Residents, here's a new way to measure a hospital's quality

#TPSER8 At the final session of the Telluride Patient Safety Camp today, co-organizer David Mayer (who, by the way, is the recently appointed vice president of quality and safety for MedStar Health) set forth a goal for the future.  Someday, he suggested, the first question of residents arriving at any hospital will be "Where do I report?" safety and quality issues.

Why is this important?  Simply, no organization can succeed at continuous improvement without a mechanism for recognizing where it is not doing well or well enough.  Only those hospitals that cherish the opportunity to learn not only from adverse events, but also from near misses, work-arounds, and plain old inefficiencies in the delivery of clinical care will rise to a level of high quality and will maintain that level.  Residents have a key role in this because of their many hours of clinical duty in hospitals. They, especially as incoming interns, have the fresh eyes to see things that long-term attending physicians and nurses no longer see.  An organization needs to hold itself accountable to the standard of care it has set for itself, and the residents play a central role in ensuring that this happens.

Speaking of today's hospitals, David said, "A record of sustained reports on quality and safety is an indication of deep organizational commitment to improvement."

So, I take David's hope for the future and offer it as a simple metric of hospital quality and safety today.  I suggest that medical students who are applying for residency positions during the match process should ask the same question, followed by a few others, "Where will I report quality and safety issues?"  "How and by whom will those reports be received and evaluated?"  "How and when will I hear back as to whether changes resulted from reports I submit?"  "How will the story of those improvements be spread so that other floors or units will be able to learn of them and adapt those lessons throughout the hospital?"

Photo at Bear Creek Falls by Tim McDonald

Reaching greater heights at Telluride

#TPSER8  A requirement of attendance at the Telluride Patient Safety Camp is that each resident must implement, lead and successfully complete a safety or quality improvement project at his or her institution over the next twelve months. Today, we started to hear from students as to the nature of their proposed projects.  Here are some summaries.  After each summary, I present a portion of the person's biographical statement to give you a sense of the breadth of experience at this conference and also the level of commitment represented by these residents:

Christopher Smith will design and implement an improved resident hand-off system to be integrated into the new EPIC electronic medical record system being installed in his hospital.  Chris is the current chief resident for Internal Medicine at the University of Nebraska Medical Center (UNMC) in Omaha, NE.  His burgeoning interest in patient safety stems from his experience designing a patient hand-off curriculum and his involvement with his program’s Clinical Quality Improvement Conference.  In the past year he also attended several quality and safety workshops through the Veterans’ Administration and worked through the Institute for Healthcare Improvement’s Open School courses.  Starting in the next academic year, he will join the UNMC faculty as an academic hospitalist.  His professional goals include developing a quality and patient safety curriculum at UNMC and expanding their simulation procedural training.

Sujata Sofat will introduce a curriculum for new residents focused on safety, to be delivered as part of their orientation. She notes, "My mentor, Dr. Stephen Evans, and I embarked on a project to create a curriculum for patient safety for the residents at our hospital. This in turn led to me finding a passion for quality improvement that I didn’t know I had. I joined the Center for Patient Safety and then became an active member of our House Staff Quality Council. I also volunteered to be a part of the AIAMC National Initiative Phase 3, and am working with others to combine our resident curriculum with a more comprehensive curriculum which will encompass medical students and attendings.  At Georgetown, Dr. Evans is known as 'Safety Steve,' and I’ve attained the nickname of 'Safety Su' for my heartfelt dedication to aiding him in his wholehearted efforts."

Jonathan Hatoun will conduct research on why residents are not reporting adverse events in his hospital and will then recommend changes in the reporting system to increase performance in this area.  His proposed project includes focus groups, surveys of senior residents, and contacts with program directors.  Jon grew up in the suburbs of Boston and is currently a resident in pediatrics at Boston Children's Hospital and Boston Medical Center and developed a strong interest in quality improvement and patient safety after being introduced to his residency's QI curriculum this year.  He notes, "Initially I started a project at Boston Medical Center to ensure that patient's who were admitted with asthma exacerbations were discharged with their medications in hand.  Through many iterations, we have developed a system that has increased the number of patients filling their scripts before discharge from around 10% to nearly 85% in less than a year."

Jon notes that he has gone full circle this week:  "During medical school I actually biked across the country - through Telluride - with my best friend as a fundraiser for the free, student-run clinic at Columbia." 

Jennifer Pinnick had a number of project ideas, an in-service education program about epidurals for nurses; a standard check-list for intern handoffs; and creating resident forums across hospitals in Chicago, like those held in in New York City.  Jennifer is an upcoming 3rd year anesthesia resident at the University of Illinois in Chicago.  She reports, "I got my undergraduate degree in biology from the University of Kentucky in Lexington, Kentucky (GO CATS!). I also went to medical school at UK. There, I became a huge basketball fan and learned to wear hats to horse races. I also became interested in multiple aspects of patient safety. I had the opportunity as a fourth year medical student to do away rotations at 7 different hospitals. Some were huge university centers, others were very small hometown facilities. From east coast to west coast, these different experiences only further stirred my interest in improving safety for patients. "

Swing photos by Tim McDonald

Effective Communication Videos from CIR

#TPSER8  As I mentioned earlier, CIR (the SEIU Committee of Interns and Residents) has been a strong supporter of the Telluride Patient Safety Camp, sponsoring attendance by residents from a number of locations.  But CIR also has a much broader agenda in promoting a better patient quality and safety environment in the hospitals in which its members work.

