Monday, April 30, 2012

How to become a partner in your health care

People are talking more and more about patient-centered care.  What does this mean?  It means having a health care system that allows and encourages greater participation in people’s preventative care and, when they need it, in medical treatment at their doctor’s office or hospital.  But it takes two to tango in this kind of world.  Obviously, doctors and nurses and other health care providers need to be open to this partnership.  But patient-centered care also relies on patients to be more informed consumers.

“Oh, no,” you are saying, “He wants me to be an expert.  That’s why I go to my doctor in the first place.” Not at all.  I just want you to know that you can help your own cause by being informed.  But, like you, I want this to be an easy as possible, and I don’t want to spend a lot of time doing it.  I want it to be interesting, and maybe even fun.

Along those lines, here are two free services that can help you be a more educated health care partner.  I think they are really well written and engaging.  You will even like reading them when you do not need medical care.


I don’t know about you, but I am often at a loss when I read or hear stories about great new advances in medicine.  What does this new research mean to me or my elder relatives or to my children?  Where can I learn more to help me translate a two-minute story on television, to decide if it matters?

Well, Aaron Rosado and some fellow students at the Emory University School of Medicine want to help. They created a website called uPrevent.  Aaron sent me a Facebook message the other day telling me about it, noting, “Our main goal is to produce a body of distilled knowledge for people compiled from numerous peer reviewed resources that simplifies information allowing for greater accessibility. Our goal is to create a blog that empowers people with information they can use to make informed decisions about their lifestyle and healthcare.”

As you can tell from this Facebook profile picture (!), these are well intentioned and generous young people.  They note:  “We  . . . derive no profit from these pages, nor do we intend to. We are not selling any treatments nor do we have any financial interest in any companies selling medical products. The information on the site is presented for the sole purpose of disseminating health information for general educational purposes only.”

I checked out the site and found it readable and interesting.  There are stories on a number of topics, for example, birth control, weight loss surgery, and ankle sprains.  There are also stories about lifestyle choices.  For example, one article discusses the Mediterranean diet and explains the health benefits of it.  The articles assimilate the latest research advances, and at the end of each article is a list of technical papers and other resources for those who want to dig in further.  But, you don’t need to do that to get a lot of good information.

Journal of Participatory Medicine

For those who want to focus on improving the doctor-patient or nurse-patient relationship, there is the Journal of Participatory Medicine.  This is published by the Society for Participatory Medicine, which defines itself as part of a movement in which “networked patients shift from being mere passengers to responsible drivers of their health, and in which providers encourage and value them as full partners.”  The journal is a peer-reviewed and freely available to all “with the mission to advance the understanding and practice of participatory medicine among health care professionals and patients.”  The editorial board of JPM comprises an impressive array of people from a variety of backgrounds who have banded together in support of this cause.

You will find different kinds of articles at JPM.  There are often pieces offering examples of where and how medical partnerships work.  For example, a recent editorial by editors Joe and Terry Graedon entitled “Making Every Second Count” has the following teaser: “Let’s face it, the good old days when you could schmooze with your doctor are long gone. But there are ways for patients to make every second count during brief office visits.”

But there are also articles about cases where that kind of partnership is non-existent.   There is research on how to improve the patient-doctor experience.

In other words, JPM is not about specific diseases and cures.  It is about ways to improve the practice of medicine and the delivery of care by building stronger relationships between patients and their health care providers.  The perspectives offered are valuable, and you might find that you can apply the lessons to your own life or that of a loved one.

With the ACPE

I had the pleasure of addressing the Vanguard Program of the American College of Physician Executives at the ACPE annual meeting in San Francisco.  The goal of this program is to empower and inspire this group of 100-125 senior physician leaders to practice transformational leadership in health care, something they are uniquely gifted and positioned to do.  After they were welcomed by ACPE CEO Peter Angood (seen here), I gave a talk focused on the the leader as coach.  My lead was borrowed from the legendary coach John Wooden, who once said "You haven't taught until they have learned," suggesting that a failure of a team to learn is more a statement of the teacher's inability to present the lesson well than the students' inability to learn.

