--30--

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

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

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

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

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

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

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

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

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

How to get patient opinions: Ask.

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

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

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

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

The response from the hospital chief executive was empathic:

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

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

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

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

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

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

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

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

Here are excerpts from the response from the chief executive:

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

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

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

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

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

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

After some personal contact, the mother responded:

Thank you Mr Lilly,

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

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

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

Callahan tells about stories

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

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

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

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

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

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

And some basic rules:

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

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

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

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

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

US News rankings reward transparency

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

Check out this news release. Excerpts:

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

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

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

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

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

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

Meanwhile, back in Massachusetts

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

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

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

Mohl notes that under the proposed legislation:

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

He also reports:

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

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

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

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

Getting past denial in Victoria

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Time for a "no dickheads" rule

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Mateship

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

What can I do? May Wong answered the question.

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

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

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

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

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

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

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

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

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

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

Staff at work

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

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

What will their legacy be?

A danger of being "Thinker in Residence" for several months here in the state of Victoria, Australia, is the danger of diagnostic anchoring--too quickly reaching conclusions about the state of the health care system--followed by confirmation bias--valuing only those observations that support the conclusion you've reached, while ignoring other data.  With cognitive errors of this sort, the best defense in avoiding them is to be aware of their existence.  So, I've tried assiduously to be careful during my visit here.  But the time has come to offer my considered view on several matters.

In a recent blog post, I noted that the extensive program of traffic safety run by the Transport Accident Commission is an example of the strong sense of communitarianism that pervades this society.  I suggested that a future column would explore whether this communitarian view within Victorian society carries over into health care--whether there is a comparable commitment "towards zero" with regard to preventable harm in hospitals.

I conclude, with some sadness, that the answer is "no."

At a meeting with a high government official, I was asked how the the situation with regard to quality and safety in this state compares with other jurisdictions I've visited around the world.  I answered that the situation was comparable.  The offical seemed satisfied with that answer.  I was too polite to point out that satisfaction was not the appropriate response.  As I often note, there is no virtue in benchmarking yourself to a substandard norm.  In most of the developed nations, the situation with regard to quality and safety can best be described as islands of excellence in a sea of mediocrity.  That such is also the case in Victoria should be no cause for contentment--for the simple reason that this state has the potential to do better.

What's behind the failure to act decisively in the communitarian manner exemplified by the TAC in the transportation arena?  A hint was given in a meeting with a senior official in a private hospital system, when I asked if there were any efforts to share advances in quality and safety among the region's hospitals:

"We won't share what we learn about quality and safety improvement because that information gives us a competitive advantage, e.g. with regard to reducing lengths of stay, which has a direct impact on our finances."

I was shocked by this statement, but several of my more knowledgeable colleagues were not when I mentioned the reply to them.

Contrast this attitude with that of several pediatric hospitals in the Midwest United States:  "We compete on everything, but we don't compete on quality and safety."

Like many other countries, increasing health care costs vis-a-vis available public tax-generated money and private health care premiums are big issues here.  There is a tendency for those in government and those in the industry to list financial issues as the primary ones facing the health sector.  That, in turn likely leads to the kind of comment made above about competition.

But such competitive forces and the narrow priorities drawn from them are not compatible with the underlying purposes of the hospitals and people working in them.  Nor are they compatible, if the public understood fully, with what would be the expectations and demands of the populace.

In his marvelous book Legacy, James Kerr writes about the greatest rugby team on earth, and notes:

In answer to the question, "What is the All Blacks' competitive advantage?", key is the ability to manage their culture and central narrative by attaching the players' personal meaning to a higher purpose.  It is the identity of the team that matters--not so much what the All Blacks do, but who they are, what they stand for, and why they exist."

What happens when hospital leadership focuses so intensely on money and competitive standing?  A former trainee from Boston put it this way:

The absence of a sense of purpose of this kind is toxic. For instance, if you have an advertising campaign that emphasizes our kindness or humanity, but we have no policies or practices that distinguish our kindness or goodness from anyone else's, it may be persuasive to our market as a branding tactic, but it's actively alienating to those of us who work within this system. 

