--30--

With 4646 blog posts dating back to August 2006, it's time to end this adventure. After over 9-1/2 years of almost daily output, I will cease adding new posts to this blog.

Why? The main reason is that it is simply time to move on to other pursuits. The time and effort spent conceiving, researching, writing, and editing articles has pushed off other projects that I've had in mind for several years. I'd like to focus on those.

I'm deeply appreciative of my loyal and engaged readers.  They commented directly on the blog over 22 thousand times, and many have also sent private emails with their observations.  The readers have been polite, respectful, attentive, and thoughtful, and I cherish the time we've spent together.

I'm also grateful to members of the Fourth Estate with whom I have corresponded on many of the topics covered here.  Sometimes we have sourced one another, sometimes we have collaborated, and sometimes we have offered mutual support in the face of harsh criticism from the subjects of our articles.  I've generally found that the business pressures faced by the media have not eroded the diligence of reporters in this field, and their commitment to the First Amendment is powerful and lasting.

As to those in the health care world, as I said in my first blog post:

I have never worked in a place where people are so consistently caring and devoted to alleviating human suffering caused by disease. It is, in many ways, a beautiful place to work. But many of the forces facing hospitals, doctors, nurses, and others make it really hard to do the job well.

That dedication persists, but the corporatization of the health care world weighs heavily on these well-meaning people.  They need our support and encouragement, and they deserve to be led by leaders who understand the value they bring to society.

Finally, a tribute to those who have mattered the most in making this blog worthwhile, the hundreds of girls I have coached in youth soccer over the course of over two decades.  They've taught me immensely important leadership and teamwork lessons, and I've done my best to impart those lessons to you.

I'll leave the blog up for those who might like to use it as a reference.  A note: Do not use the search box within the blog page.  It is not well supported by Google (even though Blogger is a Google product.)  If you want to search for a topic, conduct a search from the main search engine you prefer on your browser--using "runningahospital [item]"--and you'll be more likely to be successful and get a more complete listing.
                                                               --30--

How to get patient opinions: Ask.

Michael Greco and his mates at Patient Opinion have developed a simple and useful way to collect opinions about medical care from patients and provide a lovely forum for interactions back and forth with the hospital and providers.  The purpose is simple: To enable and enhance issue resolution, relationship restoration, and improvement. An easy-to-use website makes it possible.

The folks at Eastern Health in Victoria have had PO in place for some time.  Here are some stories from their health system.  As you can see, things go in both directions in a helpful, direct, and friendly fashion.  In fact, this first story is actually an apology from a patient to the staff. An excerpt:

I was upset and not in the mood to talk much nor was I paying attention to what was being said, as a result I presented as being rude. When the descending red misty haze had finally settled, remorse set in. I regret deeply if I had offended this person and caused them to perform their duties to other patients in a non satisfactory manner.

If you have any idea as to who the unfortunate recipient of my bout of bad manners was, could you please forward my most sincere apologies to him.

The response from the hospital chief executive was empathic:

Thank you so much for sharing your story on Patient Opinion and I do hope that you are feeling better for having communicated your apology to us. Please be reassured that we understand how these things happen and I hope that you have relieved a burden which I imagine you have been carrying for a while.

Please be reassured that I will do my best to identify the person . . . and be sure to send on your apology to him.

Look after yourself and thanks again for getting in touch - no doubt, if I can identify who this person is, your apology will make his day.

Here's another story, in which a mother expressed concerns about her daughter's care.  An excerpt:

There have been a number of issues that I am concerned about and I believe need to be addressed, these are:

1. My daughter should never have been discharged from the Angliss as she was in pain, nauseous & unwell. Surely an indicator that something was seriously amiss!
2. This damage to her bladder has been devastating for her & us as a family.
3. No phone communication from nursing staff when I rang as the phone rang out.
4. There appears to be a shortage of staff? Why are there not more ward clerks?
5. I am not the sort of nuisance person who makes complaints just for the sake of it.
6. I am very disturbed at how my daughter has been treated and I feel angry she has had to endure so much pain and an operation that went so terribly wrong!

I suggest the issues I have pointed out require investigation & rectifying to avoid further insult & pain to others.

I also hope you take note of the staffing in your hospitals and that more thought is put into place regarding the discharge of patients.

