A storm brews across the pond

Remembering, as Shaw said, that we are "two peoples separated by a common language," I am nonetheless left aghast by some of the comments from British medical folks in response to a recent post by Anne Marie Cunningham on her blog, entitled "Social media, black humour, and professionals."  Anne Marie is a GP and Clinical Lecturer in Cardiff University, Wales, UK, with a specific interest in improving the quality of medical education.

I'll excerpt the pertinent phrases from this post:

I came across a discussion between several male doctors on Twitter. The doctors were using slang, which I have not come across before, to refer to the wards in which they might have been working. The terms used were "labia ward" and "birthing sheds" to refer to the delivery suite where women give birth, and "cabbage patch" to refer to the intensive care ward where many patients are unconscious.

I was shocked at this and angry and did query the doctors about some of the other things they said, but I felt I couldn't challenge them directly at that time about this language. One of the doctors referred to midwifes as "madwives" . . . 

I did feel the need to check with others how they felt about this exchange so I sent them a link to the collated tweets by private message. I wanted to find out if my own shock and revulsion was  typical and also to gain some advice on what to do about this. 

My account of this episode, so far,  has been very personal. But I also want to place this story in a wider context within the medical education literature on professionalism and black humour.  Is the use of derogatory humour or slang by medical professionals inappropriate? Berk thinks that: "Simply put, derogatory and cynical humour as displayed by medical personnel are forms of verbal abuse, disrespect and the dehumanisation of their patients and themselves. Such humour is indefensible, whether the target is within hearing range or not; it cannot be justified as a socially acceptable release valve or as a coping mechanism for stress and exhaustion."

I want to raise this topic here -- in this public space -- so that I can think about how I respond to it in the future when I "overhear" it. The next time I may choose to ignore it. Despite Wear's suggestion that incidents like this  provide "teachable moments", and should be challenged, the spaces of social media are much more exposed than a hospital corridor. 

The comments on the blog reflected a variety of points of view, generally said in a thoughtful manner, but then the conversation spread over to Facebook, to this page.  It was here that things picked up and revealed, in my mind, a mindset among some that was extremely upsetting.  In addition to the personal attacks on the author, they indicate some underlying attitudes that make me squirm.  Here are some samples.  Sorry, expletives are not deleted:

The quasi-academic language and touchy-feely social social science bullshit aside, this woman makes very few points, valid or otherwise. Much like these pages, if you're offended, fuck off and don't follow them on Twitter, and cabbage patch to refer to ITU is probably one of the kinder phrases I've heard...

Agree, she sounds like the most naive child like GP ever- most of us do have sense of humour I promise. Those that don't obviously do shit like "research social media"...

For those who have never heard/used this "dark" humour to which the article refers, every profession/trade/workplace make jokes about the work they do. Work is work, not all of it can be enjoyed, it is very normal to make light of things. This is especially true of the high stress environments mentioned in the article.

This sort of humourless blog is the reason that medical students are overfilled with touchy feely bullshit. The time spent doing this detracts from learning skills which might actually be useful on the shop floor such as clinical skills.

It may be my view and my view alone but the people who complain about such exchanges, on the whole, tend to be the most insincere, narcissistic and odious little fuckers around with almost NO genuine empathy for the patient and the sole desire to make themselves look like the good guy rather than to serve anyone else.

Oh and one more thing- my job is to provide the best clinical care I can to EVERY SINGLE patient that I meet. Not to act like a mewing prat. I'd rather be treated by someone who is a dick and gets it right than someone who is lovely but fucks it up. As one consultant once said "my house officers know everything there is to know about bereavement... except how to prevent it." Unless I'm parading a patient through the hospital corridors whilst they're mid shit on a commode I think most acts of indescretion are neither here nor there as long as I'm not deliberately killing people and, you know, trying to make them better and stuff... 

Fortunately, we also see several examples of mature insight and thoughtful behavior:

I take offence being referred to as "insincere, narcissistic odious little fucker." If you read your MPS/MDS bulletins you will discover it people with your attitude to medical practice who are more likely to be sued for clinical troubles because you are too cocky to ever think you might be wrong.

Isn't the issue more to do with the use of public social media rather than the sense of humour? Medical acronyms exist both cos they're funny and to conceal information a layperson might take offence to, like flk or ttfo. I don't think the terms here would have offended anyone but the point is that Twitter isn't private and can be "overheard" by people who could take offence. Use acronyms or use closed social media. The whole world doesn't need to see what's essentially a conversation between a particular group with its own frames of reference.  

From a patient's viewpoint terms like “labia ward” are indeed derogatory and should be avoided on open social media platforms.

Some of you need to really take a long look at the dehumanising nature of your jobs and try to rise above it. Anne Marie Cunningham makes some valuable observations in her blog. As a former surgery SpR, lymphoma survivor, cabbage patch survivor on 2 occasions some of you make comments that make me very concerned for your emotional well being. Social media makes the world a smaller place. Sometimes you should refrain from writing down your thoughts in public places like to FB and Twitter. If nothing else, making derogatory remarks about people you are supposed to care about may in time blunt your ability to make compassionate and "patient-centred" decisions. Please guard against this.

This has issue has nothing to do with whatever subjectively constitutes "humour" in our personal opinion. It has everything to do with professionalism. No-one expects healthcare professionals to live on a Higher Plane. However, every hopes that the healthcare professionals that they work with will extend them the courtesy of treating them with respect. That includes not talking about them, in any context, at any time, in terms that they would not use if they were in the same room. So: guess which of the participants in this thread I'd like to co-create my healthcare, and share in my healthcare decision making?