Kerr paraphrases Jim Collins' Good to Great by noting that "When enthusiastic and rigorously adhered to, a dramatic, compelling purpose is a fundamental driver of the companies that go from good to great."

So an irony is that, while many health care institutions seek competitive advantage, they will not achieve what is possible even on that front because they fail to focus sufficiently on the public good aspects of their business.  They give their doctors and nurses insufficient reason to have a fulfilling sense of purpose that could in turn make a huge difference on the commercial front.

Here, of course, the penalty for a lack of purpose is worse than the commercial consequences.  People are dying and are being harmed in Victoria's hospitals to a greater extent than is necessary.

As noted earlier, the TAC is not content with even 300 traffic fatalities per year and instead helps the people of the state move that number towards zero. In contrast, in the health care arena, the number is far greater and yet there is a systemic failure to acknowledge the problem.  Government agencies fail to cooperate on solving it to the extent commensurate with the public health hazard.  No one proposes a standard of zero preventable harm for the Victoria hospitals.  Instead, the focus is solely on sentinel events, which are just the tip of the iceberg with regard to preventable harm.

Hospitals themselves fail to work together on the issue.  The various colleges representing the doctors' specialty groups have not addressed it in a meaningful way.  The medical schools, likewise, do not work together on making longitudinal training quality and safety and clinical process improvement part of a shared curriculum.

It may be that that the nascent patient quality and safety movement in Victoria will grow and help nudge government and health sector leaders to make elimination of preventable harm a priority activity comparable to eliminating traffic deaths.  In the meantime, unfortunately, self-satisfaction reigns and harm persists.  The people of Victoria deserve better.

Hear me. Do you know me?

It isn't often that I can report that I was honored to see a play, but such was the case recently when I was invited to view the showing of a short four-person drama at West Gippsland Hospital in Warragul and especially because I was permitted to attend the staff discussion that followed the performance.  Here's the background:

The Australian Institute for Patient and Family Centred Care was established a few years ago by Catherine Crock and colleagues to promote just what its name implies.  As noted:

We aim to to transform people’s experience of healthcare through a three-fold approach:

1. Develop partnerships between patients, their families and health professionals
2. Create a culture that is both supportive and effective
3. Improve healthcare environments through high-quality integrated art, architecture and design.

One medium used by the AIPFCC is to commission short plays on key themes in health care delivery and present them, upon invitation, to hospitals throughout the country.  The hospital plays a small fee for the show, and the balance of the cost is covered by donations to the Institute.  The plays have now been seen in dozens of health care institutions by thousands of people.

Two plays are offered, Hear me and "Do you know me? The first deals with medical error, disclosure, apology, and communication.  The second deals with care of the aging population.

We viewed the latter play in Warragul.  It was organized and supported by CEO Dan Weeks. The audience of doctors, nurses, and trainees were deeply affected by the performance and the themes raised.  Afterwards, Dr. Crock facilitated a discussion, and the honesty and vulnerability displayed in the comments was truly extraordinary.

The actors had permitted people to reach into their experiences--whether with their own family members or with patients--and share observations that will help bring a better sense of clinical teamwork in the hospital and empathy with patients and families.

I was particularly pleased to see that medical students and more advanced trainees were permitted time away from their ward-based clinical activities and were invited to attend.  They, too, were active participants in the discussion and clearly benefitted from the experience.

Meanwhile, the actors stayed and listened, no doubt enhancing their own ability to offer even more engaging performances in the future.

Towards zero on the roads in Oz

In America, drivers don't try to kill other drivers. In Australia, drivers try not to kill other drivers.

After almost three months here, I've decided that this difference in attitudes is the biggest thing that separates these two cultures.

America was built on a culture of individualism, sometimes called "rugged individualism."  In Australia, society is characterized by a much greater degree of communitarianism.

