spent significant sums of money in marketing the availability of the robotic surgery in its service territory.  There is evidence, too, that ties the marketing campaign to a change in that hospital's market share for the particular procedures advertised.  The profit-and-loss statements of doctors in the hospital show the income gained from this change in market share.

The doctors in that hospital present poor documentation as to why they chose to employ the robot on particular patients, failing to show in the medical records--or in the patient consent forms--a clear demonstration of relative risks and benefits vis-à-vis other forms of laparoscopic or open surgery.  At the hospital governance level, the medical executive committee of the hospital has failed to adopt specific rules and regulations concerning such documentation in the medical records or patient consent forms.

Even if there is a record of simulation or other training by the doctor using the machine, the evaluation of his or her performance in that training session is not carried out by an objective observer.  Maybe the extent and type of training are not even documented.  Perhaps, too, the general pedagogical efficacy of the training has not been subjected to peer review by experts in clinical process education.  At the hospital governance level, the medical executive committee of the hospital has failed to address the issue of granting privileges for use of the robot that sufficiently address these pedagogical and documentation concerns.

(In some cases,) the doctor has employed the robot in novel settings, beyond those used by the preponderance of physicians.  At the hospital governance level, the medical executive committee of the hospital has failed to systematically address the issue of granting privileges for use of the robot for these purposes.

Each of these opportunities to enhance the plaintiff's case can be offset by an appropriate risk management approach.  But how many medical malpractice insurance companies have recognized this new vulnerability and taken steps among their insured entities to ameliorate the risks?

Apparently not many, if these ads from a simple Google search on "medical malpratice robotic surgery" are any indication.

#QIIQ: @CIRSEIU asks, "What's your QI IQ?"

I have made note before of the excellent work being done by CIR, the SEIU Committee of Interns and Residents, in promoting a better patient quality and safety environment in the hospitals in which its members work.  Now, comes a new effort worth watching--and you can watch on Twitter if you follow the hashtag #QIIQ.  Here's a description sent by a friend at CIR:

This year, the CIR Policy and Education Initiative, partnering with the Healthcare Transformation Project of Cornell University, is organizing a series of conferences in the New York metropolitan area to focus  on the topic of physician leadership in quality improvement and patient safety.

The first conference is on April 13 (9:45am-4:00pm) in Manhattan and is entitled: 

"What's your QI IQ?: Resident Physicians as Quality Improvement Leaders."

The conference will feature: 

• interactive didactic sessions led by James Pelegano, MD, MS, Program Director for the Jefferson School's Master's Program for Healthcare Quality and Safety, and an innovator in the field of Patient Safety and Quality;
• Small-group breakout sessions that will allow participants to practice and refine the methods they have learned;
• Panel discussion with resident physicians who are currently working on Quality Improvement and Patient Safety;
• Hands-on workshop on the formulation and writing of QI/Patient Safety project proposals. 

We are interested in hearing from others and sharing our experience in engaging housestaff around Quality and Safety. We would appreciate any feedback on how to meet the needs of current and future physicians who face the prospect of practice in a rapidly changing healthcare system. 

Good people helping people in need

Every community has them.  People who need help.  Every community has them.  People who offer help. But, expecting nothing in return, these are unsung contributors to the heart and soul of the region.

It's time to mention one such group here in the Boston area.  It's a small nonprofit called Hospitality Homes.  The mission is simple:

Hospitality Homes was the first program of its kind in the nation.  The organization has about 150 host families.  The services are free of charge and are made possible by the generosity of the volunteer hosts and supporters.

Anyone is eligible to be a guest who:

• Lives more than 50 miles from the hospital. 
• Has a permanent home to return to after his/her stay.
• Is an important support person for the patient.
• Is not likely to put the host family at risk.

Unfortunately, the need for convenient, caring, and cost-free accommodations for patients’ family members increases every year.  The place needs volunteers and financial support.

Dr. Louis Caplan, a neurologist at BIDMC, is quoted on the HH website about the pleasure of being a host:

My wife and I have been enriched by our experiences with the many families we have hosted. In one instance, we met a woman from India with a condition that left her effectively blind.  At the end of her stay we shared in the sheer joy of her regained sight.
 

Hospitality Homes is a 501(c)(3) nonprofit organization, governed by an able and diverse board of directors and operated by an excellent staff. Donations are fully tax-deductible.