Well said. Derogatory comments about people in your care, in a public forum, tell us lots about you , as do the self serving defensive "lalalalala I can't hear you I never do anything wrong" responses with ears covered.    

Terps do health care, too!

Accelerating Information Technology Enabled Healthcare Transformation in Maryland and the Nation

(I am posting this at the request of Liz Barron at the Univerity of Maryland.)

When: Friday, October 7, 2011, 8:30am - 5:30pm

Where: Stamp Student Union, University of Maryland, College Park
Website: http://bit.ly/FallHealthITSummit

Engage with faculty from across the University of Maryland, College Park and Baltimore campuses, as they provide briefings on their latest health IT research; hear from state leaders as they provide insights on health reform in Maryland and implications for the state’s health IT strategic roadmap; join with industry, federal and university executives as they share perspectives on driving fruitful collaboration and tapping the rich resources available through the university; and much more!  Joshua Sharfstein, Maryland's secretary of health and mental hygiene, will deliver the keynote address.  The University of Maryland Fall Health IT Summit is hosted by the University of Maryland Center of Excellence in Health IT Research.

The Summit's goal is to stimulate research and collaboration between the University of Maryland and potential partners in government, industry, clinical organizations and advocacy groups.  It is a forum for stakeholders across the health ecosystem to discuss current health information technology strategy, policy and technology issues that Maryland and the nation is facing. The event also showcases the multi-disciplinary resources of the university, through its College Park and Baltimore campuses, that are being leveraged to accelerate health transformation. The event also provides a forum for engaging students and furthering intra-campus collaboration and research opportunities.

The event is free, but space is limited. Please RSVP by sending an email including your name, organization and title to Faye Baker at  fbaker [at] rhsmith [dot] umd [dot] edu.

Hobbs Hospital: We're ranked #1 in everything

Here's a wonderful animation from Gregory Warner and Adam Cole presented by Marketplace on American Public Media.  It explains one aspect of the medical arms race, although it focuses on local politicians as opposed to local doctors and hospitals.

Ironically and tragically, in light of the blog post below, current Medicare pricing stimulates this arms race.  Recall, for example, my post about proton beam machines.

If you can't see the video, click here.  (Thanks to Pamela Johnson for the heads up!)

Oh The Jobs (Debt?) You'll Create! from Marketplace on Vimeo.

Surrealism surrounds federal payment discussions

The discussions in Washington, DC, about the future of Medicare and Medicaid have gone totally haywire.  Check out this story in the New York Times.

We'll start with the lede:

As Congress opens a politically charged exploration of ways to pare the deficit, President Obama is expected to seek hundreds of billions of dollars in savings in Medicare and Medicaid, delighting Republicans and dismaying many Democrats who fear that his proposals will become a starting point for bigger cuts in the popular health programs.

Is this some odd way of the President delivering on his promises relative to his health care reform legislation?  Remember, he said he was hoping for three things: (1) a reduction in health care costs; (2) an increase in access for people currently uninsured or under-insured; and (3) maintaining choice for people in their selection of doctors and hospitals. But, as I noted at the time:

On the cost front, the president for now seems to be confusing underlying costs with how much the government chooses to pay. . . .  Reductions in appropriations might reduce costs to the federal government, but they do not reduce the underlying costs of care. 

Well, maybe they intend to just cut the rates to doctors.  After all, each year, just before an automatically scheduled rate reduction occurs, Congress votes to defer it.  But this year for sure.  Right.

Or maybe they will change the eligibility age for Medicare.  From the Times:

In negotiations with Congressional Republicans in July, Mr. Obama went further. He indicated that he was willing to consider a gradual increase in the age of eligibility for Medicare . . .

Gee, we've come a long way from proposals that might have decreased the age of eligibility.

. . .  and cuts in federal payments to states for Medicaid. 

The head of the New York Hospital Association explains:

Further cuts in the growth of Medicare and Medicaid would not only impair access to care, but also lead to job loss in the health care industry, directly contravening the president’s goal of job creation.

I have made this point, too:

With 50% of American hospitals operating at a deficit right now, it is hard to imagine how a reduction in federal payments . . .  deals with the cost problem. 

It isn't often that I hope for gridlock in Washington, DC, but these folks seem so confused about what's up that paralysis might be just what the doctor ordered.

High standards in evidence at Duke

Here's the counter-example to the folks at Parkland Memorial Hospital, in terms of transparency and taking ownership for failure.  After bouncing around the scientific world, the story regarding a Duke University School of Medicine researcher padding his resume went worldwide last year, but there were also questions raised about the methodology behind the three clinical trials.  This kind of thing is an embarrassment to any institution, and the manner in which it is handled is indicative of the kind of leadership in place.

Hunt Willard, the Director of the Institute for Genome Sciences & Policy, has issued a letter to the community that makes clear he is the exemplar of what you would hope for.  Here are the key excerpts:

These events represent a teachable moment for all of us, and I want you to hear directly from me about what I think it means for us.

It is very clear now that we were too slow to recognize and acknowledge flaws in the underlying data, insufficiently attentive to the need to carefully track versions of both data and software, and inadequately responsive to external publications and communications that pointed out errors in the underlying data. All of these indicate a need for a tighter process, and I recognize all of this as a failure of leadership and a failure of oversight, failures for which, as director of the IGSP, I feel a level of responsibility.