Here are excerpts from the response from the chief executive:

First of all, let me say how sorry I am to read about your daughter’s experience at Angliss Hospital. I understand that you would be upset about this and I am alarmed too when I read the detail.

Secondly, at the outset, I want you know that we will work with you to resolve these issues and importantly, learn from your experience so that we can prevent a recurrence.

You have raised a number of issues related to lack of care and I can’t imagine why this has happened. . . . Then, when I read that you have made contact with Eastern Health and we have not responded, I am even more concerned. We really do pride ourselves on responding to all feedback and share this with our staff as part of our process of feedback for improvement.

I would like to arrange a full investigation into the issues which you have raised as well as the matter of sending a letter and an email without a response from us.

Based on the facts which have been raised, I can indeed have very general discussions and piece little pieces of information together but it would be even better and more targeted if I could have a conversation with you and discuss a plan of action. 

I would welcome your contact and if you could email me privately . . .

After some personal contact, the mother responded:

Thank you Mr Lilly,

It was very reassuring to hear from you and that the issues mentioned will be followed up. It is not about blame merely that more thought should be put into place when a patient says something is wrong....we as humans know our own bodies.

I would not like to see this happen to another person. We are only human and things happen however it just goes to show we need to listen. . . . I thank you sincerely for your compassion and concern. 

Michael notes that many stories have been viewed by the public hundreds of times.  That all of these conversations are public makes them even more powerful--in terms both of process improvement in the hospital and the messages and information that is provided to other patients and families.

Callahan tells about stories

With a plethora of books about the value and importance of storytelling, we might wonder if another could offer any value. Well, the answer is yes, emphatically.

Shawn Callahan's about-to-be released book Putting Stories to Work: Mastering Business Storytelling, is a must-have for your actual or digital library.  It is available now on pre-order and will be on the "bookshelves" on March 20.

Shawn is the founder of Anecdote, the world’s largest business storytelling company.  His book is engaging and wise, and yes, replete with useful stories. His advise is concise and helpful, and--unsurprisingly--he has a way with words!  Let me provide some excerpts.  First, this teaser:

Natural as it is for us to tell stories, as soon as we enter a meeting, begin a presentation or start a formal conversation with a colleague, all our stories disappear. We bring forth our most authoritative voice and opine away, saying things like: ‘There are three key points here...’ and ‘I think that...’ and ‘It’s my view that...’ But as we’ve seen, the problem with this approach is that it’s mostly forgettable. You need to inject some storytelling into business proceedings to get the right balance of argument and narrative. And to do this effectively as a leader, you need to concentrate on what I call small stories.

Big ‘S’ storytellers apply plot structure, character development, beats, scene design and myriad other storytelling principles and practices—they’ve probably read Robert McKee’s fabulous book Story: Substance, Structure, Style, and the Principles of Screenwriting. At the other end of the spectrum is little ‘s’ storytelling, where we find the stories we tell on a daily basis in conversations: anecdotes concerning real-life experiences. 

We can certainly improve our storytelling by applying some of the techniques used by the best screenwriters, playwrights and novelists. But beyond a certain point, your storytelling will drop into the Uncanny Valley, at the bottom of which your efforts will seem artificial, forced and unappealing. And that’s fatal for business communications. 
 

And some basic rules:

It’s been proven that the real efficacy of storytelling lies in three standout features of stories that can help us do our jobs as business leaders:

They're memorable—There’s no point in saying something if it’s forgettable.

They convey emotion—People are inspired to act when they feel emotion.

They’re meaningful— In the complex environment of work, people need to be able to make sense of what’s going on and how they fit in.

I could go on with more, but you can download a free sample here. Reading this book once will be well worth your time.  And, then you will come back to it many times over the years.

US News rankings reward transparency

Regular readers will know that I am no fan of hospital rankings and have been quite critical over the years at the ones at US News and World Report.  But let's give credit to where it is due:

Check out this news release. Excerpts:

Patients and families who've used our rankings tell us they want more from hospitals. What they want is meaningful transparency.

U.S. News will implement two closely related methodology changes this spring that could drive broader transparency. Both will affect only our rankings of Best Hospitals in Cardiology & Heart Surgery. In that specialty, we will award credit to hospitals that publicly release their own performance data via one or both of two clinical registries, the Society of Thoracic Surgeons' (STS) Adult Cardiac Surgery Database and the American College of Cardiology's (ACC) National Cardiovascular Data Registry. In the case of the ACC data, two constituent registries will be considered: CathPCI and ICD. ACC and its participating cardiologists began voluntary public reporting from CathPCI and ICD in November.