The place of traffic fatalities in the two countries provides a nice example.

There are about 32,000 traffic-related fatalities in the US per year, about 10 per 100,000 population.  I think if you were to ask most American drivers about this figure, they would probably answer, "These things happen."  There is virtually no concern in the general population about these deaths, and there is certainly little or no evidence that road dangers influence the manner in which people drive.

In Australia, there are about 1200 deaths per year, or about 5 per 100,000 population.

A two-fold difference is pretty significant, and Australia would certainly be entitled to rest on its laurels.  But folks here understand that there is no virtue in benchmarking yourself to a substandard norm.  Instead, as illustrated by the a program of the Victorian Transport Accident Commission, they've set an objective of zero.  The agency explains:

At the heart of Towards Zero is the belief that human health is paramount to all else. It acknowledges that, as people, we all make mistakes. However, when mistakes happen on our roads they can cost us our lives or cause serious injury. That's because our bodies aren't made to absorb the forces of high impact speeds. We are fragile, and there's only so much physical force we can withstand and this is why we need to build a safer road system. Improving the safety of our roads, our speeds, our vehicles and our people will improve safety for everyone. The move Towards Zero is a collaborative effort between everyone in the community. Together, we can build a safer road system and help change road safety for the better.

A campaign is just a campaign if it does not take hold in the minds and behavior of the target audience.  I'm here to report that as I drive on the highways and streets of Victoria, I see it in action.  When you are on the highway, and the speed limit is 100 km/hour, people go at 100 km/hour.  In the US, when the speed limit is 60 mph, the expectation is that you will go above that.  In Victoria, you don't see people engaged in a "Grand Prix" form of driving, weaving in and out of lanes to pull ahead of cars in front of you.  As a result, automobile travel is a lot less stressful and more comfortable, not to mention safer.

In talking with friends here, they acknowledge that very strict enforcement of the speed laws--and high penalties--keeps your mind on doing the right thing.  But they also follow up by saying that they are pleased that such is the case.  Why, they say, should people die when they don't have to.

In the US, if we think about the issue at all, we tend view those who might die as "somebody else," and we feel no sense of responsibility towards those potential victims.  In Australia, when they think about the issue, they view those who might die as a member of their community, and they feel a great sense of responsibility in minimizing the potential for harm.

In a future column, I will explore whether this communitarian view of Australian society carries over into health care--whether there is a comparable commitment "towards zero" with regard to preventable harm in hospitals.

Ultimate advice

When I was growing up, ultimate (originally known as ultimate frisbee) had not yet been invented.  While we played with frisbees, it was mainly just a lot of tossing them around.  Since then, the sport has developed and highly skilled players and teams compete worldwide.

I've had a forced sabbatical from playing soccer here in Melbourne (no one plays during the summer apparently), but have been lucky to be invited to join a local co-ed division three ultimate team.  It's been great fun to play a sport which in which the rules are self-enforced, i.e., without referees, and where the "spirit of the game" is the dominant culture.

Nonethless, there remains a role for a team leader, often a player-coach, and in this case we are blessed to have Michelle Phillips, a world class player, as ours.  Off the field, she and I have traded stories about leadership, and I've also had a chance to watch her skills in that regard during games and her post-game advisories to the team.  The latest one struck me as having lessons well beyond the playing field.  Here's an excerpt:

There's a tendency in teams (whether sporting or otherwise) to try to 'fix' everything, to try to have the strategy perfect, to try to get everything absolutely right.

It's not possible. More importantly, trying to do this is actually detrimental to the overall performance of a team. Let's have a look at why, and at what we can do instead.

When we try to correct every non-perfect action out on field, we crowd our minds with more information than we can process. What that looks like is multiple voices in the circle, talking about strategic points while we're on the line, and tacking extra pieces of information onto the main message. Doing this means that not only do we not remember all the little things we've been told to do, but we forget the most important things that we started with. 