In accepting responsibility for these failures, I underscore my deep commitment to the responsible conduct of research and to setting standards for accountability at all levels of our organization. I welcome your thoughts in this area, as well as any concerns you may have throughout the coming year.

Really, what more could you ever want from a leader?  But there is more, a lesson in the nature and values of the profession:

Bravo to Dr. Willard and his colleagues.

Have we not been looking at things we should have seen?

A remarkable aspect of the Parkland Memorial Hospital saga was the degree to which the hospital's Board was not given information by senior management about the clinical outcomes in their hospital.  The lack of transparency, in other words, even went to management's relationship with its fiduciary board.

A recent article by the Dallas Morning News outlines some of these points:

On August 19, the hospital's seven-member board of directors got its first chance to read the full report by the U.S. Centers for Medicare & Medicaid Services.  Almost 10 days had passed since [the CEO] first received the findings.  As members began leafing through pages of the report, surprise, even shock, began to register.

The Chair of the board said, "We had direct culpability, but none of us even knew we were in the report."

Earlier in the year:

Board members became increasingly alarmed that [the CEO] and his staff weren't acknowledging the problems, even in closed meetings.  When they sought more information, [he] warned them against micromanaging the hospital.  Board members said he frequently told them in private, "If you don't trust my decisions, you need to replace me."

So, they resorted to their own methods.

Some visited the hospital alone to check on operations.

[One] board member . . . stopped patients as they left the hospital and asked how they had been treated by staff.  The member heard many complaints about a lack of civility.

[One] wanted to see patient-care findings that he thought Parkland was collecting from industry groups.  [The management team] wouldn't make that information available to the board.   On his own, [he] began searching in June on [federal] websites for patient-satisfaction information.  He found that Parkland's scores trailed national and Texas averages in seven of 10 categories for what HHS describes as "important measures of patients' perspectives of care."

"I wonder now:  Have we not been looking at things we should have seen?"

Lest you think this is an extreme example, please understand that a significant percentage of US hospitals do not compile quality and safety information, even for the senior clinical and administrative leaders.  How can a person serve on the board of a hospital in this country and not demand that such information be collected and shared with the governing body?

A colleague wrote me the other day: 

Why is there PhysicianCompare and HospitalCompare but not HospitalCEOCompare?

Think that might make more CEOs consider patient safety and outcomes as their primary mission?

Indeed.  But it is ultimately up to the board to make this happen.

Good catches are catching on

For every adverse event that is reported in a hospital, there are likely 100 or maybe 1000 near misses that often go unreported.  Those close calls contain a wealth of information regarding systemic problems within a hospital.  Some hospitals have expanded their computerized reporting system to catch these problems.  For example, Children's Hospital in Denver did this.  After an electronic, web-based, secure, anonymous reporting system for anesthesiologists was put in place, a total of 150 incidents were reported in the first 3 months of operation, compared to four entered in the same time period a year previous.  "This . . . provided data to target and drive quality and process improvement."

Johns Hopkins uses another approach, a Good Catch Award. As noted in this paper presented to the Maryland Patient Safety Center last year:

The Good Catch Award creates positive incentives for providers and staff to report patient safety events. At the institutional level, the Good Catch Award encourages individuals to identify and report adverse events, near-misses, or other medical errors. The program rewards individuals who contribute and has been received positively by many providers and staff. The pilot phase of this program focused on identifying defects in the perioperative environment and devising a partial solution. The current phase of the Good Catch Award program shifts its focus to sustainability and strategies to maintain the implemented systems changes that resulted from the 13 Good Catch Awards given in the past two and a half years. This includes an educational component for providers, one of the original steps in the Good Catch Award process, to ensure better dissemination of information and implementation of systems improvements throughout the ACCM department. The program is ongoing in its effort to identify defects, formulate solutions, and recognize those who actively work to create a safer environment.

Here's a summary chart of the results:

This kind of program also exists at the University of Connecticut Health Center.  As noted:

John Dempsey Hospital's goal is to change any negative perceptions healthcare providers and others may have about reporting errors. Staff is encouraged to report near misses. It helps to identify areas where patients’ quality of care and safety might be improved. Reporting a near miss is considered a “good catch” and comes with rewards:

• Good Catch award certificate.
• Good Catch lapel pin.
• Special recognition within the Health Center community.
• A copy of the award certificate in Human Resources personnel file.
• Sincere thanks for dedication to patient safety and personal satisfaction.
• Reviews of all good catches to determine if additional safety measures should be implemented.

At our hospital, we had a Caller-Outer of the Month Award, similar in concept.  Instead of honoring someone who had solved a problem, our Board decided they would honor someone who had called out a problem. The idea was to provide further encouragement through the organization to those who notice and mention problems. 

These are all variations on the theme. All approaches lead to much good and are worth a look to be considered for emulation elsewhere.

Doctoring financial incentives

Mixed results are reported in a recent paper entitled, "The effect of financial incentives on the quality of health care provided by primary care physicians."  In the paper, Australian researchers collected and analyzed data from studies of incentive programs in the US, the UK and Germany.

As noted in this summary article by Reuters:

In those studies, researchers looked to see if financial incentives made a difference in how often doctors screened for different diseases, referred patients to follow-up care or achieved a certain health outcome -- such as helping a patient quit smoking. Overall, the effects were mixed.