One aspect of that improved environment is to promote evidence-based patient communication skills for physicians.  In that light, they have produced two videos on motivational interviewing and patient-centered interviewing.

Conference attendees Justin Wood and Hilary Kunizaki distributed these two videos to all the participants, asking for feedback and suggestions for future efforts in this arena.  I am taking the liberty of spreading their request more widely by presenting those videos here for your review.  Please offer comments below.

The first video features August Fortin, MD (Yale Medical School), and Sheira Schlair, MD (Montefiore Medical Center) on the topic of patient-centered interviewing.  The second video features Jonathan Fader, PhD. on the topic of motivational interviewing.  If you cannot see the videos, click here.


Physician-Patient Communication: Drs. Fortin & Schlair present patient-centered interviewing techniques from CIR/SEIU Healthcare on Vimeo.


Dr. Jonathan Fader Demonstrates Motivational Interviewing Skills from CIR/SEIU Healthcare on Vimeo.

Telluride Day 2 -- Informing consent

#TPSER8  The picture above shows the nearly unanimous positive response to a question I posed near the end of day 2 at the Telluride Patient Safety Camp. Hang on for a few paragraphs to learn what I asked.

The emotional aspects of health care have come forth during this conference in several ways.  Today, it was the presentation of a video entitled, The Faces of Medical Errors...From Tears to Transparency:  The Story of Michael Skolnik.  This powerful story is described as follows by the producers:

Viewers are compelled to rethink the critical role that shared decision-making and informed consent play in patient safety and transparency. This emotionally engaging program tells the story of Michael Skolnik, an intelligent, compassionate young man who died at age 25 after a three-year ordeal following brain surgery. Michael’s parents, Patty and David Skolnik, are joined by industry visionaries who together challenge viewers to consider how fully informed consent, true shared decision-making, and open and honest communication can change outcomes, how it could have changed the outcome for Michael, can change outcomes for countless others, and in the process reduce risk for institutions and the dedicated providers who care so deeply.

For our session today, the residents were asked to reflect on the training they had received with regard to obtaining informed consent from patients and/or family members, recognizing that all procedures have inherent risks and possible benefits.  The responses were clear and virtually uniform:

"In medical school, we never got training in informed consent."

"In my training, there was none.  We would always say there was a risk of infection and bleeding because we figured that was safe."

"I remember as an intern getting consents for central lines.  I was so excited [to be doing the procedure], but I didn't really understand the risks."

"Sometimes the surgeon orders the nurse to get the informed consent and send it to the OR, where he will see the patient for the first time."

From this, we migrated into a discussion of shared decision-making, how to give the patient sufficient information to know about the potential risks and benefits of a procedure, the alternative to it, and the like.  The idea is to create a true partnership between the physician and the patient to reach a decision that is acceptable and understood by all.

But some of these items are quite technical and are delivered under stressful circumstances.  People talked about the idea of "teach-back method."  Should we have in place system that allows us to get to the point that the patient can explain back to the doctor the risks and benefits and alternatives in a cogent fashion?  Is it better to have the informed consent form in hand when talking with the patient, or does that interfere with communication?  How do we deal with the fact that administration of certain medications can have risks as great as procedures but often do not require informed consent?  How does one actually quantify risks and benefits, especially if one is a doctor in training and does not have a full knowledge of those matters?

Between the movie and the discussion, we devoted about 2.5 hours of excellent thought and commentary to this topic.  The question I then asked the residents was, "Hold your hand up if this discussion was the most extensive or intensive conversation about informed consent in your entire medical education."  Virtually every hand in the room went up.

What an indictment of the medical education system.  The most basic of interactions between a physician and a patient get virtually no attention in the undergraduate medical curriculum and in the graduate medical education training program.  And, yet, as illustrated in the case of Michael Skolnik, a conversation can change a clinical outcome.  Indeed, a conversation can save a life.

Jumping for joy in Telluride

#TPSER8  We took a break during the Telluride Patient Safety Camp for group pictures.  Seen here are two of the more exuberant groups of residents.  The ones above were sponsored by CIR, the SEIU Committee of Interns and Residents.  In addition to traditional collective bargaining issues, CIR has a major focus on creating a better patient quality and safety environment in the hospitals in which its members work.  Also, it supports education and training to improve the quality of care the members are able to provide to patients.

The ones below were sponsored by COPIC, the major medical malpractice insurance company in Colorado.  In addition to traditional insurance issues, COPIC has a strong presence in the risk management arena, with active participation in state and national initiatives aimed at improving patient safety and transferring this knowledge directly to health care professionals, facilities and hospitals in its communities.

Photos by Tim McDonald

When a bulb does not represent a good idea

#TPSER8 We are all familiar with the cartoon image of a light bulb glowing or flashing as representing a good idea that has occurred to someone.  There are other types of bulbs, including those used in medicine, which are also good ideas, except when they are left in the wrong place.

A case documented in the Journal of Robotic Surgery (2009) 3:45-47, entitled, "To forget is human: the case of the retained bulb," presents a whole new category of retained foreign objects in people who have undergone laparoscopic surgery.  In this case, a 34-year-old woman had a robot-assisted laparoscopic hysterectomy.  An asepto bulb was placed in the vagina by the surgery technician "to maintain the pneumoperitoneum during the laparoscopic closure of the vaginal cuff."

Wikipedia tells us that, "A pneumoperitoneum is deliberately created by the surgical team in order to perform laparoscopic surgery. This is achieved by insufflating the abdomen with carbon dioxide."