Of approximately 700 hospitals evaluated for the heart rankings, more than half already publicly report through STS. (Their performance can be freely accessed at STS.org.) Many STS reporters publicly report through ACC as well. In addition, some hospitals that haven't yet opted into the STS reporting program, which began in 2010, have already elected to participate in the ACC's program. (ACC data can be found at CardioSmart.org.)

Slightly more than 300 of the hospitals in the U.S. News cardiovascular-care analysis, however, have not yet opted to be transparent through either registry. That deprives patients of an opportunity to assess the holdouts' quality of care.

To accommodate the new transparency measures, U.S. News will reduce reputation's scoring weight in Cardiology & Heart Surgery from 27.5 percent to 24.5 percent.

Well done! This is an excellent step.  I hope it will be expanded to other specialties over time.

Meanwhile, back in Massachusetts

It's been some time since I commented on issues of market dominance in Massachusetts, but a recent story by Bruce Mohl at Commonwealth Magazine caught my interest. He writes about a petition being supported by a health care union, SEIU, and Steward Health Care that would mandate a flattening of rate disparities among the state's hospitals.

The Massachusetts Hospital Association opposes the ballot question.  Mohl notes:

All but one of the hospital association’s board members head institutions that would benefit financially from the ballot question, but nevertheless they have formed a united front against it. Their reasons vary. Some are wary of government price regulation; others don’t think a ballot question is the best way to set health care policy. Whatever their motivation, the united front benefits Partners HealthCare, the one association member who would take a big hit if the ballot question becomes law.

Mohl notes that under the proposed legislation:

Lowell General Hospital would receive $27 million. Cambridge Health Alliance would get $22 million. CareGroup, which owns Beth Israel Deaconess and Mount Auburn Hospital, would pick up a total of $17 million. Baystate Health and Lahey Health would each receive $10 million, New England Baptist would get $7 million, Boston Medical Center would recover nearly $4 million, and Tufts Medical Center nearly $3 million.

He also reports:

A source familiar with the board’s discussions said Partners wields enormous power within the association, since it supplies 20 to 25 percent of its revenue. The source said the hospital association has pledged $14 million to the ballot question fight, with $12 million coming from Partners and $2 million from the association’s other members. The Rasky Baerlein firm is being enlisted to run the ballot campaign, the source said.
 
What more evidence do you need of the power and intimidation that Partners can wield among the insiders of the Boston health care market?

Some in the MHA find inimical the prospect of regulation of hospital pricing by the state.  Oddly, some of those very people are among the first to complain that the market-power-based rate-making system current employed by Blue Cross Blue Shield and the other insurers is unjust. Now, when they could act, they adopt an ostrich-like pose.  Do they really think that "a hospital association subcommittee headed by Michael Widmer, the former head of the Massachusetts Taxpayers Foundation" will find ways to address the pricing differentials?  Over the course of the last decade, two Attorneys General have documented the disparities problem and its untoward effect on overall health care costs in the state, and the MHA has failed to do anything about it.

Meanwhile, Steward's support for the petition is humorous.  That system has always bragged about being a "low-cost" alternative to the pricey academic medical centers.  It now seems to realize that it is not really "low-cost" but simply "low-paid."  Meanwhile, for years it sent its tertiary referrals to Partners' Massachusetts General Hospital, the highest paid tertiary center--a move that undercut the profitability of the global payment based system Steward has chosen to sign with insurers.

In short, everybody seems to want to have it both ways.  Except Partners.  Which has is (again) their way.  Bravo, Partners!  Well done.

Getting past denial in Victoria

You have to be willing to acknowlege your problems before you can remedy them.  If I were to characterize the state of public and private hospital care in the state of Victoria, Australia, I'd have to say that this first step is lacking.  Both the public and private hospital systems and the goverment regulators who oversee them are in a state of denial with regard to the level of harm being caused to the public by inadequate attention to quality and safety deficiencies. The health system as a whole, also, is characterized by an uwillingness to engage patients and families in the appraisal and improvement of care.

The question is when and if the body politic and hospital governing bodies and clinical and administrative leaders will overcome their denial of the extent of the problem.