My talk was followed by that of Andre Delbecq, McCarthy University Professor at Santa Clara University (seen here), who presented similar themes.  In particular, Andre reinforced the message that while managing change is a key leadership challenge, change requires movement away from "expert decision making" to managing a discovery process and pooling judgments.

This theme of physician leadership and innovation was pervasive during the day, and the group was fortunate to hear from a number of experts in both the plenary sessions and workshops.  I was pleased, for example, to have a chance to talk with Dr. James Thompson, of The Hayes Group International, who likewise reinforced the idea of physicians as mentors and the concept of servant leadership.

Attendees included people from many parts of the country, with highly varied backgrounds.  It was a convivial and good humored group, especially when one took into account a Sunday morning 7am starting time!

Saturday, April 28, 2012

Dancers en route to Iceland

Continuing our dance culture break from health care issues, I want to share this short video -- a compendium of excerpts of longer pieces -- produced by choreographers/dancers Rebecca Levy (yes, related) and Tiffany Fish.  It was posted as part of a web-based campaign to raise funds for the two of them to attend an artists' residency in Iceland.  That campaign succeeded, and now they will be off to the quiet north country to produce new pieces.

If you cannot see the video, click here.

Friday, April 27, 2012

Nick Cave's soundsuits

Continuing our culture break from health care, this is a wonderful video about Nick Cave, an interesting artist who creates "soundsuits" and then uses them as costumes for people in modern dances.Two minutes well worth watching.

Thursday, April 26, 2012

Prepared at the Boston Ballet

A culture break to get away from health care stuff for a moment.

Seen at the Boston Ballet's opening night of Rudolf Nureyev's Don Quixote, this young understudy for the prima ballerina was napping comfortably on her mother's shoulder before the show -- but clearly dressed to perform -- just in case she might be called in to substitute.

She was not called, as it turned out.  (I wonder if she ever woke up.)  The performance was wonderful, and I highly recommend subsequent shows to people in the Boston area.

Old data is valueless

A part of my presentation to folks in Denver related to the organizational value of clinical outcome transparency in helping the clinical staff to hold themselves accountable to the standard of care that they value for their hospital.  (Regular readers of this blog will not be surprised by that message, as I have been making this case for a long time!)  One person later suggested that this was being accomplished in Colorado because the state government has had a website for several years with publicly reported data.

Well, not so.  Sure, there is an official website, but the data contained is old and not helpful for the purposes I have set forth.  Here, for example, are the rates for central line associated blood stream infections.  The data is from 2009 and 2010.  The chart says nothing about the current state of things.  Try to imagine how you could possibly use the posted information in your hospital if you were committed to reducing patient harm.  You really cannot.  As I have noted with regard to another such site run by CMS and a recent report from the CDC, unless real-time data is presented, such presentations offer no value to clinicians in helping to improve care in their organizations.

The existence of government websites of this sort does not preclude a hospital or group of hospitals from expanding the concept of transparency and offering value to the clinical staff by posting real-time information on progress in reducing infections and making other clinical improvements.  Whether such transparency is adopted is solely a matter of local choice, and each place needs to make its own decisions as to the value thereof.  The hospitals in the New Hampshire Hospital Association, for example, have to decided to present a website with much more recent information on topics of interest to them.  This is part of a jointly determined common goal of eliminating patient harm over the next few years.

Wednesday, April 25, 2012

Residents report and learn about quality and safety

Day two of my visit to Denver to learn with residents who are part of the PSE Partnership quality and safety training program was as satisfying as the first day.  The highlight was being present for resident report at Swedish Hospital.  The session was supervised by Dr. Scott Strauss, an attending physician in the family practice group, with chief resident Brieanna Seefeldt leading the discussion of two fascinating cases involving a number of quality and safety issues (both pictured here).

