tag:blogger.com,1999:blog-32053362.post165864586820818254..comments2024-03-29T06:37:18.029-04:00Comments on Not Running a Hospital: Mea culpaPaul Levyhttp://www.blogger.com/profile/17065446378970179507noreply@blogger.comBlogger13125tag:blogger.com,1999:blog-32053362.post-67152429329025398182008-09-18T22:06:00.000-04:002008-09-18T22:06:00.000-04:00One thing I didn't notice about the time-out (mayb...One thing I didn't notice about the time-out (maybe I skimmed too much?) is how many times we catch registration errors. As a CT tech, we have the "Two patient identifiers" policy where we always ask first and last names and also birthdays before we begin anything. The key is to also check the patient's wristband to be sure the birthdate is actually the one the patient states. We have had several women with M for male on their bands. We also do an extensive time-out before all interventional procedures. I am personally happy for that because I am used to having the patient on their back, but when they get on their stomachs, I get my left and rights all mixed up. I understand that some patients feel we do this because nobody has a clue as to what we are doing, but most of them fell better when I explain why we ask all the questions. Thanks for an interesting post!AsTiMahttps://www.blogger.com/profile/03302020651626359830noreply@blogger.comtag:blogger.com,1999:blog-32053362.post-54374735840867752782008-09-18T16:27:00.000-04:002008-09-18T16:27:00.000-04:00Recognizing that I am a "nobody", I must respectfu...Recognizing that I am a "nobody", I must respectfully disagree somewhat with Mr.(?Dr.) Conway's attitude that quality care and patient safety are part of a long journey and we should celebrate the positive things. The IOM report on medical errors came out several years ago, and I sat on a hospital quality improvement council which was talking about all these things at least 10 years ago. Many hospitals are not even close to achieving the improvements that are going on in isolated medical centers around the country.<BR/><BR/>I believe a little bit of controlled impatience is needed in pushing this process along faster. JC and CMS are beginning to have an impact in this area, but the fact remains that many administrators just don't see it as a priority. This must change for the patients' sakes, and I think we must develop a higher sense of urgency in this movement.<BR/>For that reason, no, I don't think the SVP for Quality should be let off the hook here or anywhere else. He or she should be out there every day educating the physicians and staff and pushing this along, not being pushed along by his/her CEO.<BR/>(With personal apologies to the SVP/Quality; it's nothing personal and I am just seizing upon this as an example!)<BR/><BR/>nonlocal MDAnonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-29895943830612311062008-09-18T14:23:00.000-04:002008-09-18T14:23:00.000-04:00Paul,This is such a great posting – rich with all ...Paul,<BR/><BR/>This is such a great posting – rich with all kinds of lessons. You deserve a lot of credit for the catches you made: empowering everyone in the room on a timeout as opposed to laying it all on the doc; also establishing a presumption that the patient should surely participate unless circumstances make that impossible. That the CEO of a major academic medical center is involved in the quality and safety effort at such a detailed level is really impressive. <BR/><BR/>It’s reasonable of you to ask why you had to make those catches. It would have been better if the members of the MEC had fixed both of those items. But learning about and writing about the quality/safety journeys at other institutions it’s pretty clear that these processes are often untidy. Rarely does anybody get it entirely right first time out. The Toyota Production System is instructive here. A number of U.S. hospitals have drawn from the Toyota approach to improve quality and safety and Toyota has been at the business of quality improvement for generations. Yet their system is by no means static. Gary Kaplan, MD, CEO at Virginia Mason Medical Center in Seattle, which uses the Toyota approach, told me that Toyota receives hundreds of thousands of suggestions each year from employees on how to improve their processes – and many are implemented. The commitment to quality and safety improvement – the journey itself – generates continuous improvements and that, I think, is what happened in your case. You are committed to the journey and you are improving in the course of the process. In this case, the process actually worked really well – because you are part of that process and made the improvements.