Wednesday, September 17, 2008

Mea culpa

We are really, really trying to get better at this quality and safety stuff, but there are so many aspects to it that sometimes things slip by. Here's an example. Today our Medical Executive Committee was preparing to vote on a universal protocol policy related to taking "time-outs" before invasive procedures. We already had done this for surgical time-outs; but we recognized that a slightly different approach would be more suitable for procedures outside of the ORs (e.g., in endoscopy or interventional radiology suites).

Part of the policy includes some unambiguous guidelines, like this: The team will stop, pause, and verbally verify their agreement on the identity of the patient, the procedure to be performed, all patient allergies, the site of the procedure, including laterality, the correct position of the patient and radiological exams, if applicable. There was unanimous support among the MEC members about the need for this policy, and it started to move quickly to adoption.

But then I noticed two problematic items in the document that was about to be approved. Here's the first: It is the responsibility of the physician initiating the procedure to initiate the time-out. On its face, there is nothing wrong with this, as it is, indeed, the physician who has final responsibility for what happens to the patient. But, I said, don't we want to expand on this and make it clear that each staff person in the room is encouraged and empowered to question whether the time-out has taken place and/or to remind the physician that it should be. After all, when we had our recent wrong-side surgery case, only part of the problem was that the surgeon was distracted and forget to initiate the time-out. An equal contributing factor was that no one else in the OR thought to remind the doctor or question whether the time-out had occurred.

The second problematic sentence was this: It is not necessary to include the patient's participation in the time-out process as this may not be applicable. Hold on, I said, don't we want to reverse the emphasis and establish a presumption that the patient should be invited to participate, unless it is somehow inappropriate or not possible. Why not involve the person with the most direct interest in the procedure to help out?

In both cases, the doctors and nurses on the MEC immediately agreed and even suggested helpful language that would accomplish these objectives. But I was left thinking, "Why did I have to suggest these modifications? Why wouldn't they be self-evident to the subcommittee that had written the policy? And if not, why wouldn't any other member of the MEC have thought to raise them." In fact, later I was a bit critical of our SVP for Health Care Quality on these points in a private conversation with him.

One of our trustees was observing the meeting, and I also raised these questions with him. "Too much to do, too busy to read," was his commentary about the medical staff members of the MEC. While that is true, it is not a satisfactory answer. After all, it has just been a few weeks since the wrong-side surgery case, and everyone is attuned to this type of error.

My friends in the patient advocacy world will probably say, at this point, that's why you need patients on every committee and working group in the hospital. Patients will see things that the medical staff overlook and bring in a useful perspective. This can be true, but it actually takes a lot of thoughtful planning and time to create a productive environment for that kind of patient advisory input -- and, even then, there will always be some decisions made without patient consultation.

I have a different answer. After the Blue Cross Blue Shield conference yesterday, I asked a question of Sweden's Göran Henriks, who has worked for two decades on improving safety and quality to make Jönköping County's health system one of the best in the world. "Knowing what you now know," I said, "how long would it take your doctors, nurses, administrators and staff to get to your current level of performance if you were starting afresh?" His reply: "Five years."

Old habits and viewpoints, in other words, are deeply embedded. While every sentinel event presents an opportunity for learning and improvement, it is in the everyday tasks that the possibility for continuous and lasting improvement exists. I happened to be the one to call out two examples today. But, it is the marvelous diversity of experience and perspectives of the people in an organization that provides a reservoir of such possibilities. Our goal is to create an environment in which everyone in the hospital will feel empowered and excited to do the same, whenever they see opportunities for improvement. Training people to do that is what takes time, as we each have a unique way of learning.

And so I realized that I was wrong to have criticized the SVP. It's my job to help people to engage in this learning adventure by setting the appropriate example of humility and encouragement, and I blew the chance today with one very well intentioned individual. But tomorrow will certainly provide other chances to do better.


Stephanie said...

Last year I had my first surgery ever. At every point of contact with a hosptial official, be it the gal that gives you a bag to put your clothes in and assigns you a locker, right to the surgeon (thankfully it was my obgyn, I was SO happy it was her!), asked me my name, and what surgery I was having. This happened in the operating room as well.

