Monday, March 15, 2010

What does it take? (revisited)

I beg your indulgence to read this old post of mine, but more importantly, to read the comments that it stimulated from some of the world's experts in process improvement, but also from some "regular people."

All things considered, are we in the health care professions moving fast enough to transform the delivery of care? And whatever you think about today's problems and this generation of caregivers, how about trying harder for the next? An excerpt:

The Lucian Leape Institute at the National Patient Safety Foundation released today a report that finds that U.S. “medical schools are not doing an adequate job of facilitating student understanding of basic knowledge and the development of skills required for the provision of safe patient care.” The report comes approximately 10 years after the Institute of Medicine’s landmark 1999 report “To Err Is Human,” which found that 98,000 Americans die unnecessarily from preventable medical errors. “Despite concerted efforts by many conscientious health care organizations and health professionals to improve and implement safer practices, health care remains fundamentally unsafe,” said Lucian L. Leape, MD, Chair of the Institute and a widely renowned leader in patient safety. “The result is that patient safety still remains one of the nation’s most solvable public health challenges.”

A major reason why progress has been so slow is that medical schools and teaching hospitals have not trained physicians to follow safe practices, analyze bad outcomes, and work collaboratively in teams to redesign care processes to make them safer. These education and training activities, the report states, need to begin on Day 1 of medical school and continue throughout the four years of medical education and subsequent residency training.

“The medical education system is producing square pegs for the delivery system’s round holes,” said Dennis S. O’Leary, MD, President Emeritus of The Joint Commission, a member of the Institute, and leader of the initiative. “Educational strategies need to be redesigned to emphasize development of the skills, attitudes, and behaviors that are foundational to the provision of safe care.”

Questions for medical students and residents out there. Have you received training in process improvement or the science of care delivery? If so, tell us about it. If not, is it something that you would fine useful? Would it influence how attractive you found potential training programs when planning your career?


Maureen said...

Thanks for raising this issue,Paul. It will interesting to see what the students tell us. You can refer them to IHI's Open School ( if they want to learn improvement methods for health care settings. All free.
Maureen Bisognano

Anonymous said...

I agree that IHI's Open School is a fantastic resource. Thanks for mentioning it.

e-Patient Dave said...

Maureen, I had no idea IHI's resources were free. Thanks! That makes this even starker: why would a healthcare manager not use free resources to save lives?? Why wouldn't s/he DEMAND it?

The most significant phrase in the Leape quote is "most solvable." That's Lean, that's continuous improvement thinking. Pick something achievable, do that, get started.

Along those lines, last week I got to be a "voice of the customer" (patient)in a Beth Israel Deaconess Lean / quality improvement retreat. (See my diary.) It was inspiring to work with a bunch of residents, plus attendings and RNs and other staff. All those young sharp well-trained minds, being taught "It doesn't have to be this way" from the start!

Please look back 14 months at Paul's original post - and the 50 comments, including IHI's Jim Conway, Atul Gawande, BIDMC's chief of medicine (Mark Zeidel) and VP of Quality (Ken Sands) and Ethics Program Director (Lachlan Forrow) - some heavy hitters.

During my treatment I had four central line insertions. Because of this blog I knew about the work being done to standardize and improve safety, and I'm really glad the infection rate dropped from 4.14 to 0.52 per thousand. (More data in this update.) It matters when it gets personal - and to the patient & family it's always personal.

In last week's quality retreat one resident reflected on realizing that much useful wisdom exists in disciplines outside healthcare: "If we don't use it, that's not scientific." Well said.

Pam said...

Dave, how lucky to have been a part of that retreat. I wish I could have taken part in it.
This is a difficult course to find and when you do, it's cost prohibitive.

Anonymous said...

I will break my long comment into two parts:

I highly recommend that medical professionals take the time to read the entire report (in pdf, available from the site Paul cites),which gives a detailed blueprint for curriculum modification. It was compiled by a roundtable of medical experts including representatives from the Assoc. of Medical Colleges, medical schools, several accrediting boards, patients, and 2 physicians from BIDMC. Allow me to quote from the report:
“Experts agree that patient safety is predominantly about the proper design of health care systems and patient care processes. This thesis was the main thrust of the IOM’s To Err Is Human report and is now widely accepted in the health care community.In the engineering community, this has never been news at all. Unfortunately, system design failures continue to translate into preventable patient deaths every day. Thus, one would expect that teaching the prevention of iatrogenic patient deaths would be among the highest priorities in medical schools,but sadly it is not. Missing in part, or totally, from the typical medical school curriculum is substantive attention to safety science, systems thinking, the science of improvement, human factors, and…..teamwork.”

And another, “professional egocentricity inhibits team building across disciplines.”

nonlocal MD

Anonymous said...

Part 2: what should we do about this?
I sent the report link with a cover letter to all 3 institutions of which I am an alumnus, urging them to consider its implementation. The only reply I received so far was from the Iphone of one dean who shall remain anonymous since at least he had the courtesy to reply: “I think you will find we are a leader in this.. Google ___ ____. Med ed includes.”
(Hint: __ __ is a patient safety expert whose initials are PP). Now, do you think this dean will read the report? Interestingly, his institution was NOT included on the list of 23 medical schools on p. 30 of the report who are beginning to implement its recommendations. Neither, ahem, is Harvard Medical School.