First year resident Erica Liesmaki (shown here) presented the details of the cases in a clear and organized fashion.  Those details of the cases matter less for our purposes here than overall characteristics that are present thousands of times across the nation and the world.  Problems of work flow design, hand-offs, communication, and protocols all were evident.  The value of this training program was also evident, though, as the residents displayed an excellent grasp of how to analyze flaws in care delivery and to make recommendations for improvement. 

Seeing quality clearly in Denver

I am spending a couple of days in Denver as the guest of the PSE Partnership.  This is a small non-profit that has received a grant from The Colorado Health Foundation to provide patient safety curriculum for medical students and residents in three 3 metropolitan area hospitals that are part of the HCA/HealthOne network.  In this picture, you see Shelly Dierking, who runs PSE Partnership, with Brian Dwinnell, director of graduate medical education at Presbyterian/St. Luke's Medical Center.

The day started when I joined a small group to watch teaching rounds on a medical unit at P/SL.  Dr. Erin Marcum, an internal medicine attending, was in charge, and her brood included Sara Grace, a transitional year intern, and Obiora Chidi, a third-year medical student on his first rotation in the hospital.

Obi, Erin, and Sara consider a patient's needs
There is something remarkably old-fashioned about teaching rounds.  You really get the feeling that you are watching the apprentice system of old-time craftspeople at work.  And, in fact, that is a large element of what goes on.  The residents and students are given the responsibility of analyzing and summarizing each patient's condition and recommending a treatment plan.  While there is an order and protocol to their rounding -- subjective assessment, objective assessment, and treatment plan -- each presentation is a stand-alone report, incorporating the experience, skills, judgment, and intuition of the trainee.

This is a necessary part of medical education, for sure, but as I have noted elsewhere, rounding does not generally teach residents and medical students about process improvement in hospitals.  So, the work done by Shelly and her colleagues is an important supplement.

Today, though, I had a chance to see an excellent teacher in action.  Obiora was responsible for reporting on two patients, based on what he had learned earlier from the nurses, test results, and chart reviews.  This being his first day, he was understandably nervous:  You could literally see his mind churning as Erin would ask questions.  But, she in turn, was an excellent practitioner of the Socratic method, gently applying and relieving pressure, allowing him to learn adaptively.  As Ronald Heifetz would have admired in his book Leadership Without Easy Answers, Erin was displaying a strong aspect of leadership, "a special sort of educating in which the teacher raises problems, questions, options, interpretations, and perspectives, often without answers, gauging all the while when to push through and when to hold steady."

Later, I was invited to address many of the residents in Shelly's program, focusing on issue of quality and safety improvement, transparency, and front-line process improvement.  Following that talk, it was off to the University of Colorado Anschutz Medical Campus, for another presentation in front of the local chapter of the IHI Open School.  My hosts (seen here) were Wendy Madigosky, the faculty lead and the director of the Foundations of Doctoring Curriculum, and Daniel Stoll, a first year medical student and president of the local chapter.  Again, the topics of the day were quality and safety improvement, transparency, and front-line process improvement, but also with a strong emphasis on engaging patients and families in hospital decision-making.

All in all, it was a very full day and rewarding for me and, I hope, the students and faculty with whom I met.  I was left, though, with one unanswered question:  What on earth is this sculpture on the Anschutz Campus supposed to symbolize, if anything?

Tuesday, April 24, 2012

The choice facing New Hampshire

The saga to give preferred treatment to private specialty hospitals in New Hampshire continues this week.  You will recall that the House of Representatives approved a series of measures that would grease the skids for entry of Cancer Treatment Centers of America® and other such facilities.  Now things move to the Senate Health and Human Services Committee, which is holding hearing on bills this Thursday at 1:00 pm in Room 100 of the State House.

There are two bills.  One, HB 1617, would eliminate the state's certificate of need process.  The other, HB 1642, would give preference to to specialty hospitals under the existing CON process, plus offer other financial advantages.