There's a direct parallel between these points and about achieving process improvement in hospitals and other organizations.  Improvement in efficiency, quality, safety, and customer satisfaction occurs one small step at a time, within an overall strategy.  If you try to change too many things at once, the effort usually fails, and because you've changed too many things, you don't know how to analyze the cause of the failure.

Now, let's get back to Michelle's summary as she discusses a leadership (and the followship) issue:

A leader's job is not to fix everything. A leader's job is to filter all the information they receive, decide what is most important for the team, and direct the focus there. If you're leading (and we all do, at different times) you need to be able to give your team one clear set of directions out of the hundreds of possible actions that could be taken. If you've passed information onto a leader and they haven't acted on it, realise that they have made a decision not that it isn't valuable, or true, but that it isn't the message that the team needs in that moment. Trust that they are storing it away, and when the time is right it will be packaged up and delivered.

Finally, we return to the relative importance of strategy versus implementation:

And let me tell you a secret. It's way less about the strategy than we think.

If it was all about strategy, the underdogs would never win. If it was all about strategy, team sport results would be far more predictable than they are. If it was all about strategy, the state of your athletes wouldn't matter - only the state of your coach.

Games are won by the team that controls the mood.

I don't think people think much about this concept of mood in a hospital or an industrial or service organization, but it is key.  We might use another word, like "morale." Having now visited thousands of places, I can usually tell within 15 minutes whether a place is a true learning organization--one described by my late friend and colleague Donald Schön (1973), as one that is “capable of bringing about its own transformation."  You can see it in the faces and demeanor of staff as they walk down the corridors.  You can feel it in how they interact with one another on the front line.  Call it mood, morale, or a shared sense of purpose and mutual support.  I described this in my book Goal Play!

The girls who play soccer in our town’s league in Eastern Massachusetts are among the luckiest kids in the world. They get to go out and play a beautiful game with their friends in a safe environment with terrific coaches and parents who support them. But there is an additional bit of magic that occurs during a game.

As the girls play, they unconsciously adapt to one another’s strengths and weaknesses, creating a seamless web of teamwork. As a coach, when you see this happen, all you can do is smile. You know you had something to do with it, but you also know that something has happened among the girls themselves. It is a marvelous thing. They will remember it all their lives, but they may not entirely understand what they are remembering.

They will think their fond memories of the season had something to do with friendships or other social relationships or new skills acquired or the team’s exceptional record. But there is something even more important that made the season so memorable. It is an elemental statement about the human condition: We are born to work and play together in teams. Many people do not get to experience that sense of ensemble, which requires giving enough of ourselves to let the filaments connect. That the girls discover it for themselves is very, very special. They are, indeed, the luckiest kids in the world, and we are likewise blessed in being able to share this time with them.

Sea spurge, compacts, and other descendants of Wipe off 5

Today's story is about how to implement a cultural change among a large group of people.  Stick with me, as this will take a moment.

Back in 2001 the Victoria Transport Accident Commission wanted people to slow down just a bit while driving.  They understood that "Speeding just 5km/hr over the speed limit can mean the difference between a close call and a serious accident."  The question was how to get people to do it, and do it consistently.  Of course, you could have police and traffic cameras trying to enforce the speed limit, but that is resource intensive and can never be pervasive enough to hold thousands of drivers accountable to this standard. It would be better if people would internalize the message and hold themselves accountable.

What resulted was the Wipe off 5 campaign.  TAC employed a simple statement of principle and combined it with an easily understood and remembered action that every driver could take.

The fact statement was pretty straightforward and incontrovertible:

Each year about 100 hundred people die on our roads every year in crashes where speed was a contributing factor. The TAC spends about $1 billion every year on support services for those affected by road trauma and accepts about 19,000 claims each year from people injured in crashes.

The ask from the public was widely publicized in forums that were frequented by people--standard media and social media.  Highly respected advocates (Footy stars!) lent their names and images.

Low level speeding is the target of this latest TAC campaign - the aim to make people aware that travelling only 5km/hr over the speed limit can have disastrous results.