I was a bit overwhelmed and it made me really nervous - especially as it was my first surgery ever! I kept thinking, "Jesus people, don't ANY OF YOU know why I'm here?"! It's funny now that I look back, but it terrified me at the time. First time in a hospital can be overwhelming!

When my husband went in, years ago, for surgery on his knee, the surgeon make him draw something in pen on the knee he was getting operated on. It kind of freaked him out too! We both do understand why, and we are both grateful for it.

But when I go in next year to give birth, and if they ask me why I'm there.. I think I'll just completely give up, lol!!!!

Thanks for the informative post Paul.

Anonymous said...

And let's hope, too, Stephi, that they don't ask you which side!

Last year, I was in the lab to have some blood drawn. The lab tech recognized me and started a five minute conversation about all kinds of things related to the administration of the hospital. Then, when it came time to draw the blood, she stopped and said: "What is your name? What is your birth date?" It was exactly the right thing to do.

Anonymous said...

I think your question about why it had to be you to raise the flaws has important implications. My belief is that people on the inside get too close to an issue or a way of doing things, such that, as you say, "we've always done it that way", or "everybody does it" becomes embedded in their thinking.
I have been interested in how you, coming from outside the industry, often have a different and refreshing viewpoint on health care issues. I think it often takes someone from outside, who has the clout to be listened to, to perceive the flawed thinking of everyone else.
We could only wish that there had been someone analogous to you before the current Wall Street debacle, which could easily have been prevented, if only someone (with clout; that's critical) along the way had asked similar questions.
BTW, I don't think it was wrong to be critical of an SVP for Quality for not reviewing every sentence of a quality document and asking "is there any better way to do this?" Perhaps if you had changed "critical" to "educate", yes.


Anonymous said...

ps, Paul, I have been meaning to ask; what changes in OR procedure/policy have you implemented based on what you learned from the wrong site surgery analysis? If you can say so publicly, of course.


Anonymous said...

After reading Paul’s blog entry this morning, I wanted to offer an alternative view regarding putting into the policy the expectation that all others in the procedure room should also be responsible for ensuring that the time out occurs. I certainly agree this is the case. But I think the state we’re trying to reach is that this expectation is true with all policies and standardized processes, i.e., that anybody who observes that it doesn’t happen is expected to “call out” that problem and if it poses any kind of risk to a patient to “pull the cord” (as they say at Toyota) in real time. If so, then should we be putting into every policy that all observers at each step should speak up if they don’t see it occur? I suppose we could but I think that’s the culture we want and repeating that in every section of every policy doesn’t seem the way to get there. Now, I recognize that it may be that time out policies are so critical that it is worth being explicit in that policy, but I think there are many other policies just as critical to safety (double ID, PPE, hand washing, et al).

Anonymous said...

Dear SVP,

At this point in our education, maybe it makes sense to include it explicitly in each policy. You're right, of course, that it should be understood to apply to everything, but that will take time, and maybe a reminder in each one would be a good device for a while.

I welcome thoughts from others on this.

Dear Nonlocal,

Will do. Stay tuned.

Anonymous said...

I would like to see your policy state instead of "all patient allergies", "all patient allergies, and adverse reactions". As a patient, I think of allergies as something that gives me hives or makes my throat swell. So if asked about allergies, I would mention things that gave me hives.

I would not be thinking about something that made me faint unexpectedly, or have violent outbursts during a procedure.
These reactions might be more dangerous than an allergy, but they don't get the same attention in patient histories, or consideration on charts.

Anonymous said...


I'm very interested in your post because my husband was recently in the hospital (not yours!) for heart surgery and was taken for an ultrasound. The technicians confused him with another patient and insisted that he needed an x-ray despite his objections and attempts to correct their misunderstanding. The culture of ignoring what the patient says trickles downs to every level. If you are able to bring about a change in this attitude, you will have done something really miraculous.

Anonymous said...

Culture change can occur rapidly, but there have to be sufficient rewards - strong 'pushes' and 'pulls' in the system to overcome the inertia of habitual thinking and behavior. This is Boston, and medicine, after all. It will take a lot of carrots to reach the tipping point. You have power and voice as CEO, but is power and vision dispersed in the organization? Are staff rewarded for thinking differently?

Jim Conway said...

Paul, good to see that you too suffer from being human. I agree, the SVP deserved an apology.