My regular readers know that I am no fan of protectionist policies designed to secure the market position of incumbent health care providers, but this debate seems to me to be quite different from that.  These bills are designed to take existing regulatory structures -- which were adopted to protect against "supply push" expansion of health care utilization and costs -- and throw them aside for a special interest group.  In addition, there can be little doubt that passage of the bills would allow these specialty facilities to direct their marketing to patients who have private insurance.  This kind of cream-skimming would have an adverse affect on the state's community hospitals.

As an aside, I notice that the Boston media has completely ignored this story even though the legislation would have spill-over effects.  The House bill, for example, provides that these specialty hospitals must target patients from out of state.  Clearly, they would look for patients from the Massachusetts-New Hampshire border region.  That might not be of great concern to the Boston-based academic centers, but it surely should be a concern for those community hospitals in northern Massachusetts that offer local service to cancer patients.

Un-Lean hotels

Hotels, like hospitals, provide an excellent environment for the Lean process improvement philosophy.  There are many opportunities for improvement in work flow, reducing waste, and enhancing both customer service and the work environment for the staff.  Here are two recent stories that illustrate the potential.

On Sunday, my correspondent Sharon reported:

I thought you would enjoy this example of inefficiency.
We are spending the weekend at the Westin Copley.  We went for a walk this a.m.  We returned to our room, which had been cleaned.  Dirty glasses had been removed, but had not been replaced with clean ones.  I hunted down the housekeeper who said, "I don't do glasses."  I asked, "What do you mean you don't do glasses?"  She said that was handled by someone else.  I asked her to find that person and bring us two glasses.  45 minutes later, the same housekeeper showed up with one glass.  I reminded her I asked for two.  Ten minutes later she arrived with another glass.
Add that to the fact it took 90 minutes for them to get our bags to our room upon check-in, I would say this property needs to try Lean!

Last week, I was at the Delta Bessborough hotel in Saskatoon. This is a wonderful old property, built by the Canadian National Railway during the Depression.  It is currently going through renovations.

At midnight, the fire alarm sounded on my floor.  I quickly dressed and went to the door, carefully using the peephole to check hallway conditions.  Seeing no smoke, I opened the door to look out, finding other people on my corridor doing the same.  We were not sure if it was a false alarm or the real thing.  No announcement was made on the public address system, and nobody from the hotel was to be seen to advise us.  As my room was immediately adjacent to the emergency exit stairway, I thought I could take a chance and wait a few minutes.  (Hey, it was cold outside!)  Sure enough, 15 minutes later, the alarm was turned off.

The next morning, I went to the desk clerk and suggested that it would have been helpful to provide information to guests during the fire alarm.  She apologized, saying that the PA system was out of service during renovations, as was the fire alarm control panel.  Also, there were only two people on duty when the alarm sounded, and so they couldn't leave the front desk uncovered to go up to the floors and provide information.

"Rest assured," she said, "If it had been a real emergency, you would have received notification and advice."

I thanked her and then said to myself, "How?  How would I have received any more notification?  The same conditions would have been present as during the false alarm."

It seems to me that if a hotel's safety systems are not working properly, it is a good idea to notify all the guests as they check in, so they can be prepared for contingencies.  Indeed,  how could the local fire department permit the place to receive guests without that kind of contingency planning?  In Lean parlance, shouldn't the work flow of the staff be changed to reflect a new set of potential customer needs?

Monday, April 23, 2012

Please pretend to pay attention

I know some business travelers who try to avoid Southwest Airlines:  Some don't like not knowing what seat they will have on a flight.  Others habitually fly in business class and don't like the democratization of seating on Southwest.  But, to me, the sense of humor and warmth displayed by the gate agents, pilots and flight attendants always make it a pleasant experience.  And, how often do you finish a flight on another airline saying, "That was a pleasant experience"?

What I really like is how the flight attendants intersperse humor into the standard announcements.  They get a laugh, but they also cause you to actually listen to those important matters.  Safety experts will tell you that the routine repetition of safety procedures can lead to complacency, something to be avoided.  So there is method to the SW madness.  Today, Vanessa started by saying, "Please pay attention -- or pretend to pay attention -- to these important safety instructions."