Here's how the bulb is usually configured, as part of an irrigation syringe.  In this case, the bulb was removed from the syringe to be used by the surgery technician.  In essence, s/he used it to plug up the pressurized air pocket in the abdomen needed by the surgeon using the laparoscopic instruments.

You can almost imagine the surgeon saying -- sitting in his robotic console physically apart from the operating table -- "I am losing air pressure.  Do something to stop the leakage."

Here's the interesting aspect of the case.  Unlike sponges and other operative supplies, "No verbal or written account was made of this action."  And then the non-hand-off occurred, "Subsequently, the scrub technician left the room prior to the end of the case in order to help with the next case."

"The procedure was uneventful and the patient was discharged the same day."  Except for one thing.  The bulb was left behind.  A few days later, the woman and husband came back, the object was found and removed, and after some ensuing complications, she was fine.

I first learned of this case from my colleague David Mayer here at Telluride.  He related other similar cases that he has heard about.  We discussed how a new set of operative procedures can create its own cottage industry of opportunities for patient harm.  How?  Well, it all goes back to the fact that clinicians and their assistants are extremely task-oriented as they take care of patients.  Here, the surgeon expressed concern about an inability to proceed with a case because of gas leakage.  The surgery technician, responding in the moment, cleverly created a solution that enabled the surgery to proceed.  S/he was then distracted by the next task and forgot that the solution had left behind a foreign object -- or maybe s/he figured the "next person" would remove the bulb.  The surgeon might not even know how the leakage was stopped.  Even if s/he knew, s/he would certainly not stop to ask if the the bulb had been counted, perhaps assuming that it would be counted in the same manner as sponges.  The absence of a standardized work protocol for this type of procedure and its contingencies was the systemic cause of harm to this patient -- and patients in other hospitals.

Further, if David is correct that this error has occurred elsewhere, we can note that there is no reflection of those cases in the literature.  Doctors and hospitals are very reluctant to publish papers indicating errors that they have made or that have occurred in their hospitals.  The inability of the profession to take note of this category of error is therefore inhibited, further increasing the likelihood that it will take place again.

Telluride Patient Safety Camp -- Day 1, Part 2

#TPSER8 We continue the saga of the first full day of the Telluride Patient Safety Resident Summer Camp program.  The first activity after lunch was my session on strategic negotiation, focusing on key concepts of negotiation theory.  There was plenty of time for interaction, as I used some classic simulation exercises to demonstrate the ideas of BATNA (best alternative to a negotiated agreement); interest-based rather than positional bargaining; and trading on differences.  The final simulation, entitled "Win as Much as You Can," (seen in progress above) demonstrates the importance of considering the structure, people, and context of negotiations and the need for compliance, enforcement, and re-opener provisions in many agreements.  These principles will come into play in sessions tomorrow in topics as diverse as the meaning of true informed consent and working within teams to infuse patient quality and safety into clinical practices.

But next, we turned to eggs. These poor unsuspecting specimens were put to use in a team-building exercise.  Dave explained the rules.  A long plank was balanced on a cinder block, and each team was given ten minutes to get six people to stand on the plank without see-sawing and crushing the eggs placed on the ground underneath each end of the plank.  The catch was that all players had to step on to the plank at its midpoint, and then all had to exit the plank in the same way.  This is tricky and requires excellent teamwork and execution.

Tragedy befell the first patient, er, egg, as the team did not coordinate its communication and work flows sufficiently well.  One player took the blame for this failure, but the team and faculty reminded her that a just culture was in place.  Her error could have happened to anybody, especially given the lack of a standardized work flow among the team members.  The high degree of variation in each person's assent was clearly at fault.

The second team, perhaps learning from the first, in addition to designing its own process flow and communications mechanisms, succeeded on its first try, with several minutes to spare.

Not to be outdone, team #1 came back for a rematch and also succeeded, proving to be "the best at getting better."

Telluride Patient Safety Camp -- Day 1, Part 1

#TPSER8 Today was the first full day of the Telluride Patient Safety Resident Summer Camp program.  The mist had barely cleared the local mountains when co-host David Mayer presented the assembled residents with the outline of the 3-day session and set forth the objectives.  The Telluride program began after David and colleagues introduced the first-in-the-nation 4-year longitudinal curriculum for medical students in quality and safety at the University of Illinois medical school.  Noticing a lack of literature in the quality and safety field, they thought of organizing a conference to remedy the deficiency and contacted the folks at the Telluride Science Research Center.  They feared that their proposed conference would be outside the normal scope of the TSRC scientific mission, but the board quickly endorsed the patient safety curriculum design session, noting, "We are all patients!"

The mission of the sessions was set forth as follows and persists to this day:

David talked about the desire to teach open and honest professional communication skills to overcome obstacles to improved quality and safety.  Also, to focus on mindful practice -- understanding our own mental processes and thereby the biases we bring to the practice of clinical care.

An ice-breaker among the students and faculty followed this short history, and within a short time the amusing comments and stories about one another created the beginning of a sense of camaraderie that grew as the day went along.  Indeed, during the introductions, someone bravely admitted to being a Miami sports fan.  This created the first difficult moment for the group, but they adapted and worked their way through the problem.