Teaching Girls Soccer

One day left to contribute to this Kickstarter project to create a great video for coaching girls soccer.  It's close.  Please help, now.  Watch the video.

Validating communication

This video was produced some time ago, but I had not seen it.  Please take a few minutes and watch the interaction between Naomi Feil and Gladys Wilson. Stick with it to the end.


Many thanks to Janice Lynch Schuster for bringing this to my attention.  Janice recently wrote an article about steps you can take to communicate with people with dementia.  The article made mention of the "validation method" pioneered by Feil in the 1980's.  That is what is at work in the video.

While there have been questions raised about the method in the scientific community, I dare you to watch this video and not feel that it has some power.

If you cannot see the video, click here.

Learning from the un-checked checklist

As long as we are on the issue of cognitive errors, it is instructive to review the crash of an MQ-9 Reaper in an unpopulated area in Nevada on Dec. 5, 2012.  The U. S. Air Force Air Combat Command recently published a full report of the incident, noting, "The aircraft, one inert Guided Bomb Unit, a Hellfire training missile, a Mission Kit, and one M299 missile rail were destroyed. The loss is valued at approximately $9.6 million.  There were no injuries or damage to other government or private property."

A summary:

The Accident Investigation Board President therefore found by clear and convincing evidence that the causes of the mishap were:

1) prior to the flight, the throttle-quadrant settings were improperly configured during the reconfiguration of the GCS from MQ-1 to MQ-9 operations

2) this throttle change went unrecognized because the mishap pilot did not personally execute the checklists on his control rack prior to gaining control of the aircraft, and

3) the pilot stalled the aircraft due to an unrecognized, commanded reverse-thrust condition that existed whenever the pilot's throttle was at any position except fully forward.

Additionally, the AAIB found by a preponderance of evidence that the mishap pilot failed to execute his GCS preflight in accordance with technical order procedures, substantially contributing to the mishap.

How many hospitals would publish such a report for the world to see?

Applying resilience engineering to health care

A very special conference is coming up in June 13-14, entitled "Ideas to Innovation: Simulating Collaborations in the Application of Resilience Engineering to Healthcare."  It is a joint production MedStar Health and the University-Industry Demonstration Partnership (UIDP) as the first conference in UIDP’s Ideas to Innovation series.

Here's the description:

Resilience Engineering is a paradigm for safety in complex socio-technical systems, yet its application to healthcare is still very limited. Resilience engineering focuses on the fundamental systemic characteristics that enable safe and efficient performance in both expected and unexpected conditions. 

How can resilience engineering be applied to make our healthcare systems safer? During this two day gathering at the National Academies’ Keck Building in Washington D.C., world experts in resilience engineering and resilient health care will present a set of principles and practices that practitioners can leverage in their efforts to improve safety. The workshop will share knowledge, spark innovative ideas, and inspire new collaborations and partnerships to apply resilience engineering in healthcare. Representatives from sectors of academia, industry, and government will work together to explore the ways in which resilience engineering can be applied in healthcare.

Registration information is available at this site.

Raj teaches us human factors

A subtle advantage enjoyed by MedStar as it engages in its quality and safety transformation is the existence of its close affiliate, the National Center for Human Factors Engineering in Healthcare.  Another presenter at today's Quality and Safety Risk Management Retreat was Raj Ratwani, senior human factors scientist at NCHFEH.  Raj is a behavioral scientist with extensive experience in the airline industry and in the defense field.  I found--as did the attendees--much to learn from him.

Raj's presentation was an excellent primer on the types of errors that present themselves in complex systems.  Rather than knowledge-based errors (where people perform the wrong step as a result of a lack of knowledge) or rule-based errors (where people perform the wrong step because of misapplication of a rule), the predominant form of error in hospitals and other types of organizations is skill-based.  In this category, people perform the wrong step because of a slip or a lapse.

Raj stated, "No matter how capable we are, there is variability in our performance."  He noted that we all come to work with intentions to work at our highest level, but our work environment is full of interruptions, the workload is generally high, and fatigue and stress are real issues.

The task then is to design mechanisms that make it more difficult for people to make these kind of errors.  Instead of a "person approach" that focuses on the errors of individuals and blames them for failures of memory and attention, adopt a "systems approach" that focuses on the conditions under which individuals work and that builds defenses to avert errors or mitigate their effects.