When you made your comments at the MSEC, you made them as a CEO setting a new expectation and a member of the team brining fresh eyes. Both comments—that patients and families are partners and that their power and shared responsibilities of team— are essential. They are also, unfortunately new areas of priority focus—they are not elements of success previously emphasized in healthcare. The fact that staff “missed it” isn’t anyone fault. As Goran, suggested culture is a long journey and for many of us, we are very early on it. I celebrate they received the suggestion so well, respecting the important role you play as a member of the team. What we need to be doing is setting clear expectations, be respectful of the various places people are, and position staff to be successful in that new environment.

One final note. When I left a DFCI a number of people commented on the helpfulness of times when I acknowledged I had “screwed up.” You’re not alone. These too become great moments for learning and high performance team development. Thanks for sharing the story.

Jim Conway, SVP IHI

Charlie Kenney said...


This is such a great posting – rich with all kinds of lessons. You deserve a lot of credit for the catches you made: empowering everyone in the room on a timeout as opposed to laying it all on the doc; also establishing a presumption that the patient should surely participate unless circumstances make that impossible. That the CEO of a major academic medical center is involved in the quality and safety effort at such a detailed level is really impressive.

It’s reasonable of you to ask why you had to make those catches. It would have been better if the members of the MEC had fixed both of those items. But learning about and writing about the quality/safety journeys at other institutions it’s pretty clear that these processes are often untidy. Rarely does anybody get it entirely right first time out. The Toyota Production System is instructive here. A number of U.S. hospitals have drawn from the Toyota approach to improve quality and safety and Toyota has been at the business of quality improvement for generations. Yet their system is by no means static. Gary Kaplan, MD, CEO at Virginia Mason Medical Center in Seattle, which uses the Toyota approach, told me that Toyota receives hundreds of thousands of suggestions each year from employees on how to improve their processes – and many are implemented. The commitment to quality and safety improvement – the journey itself – generates continuous improvements and that, I think, is what happened in your case. You are committed to the journey and you are improving in the course of the process. In this case, the process actually worked really well – because you are part of that process and made the improvements.

These changes – especially cultural changes – are not at all easy as you well know. But change is possible when people are genuinely committed. Steve Muething, MD, at Cincinnati Children’s told me of a case where he had been hammering away re: time-outs before any invasive procedure. One day a child was about to undergo an invasive radiology procedure and the time-out was skipped. But a child life specialist – not a doc or nurse – called a halt to the procedure. She believed in the empowerment she’d been granted by the hospital leadership; believed in the institutional commitment to protect the children. So she bravely spoke up, paused the procedure, and an appropriate time-out ensued. She was praised and respected for doing so – a real indication of meaningful cultural change.

Anonymous said...

Recognizing that I am a "nobody", I must respectfully disagree somewhat with Mr.(?Dr.) Conway's attitude that quality care and patient safety are part of a long journey and we should celebrate the positive things. The IOM report on medical errors came out several years ago, and I sat on a hospital quality improvement council which was talking about all these things at least 10 years ago. Many hospitals are not even close to achieving the improvements that are going on in isolated medical centers around the country.

I believe a little bit of controlled impatience is needed in pushing this process along faster. JC and CMS are beginning to have an impact in this area, but the fact remains that many administrators just don't see it as a priority. This must change for the patients' sakes, and I think we must develop a higher sense of urgency in this movement.
For that reason, no, I don't think the SVP for Quality should be let off the hook here or anywhere else. He or she should be out there every day educating the physicians and staff and pushing this along, not being pushed along by his/her CEO.
(With personal apologies to the SVP/Quality; it's nothing personal and I am just seizing upon this as an example!)

nonlocal MD

AsTiMa said...

One thing I didn't notice about the time-out (maybe I skimmed too much?) is how many times we catch registration errors. As a CT tech, we have the "Two patient identifiers" policy where we always ask first and last names and also birthdays before we begin anything. The key is to also check the patient's wristband to be sure the birthdate is actually the one the patient states. We have had several women with M for male on their bands. We also do an extensive time-out before all interventional procedures. I am personally happy for that because I am used to having the patient on their back, but when they get on their stomachs, I get my left and rights all mixed up. I understand that some patients feel we do this because nobody has a clue as to what we are doing, but most of them fell better when I explain why we ask all the questions. Thanks for an interesting post!