Things then got serious, though, with a viewing of the video The Faces of Medical Errors...From Tears to Transparency.  This is the story of Lewis Blackman, a 15-year-old boy who died because of a series of medical errors.  It was produced by the Telluride faculty and relies heavily on the testimony of Helen Haskell, Lewis' mother.  This is a searing story, with Helen at one point saying, "This was a system that was operating for its own benefit."  Even after the death, "When we got home, we thought the hospital would call us. But no, they constructed a theory that was totally wrong.  I was the only person who knew the whole story, and I was never consulted. They sent a brochure about mourning."

A deep and honest discussion ensued among the residents, reflecting on their current clinical experiences.  Here are some of the comments:

"In my place, people are still not telling the truth to patients and families."

"We have to look at our own frailty."

"I am finishing my residency now. For a few patients, I know that I made the error. Not always did the attending physician want to debrief the case with me."

 "M&M's in my hospital have gotten lame.  I know of many cases that did not come up on the M&M docket."

"I often feel I don't have the support to give this [full quality and safety case review] the time and energy that is required. I have to get others to cover me."

"Calling the attending is still viewed as a sign of weakness." They will say, 'You are not able to independently manage the patient effectively.'"

All in all, a powerful morning, setting the stage and providing motivation for positive change and for attentiveness to the following events in the summer camp.

Educate the young, regulate the old.

#TPSER8 This post's title is a quote from Dave Mayer, who, with Tim McDonald, is running the eighth annual Telluride Patient Safety Roundtables and Summer Camps.  Several dozen residents from around the country are invited to Colorado to focus on this year's theme: “The Power of Change Agents: Teaching Caregivers Effective Communication Skills to Overcome the Multiple Barriers to Patient Safety and Transparency.”  I am here as an invited member of the faculty, thanks in great measure to Shelly Dierking, whom you have previously met as the director of a terrific residency quality and safety program in Denver.

You can read the origin of Dave's quote on this new blog of the same name.  It is a good story.

The organizers have set forth clear learning objectives for the sessions.  By the end of the Patient Safety Summer Camp, residents will be able to:

1 -- Give an in-depth presentation that provides at least three reasons why open, honest and effective communication between caregivers and patients is critical to the patient safety movement and reducing risk in healthcare.

2 -- Utilize tools and strategies to lead change specific to reducing patient harm.

3 -- Implement, lead and successfully complete a Safety/QI project at their institution over the next twelve months.

Tracy Granzyk, who is helping to run the sessions, sent this message out to the participants:

As the week will be filled with thought provoking conversation and sharing of ideas unlike any other medical meeting, one aim of our efforts is to help the healthcare community participate by capturing pivotal moments and sharing them through social media. As such, we will be blogging throughout the week at Transparent Health: Keeping Patients Safe and Tweeting via hashtag #TPSER8 as well!

I am sorry my readers won't be here to enjoy the scenery, but I hope you will decide to join in electronically.

Reuters rebuts Reuters report

Reuters Health Information has posted a remarkable rebuttal of its own article about screening for prostate-specific antigen.  Inside sources suggest that it was my blog post about their story that prompted this.  You might recall my conclusion, after critiquing the poor science displayed in the article:

Maybe I shouldn't judge from the article alone.  Maybe the scientific paper has a cogent hypothesis that is supported by the data.  But, as presented here -- and picked up by several other publications -- this seems like a pretty sorry analysis.

Well, now they agree.  Three days after the blog post the following appeared:

Study suggesting PSA screening for underserved men questioned

Last Updated: 2012-06-08 15:30:03 -0400 (Reuters Health)

[Note to clients: This story adds reporting and context to a May 29 Reuters Health story, "For some, prostate CA screening can be difference between life and death," which ran as 20120529clin014. Where possible, we recommend including a link to this story where that one appears.]

By Genevra Pittman

NEW YORK (Reuters Health) - Experts are questioning the claims of a study on metastatic prostate cancer in underserved men presented May 22 at the 107th Annual Scientific Meeting of the American Urological Association (AUA) in Atlanta.

"The authors are arguing that, in the absence of screening, men with prostate cancer will be more likely to present with symptomatic, advanced disease," said Dr. Robert Volk, a professor of internal medicine who has studied prostate cancer screening at the M.D. Anderson Cancer Center in Houston, Texas.

"Yet, the large screening trials in the U.S. and Europe show at best a small mortality benefit of early detection in large part because current testing does a poor job of identifying cancer that is destined to threaten longevity," Dr. Volk told Reuters Health by email.

"There is no doubt men with metastatic prostate cancer are suffering but our current screening approaches do not appear to lessen this burden."

'NO BASIS IN SCIENCE'

Dr. Steven Woloshin, who studies the risks and benefits of cancer screening at Dartmouth Medical School in Hanover, New Hampshire, agreed.

"The point that the researchers are raising, the fact that there are some men with terrible prostate cancer... that's true, but that doesn't mean screening will help them," he told Reuters Health.

"At most the mortality benefit is really small and there's probably for every death averted 40 or 50 over-diagnoses with harm and no benefit," Dr. Woloshin said.

"The assumption that we should push increased screening in that population to counteract these health disparities that we see by socioeconomic class really has no basis in science."

Take a bow, Cheetahs!

Today's game ended another successful and satisfying soccer season for our under-10 girls soccer team, the Cheetahs.  It was great to see the girls develop individually and as a team, as well as making friends with kids from all over town.  It was a privilege for me to be asked to spend time with these children and their families.

A friendly little robot

It is class reunion time at MIT, and as part of my 40th (eek!), we had a short visit with one of the robot researchers at the Media Lab.  Here's a short video with an explanation from a student named Florian about a friendly little robot.  (Click here if you cannot see the video.)