On the public side of the hospital system, the Victoria Auditor-General is about to issue an important report on patient safety in Victoria hospitals, described as follows:

Clinical incidents in healthcare settings cause, or have the potential to cause, unexpected harm to patients. They include falls, pressure sores and medication errors and may result in near misses, adverse events where harm has occurred or sentinel events resulting in serious harm or death. It has been estimated that around one in 10 hospitalised patients suffers preventable harm and an adverse event related to care. The number of near misses, the accuracy of reporting of patient safety incidents, and the effectiveness of subsequent investigation are not known. The audit will determine whether public hospitals are managing risks to patient safety.

If this study is rigorous and accurate, as I have reason to believe it will be, it will confirm a previous analysis about the public hospitals:

A study published in the journal Health Policy showed there were almost 20,000 adverse events - or incidents that cause harm to patients - in Victoria in 2005-06.

The data showed for the first time the extent of errors and complications in Victoria's hospitals and highlighted how little the state government reports such problems. It discloses only the most serious problems, or ''sentinel events'', each year.

In 2005-06, the same year as the study, it disclosed only 91 serious adverse events, including 29 deaths.

The study, led by Katharina Hauck of the Imperial College London's centre for health policy, found that adverse-event rates varied greatly between hospitals - from 6.8 per cent to 30.1 per cent for elective and from 3.6 per cent to 25.7 per cent for emergency patients.

Many believe that quality and safety problems occur mainly in the rural hospitals, but it is clear that they exist even in the most reknowned academic tertiary care institutions.

From all I can see, this study has been ignored by the body politic.  After a brief flurry of interest by media, attention to the issue evaporated.  Will the same happen to the Auditor-General's report?  Concerns about the public health system tend to focus on budgetary matters, sometimes with sniping between federal and state officials that distracts from the level of harm being caused to patients.

There is a tendency among Victorians to extol the virtues of the devolved model of health care organization that exists in the state--as distinct, say, from the more centralized approach employed in New Soulth Wales.  In that state, a Clinical Excellence Commission is directly charged with designing and disseminating improvements in patient care into the state's hospitals.

There is no inherent advantage in one system versus another.  After all, a devolved system can be a fecund environment for innnovation and creativity.  But when it comes to the saftey and quality of care, there is scant evidence that such is the case in Victoria.  An October 2015 study by the King's Fund is notably silent about any such advances.  Apparently looking for positive remarks, the best the authors could say was the following:

The picture that emerges is of a health system performing well. Available data shows that Victoria delivers good results in comparison with other parts of Australia, being at, close to and sometimes above the average on many indicators. Underpinning Victoria’s performance is a well-understood governance model that gives the boards running health services at a local level considerable autonomy within a state-wideframework of priorities.

Putting aside the fact that benchmarking a system to "the average" is meaningless,  the following remarks undercut the validity of even this conclusion:

The transparent reporting of data on performance is another area for improvement. Not only would this strengthen accountability to the public, but also it would support health care providers to compare their performance with others and identify areas in which they can improve. The ‘disinfectant of sunlight’, as it has been dubbed, is being used increasingly in other health care systems, including within Australia, and it could be a powerful means of providing an early warning of performance problems. Increased transparency on safety and quality would also provide boards with the information they need to discharge their responsibilities.

In short, the basic information that devolved boards need to carry out their responsibilities is simply not available.

All of the above is about the public hospitals, but I have now heard and seen enough to believe that similar patterns exist in even some of the most highly regarded private hospitals.  During the last three months, I did not seek stories of safety and quality lapses in the private system, but I've had many reported to me.  One hospital system, for example, has a clear and persistent pattern of mis-identifying patients under their care--sometimes from failing to attach identifying name bands to patients admitted through their emergency room--resulting in near misses as patients were sent to the wrong procedure rooms or were about to be administered the wrong medications.

As in the case of the public hospitals, as dearth of reporting about hospital acquired infections and other sources of harm impedes public debate about this important adjunct to the state's health system. A lack of transparency allows reputation and market power--rather than quality--to form the basis for the relative rates charged to private medical insurers.