<BR/><BR/>These changes – especially cultural changes – are not at all easy as you well know. But change is possible when people are genuinely committed. Steve Muething, MD, at Cincinnati Children’s told me of a case where he had been hammering away re: time-outs before any invasive procedure. One day a child was about to undergo an invasive radiology procedure and the time-out was skipped. But a child life specialist – not a doc or nurse – called a halt to the procedure. She believed in the empowerment she’d been granted by the hospital leadership; believed in the institutional commitment to protect the children. So she bravely spoke up, paused the procedure, and an appropriate time-out ensued. She was praised and respected for doing so – a real indication of meaningful cultural change.Charlie Kenneyhttps://www.blogger.com/profile/17468178948203668758noreply@blogger.comtag:blogger.com,1999:blog-32053362.post-80763403117909427052008-09-18T12:18:00.000-04:002008-09-18T12:18:00.000-04:00Paul, good to see that you too suffer from being h...Paul, good to see that you too suffer from being human. I agree, the SVP deserved an apology.<BR/><BR/>When you made your comments at the MSEC, you made them as a CEO setting a new expectation and a member of the team brining fresh eyes. Both comments—that patients and families are partners and that their power and shared responsibilities of team— are essential. They are also, unfortunately new areas of priority focus—they are not elements of success previously emphasized in healthcare. The fact that staff “missed it” isn’t anyone fault. As Goran, suggested culture is a long journey and for many of us, we are very early on it. I celebrate they received the suggestion so well, respecting the important role you play as a member of the team. What we need to be doing is setting clear expectations, be respectful of the various places people are, and position staff to be successful in that new environment. <BR/><BR/>One final note. When I left a DFCI a number of people commented on the helpfulness of times when I acknowledged I had “screwed up.” You’re not alone. These too become great moments for learning and high performance team development. Thanks for sharing the story. <BR/><BR/>Jim Conway, SVP IHIJim Conwayhttps://www.blogger.com/profile/13161819460476350966noreply@blogger.comtag:blogger.com,1999:blog-32053362.post-90570233103200504732008-09-18T12:05:00.000-04:002008-09-18T12:05:00.000-04:00Culture change can occur rapidly, but there have t...Culture change can occur rapidly, but there have to be sufficient rewards - strong 'pushes' and 'pulls' in the system to overcome the inertia of habitual thinking and behavior. This is Boston, and medicine, after all. It will take a lot of carrots to reach the tipping point. You have power and voice as CEO, but is power and vision dispersed in the organization? Are staff rewarded for thinking differently?Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-84554004711625252032008-09-18T11:40:00.000-04:002008-09-18T11:40:00.000-04:00Paul:I'm very interested in your post because my h...Paul:<BR/><BR/>I'm very interested in your post because my husband was recently in the hospital (not yours!) for heart surgery and was taken for an ultrasound. The technicians confused him with another patient and insisted that he needed an x-ray despite his objections and attempts to correct their misunderstanding. The culture of ignoring what the patient says trickles downs to every level. If you are able to bring about a change in this attitude, you will have done something really miraculous.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-56369981640455361162008-09-18T10:55:00.000-04:002008-09-18T10:55:00.000-04:00I would like to see your policy state instead of "...I would like to see your policy state instead of "all patient allergies", "all patient allergies, and adverse reactions". As a patient, I think of allergies as something that gives me hives or makes my throat swell. So if asked about allergies, I would mention things that gave me hives.<BR/><BR/>I would not be thinking about something that made me faint unexpectedly, or have violent outbursts during a procedure. <BR/>These reactions might be more dangerous than an allergy, but they don't get the same attention in patient histories, or consideration on charts.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-14598121953774694202008-09-18T09:27:00.000-04:002008-09-18T09:27:00.000-04:00Dear SVP,At this point in our education, maybe it ...Dear SVP,<BR/><BR/>At this point in our education, maybe it makes sense to include it explicitly in each policy. You're right, of course, that it should be understood to apply to everything, but that will take time, and maybe a reminder in each one would be a good device for a while.<BR/><BR/>I welcome thoughts from others on this.<BR/><BR/>Dear Nonlocal,<BR/><BR/>Will do. Stay tuned.