Why?

"Many doctors who already do well simply claim the money with no change in behavior," Anthony Scott, one of the review's authors from the University of Melbourne, told Reuters Health in an email.

"Incentives aren't often targeted at those doctors providing the poorest quality of care. And (sometimes) the amount of money may not be enough, or doctors simply aren't motivated by money by a great degree," he added.

I don't find any of this surprising.  If you are a primary care doctor, you simply have too much to do in a limited amount of time to calculate whether a given step in the clinical process is going to generate more revenue for your practice.

The authors raise an important cautionary note:

Despite the popularity of these schemes, there is currently little rigorous evidence of their success in improving the quality of primary health care, or of whether such an approach is cost-effective relative to other ways to improve the quality of care. There is insufficient evidence to support or not support the use of financial incentives to improve the quality of primary health care. Implementation should proceed with caution and incentive schemes should be carefully designed and evaluated.

Specifically, they say: 

Studies should also examine the potential unintended consequences of incentive schemes by having a stronger theoretical basis, including a broader range of outcomes, and conducting more extensive subgroup analysis. . . . Further research comparing the relative costs and effects of financial incentives with other behaviour change interventions is also required.

I have made this point with regard to plans to introduce capitated, or global payments, in the health care system.  There has been little analytical support for this kind of plan, and yet policy-makers seem to be in a big hurry to endorse it.

Time to make Joint Commission surveys public

Can anyone doubt that the recent kerfuffle faced by Parkland Memorial Hospital in Dallas would have had a greater chance of being avoided if earlier reviews by the CMS-designee, the Joint Commission, would have been made public?  Yet, JC surveys are held in confidence.  This is a matter of federal law.

Currently, the results of hospital accreditation surveys cannot be accessed by the public under Section 1865 [42 U.S.C. 1395bb] (b) of the Social Security Act, which reads as follows:

"(b) The Secretary may not disclose any accreditation survey (other than a survey with respect to a home health agency) made and released to the Secretary by[615] the American Osteopathic Association[616] or any other national accreditation body, of an entity accredited by such body, except that the Secretary may disclose such a survey and information related to such a survey to the extent such survey and information relate to an enforcement action taken by the Secretary."

When I was CEO of a hospital, we voluntarily made our JC surveys public, posting them on our corporate website.  We felt that it was important for all staff in the hospital to have the chance to review the findings and act on them, and we also felt that public confidence in our hospital would be enhanced by this kind of transparency.  While this practice has spread somewhat, most hospitals still do not make their surveys public.

Recently over 50 of us patient advocates, led by Dr. Kevin T. Kavanagh of Health Watch USA, wrote to Senator Tom Harkin, Chairman U.S. Senate Committee on Health Education Labor & Pensions, to ask for a repeal of this provision of the law.  Here's an excerpt of the letter:

We believe it is in the public's interest to have all accreditation survey findings of The Joint Commission and other bodies accessible to the public. This includes initial survey findings as well as follow-up survey findings which takes place weeks later after remedial action may have been taken.

Hospitals have a choice. They may choose to be surveyed by state agencies in lieu of accreditation by The Joint Commission or other entities. Only a small minority of hospitals elect this option.

In your home state of Iowa, state accreditation surveys are performed by the Division of Health Facilities, Iowa Department of Inspections & Appeals. These survey results are available to the public. The survey results from The Joint Commission are not available to the public.

We believe that the public has a right to information irrespective of the entity that conducts the surveys. The present situation creates a double standard. It also raises the question as to why the federal government allows two different standards.

In comparable public services sectors such as public health and education, inspections of restaurants and performance of schools are transparent to the public. Hospitals should be held to the same standard. Their performance should no longer be shielded from the public.

Really, isn't it time?

Future Women's World Cup Contenders

Here are a couple of five-year-olds learning to play soccer in Western Massachusetts.  Kristine Lilly is lucky she retired from the game, as she wouldn't have a chance against these two.

Sad news from Dallas

One can only view this report with sadness:  The Dallas Morning News has posted a story saying the CMS has threatened to shut off federal reimbursements for Parkland Memorial Hospital “because of deficiencies that represent an immediate and serious threat to patient health and safety." 

The largest previous case like this was in 2006 when the King/Drew center in Los Angeles was informed that CMS would no longer pay for patient care there ($200 million per year in revenue, or more than half its budget).  It was then closed.  I cannot recall any other major medical center facing this kind of sanction.

There is, however, an out to avoid a September 30 deadline:

David Wright, acting deputy regional director for CMS, told The Dallas Morning News that Parkland could avert that funding cutoff if it entered into a “systems improvement agreement,” an arrangement in which the hospital would accept CMS-approved outside consultants. CMS said that Parkland had responded “favorably” to the idea, and it would be discussed next week.

I have previously written about the situation at Parkland Memorial.  It is sad that a place so indelibly etched in the minds of those of us who were so impressed by the hospital's professionalism at the time of President Kennedy's assassination may now leave an altogether different impression.

Becker's shows how Lean fights the Nut Island Effect

I wrote an article in the Harvard Business Review a while back called "The Nut Island Effect: When Good Teams Go Wrong."  It was about a group of folks at a sewage treatment plant in Quincy, MA: A team of skilled and dedicated employees became isolated from distracted top managers, resulting in a catastrophic loss of the ability of the team to perform an important mission. The irony was that most people viewing the team would say that it had all the attributes of an ideal working group -- dedication, collaboration, a strong sense of integrity and values, and indefatigable energy with regard to doing the job. It is probably no coincidence that many of the staff members had served in the military, where those virtues were highly valued.