I have discussed before the high level of communitarian behavior in much of Australia society, and this is a marvelous thing.  I have also pointed out the notable personal commitment of many clinicians to providing patient- and family-centered area.  This too is admirable.  But general evidence of communitarianism and caring do not make a safe and high quality health care system.  Unless there is a high-level and sustained commitment to reducing harm by Government, by boards, and by clinical leaders; unless all parties embrace transparency of clinical outcomes; and unless patients and family engagement is made an institutional requirement of care design and delivery, Victorians will be put at unnecessary risk during their visits to public and private hospitals in the state.

Time for a "no dickheads" rule

In his wonderful book about the All Blacks, Legacy, James Kerr reminds us that a key to the success of this remarkable rugby team is an unbreakable social contract, "No dickheads."

I'm beginning to think that the body politic needs a similar approach.  If we view each country as having an implicit social contract, we can see that its tenets have an ebb and flow--from inclusive to exclusive, from sharing to selfish, and so on.  It appears that we are now heading, in several countries, to the end of the spectrum that is dysfunctional.

Martin Flanagan sets forth this thought in his book about Australia, In Sunshine or in Shadow. Although written several years ago, I have found his observations to be apt today in many ways.  A country whose philosophy was based on "mateship" has moved.  He writes:

I ask my father-in-law--what does it mean to be Australian? He looks out the window and says, "Giving the bloke beneath you a hand up." This ethic is directly at odds with the political ideology of our day. known in this country as economic rationalism, it is a glib brew of post-modern capitalism and social Darwinism that has no meaningful notion of culture and no respect for the local except as a marketplace.

Ari Shavit, in My Promised Land, describes a similar phenomenon in another young country that came into being on a wave of mutual support and social justice. A friend of mine there in Israel, looking at the current political leadership, behavior, and social trends, says, "I don't feel I am living in my own country anymore."

And in the United States, well, what can we say about the current campaign in one of the two major parties?  This article notes:

Much of the polarization dividing American politics was fueled not just by gerrymandering or money in politics or the other oft-cited variables, but by an unnoticed but surprisingly large electoral group — authoritarians.

This trend had been accelerated in recent years by demographic and economic changes such as immigration, which "activated" authoritarian tendencies, leading many Americans to seek out a strongman leader who would preserve a status quo they feel is under threat and impose order on a world they perceive as increasingly alien.

There was never a more important time for people of influence and status to speak up for the more positive social contract that has worked to make nations great.  But, not only those people.  With the rise of social media, everybody has a forum they can employ for similar messages.  It's really time to use the resources at our disposal to encourage and support a "no dickheads" rule, a culture of respect, openness, understanding, empathy, and mutual support--one that welcomes the diversity within but also the inflow of new citizens seeking gratefully to participate in a productive and free society.

But it is just that freedom that, without diligence, diminishes us all.

If not, we best remember the quote from Martin Niemöller:

When the Nazis came for the communists,
I did not speak out;
As I was not a communist. 

When they locked up the social democrats,
I did not speak out;
I was not a social democrat.

When they came for the trade unionists,
I did not speak out;
As I was not a trade unionist.

When they came for the Jews,
I did not speak out;
As I was not a Jew.

When they came for me,
there was no one left to speak out.

Mateship

You can't be here in Australia for very long before hearing about the concept of "mateship."  Here are some explanations:

Wikipedia says: "Mateship is an Australian cultural idiom that embodies equality, loyalty and friendship."

But it goes further than that.  This government site says:

'Mateship' is a concept that can be traced back to early colonial times. The harsh environment in which convicts and new settlers found themselves meant that men and women closely relied on each other for all sorts of help. In Australia, a 'mate' is more than just a friend. It's a term that implies a sense of shared experience, mutual respect and unconditional assistance.

And this article notes: "It is a term that conjures images of young men providing unconditional support for one another amid the toughest of conditions."

But what I've found is that the term also often implies demonstrating that loyalty with a panache of machismo, sometimes--in the view of others--to the the extent of foolishness. Martin Flanagan tells a story in his book In Sunshine or in Shadow:

Just after the Rocherlea turn-off, I stopped for a hitchhiker, a young man in his twenties, who looked to be in pain. He was holding his groin and got into the car with difficulty. He told me he had picked up a pup belonging to his mate's dog, a half bull terrier bitch, which had responded by leaping up and biting him in the testicles. I asked if he struck the animal or kicked at it to get away. He looked at me as if I hadn't heard him correctly, and said, a second time, more slowly than the first, "It was the mate's dog."