Among the alumni geeks present was health care's favorite patient advocate, e-Patient Dave deBronkart (seen here with William Roberts, Principal Research Scientist at Battelle, Columbus).  At our 35th reunion, Dave was just able to attend after his run-in with kidney cancer.  Now . . . well let's just say he participated fully in the celebrations.

Ice cream is hard work!

This mother considered her options as the Green Line train approached her stop on the return trip home after a tiring visit downtown to attend the all-you-can-eat ice cream Jimmy Fund Scooper Bowl.  The event raised funds for the Dana Farber Cancer Institute.

Whaddayouworriedabout?

The New York Times reports on a proposed merger of "NYU Langone Medical Center, a highly specialized academic medical center, and Continuum Health Partners, a network of several community-oriented hospitals, including Beth Israel and the two St. Luke’s-Roosevelt campuses. It would create one of the largest health care systems in the city."

Some people are nervous:

By strengthening its competitive advantage, a merged hospital system could limit options for patients and charge more for services, advocates fear. It would also have more power to negotiate higher rates with insurance companies, which might be passed on to consumers in the form of higher premiums. 

To which I say, don't worry.  This could never happen.  Look to Massachusetts for reassurance.

In Baltimore with UMMC

I was honored to be asked to present at a seminar in Baltimore yesterday for a group of nurse managers and other folks from the University of Maryland Medical Center on the topic of financial decision-making in health care.  It was organized by Liz Barron and her colleagues at the University's Robert H. Smith School of Business executive program office.  I was paired with Dr. Michael Faulkender for the day's session.

As my readers know, I am generally impressed with the good intentions and thoughtfulness of people who have chosen to help administer hospitals.  They evidence a caring attitude and desire for self-improvement which are exemplary.  This group was no exception.

The thrust of my talk was to demonstrate that improvements in quality and safety create a virtuous cycle with the financial needs of a hospital.  This is especially so if the improvements are based on a philosophy of front-line driven change, like Lean, with managers serving in the role of servant leaders.

This resonated strongly with many in the audience, but none more so than Terrie Young, vice president of patient care services and chief nursing officer (seen above, right, with Dr. Trudy Hall, chief medical officer) of University Specialty Hospital.)  As she put it to me afterwards, "Who are we to tell folks how to improve the organization?  They are on the front lines, seeing it every day."  Exactly.

(Addendum:  Here is a self-referential link.)

Liz and colleague Caela Coil started off the meeting in an unusual way, with a tribute to Robin Gibb, the recently deceased member of the Bee Gees.  Playing "Staying Alive" to the audience got them moving and shaking off any possible post-lunch lethargy!

Is this the good news or the bad news?

PharmPro reports: 

Wrong-site surgery and falls prevention programs within Pennsylvania healthcare facilities appear to be working, with significant declines in wrong-site surgeries and harmful falls, according to the June Pennsylvania Patient Safety Advisory. The Authority's program to prevent wrong-site surgery began in December 2007 after an article revealed that Pennsylvania healthcare facilities were submitting approximately two-and-a-half wrong-site surgery reports per week.

Since the prevention program began, wrong-site surgeries in Pennsylvania have decreased by 37 percent from an average of 19 reports per quarter to an average of 12 reports per quarter. Adjusting for the increase in procedure volume over the past several years, the decline is more pronounced, as the rate of wrong-site surgery has dropped by 40 percent.

Is this the definition of "working?"  One per week?  Five years later?  I guess it is good news if you were one of the cases that went well.

(Thanks to William A. Hyman, Professor Emeritus in the Department of Biomedical Engineering at Texas A&M University, for pointing out this story.  Here's the actual report.)

Situational Awareness on WIHI

June 7, 2012: Situational Awareness and Patient Safety

2:00 – 3:00 PM Eastern Time

 
Guests:

Stephen Muething, MD, Vice President for Safety, James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center
Anne Lyren, MD, Co-Leader, OCHSPS National Children’s Network; Strategic Advisor for Quality and Safety, Rainbow Babies & Children’s Hospital
Carol Haraden, PhD, Vice President, Institute for Healthcare Improvement
 
It may seem obvious that anticipating problems makes a whole lot more sense than dealing with things after the fact. Especially if the problems could have been prevented. When it comes to patient care, this can of course mean the difference between life and death but, more often, the lack of attention to complexities that could arise leads to a lot of unnecessary complications and suffering and costs. But what exactly do the systems look like that focus ahead of time on risky situations and high-risk patients with the same degree of science and scrutiny as we’ve come to associate with studying failures, after the fact? Indeed, what if the entire emphasis shifted to doing everything possible to predict problems as a means of preventing failures in the first place? WIHI explored the road to becoming a “high reliability organization” with the Joint Commission’s Dr. Mark Chassin on the March 8, 2012, program, and we’re now returning to the issue based on the groundbreaking work going on at Cincinnati Children’s Hospital Medical Center.