"In the event of a loss of pressure, put your oxygen mask over your big nose.  Place your mask on first if you are traveling with small children or with anyone behaving like a small child."

"The flight attendants will be coming down the aisle to ensure that your shoes match your attire."

But then, an unexpected laugh, when Vanessa announced that some old version of Southwest's free drink coupons that have no expiration date were no longer valid.  I pointed out the contradiction to her, and she giggled, saying, "I didn't even realize what I was saying!"

Bringing medicine into the age of computers, finally

The economic stimulus package passed in 2009 contained billions of dollars designed to encourage hospitals and doctors to install electronic health records (EHRs).  At the time, an exceptionally small number of health care providers had computerized medical records.  It is hard for those of us who are used to dealing with credit card companies, airlines, automobile service departments, utility companies, and the like to imagine that the medical world was living in the Dark Ages.

Here was an industry that hadn’t even arrived in the 20th century – much less the 21st century -- in terms of computerization.  Accordingly, the idea of the legislation was to both create jobs and also pull the industry up by its bootstraps.

Everyone understood that this would not be an easy task, but it was the right thing to do.  Without EHRs, if you show up at a new hospital and the doctor there needs your medical history from your home institution, the file of paper records needs to be extracted from the archives.  Then, believe it or not, it is faxed a page at a time to the doctor who is treating you.  That’s if you are lucky.  Many times, the process is just too burdensome and time-consuming.  If you are waiting in an emergency room, chances are they will not even try to obtain this information.  The result is that tests you might have had recently will have to be repeated, a high cost, when you enter the new facility.

But not having EHRs is a problem even if you go to your regular hospital.  There, too, your doctor needs to put in a request for someone to dig up your files and have them delivered or faxed to his or her office.  Not only does this create delays, it offers a high probability that your doctor will not have key information about you as he or she begins to diagnose and treat you.

But all is not hunky-dory even in those places that have EHRs.  In many places, doctors and nurses resent having to enter data into the computer.  They say that it interferes with their communication with the patient and takes up too much time.

A recent comment by Kristin Trotter, director of clinical excellence at Northern Nevada Medical Center, properly finds fault with this view.  (I reprint this with her permission.)  After reading a number of comments along these lines in a national patient safety chat room, she noted:

I have been reading this series of emails complaining about what is perceived to be excessive computerized documentation on patient care that takes the clinician away from spending time with the patient.  I think it’s appropriate to remember that documentation is a communication tool.  It’s meant to document the care provided to the patient in a way that lends to communication with other clinical partners that may or may not be available for face-to-face discussion about the patient.  It’s meant to pass along information in real time to other caregivers and provide an up-to-date and historical record of the care provided to the patient during their stay so that I can plan my care based on current information and go back to review, to answer questions that may have arisen, and to adjust my care plan throughout the patient’s stay, based on care that has been given. EHRs can also serve as a checklist to assure that I have done everything that for the patient that is in my care plan.

I’m just saying that maybe you need to reflect on your own practice and really determine what it is that you don’t like about EHRs. Is it about you? Or about the patient?

I know I’m going to make some people mad.  But I have done many chart reviews over the years and dealt with many patient complaints and risk events. I can tell you that I have rarely heard a patient complain about the doctor’s or nurse’s inattention being related to charting. The complaints I receive involve the nurse or doctor not coming into the room, not interacting with them, and not explaining things. All of these things you can do while sitting at the computer charting, examining, and conversing with the patient. 

I think this is really well said.  The core message offered by Kristin is that the task for doctors and nurses is to deliver patient-centered care.  EHRs are a tool that can facilitate this.  However, like all computer systems, unless the flow of work underlying the use of the computer system reflects a clear set of values and procedures that carry out those values, a lot of that new federal money will have gone down the drain.

I don't mean to be critical. Well, yes I do!