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-8744008233413267312008-09-18T09:25:00.000-04:002008-09-18T09:25:00.000-04:00After reading Paul’s blog entry this morning, I wa...After reading Paul’s blog entry this morning, I wanted to offer an alternative view regarding putting into the policy the expectation that all others in the procedure room should also be responsible for ensuring that the time out occurs. I certainly agree this is the case. But I think the state we’re trying to reach is that this expectation is true with all policies and standardized processes, i.e., that anybody who observes that it doesn’t happen is expected to “call out” that problem and if it poses any kind of risk to a patient to “pull the cord” (as they say at Toyota) in real time. If so, then should we be putting into every policy that all observers at each step should speak up if they don’t see it occur? I suppose we could but I think that’s the culture we want and repeating that in every section of every policy doesn’t seem the way to get there. Now, I recognize that it may be that time out policies are so critical that it is worth being explicit in that policy, but I think there are many other policies just as critical to safety (double ID, PPE, hand washing, et al).Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-36795760958510134272008-09-18T09:00:00.000-04:002008-09-18T09:00:00.000-04:00ps, Paul, I have been meaning to ask; what changes...ps, Paul, I have been meaning to ask; what changes in OR procedure/policy have you implemented based on what you learned from the wrong site surgery analysis? If you can say so publicly, of course.<BR/><BR/>nonlocalAnonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-36739638599831353872008-09-18T08:57:00.000-04:002008-09-18T08:57:00.000-04:00I think your question about why it had to be you t...I think your question about why it had to be you to raise the flaws has important implications. My belief is that people on the inside get too close to an issue or a way of doing things, such that, as you say, "we've always done it that way", or "everybody does it" becomes embedded in their thinking.<BR/>I have been interested in how you, coming from outside the industry, often have a different and refreshing viewpoint on health care issues. I think it often takes someone from outside, who has the clout to be listened to, to perceive the flawed thinking of everyone else.<BR/>We could only wish that there had been someone analogous to you before the current Wall Street debacle, which could easily have been prevented, if only someone (with clout; that's critical) along the way had asked similar questions.<BR/>BTW, I don't think it was wrong to be critical of an SVP for Quality for not reviewing every sentence of a quality document and asking "is there any better way to do this?" Perhaps if you had changed "critical" to "educate", yes.<BR/><BR/>nonlocalAnonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-74826379110032988862008-09-18T06:06:00.000-04:002008-09-18T06:06:00.000-04:00And let's hope, too, Stephi, that they don't ask y...And let's hope, too, Stephi, that they don't ask you which side!<BR/><BR/>Last year, I was in the lab to have some blood drawn. The lab tech recognized me and started a five minute conversation about all kinds of things related to the administration of the hospital. Then, when it came time to draw the blood, she stopped and said: "What is your name? What is your birth date?" It was exactly the right thing to do.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-70499844199482015792008-09-18T01:45:00.000-04:002008-09-18T01:45:00.000-04:00Last year I had my first surgery ever. At every p...Last year I had my first surgery ever. At every point of contact with a hosptial official, be it the gal that gives you a bag to put your clothes in and assigns you a locker, right to the surgeon (thankfully it was my obgyn, I was SO happy it was her!), asked me my name, and what surgery I was having. This happened in the operating room as well. <BR/><BR/>I was a bit overwhelmed and it made me really nervous - especially as it was my first surgery ever! I kept thinking, "Jesus people, don't ANY OF YOU know why I'm here?"! It's funny now that I look back, but it terrified me at the time. First time in a hospital can be overwhelming! <BR/><BR/>When my husband went in, years ago, for surgery on his knee, the surgeon make him draw something in pen on the knee he was getting operated on. It kind of freaked him out too! We both do understand why, and we are both grateful for it. <BR/><BR/>But when I go in next year to give birth, and if they ask me why I'm there.. I think I'll just completely give up, lol!!!! <BR/><BR/>Thanks for the informative post Paul.Stephaniehttps://www.blogger.com/profile/02240085253574785892noreply@blogger.com