We’re going to zero in on “situational awareness” and our guide will be Dr. Stephen Muething, who enjoys a well-deserved reputation for making the principles and practices understandable and within reach. To prepare for the WIHI, we invite you to check out the resources at the James M. Anderson Center for Health Systems Excellence at CCHMC. Dr. Muething will be joined by Dr. Anne Lyren, who’s part of a children’s hospital network in Ohio and nationally, committed to sharing data and best practices. Dr. Lyren will explain the critical role that daily huddles play with getting everyone on the same page and capable of responding to problems and crises as they’re developing, in real time.  IHI’s Carol Haraden has been leading patient safety improvement initiatives all across the globe and, despite the progress, she’s the first to admit how much work still lies ahead. That’s one of the reasons Carol Haraden is so excited about the work at CCHMC, and in Ohio, where leaders have decided safety on any given day is not only job number one, it’s the product of the vigilance and preparation from the day before... and the day before that.

What does your organization’s commitment to high reliability and situational awareness look like? Please bring your stories and examples to the discussion so we can get a good picture of the work that’s emerging and help spread some of the new habits and designs. See you on June 7!

To enroll, please click here.

Yo Tarzan, make mine Janes

Meg Wirth, of Maternova, whom you met in my description of Health Foo, writes about:

. . . a fellow social entrepreneur, Sharon Linder.  She has designed Janes-- the antidote to uncomfortable, scratchy, undignified, not meant for women, johnnies!

They are specifically designed for women undergoing  a mammography or other kinds of breast procedures!  I love the idea because they are truly patient-centered--patient-empowering/patient-comforting.

 

Here's the link to Janes, which has a great tagline:  "Gotcha covered."   I also like the introduction to the site:

john· ny [n]: An uncomfortable, immodest patient gown with a rear opening that leaves you exposed and feeling vulnerable.

janes [n]: a comfortable, dignified patient gown with a front wrap opening that leaves women feeling protected and secure.

A great option for hospital administrators to consider.

[P]retty [S]orry [A]nalysis

There are interesting, legitimate, and important scientific and clinical issues under debate with regard to the efficacy of PSA screening.  The national group that looks at such matters is the US Preventive Services Task Force, which makes recommendations about the effectiveness of specific clinical preventive services for patients without related signs or symptoms.  Here are excerpts from its latest draft recommendation:

The U.S. Preventive Services Task Force (USPSTF) recommends against prostate-specific antigen (PSA)-based screening for prostate cancer. This recommendation applies to men in the U.S. population that do not have symptoms that are highly suspicious for prostate cancer, regardless of age, race, or family history. The Task Force did not evaluate the use of the PSA test as part of a diagnostic strategy in men with symptoms that are highly suspicious for prostate cancer. This recommendation also does not consider the use of the PSA test for surveillance after diagnosis and/or treatment of prostate cancer.

The USPSTF recognizes that clinical decisions involve more considerations than evidence alone. Clinicians should understand the evidence but individualize decisionmaking to the specific patient or situation.

Now, along comes an article from Reuters Health Information that turns the process of scientific discourse on its head, first with an inflammatory headline:  "For Some, Prostate CA Screening Can Be Difference Between Life and Death."  Then a summary of a talk from the 107th Annual Scientific Meeting of the American Urological Association is presented.  Here are excerpts from the article:

Men of lower socioeconomic status and those from third world countries are a subset of patients who do need prostate-specific antigen screening, researchers said last week. . . .  That's because these men often present with advanced, metastatic prostate cancer, Dr. Brian K. McNeil, from SUNY Downstate Medical Center, Brooklyn, NY, told Reuters Health in an interview.

"Considering the recent controversies regarding PSA screening, including the recent US Preventive Task Force recommendation against screening, we decided to study those patients in our population who presented to Downstate with metastatic prostate cancer to identify those who would suffer if PSA screening was eliminated," Dr. McNeil said.

He and his team searched a prospectively maintained androgen deprivation therapy database from their inner city hospital and identified 148 men who presented with metastatic prostate cancer.

[Details of clinical metrics for these men are then presented.]

"The scary thing for me is that the US Preventive Service Task Force recommendations could discourage some men from getting screened who would benefit from screening. With the patients in our study, who knows what would have happened if they were screened and the cancer was detected much earlier," Dr. McNeil said.

Huh?  The entire article is all about how these men presented with advanced disease and all about the advanced disease. There is not one further word about how the researchers determined that "men of lower socioeconomic class and those from third world countries" were the ones who needed the PSA test.  We never learn how they decided that this group is somehow distinguishable in some way that would warrant a different conclusion from that reached by the USPSTF -- particularly the part that said regardless of age, race, or family history.

Maybe I shouldn't judge from the article alone.  Maybe the scientific paper has a cogent hypothesis that is supported by the data.  But, as presented here -- and picked up by several other publications -- this seems like a pretty sorry analysis.

Why can't facts persuade?

WBUR's Martha Bebinger asks the question, " Are We Lowering Health Costs Or Just Shifting Them To Consumers?" Using figures provided by the state, she says:

Note the premium increase in 2010 when “adjusted for benefits.” If you put back all the costs that have shifted to members (higher co-pays, deductibles, co-insurance, etc.), premiums in 2010 would be rising at almost the same rate they have for the last decade or so. In healthcare-speak, this is called “benefit buydown.” The market is producing lower premiums, but it is because patients are paying more health care costs on their own.

The state agency then added:

Other contributors include a decreasing trend in medical claims expenditures, reflecting lower utilization (likely related to the recent recession).

I read recently that people have a tendency to ignore facts when they have already made up their mind about an issue.  The clearest example recently is some people's inability to accept a Hawaii birth certificate as proof of President Obama's citizenry.