Regular readers know that I am a strong advocate for forgiving mistakes, especially in clinical settings where systemic problems are often at play, causing errors to occur.  Notwithstanding that, in art, literature, and science, there is a place for unvarnished criticism.  After all, when we put ourselves out there with with a piece of work, it is ours alone, and it is free game for anyone who wishes to comment on it.

My daughter, the choreographer, likes to remind me that "you are neither as good or as bad as they say in the reviews."  That is something worth remembering.  But I want to present you with two negative reviews that are so artfully done that the authors should be immediately offered jobs as surgeons, so deftly do they wield the scalpel!

The first is a theater review by Charles Isherwood in the New York Times. You should really read the whole thing, but here are excerpts:

Time crawls to a dead stop as you watch “Ninth and Joanie,” a stupefyingly dull drama by Brett C. Leonard presented by the increasingly rudderless Labyrinth Theater Company at the Bank Street Theater. The actual presence of a kitchen sink might enliven Mr. Leonard’s kitchen-sink drama about an Italian-American father and son immured in grief in South Philadelphia. Watching the slow drip of a leaky faucet for two hours would be more entertaining than this misguided production, directed with ponderous indulgence by Mark Wing-Davey. 

After a bitter confrontation between the truculent Michael and his contemptuous father, an act of sudden violence — somehow both predictable and perfunctory — brings the first half to a bloody close. The second act picks up on the day of another funeral, but nothing much takes place, other than more sullen cigar smoking from Charlie, and another anomalous chunk of monologue from Michael’s wife, Isabella (Rosal Col√≥n), who has brought Michael’s son, Carlito (the very good Samuel Mercedes), with her. 

Mr. Leonard  may be accurate in his observation of these stubbornly inarticulate characters, but their aversion to talking is a serious drag on a work of theater. It’s hard to grope for meaningful subtext when such minimal text lacks point. Rocco’s noodling with his Ouija board and the repeated playing of Vic Damone’s recording of “An Affair to Remember” constitute the play’s primary actions. 

Like too many Labyrinth productions, the play mostly seems to be a vehicle for actorly calisthenics. But Mr. Leonard’s flaccid writing doesn’t give them much of a workout.

The play’s slow fizzle of an ending is the final affront. The lights come up on the audience, suggesting liberty at last, but Mr. Glaudini remains rooted to his chair. Eventually he rises to stomp upstairs again, but Mr. Corrigan remains stubbornly hunched over that Ouija board. It’s a wonder the audience’s collective consciousness couldn’t prod that plastic doodad to spell out the words: “Enough already. Exit stage left!” 

The second is a book review of The Origins of Grammar Language in the Light of Evolution by James R. Hurford by Robert Berwick in Science. You have to subscribe to get the full text. Here are excerpts:

Wide-ranging and often entertaining, Hurford’s three-part account is nonetheless just a story. Crucially, despite his unflagging commitment to Darwinism, he has missed even Darwin’s own solution to the problem of novelty, one readily applicable to language. For Hurford, gradualism and continuity entail changes of both form and function. But Darwin appreciated that there had to be discontinuities of function maintaining continuity of form.

Indeed, a relatively rapid emergence of language seems to square much better with the paleoarchaeological record. Whereas Hurford’s account demands a long, slow trek from symbolic activity and single words to language, unequivocal evidence of symbolic activity first appears associated with Homo sapiens (e.g., the engraved shells in Blombos cave, 77,000 years ago). Going back that far takes only 2600 generations, too little time for a slow trek.

In addition, Hurford repeatedly presents interpretations without providing data to support them.

Biologists expecting a worked-out evolutionary model will walk away disappointed. Despite its subtitle, the book lacks explicit fitness calculations, survival and reproduction schedules, generation times, and, indeed, anything resembling the basics of population or behavioral genetics.

Tellingly for such an inherently historical science as evolution, the book contains very little about established hominin prehistory. There isn’t even an illustration of perhaps the single most striking fact about hominin evolution: whereas this clade once formed a bushy tree with many coexisting species, now there is only one lineage left, us. To be sure, Hurford does not seek to provide a historical explanation—he identifies his concern as “the ‘Why?’ and ‘How?’” of the origins of syntax. But history does matter.... We can shed all of Hurford’s speculative baggage.... All these empirical problems fade away, leaving us with a story altogether different from the one told in The Origins of Grammar.