The expert roundtable who compiled the report recommended that all medical schools should be evaluated annually on this issue and school specific results be made public.
To paraphrase Warren Buffett’s comment( regarding company CEO’s), “there’ve been plenty of carrots; it’s time for more sticks.”

Docs who are believers, please send this report to your institutions. It’s time.

nonlocal MD

e-Patient Dave said...

Pam, what's your role? (Patient, clinician, other?)

I didn't experience it as a course as much as a workshop. (I could easily have read the books in less time than the week took, especially considering the daily commute from New Hampshire!) All the facts I learned in the week was in books we were assigned as pre-reading - I'm reading Lean For Dummies (very good start) and Lean Hospitals, and I hope to soon finish Chasing The Rabbit.

Beyond that, we got coaching on our specific challenge project - reducing readmission rates after people are discharged from the hospital.

Some suggestions for sharpening one's lean:

----I knew some basics about Lean from reading this blog and Ted Eytan's excellent healthcare blog. (He's a Kaiser guru in DC, though he'd disagree with guru.)

----Mark Graban, author of Lean Hospitals, writes on the Lean Blog and is @LeanBlog on Twitter.

----Steven Spear blogs also at Chasing The Rabbit.

Hope this helps -

e-Patient Dave said...

Wow, go get 'em, nonlocal.

I'm trying to recall whether I heard things like this two years ago when I started paying attention to health systems. If I did, I couldn't believe my ears, because only now is it starting to sink in.

I'm about to go twitter my fingers off about "professional egocentricity inhibits team building across disciplines." If I believed shaming was useful, I'd say Shame to that one. How unscientific! When lives are at stake!

Methinks the reason we need is a patient-in-chief is to slap down people whose egos are more important to them than lives.

Anonymous said...


You're what I need, a fellow rabble-rouser. Did you read the interview with Pronovost in the NYT where he tells the story of the surgeon who refused to change his gloves when Pronovost suspected intra-operative anaphylaxis due to latex allergy?
Now THERE'S professional egocentricity.


Eva Luo said...

Thank you blogging about the LLI report. I really do hope medical school faculty are following your blog! The demand for patient safety and quality improvement skills from students is high- just look at the number of students registered with the IHI Open School and the number of Chapters around the world just one year into its existence. What we need is more time and space for patient safety and quality improvement to be formally addressed in the curriculum. Here at the University of Michigan, we are taking creative baby steps to make this happen through brief moments of exposure. In addition to more training during the basic science years, we need solid modeling from faculty when we hit the wards in our third year. I've made some additional comments on the IHI Open School Blog:

1st Year Medical Student
University of Michigan Medical School

Anonymous said...

Eva raises two points also addressed in the report:

1. current faculty are ill-equipped to teach the new culture since they come from the old one;

2. Medical students are often subjected to the hierarchical and demeaning behavior patterns of the old culture, thus learning to repeat them - just as abused children become parental abusers.

This morning I remembered the old saw about medical research taking 17 years to reach medical practice. When was the IOM report issued? We are closing in on the deadline....

nonlocal MD

Anonymous said...

It is not only culture. It is substantive knowledge of process improvement, which for the most part will have to come from other industries. Brent James can't be everywhere. This takes a new cadre of teachers, with different methods.

Anonymous said...


The report addresses both the culture and process improvement issues, as well as virtually every other issue surrounding this problem. As I said, it is a very detailed blueprint, if the right people would just READ it. (36 pages is getting so it exceeds peoples' attention spans these days.....)
....I think the med schools can just pull in certain engineering profs from their associated universities and pretty much solve the problem you address, inhouse.

Anonymous said...

Amendment: you know, I think it really IS the culture, first. What's the use of process improvement knowledge if you're too scared to use it? See:


NYC Patient said...

Did others read the story in the Times this week about the soldier who got a Silver Star AND a career-ending letter of reprimand, for the same incident?

I think the paranoia about repercussions stemming from investigation naturally keeps professionals from wanting to spend too much time on what went wrong.

76 Degrees in San Diego said...

Wow, some people are venomous! Many of these comments demonstrate a lack of understanding of a medical school curriculum. When you add a new segment to a curriculum, you have to take something out. Each person involved in medical education deeply believes that their area is essential. So, curriculum committees are faced with the very difficult task of ranking and reranking priorities for the student's education. It is also paramount that the teachers provide a concise, understandable, and useable aliquot of information. Students of all types quickly "turn off" to poor teaching. They are "under the gun" with their performance measured at each step over and over. It is the responsibility of the proposed teacher to present a proposal to the Curriculum Committee for evaluation, ranking, and possible incorporation into the overall teaching. As far as I know, the earth rotates on a 24 hour basis; sleep is necessary; as are other things. So, submit it in writing!

Anonymous said...

76 degrees:

I saw no venomous comments above. I repeat, READ the report. It addresses your issue also. The people who wrote it are not laymen, after all.

nonlocal MD

Anonymous said...

I agree with nonlocal. This is all a very reasonable discussion.

Anonymous said...

Ha! Good old Maggie the pit bull gets hold of this:

Of course she starts with the most sensationalist part, but promises a part 2. The comments should prove interesting....


Anonymous said...

I am a medical resident. To answer your question there is precious little on care delivery and process improvement. We are cheap labor and anytime we are not working clinically requires someone to get paid to do the work.
My education in this area is strictly of my own initiative and largely drawn from reading your blog daily.