The same thing happens in health care.  Without quantitative support, some people assert that structural changes have occurred in the industry that make government intervention unnecessary.  Such views are aided and abetted by unsupported self-serving numbers offered by others that have served to anchor the discussion in people's minds.  For example, Martha's own radio station runs an ad from the dominant health care system in the state asserting that it will be passing back savings to consumers in the amount of $345 million over the next four years. But the difference between the numbers contained in Martha's story and the numbers contained in the advertisement is that publicly available figures form the basis for her story.

Why doesn't the media push on the fact that a presentation of the numbers behind the alleged $345 million has never been made public?  As a casual observer, I would guess that a major portion of the savings is based on the rate increases that this health care system previously projected for future contracts, i.e., trending forward rate increases that were extremely unlikely given the changes in the economy.  In that sense, these are not real savings.  But I admit that is my guess, and I am happy to be corrected by a showing of the facts.

After the rankings, what happens in the doctor’s office?

There was a lot of coverage last week when Consumer Reports joined up with the Massachusetts Health Quality Partners to provide public rankings of primary care practices in the state. At GoLocal Worcester, for example, you were able to read a report about Central Massachusetts practices and see how they stacked up against one another.  The survey came out of a MHQP pilot project funded by the Robert Wood Johnson Foundation to provide consumers with valid, reliable, and useful health information.  MHQP is a coalition of consumers, government agencies, hospitals, insurers, physicians, and researchers with a strong interest in improving the delivery of care to residents of the state.

While the comparative aspects of the report are of great interest, there is another aspect of the Consumer Reports article that deserves equal reading.  It is the section that tells you what you can do to improve the experience with your doctor, regardless of which physician practice you have chosen.  Let’s go through the main points:

What you can do to help make sure that your doctor explains things in a way that is easy to understand: 

 

Take detailed notes. Repeat your doctor’s instructions back in your own words to check that you got them right. If you’re confused, say so. Finally, consider bringing along a friend or relative.

What you can do to do to help make sure your doctor listens carefully to you: 

Ask your doctors to repeat what you’ve told them, to make sure they hear you. If you still have concerns when you get home, ask for a follow-up appointment, on the phone even, and perhaps with a nurse practitioner or physician’s assistant who can spend more time with you. If you would like your doctor to make more eye contact, or sit when he or she talks with you, say so. 

What you can do to help make sure your doctor shows respect for what you have to say: 

A doctor might focus on the benefits of a particular treatment, while you might be more concerned about the side effects or alternatives. Tell your doctor what’s important to you. If you don’t think your feelings are being respected or taken into consideration, speak up. “Say, ‘I don’t think you’re hearing what I’m saying.’” 

What you can do to help make sure your doctor spends enough time with you: 

To maximize your time, prepare a list of questions and concerns in advance, listing the most important first. Ask if there are other health providers on staff who can help you with the less pressing questions. If you want to raise a new health concern during your visit, mention that to the office staff when you make the appointment so they can schedule enough time. 

What you can do to help make sure that your doctor is informed and up-to-date about the care you received from specialists? 

Make sure your doctor knows about the care you get from other providers, including other physicians as well as acupuncturists, chiropractors, herbalists, and other alternative health-care practitioners. Explain why you saw them, what happened during the visit, and what treatments or drugs were prescribed. Make sure those providers communicate with your primary-care doctor, too.  Ask for copies of letters or reports that the specialist plans to send to your primary-care provider. 

How to help make sure someone from the office follows up a blood test, X-ray, or other tests and gives you the results? 

Your doctor should tell you when to expect test results and who will give them to you—and then deliver them as expected, even if they’re normal. Ask for a written copy for your files, too, and see if the practice uses a secure online health portal that gives you access to test results and other information. 

How to help make sure your doctor’s office reminds you to get recommended preventive care, such as the flu shot, cancer screening tests, or an eye exam? 

Ask your doctor about the preventive screenings, tests, and vaccines that are appropriate for someone of your age and health.  If tests have been ordered for you, ask why the screening tests being recommended are needed. 

There is also a similar advice for your child’s relationship with his or her pediatrician.  I urge you to review it. 

Congratulations to MHQP for joining up with Consumer Reports.  While MHQP has been known for excellent data analysis and public policy support, this partnership with an organization well practiced in providing assistance to consumers was huge step in trying to get their information to patients and the public in a more effective way.  As noted by Barbra Rabson, CEO of MHQP, “This is a work in progress as we move closer to giving patients what they demand and deserve in terms of credible health care information, and what is needed to improve our system overall. 

A short history of MA highway signs

For years, the logo of the Massachusetts Turnpike was a Pilgrim's hat with an arrow through it.  But back in 1989, a second-grade class in Amherst began a campaign to remove the arrow, feeling it was disrespectful to the Native Americans who had lived in the state.  They were successful, and the logo no longer contains the arrow.

Now, some underground sign designer has gone further and has provided this addition to one of the signs on the Massachusetts highway system.  It seems to be his or her way of saying, "Let's never forget who was here first."

558 minutes without a goal!

I am sure the players and coaches of the Magdeburg team in Germany appreciated this extra help from their fans.  The team had failed to score for five consecutive games, but "rather than boo their own players as is the modern way, these fans decided to lend a helping hand."



The fans gathered in the stands behind the goal and held up a banner reading: "Don't worry, chaps, we will show you where the goal is!"  And their efforts seemed to work. American forward Chris Wright finally found the back of the net to equalise for Magdeburg and end their 558-minute goal drought.

The team still lost the match 2-1, unfortunately.

Why you should never use PowerPoint

Stick with it to the end!  (Click here if you cannot see the video.)