When I told Bob Brown [a Tasmanian environmental activist] this story, he laughed till he cried, big sodding drops that fell on his shoes, and I knew he loved this poor silly bastard and the foolish splendour of his male pride.

The term is also exemplified in the 1890 iconic epic poem by A. B. "Banjo" Paterson, "The Man from Snowy River."  When I heard the musical version by Wallis & Matilda from their album "Pioneers," I remarked that the difference between this story and America is that the guys in the American Old West would not necessarily have come to the aid of one of their fellow horse owners to go after the colt.  Here they did, to be helpful for sure, but especially for the sport of the difficulty in retrieving it.  Here's the poem.  [Sorry, I can't get the formatting exactly right here, so go to the original to see all the words.] Note the description of the pony in the third verse--the perfect horse for this mate:

There was movement at the station, for the word had passed around
That the colt from old Regret had got away,
And had joined the wild bush horses - he was worth a thousand pound,
So all the cracks had gathered to the fray.
All the tried and noted riders from the stations near and far
Had mustered at the homestead overnight,
For the bushmen love hard riding where the wild bush horses are,
And the stockhorse snuffs the battle with delight.

There was Harrison, who made his pile when Pardon won the cup,
The old man with his hair as white as snow;
But few could ride beside him when his blood was fairly up -
He would go wherever horse and man could go.
And Clancy of the Overflow came down to lend a hand,
No better horseman ever held the reins;
For never horse could throw him while the saddle girths would stand,
He learnt to ride while droving on the plains.

And one was there, a stripling on a small and weedy beast,
He was something like a racehorse undersized,
With a touch of Timor pony - three parts thoroughbred at least -
And such as are by mountain horsemen prized.
He was hard and tough and wiry - just the sort that won't say die -
There was courage in his quick impatient tread;
And he bore the badge of gameness in his bright and fiery eye,
And the proud and lofty carriage of his head.

But still so slight and weedy, one would doubt his power to stay,
And the old man said, "That horse will never do
For a long a tiring gallop - lad, you'd better stop away,
Those hills are far too rough for such as you."
So he waited sad and wistful - only Clancy stood his friend -
"I think we ought to let him come," he said;
"I warrant he'll be with us when he's wanted at the end,
For both his horse and he are mountain bred.

"He hails from Snowy River, up by Kosciusko's side,
Where the hills are twice as steep and twice as rough,
Where a horse's hoofs strike firelight from the flint stones every stride,
The man that holds his own is good enough.
And the Snowy River riders on the mountains make their home,
Where the river runs those giant hills between;
I have seen full many horsemen since I first commenced to roam,
But nowhere yet such horsemen have I seen."

So he went - they found the horses by the big mimosa clump -
They raced away towards the mountain's brow, 
And the old man gave his orders, "Boys, go at them from the jump, 
No use to try for fancy riding now. 
And, Clancy, you must wheel them, try and wheel them to the right. 
Ride boldly, lad, and never fear the spills, 
For never yet was rider that could keep the mob in sight, 
If once they gain the shelter of those hills."

So Clancy rode to wheel them - he was racing on the wing 
Where the best and boldest riders take their place, 
And he raced his stockhorse past them, and he made the ranges ring 
With the stockwhip, as he met them face to face. 
Then they halted for a moment, while he swung the dreaded lash, 
But they saw their well-loved mountain full in view, 
And they charged beneath the stockwhip with a sharp and sudden dash, 
And off into the mountain scrub they flew.

Then fast the horsemen followed, where the gorges deep and black 
Resounded to the thunder of their tread, 
And the stockwhips woke the echoes, and they fiercely answered back 
From cliffs and crags that beetled overhead. 
And upward, ever upward, the wild horses held their way, 
Where mountain ash and kurrajong grew wide; 
And the old man muttered fiercely, "We may bid the mob good day, 
No man can hold them down the other side."

When they reached the mountain's summit, even Clancy took a pull, 
It well might make the boldest hold their breath, 
The wild hop scrub grew thickly, and the hidden ground was full 
Of wombat holes, and any slip was death. 
But the man from Snowy River let the pony have his head, 
And he swung his stockwhip round and gave a cheer, 
And he raced him down the mountain like a torrent down its bed, 
While the others stood and watched in very fear.