Over the years, many people have noticed the same phenomenon in other industries.  Bob Herman, with Becker's Hospital Review, has picked up on that fact, with an article focusing on the presence of this syndrome in hospitals.  He cites my experience after entering this field:

[H]e found that the "us versus them" behavior was rampant in healthcare. "We have a team of people that's motivated by the best possible values — physicians, nurses, operating room staff, people in the pathology lab — and they get isolated the same way the guys at Nut Island did," he says. "You can go into any hospital in the world, and I bet if you described this syndrome to five or 10 people, they'd look at each other and say, 'That happens all the time.'"

 

Bob relates how the use of Lean process improvement in the hospital setting can help reduce the likelihood of this pattern occurring.

Once frontline staff members are trained to report setbacks and managers act on those calls, hospital leadership can map out the processes in question, diagnose the problems and reduce the waste that is bogging down production.... [T]here is a bevy of benefits from this type of systematic hospital improvement based on Lean principles: Employees are not as tired; employees are less likely to make a medication error because they are not as rushed; staff morale improves as more people get to know each other; there is less staff turnover; there is an improvement in overall quality of care; and money is saved as the waste in all processes gets weeded out.

Thanks to Bob for such a clear exposition of these points.

What would you do?

This is a story from many years ago, a couple of decades back:

An OB/GYN doctor performed a hysterectomy on a patient in her 40's for irregular bleeding and other problems. She had a long history of infertility and had finally given up. Given this history and the bleeding, the doctor did not do a pregnancy test prior to the surgery.

The pathologist found a tiny fetus in the uterus. The OB/GYN was devastated to learn of this.

It was eventually decided that it would do more harm to her and her family to disclose the fact than not to, since it was an irretrievable situation.

 

Your call.  Was this the right decision, for that era?  Would we handle this kind of case differently today? Please comment.

Always Events® on WIHI

Always Events®: Raising Expectations for Patient Experience​
September 8, 2011, 2:00 PM – 3:00 PM Eastern Time

Guests:
Lucile O. Hanscom, Executive Director, Picker Institute

Dale Shaller, MPA, Principal, Shaller Consulting Group

Martha Hayward, Lead for Public-Patient Engagement, Institute for Healthcare Improvement

Gaye Smith, Chief Patient Experience and Service Officer, Vanderbilt University Medical Center

Anthony M. DiGioia, MD, Founder, The Orthopaedic Program and Innovation Center, Magee-Womens Hospital of UPMC

Most of us are familiar with the National Quality Forum’s list of Serious Reportable Events in health care — often referred to as “Never Events.” There’s a wide consensus that everything from performing surgery on the wrong patient or wrong site, to a medication error-induced death, to a physical assault aren’t only tragic and harmful, they are not supposed to happen. Period. It’s a strong statement about patient safety and what the system as a whole should not be willing to tolerate. And, by extension, it’s a call to action to do better and to take care of patients differently so that terrible things do not occur. 

There are, of course, many ways to draw a line in the sand or to envision the health care system patients deserve and that providers want to work in. One of the most innovative in the last few years has been the Picker Institute’s development of a concept they’ve dubbed “Always Events®.” First conceived in 2009, Always Events® are activities and processes that should routinely be part of patient care and the patient and family experience, to ensure optimal communication, discharge, handoffs, transitions, health literacy, and more.

WIHI is pleased to welcome the Picker Institute’s Executive Director, Lucile Hanscom, to the program on September 8, along with consultant Dale Shaller, who has an extensive history developing benchmarks and measurement systems for patient-centered care. They’ll be joined by dynamic leaders from two organizations that have received Always Events Challenge Grants: Gaye Smith of Vanderbilt University Medical Center and Tony DiGioia of the University of Pittsburgh Medical Center (UPMC).

Dr. DiGioia’s groundbreaking improvements at UPMC are anchored in a first of its kind patient- and family-centered methodology. Picker’s support is helping to integrate these processes into the hospital’s transplant program. The grant-funded work at Vanderbilt is targeting better communication and collaboration between patients, family members, and providers to prevent patient falls during hospital stays. Gaye Smith will describe the overarching strategy this work fits into, including an effort now underway at Vanderbilt to develop an “always promise” from the hospital to patients and families to make good on reliable and patient-centered care.  

The program’s guest roster wouldn’t be complete without Martha Hayward. Martha’s been working with IHI in 2011 to help shape public and patient engagement, drawing on her own history as a patient and as a strong and effective leader in Massachusetts.

Please mark your calendars for this first WIHI after a summer break. We look forward to your participation!

To enroll, please click here.

Never events. Well, hardly ever.

Many thanks to Ishani Ganguli for inviting me to write an op-ed in Virtual Mentor, the journal she guest-edited for the American Medical Association.  In it, I discuss the persistent rate of wrong-site surgeries and argue that financial penalties for such "never events" are ineffective:

In the face of slow progress, there is little doubt why the regulatory hammer is employed. But it is a crude tool. Its effectiveness as a deterrent is minimal because it does not address the structural issues underlying the problem. It emphasizes a particular outcome rather than a process that will achieve it. It penalizes people when it is too late to make a difference. Finally, it serves mainly to create resentment among those who are targets for improvement. Such is often the nature of regulation, no matter how well intended.