Throughout the month of August, the Wipe off 5 message will be spread through social media, a Statewide roadshow that will tour Victoria and the commercial featuring famous AFL number 5’s, Carlton's Chris Judd and Collingwood's Nick Maxwell.

The results were both immediate and sustained:

Over time there has been a change in community attitudes towards speeding and also in behaviour. According to Sweeney Research, people who report they speed most, or all, of the time has dropped from 25% to 11%.

Market research surveys show that the Wipe off 5 concept is generally understood by Victorian motorists and is having a positive affect on their driving behaviour. Since the campaign began, Vic Roads has reported a drop in average travel speeds in 60km, 70km and 80 km/h speed zones.

Now another story, this time from the beach.  There is an invasive plant species, sea spurge (Euphorbia paralias), that has taken over many of the dune areas in Australia beaches.  As noted here:

Sea spurge can produce up to 5000 salt-tolerant seeds. These seeds can survive for a number of years on ocean currents that spread them from beach to beach. Once established, a sea spurge colony can spread rapidly, displacing the native vegetation and changing the structure of the beach. This can disrupt many native species including the endangered shorebirds (hooded plovers, little terns and oyster catchers) that use open sand spits for nesting.

Although the plant is not unattractive, its displacement of local species is troubling, and a number of people in the Cape Paterson region have banded together to try to remove it from the dunes in their area.  Work parties go out periodically to carefully pull up the plants.  (It has to be done carefully or, as seen above, the remaining root structure will spread into dozens of new plants.)

But two or three dozen stalwart volunteers alone cannot maintain several kilometers of beach front, and so the group has been encouraging other folks who use the beach to pitch in--to be part of the culture of removing the invaders.  But the trick was to make the job memorable and approachable, so that each person would take personal accountability to help out.  Rod Phillips, one of the organizers, suggested that the team adopt a take-off of the Wipe off 5 campaign, and "Take out 10" was born!  As people walk along the beach, they can easily pitch in by pulling up ten of the plants and walk on, knowing they have helped.  There are now several sections of the beach that remain remarkably free of the plant.

Finally, let's turn to a story that is in its early stages.  A group of senior administrators and clinicians at Royal Children's Hospital in Melbourne have spent several months engaging staff in the construction of a compact between and among the medical and managerial staff. Hundreds of people have spent thousands of hours constructing this document, which is meant to reflect the values that should govern behavior in the hospital.

The compact represents a personal commitment of those who sign on to it.  There is no enforcement mechanism.  It is the exemplar of self-accountability.  The as yet unanswered question is whether is will make a difference in changing the culture of RCH.

As one staff member noted:  "Getting the words down is just the first step.  It's all about the deeds."

Another, analyzing behavior patterns in the hospital, said: "We need to look at ourselves as a tribe, not at the tribes within the hospital."

Another noted that there is "a need to call out bad behavior in real time" in a way that is viewed as positive and constructive.

The best summary of one desired outcome was:  "We need to stop saying this is my patient and instead say that this is our patient."

And finally, the clincher: "We should look after each other."

So the question for RCH and other institutions that seek to raise the level of kindness in their delivery of medical care is how to translate excellent words into excellent action.  And it is here that perhaps the lessons of "Wipe off 5" and "Take out 10" might offer assistance.

If staff members at the RCH focus their efforts on the global behavioral change that is envisioned in the compact, the task may seem overwhelming.  There are so many sentences and so many words.  Which should get priority?  How should this affect my daily life?  Viewing such a large task might even be paralyzing.  Instead, what if the hospital were to implement the compact by adopting an analogy to a simple mnemonic, a daily standard that could be incorporated into each person's work flow and interactions?

I'm not clever enough to know what might work, but perhaps something like "Show five types of caring each day."  Or, "Offer ten kinds of kindness."  The point is to make the desired task clear, compelling, and practical--allowing each person to go home at the end of the day claiming success in helping to instill the culture so eloquently set forth in the compact.