He sent the flint stones flying, but the pony kept his feet, 
He cleared the fallen timber in his stride, 
And the man from Snowy River never shifted in his seat - 
It was grand to see that mountain horseman ride. 
Through the stringybarks and saplings, on the rough and broken ground, 
Down the hillside at a racing pace he went; 
And he never drew the bridle till he landed safe and sound, 
At the bottom of that terrible descent.

He was right among the horses as they climbed the further hill, 
And the watchers on the mountain standing mute, 
Saw him ply the stockwhip fiercely, he was right among them still,
As he raced across the clearing in pursuit. 
Then they lost him for a moment, where two mountain gullies met 
In the ranges, but a final glimpse reveals 
On a dim and distant hillside the wild horses racing yet, 
With the man from Snowy River at their heels.

And he ran them single-handed till their sides were white with foam. 
He followed like a bloodhound on their track, 
Till they halted cowed and beaten, then he turned their heads for home, 
And alone and unassisted brought them back. 
But his hardy mountain pony he could scarcely raise a trot, 
He was blood from hip to shoulder from the spur; 
But his pluck was still undaunted, and his courage fiery hot, 
For never yet was mountain horse a cur.

And down by Kosciusko, where the pine-clad ridges raise 
Their torn and rugged battlements on high, 
Where the air is clear as crystal, and the white stars fairly blaze 
At midnight in the cold and frosty sky, 
And where around The Overflow the reed beds sweep and sway 
To the breezes, and the rolling plains are wide, 
The man from Snowy River is a household word today, 
And the stockmen tell the story of his ride.

What can I do? May Wong answered the question.

The most common question I get--worldwide--after I give a talk or seminar on creating a learning organization to improve clinical processes in hospitals is:  "I really like what you are saying, but what can I do if those above me in the organization have not adopted the philosophy you espouse."  I respond by saying, "Start small, and just try to get something fixed in your area, working with other like-minded people. Maybe the ideas will spread organically. Maybe they won't, but at least you will have made things better for some."

Well, May Wong from Sydney didn't need my advice.  My buddy Sarah Dalton at the New South Wales Clinical Excellence Commission told me the story:

Several years ago in her intern year, the thing that most frightened May was having to participate in a resuscitation.  To alleviate part of her anxiety, she checked the resuscitation trolley ("code cart" in our region) in her ward to be intimately familiar with the location of every device or supply she might need if an emergency arose.

A few weeks later she was working in another ward, and a code was called, and she found to her dismay that the trolley on that ward was organized differently, and she had difficulty finding the airway equipment.

She said to herself, "This is ridiculous.  Shouldn't every cart be organized the same way?" And she decided to get the problem fixed.

She started knocking on doors.  Her registrar (senior resident) said, "That's the way things are."  Her consultant (attending physician) said, "That's not my problem."  The nurse manager said, "It's not a problem. All of our nurses know how to find what they need."

Eventually, someone suggested that she should talk to the Director of Clinical Governance.  She searched around to find out who the DCG was and where to find him, and he said, "Oh, is that a problem?  I didn't know."  He said, assemble a team, collect data, construct a statement of aim, come back to me, and suggest the change concepts you want to implement.

So she did.  She brought the issue to the Resuscitation Committee, gathered other junior medical offices, invited the nurses from several wards, and even engaged the medical head of the ICUs.  And she got it done.  By the end of her intern year, all of the resuscitation trolleys in the hospital were organized in the same way.

But things didn't stop there.  May went on to work with other house staff to create a regular forum in which they could compare their quality and safety improvement ideas and progress and help one another with suggestions.  It is now a regular part of the hospital's culture.

What can you do?  May has provided you with the path to your answer with her thoughtful actions.

Staff at work

One of the great pleasures of being ex-CEO of a hospital is to visit other places around the world and see the staff in action.  Whatever you might have heard about the stresses and problems faced by doctors and nurses and others, there remains an underlying sense of purpose and commitment that often shines through.

Here's a example, from the theatre in which young patients at Royal Children's Hospital receive lumbar punctures and bone marrow tests to receive chemotherapy and/or to assess their progress with regard to leukemia treatments.  I offer the explanation totally in pictures, which pretty well tell the story.  The only one warranting a bit of explanation is the one showing Steve, the anaesthesia technician, driving a small toy car as the patient enters the room--to distract and engage the child!