I argue, instead, for the power of training in crew resource management and transparency. 

Transparency, combined with a commitment to and training in crew resource management, enables doctors to hold themselves accountable to the standard of care they would wish for their own family members. This combination of ingredients offers far more potential than financial penalties or other regulatory actions for sustained process improvement in the operating rooms of America.

The entire article is here.   I welcome your comments.

Bob is good and lucky; Others are not

Bob Wachter, one of my heroes in the patient safety arena, is on sabbatical and has written this blog post comparing the approach of US and UK hospitals with regard to improvements in this area.  As always, it is thoughtful and provocative.

I found the post a bit too self-congratulatory, though, with regard to the progress made in US academic medical centers.

While engaging practicing doctors is vital, so too is capturing the hearts and minds of the next generation.... In the US, kids go to four years of college, then to medical school for four more years. From there, they enter a residency in the specialty of their choice and, for some, additional fellowship training. Training programs are run by individual academic medical centers, such as NYU or Johns Hopkins, or smaller teaching hospitals. While in training, American residents work under the wing of a single program director and rotate through a limited set of training experiences, usually in 2-3 hospitals.... Because the training director is responsible for the residents and can track them easily, he or she has the tools to create new curricular experiences in crosscutting areas like patient safety. At UCSF, for example, all our interns now have a two-week safety/quality rotation, during which they learn core principles and begin working on a project.

While I would like to think that USCF is the norm, it is not.  I have met residents and young attendings from throughout the country who have decried the lack of such programs as part of their multi-year graduate medical education.  At my former hospital, where such training was included, we noticed a stark difference in the ability of our residents to perform systems analytic work compared to residents from other institutions who had rotations in our hospital.

Perhaps the biggest difference I’ve noticed is in the background of the leaders in safety research and policy. In the US, the vast majority of the leaders are physicians, most of them based in academia and still seeing patients part-time. In the UK, most of the prominent and highly published patient safety experts are PhDs—mainly in psychology and sociology.

How to explain this striking difference? I’m guessing it reflects several factors. The first is the US college-before-med school system, which allows kids with a social science intellectual sweet tooth to pursue their passion in college, yet still become physicians. Atul Gawande, for instance, has a Stanford degree in biology and political science, and then studied philosophy at Oxford. Johns Hopkins safety expert Peter Pronovost double majored in biology and philosophy at Fairfield University, and I majored in political science at Penn. One can’t really do this in Great Britain; kids here begin their professional education at age 17. In England, a student like me probably wouldn’t go to med school in the first place, and if he did, he wouldn’t have had much time to study politics during his university years.

Second, the US has a strong tradition of physicians receiving additional social and political training after their clinical years, through the Robert Wood Johnson Clinical Scholars and similar fellowship programs. In the UK, while many MDs pursue additional training in biomedical research, relatively few receive (or have access to) the kind of training that promotes leadership in safety or quality. Just as importantly, there isn’t an obvious pathway for physician-leaders in quality or safety research to be promoted, funded, or valued by their academic institutions, as they increasingly are in the States, and so there are few role models with this phenotype.

Yes, the leaders in the US are the type of people mentioned, but they are often "prophets in their own land," valued more by people in other hospitals than their own.  Some cannot even get their own hospital to agree to conduct studies of their safety theories.  Some cannot get their hospital to implement the protocols and approaches that have proven to be efficacious in their experiments elsewhere.

Indeed, you sometimes get the feeling that academic medical centers are very happy to have these "trophy doctors" on staff more for the prestige they bring to those centers than for the knowledge they offer.

I think Bob is lucky that UCSF values his work so much and has done the types of things he mentions in his blog post.  (The patients there are even more lucky!)  But I fear that his view is skewed by that positive experience and overstates the progress made in the attitude and work of many other academic medical centers.

Periodic Table of Texting

Seen today on a young lady, this t-shirt tells you all you need to know!

Labor, Delivery, Disclosure, Malpractice

Let's talk about a different kind of labor on Labor Day weekend, the kind that delivers babies, and an order issued this past week by the U.S. Court of Appeals for the Seventh Circuit in Chicago.  The case is styled Arroyo vs United States, and I want to focus on the concurring decision by Judge Richard Posner.

The appeal involved a question of whether a malpractice lawsuit was filed by the Arroyos after the statute of limitations had run out.  The statute exists to prevent "stale" lawsuits, those filed years after a reasonable period of time.  It makes sense to have such a statute of limitations, in that defending a case gets progressively difficult as years go by:  Memories fade and potential witnesses become unavailable.

The Court ruled for the Arroyos, based on the fact that it would have been unlikely for them to have understood that malpractice might have occurred during the aftermath of their baby's birth.  It therefore allowed the case to proceed.

Judge Posner, one of the world's most distinguished legal scholars,  issued a concurring decision that is interesting in its implications, were it to be come the law of the land.  He said that, had the hospital given full disclosure of the medical error at the time it occurred, the start of the clock for the statute of limitations would have begun sooner.  He asserted that the current standard of medical care envisions the ethical duty of such disclosure, and that failing to offer it cannot be used as a defense against a stale malpractice lawsuit.

Many of us have talked about the wisdom of early disclosure and apology.  It is an essential component of respectful and compassionate care.  In practical terms, it also reduces the risk of the kind of anger and distrust that leads to malpractice lawsuits or unreasonable demands for financial damages. 