Sunday, April 22, 2012

Do ICUs make a difference?

Here is an interesting article from the Archives of Internal Medicine, sent to me by Marco D. Huesch, MBBS, PhD, of the Leonard D. Schaeffer Center for Health Policy and Economics at the University of Southern California.  The article is by Henry Stelfox and others and is entitled "Intensive Care Unit Bed Availability and Outcomes for Hospitalized Patients With Sudden Clinical Deterioration."

Looking at a cohort of 3494 patients in Alberta, the study team investigated whether clinical outcomes varied depending on whether such patients were treated in the ICU versus the regular wards. In a nutshell, there was no difference in in-hospital mortality for these inpatients with sudden clinical deterioration, when they were effectively randomized (as a result of temporal variation in ICU capacity) to receive ICU referral or ward treatment. 

Perhaps this suggests that, in this study, many patients who are too well to benefit -- or too sick to benefit -- from ICU care tend to occupy ICU beds. Does the data about the latter group have implications for our efforts to improve critical care?  Does the data about the former group suggest that we are incurring the expense of ICU treatment when it is not always necessary?

I'd love to hear from you critical care folks out there.

More devices, less communication

What if all the new gizmos we have -- iPhones, Blackberries, and the like -- are actually degrading the level of communication we have?  That is the premise of an article in the New York Times by Sherry Turkle, entitled, "The Flight from Conversation."  What if that is carrying over, in a perverse way, into health care?

First, some excerpts from the article:

We live in a technological universe in which we are always communicating. And yet we have sacrificed conversation for mere connection. 

Over the past 15 years, I’ve studied technologies of mobile connection and talked to hundreds of people of all ages and circumstances about their plugged-in lives. I’ve learned that the little devices most of us carry around are so powerful that they change not only what we do, but also who we are.  

We’ve become accustomed to a new way of being “alone together.”

Human relationships are rich; they’re messy and demanding. We have learned the habit of cleaning them up with technology. And the move from conversation to connection is part of this. But it’s a process in which we shortchange ourselves. Worse, it seems that over time we stop caring, we forget that there is a difference. 

We are tempted to think that our little “sips” of online connection add up to a big gulp of real conversation. But they don’t. E-mail, Twitter, Facebook, all of these have their places — in politics, commerce, romance and friendship. But no matter how valuable, they do not substitute for conversation.

Now, look at this note from a friend, who has a friend who has been advised to have aortic valve surgery:

As I was talking to her, it became very clear that she has not utilized the primary resource available to her – the doctor in front of her. While ePatient Dave and others exemplify the ideal of the empowered patient, in my experience, this is uncommon. On average, American patients ask more questions about the new TV they consider buying than about their own health. Health care providers need to do a better job of communicating – without a doubt. But, this needs to be a conversation. And, in my experience, neither side is excelling in facilitating this conversation. I know AHRQ has made some attempts to promote asking questions of your doctor – but maybe a more robust effort to promote these conversations and, perhaps train patients to have them, would help to improve the quality of care. My friend is considering a second opinion. My question for her was how she will get any more out of this visit since she made so little of an attempt to extract information from her first visit.

An interesting parallel, no?

Saturday, April 21, 2012

Unethical and shameful behavior at the CDC

At the recent Health Care Quality Summit in Saskatoon, Sarah Patterson, the Virgina Mason Medical Center expert on Lean process improvement, noted,  "I'd rather have no board rather than an out-of-date board. They have to be real."  She was referring to the PeopleLink Board that is placed is key locations in her hospital to provide real-time visual cues to front-line staff as to how they are doing in meeting quality, safety, work flow, and other metrics in the hospital.

Now comes the CDC, announcing in April 2012, that 21 states had significant decreases in central line-associated bloodstream infections between 2009 and 2010.