There are no big problems, there are just a lot of little problems.

If the first chapter is any indication, Healthcare Kaizen, a forthcoming book by Mark Graban and Joseph Swartz, will quickly rise to the "must have" category for people interested in adopting the Lean process improvement philosophy for their organizations.  Mark has worked as a consultant and coach to healthcare organizations throughout North America and Europe. Joseph is the Director of Business Transformation for Franciscan St. Francis Health of Indianapolis, IN.

This is more than a how-to book.  It promises to be replete with examples of success and failure.  I found these simple stories to be inspirational, while also exemplifying the underlying premise of Lean:  Empowerment of front-line staff.

The authors note:  "In this book, we will use the term Kaizen in the context that is often least practiced and least appreciated in healthcare (as well as other industries)—continuous improvements that happen without the formal structure of a large team or a major project.."

"Kaizens tend to be small, local changes at first. In many organizations, the focus of improvement is on innovation or larger scale improvements, or home runs, to use a baseball analogy. . . . A Kaizen organization supplements necessary and large, strategic innovations with lots of small improvement ideas—the equivalent of singles and doubles in baseball. The expectation is that a large number of small changes leads to an impressive impact to an organization’s core measures. Small changes, which can be completed more quickly than major projects, can build enthusiasm and problem-solving skills that people can then apply to larger problems."

Here's one example:

Changing Back Can Be Better for Babies

In early 2008, the Franciscan maintenance department replaced the manual paper towel dispensers in the NICU with hands-free automatic paper towel dispensers. One automated dispenser located near a group of babies made a loud grinding noise each time it dispensed a paper towel and nurses noticed babies flinching when this happened. Occasionally, the noise would wake one of the babies and the nurses knew how important rest was for recovery. Most of Paula Stanfill’s nurses chose a career in the NICU because of their passion and compassion for babies.

After some debate, her nurses suggested they go back to the manual dispensers . Paula wondered if she should let them because it seemed as though they were going backward. Then, her staff measured the decibel level of the automatic paper towel dispenser and found it was greater than 50 decibels. Paula was convinced. She approved having the automatic dispenser removed and replaced with the old manual paper towel holder. It was not as fancy, but it was better for the babies under their care. The babies were happier and healthier, which led to happier staff, which made Paula happy. Their Kaizen Report is shown in Figure 1.5. Paula learned that she needed to listen.

For more information, visit the book's website.

Peer pressure teaches germ theory?

I post this abstract without comment.  I welcome your observations, though, about what this might mean about the effectiveness of education of health care professionals.  The photo above comes from an old blog post.  The disk on the left shows bacteria colonies that grew from my hand before it was washed with a disinfectant. The disk on the right shows the number of colonies that grew from my hand after it was cleaned with the waterless, alcohol-based antiseptic that is in dispensers outside every patient room in my former hospital.

BMJ Qual Saf. 2012 Jun;21(6):499-502. Epub 2012 Feb 22.

Getting doctors to clean their hands: lead the followers.

Haessler S, Bhagavan A, Kleppel R, Hinchey K, Visintainer P.

Source

Division of Infectious Diseases, Baystate Medical Center, 759 Chestnut Street, Springfield, MA 01199, USA; sarah.haessler@baystatehealth.org.

Abstract

BACKGROUND:

Despite ample evidence that hand hygiene (HH) can reduce nosocomial infections, physician compliance remains low. The authors hypothesised that attending physician role modelling and peer pressure among internal medicine teams would impact HH adherence.

METHODS:

Nine teams were covertly observed. Team member entry and exit order, and adherence to HH were recorded secretly. The mean HH percentage across encounters was estimated by compliance of the first person entering and exiting an encounter, and by the attending physician's HH compliance.

RESULTS:

718 HH opportunities prior to contact and 744 opportunities after contact were observed. If the first person entering a patient encounter performed HH, the mean compliance of other team members was 64%, but was only 45% if the first person failed to perform HH (p=0.002). When the attending physician performed HH upon entering the patient encounter, the mean HH compliance was 66%, but only 42% if the attending physician did not perform HH (p<0.001). Similar results were seen on exiting the room. The effects of the first person were not driven solely by the attending physician's HH behaviour because the attending physician was first or second to enter 57% of the encounters and exit 44% of the encounters.

CONCLUSIONS:

If the first person entering a patient room performs HH, then others were more likely to perform HH too, implying that peer pressure impacts team member HH compliance. The attending physician's behaviour also influenced team members regardless of whether the attending physician was the first to enter or exit an encounter, implying that role modelling impacts the HH behaviour of learners. These findings should be used when designing HH improvement programmes targeting physicians.

Why would I stop laughing?

Those of us in the United States missed "Dying Matters Awareness Week" in the United Kingdom (May 14-20).  Of course, here in the US, we would have called it "Death Panels Week" and skewed the entire presidential campaign around it.  But they seem to have a more sensible approach to end-of-life issues on the other side of the Pond.  You can help plan the next DMA Week (May 13-19, 2013) here.

Comedian Alexei Sayle produced this short video, entitled "Last Laugh," to help people confront attitudes about terminal illness.  It brought back some things I learned from my late friend Monique Doyle Spencer.  She noticed that you sometimes had to edit your friendships once you were terminally ill, in that some people just are not able to be helpful and spend their time with you focusing on their problems.  As someone in this video says, "You tend to be drawn to people who make you laugh."

Take a look.  Click here if you cannot see the video.