But Judge Posner offers an additional incentive.  And he raises the issue to a new level by claiming that disclosure is an ethical duty inherent in the legal review of this type of matter.

Here are some excerpts from his concurring decision:

I need to make clear that I am discussing only the standard for determining when the statute of limitations begins to run, not the standard of care. Kubrick holds that the statute of limitations begins to run in a malpractice case when the plaintiff either discovers, or if diligent would have discovered, that he has been injured by the (at that point merely potential) defendant, and not when the plaintiff discovers or should have discovered that his injury was the result of negligence. This is not only the law; it is sensible. Even unsophisticated people, when they learn that they have been injured by a physician rather than (just) by the condition the physician was (or should have been) treating, should know that there may have been malpractice, and so should consult another physician, or other medical person, or a lawyer.

...Had someone informed the Arroyos that it was “highly possible” that the injuries to their child had been caused by the failure to administer antibiotics to Mrs. Arroyo, the statute of limitations would have begun to run then, just as in Kubrick. For they would have known, or in the exercise of reasonable diligence (reasonably understood in light of their socioeconomic position) should have known, that a cause of their child’s injuries might have been the failure of the doctors to administer antibiotics to Mrs. Arroyo; given that information, they would or should have known enough to consult a lawyer or other expert. That may be asking a lot of them; but to ask that they have suspected malpractice in the absence of any disclosure of the possibility of an iatrogenic injury would be to ask too much.

...[I]f the Erie Family Health Center (or its backer, the United States) wants to avoid being hit by stale malpractice suits, it has only to level with patients (or in the case of a child, the patient’s parents) concerning possible causes of a medical injury. When the Arroyos’ child was discharged from the hospital with brain injuries two months after his birth, the Center’s physicians told the parents only that their child’s injuries had been caused by an infection that Mrs. Arroyo had transmitted to him during his birth. They said nothing that might have alerted the Arroyos to the possibility that a medical act or omission had contributed to the infection. The physicians did not have to confess liability; indeed, at the trial the defense presented respectable evidence that there had been no negligence. All the Center would have had to do was give the Arroyos a reasonably full account of the circumstances of the child’s injuries — that antibiotics could have been administered to the mother before the birth and to the child immediately after and that had this been done the injuries might have been averted, or been less serious.

...“According to recent codes and guidelines . . . individual clinicians and institutions have an ethical responsibility to disclose unanticipated negative outcomes. Respect for personal autonomy entails disclosure of what occurred — even if no further medical decisions are involved — and of options to take nonmedical actions, including legal actions, if appropriate.” Tom L. Beauchamp & James F. Childress, Principles of Biomedical Ethics 294 (2009); see also American Medical Association, Code of Medical Ethics: Current Opinions with Annotations § 8.12, pp. 141-42 (1998). If a patient dies as a result of his physician’s failure to diagnose a readily diagnosable, and if diagnosed readily curable, condition, such as appendicitis, it is a deceptive half-truth to tell the grieving spouse or parents that the patient died of appendicitis; the patient’s death was jointly caused by appendicitis and medical negligence. Compliance with the ethical duty of disclosure of possible medical errors in simple, intelligible terms would give medically unsophisticated plaintiffs enough information to recognize that medical decisions might have contributed to their injuries.

...I am not arguing that a breach of the ethical duty of disclosure is itself malpractice, although it could be if it prevented the patient from obtaining medical treatment that would mitigate the consequences of the original medical error. I am not arguing that the disclosure must go beyond an acknowledgment of the possibility of medical error and become a confession that there was a medical error; or that a doctor is required to explain that additional treatment might have avoided the patient’s injury if failure to provide that treatment would not have been negligent, because of the expense, side effects, or uncertain benefits of the treatment, as when a patient suffers an injury that would have been prevented had the doctor performed a battery of painful and expensive experimental tests. But if a potential defendant in a medical malpractice suit wants to take advantage of the statute of limitations he should have to disclose information known to him that would alert the patient to the possibility of an error. By doing that he can be sure that the statute of limitations will begin to run immediately . . . and not years later.

We're interested, but only if you are quick

I'd like to give American Airlines credit for being interested in customers' opinions: A computer sent out this email three days after a recent trip.  But, then it put this odd deadline on the survey.  I guess my opinion doesn't matter if I need think about it for a while.

Question causality

Another statistics lesson for Samantha Riley and her folks at the NHS South East Coast, as well as for the rest of you.  This is from Randall Munroe's book xkcd:

 

That clears things up

For some reason, this status report on Facebook from an employee of an insurance company  attracted my attention:

I spent an hour looking for a Dr.'s contract in my system only to find out she changed the spelling of her name last year to "avoid confusion." You'd think she would mention that.

Halamka rises to the occasion

When Dr. John Halamka talks about the future of computing in health care, it is worth paying attention.  You will find a superb overview by him in this month's issue of Technology Review, in an article entitled, "The Rise of Electronic Medicine".

I like these excerpts, in particular:

A Network of Networks
Many people believe that doctors continually share data electronically with one another to coordinate treatment, do research, or track disease outbreaks. The reality is that only a few hospitals and cities in the U.S. are able to securely exchange health records, and even fewer have economic reasons to do so. Over the next few years, however, new standards for secure e-mail of data between providers will be integrated into electronic health records. The use of the fax machine will wane and patients will expect that every time they see a new doctor, or visit a new hospital, their health record will follow them.

Will one giant database hold all our health records? Will a monolithic network link insurers, doctors, and patients? Given privacy concerns, that's unlikely. What we are seeing instead is that cities, states, and regions are developing regional data exchanges. Just as the Internet has many e-mail providers and many Internet service providers, a collection of private and public "Health Information Service Providers" will be able to exchange data among themselves, creating a nationwide health information network that is a federation of subnetworks.

Engaged, Connected, E-Patients
In my parents' generation, doctors were considered largely infallible, and the medical record was something owned and viewed only by clinicians. Today, with credible medical knowledge available on the Internet and electronic records allowing doctors and patients to view the same data, joint decision making is becoming more commonplace. Research shows that shared decision making between doctor and patient results in better outcomes. An engaged patient is also less likely to assert malpractice and sue.

New reimbursement models will pay clinicians to keep patients well rather than for ordering tests or performing procedures. Such an emphasis on early intervention will lead to the rise of home-connected devices such as electronic blood pressure cuffs, glucometers and bathroom scales that report data wirelessly to clinician offices and patients' personal health records. Teleconsultation in the home will become much more common. The pendulum is swinging. Fifty years ago, doctors made home visits and attempted to keep you well. Today, we have abbreviated office visits that result in prescriptions to treat disease. Home monitoring and telemedicine will return us to the bygone era of wellness.

Above average (or is it median?)

Samantha Riley and friends at the Quality Observatory at NHS South East Coast continue to publish the interesting and useful newsletter, Knowledge Matters. You can see the current issue here.  

This remains one of the best examples I have seen of a useful locally produced newsletter for hospital and health care staff of all backgrounds.  There is a variety of engaging pieces that have educational value for many.

This edition, for example, contains an article entitled "Ask an Analyst" that covers the difference between mean, median, and mode, concepts that are often confused, even by experienced folks.  I like how the presentation simply shows how the mean of a distribution can be skewed by outliers.  This is an important topic if you are measuring the quality of outcomes in a hospital.

Click on this excerpt below to enlarge it for an example of how that is presented:

September Sepsis

Dr. Jim O'Brien at OSU Medical Center reminds us that September is Sepsis Awareness Month. Sepsis Alliance is asking its partners and friends to help spread the word and encourage action to as many people as possible. 

How can you help? To encourage awareness of sepsis, SA is planning some activities for Sepsis Awareness Month and we need your help to pass on this information by forwarding this message to friends, family members, and colleagues who may also be interested in helping. 

According to a 2011 poll undertaken for SA, most Americans still don’t know what sepsis is. The telephone survey, conducted in June 2011 by Harris Interactive® on behalf of SA among 1,003 adults, revealed that more than half of Americans (58%) still have never heard of "sepsis." Even fewer could actually define it. 

The results of this poll remain significant. The fact that so few people have heard of sepsis underlines the need for increased efforts to improve education and awareness of sepsis.  As part of SA’s continuing efforts, September has been declared Sepsis Awareness Month: Say Sepsis. Save Lives.

What people may learn from the SA website or by following SA through social media:

·         Every year, over 1 million Americans are affected by sepsis. Through  September a “sepsis victim counter,” featured on the SA site, will count the number of new cases of sepsis that are expected to occur throughout the month.

·         The site will have a dedicated Sepsis Awareness Month page to highlight what SA is doing throughout September. There will be information about sepsis, as well as highlights of Faces of Sepsis stories, stories of real people who have had sepsis.

·         Social media (Facebook and Twitter) will play a large role in Sepsis Awareness Month. By tweeting sepsis facts and by highlighting sepsis information and stories on Facebook, SA supporters can help spread the word by retweeting and by sharing Facebook statuses on the own FB page.

·         Members of the public will be encouraged to vote on a Sepsis Awareness bumper sticker slogan.

 
We know that if sepsis is caught early (suspect sepsis) and it is treated as a medical emergency with antibiotics and fluids, thousands of lives can be saved. The establishment of Sepsis Awareness Month aims to continue increasing awareness among the general public and healthcare professionals across the country.

Comments from Parkland Memorial Hospital

Following up on my post on this topic, in the nature of equal time, I thought I would print excerpts from a recent edition of the Dallas Business Journal, in which a senior hospital official from Parkland Memorial Hospital rebuts aspects of coverage by the Dallas Morning News.

Anderson said the Dallas Morning News, and the investigative team it has assigned to aggressively cover Parkland, has a "vendetta" against the hospital. He characterized that paper's coverage as "sincere, but sincerely wrong," and said it's "chipping away at the trust" people place in Parkland.

"Think about the negative consequences of someone who needs care holding back instead of going to Parkland," he said. "They'll suffer as much as anything that an investigative reporter thinks he's doing or she's doing for the benefit of the patients."

Part of the problem is that Parkland is an easy target, Anderson said.

"We're the house of conspiracy theories," he said. "JFK came here. So we know every conspiracy theory that was ever pushed out about JFK. Someday, I'm going to write a book about conspiracy theories about people out to get Parkland."

Quick, e-Patient Dave needs your vote

Here's a worthwhile and time-sensitive assignment for those of you who are fans of E-Patient Dave and his message of patient empowerment.  He is seeking to be a presenter at the 2012 South by Southwest conference in Austin, Texas.  But he needs votes to get chosen, and by tomorrow!

It takes a few steps to be eligible to vote, but you and I know that the audience will be happy he was chosen for this conference.  Go to Dave's post here to learn how.

And thanks!