CDC Director Thomas R. Frieden, said “CDC’s National Healthcare Safety Network is a critical tool for states to do prevention work. Once a state knows where problems lie, it can better assist facilities in correcting the issue and protecting patients.”

I am trying to be positive when progress is made, and I am also trying to be respectful of our public officials -- whom I know to be dedicated and well-intentioned -- but does Dr. Frieden really believe that posting data from 2009 and 2010 has a whit of value in helping hospitals reduce their rate of infections?

Try to imagine how you as a clinical leader, a hospital administrator, a nurse, a doctor, a resident, or a member of the board of trustees would use such data.  Answer:  You cannot because there is not use whatsoever.

I am also perturbed by the CDC's insistence on using a "standardized infection ratio" as opposed to a simple count of infections or rate of infections per thousand patient days.

Here's what the agency's metric means:

The SIRs represent comparisons of observed HAI occurrence during each distinct reporting period with the predicted occurrence based on the rates of infections among all facilities adjusting for key covariates (referent population).

The referent period remained January 2006 through December 2008, as in previous SIR reports.

The CLABSI and CAUTI SIRs are adjusted for patient mix by type of patient care location, hospital affiliation with a medical school, and bed size of the patient care location.

Affiliation with a medical school!  Wait, do you get a bye from this statistic if you are not affiliated with a medical school . . . or if you are? Why on earth should that matter when the issue is the use of a well established protocol to avoid central line infections?

So, the bad news is that CDC data from 2009 and 2010 is too old to be useful.  The good news is that the methodology chosen for reporting the data is meaningless.  The "predicted occurrence" is basically a benchmark based on a period of time in which central line infections were an epidemic in the country.

Jim Easton, from the NHS, put it well at the Saskatoon conference:

We need to improve ourselves as leaders:  Be intolerant of mediocrity, to hate it. Reject normative levels of harm.  It is not OK to be in the middle of the distribution of the number of people we are killing.

A friend of mine, working in a Midwest ICU, read Jim's comment and said,

It's not morally ok.  But it is, unfortunately, accepted as "reasonable."

Catherine Carson, Director, Quality & Patient Safety at Daughters of Charity Health System, put it this way a few weeks ago on a safety and quality litserv:

When the goal is zero – as in zero hospital-acquired infections, or falls – why seek a benchmark? A benchmark would then send the message  - that in comparison to X, our current performance level is okay, which is a false message when the goal of harm is zero.
Jim Easton reinforces Sarah Patterson's point by saying:

It is shameful not to share clinical quality information.  We have ethical obligation to share information about how well the health care system is performing.

Maura Davies, the CEO of the Saskatoon Health Region (seen here with the province's Minister of Health Don McMorris), summarized this for her staff in an email after the summit:

As we embrace Lean as the foundation of our management system, we are learning that when it comes to safety, there are only two numbers that matter: zero and one hundred. We should settle for nothing less than zero harm to patients or staff. We should expect 100 per cent compliance with the standards and evidence based practices we have adopted, such as the surgical checklist, hand hygiene and falls prevention. Are we up to these challenges?

I wonder if Dr. Frieden understands that his agency's policy with regard to this kind of information is, fundamentally, unethical and, indeed, shameful.

Friday, April 20, 2012

Survey request

AnneMarie Cunningham, @amcunningham on Twitter, is a clinical lecturer at the NHS from Cardiff, UK.  She asked me to share this short survey she is conducting about how patients and doctors prefer to be introduced to each other.  It will just take you a minute.  I'm sure she will share the results with us, too.

Addendum at 2:00 pm EDT, the survey is now closed.

Thursday, April 19, 2012

Is there anything else I can do for you?

Bonnie Brossart, CEO of the Saskatchewan Health Quality Council told this story at one of the sessions of this week's Health Care Quality Summit.  I asked her to send it to me, and I reprint it with her permission.  It provides a remarkable example of what it takes to deliver exceptional care.  Sometimes, all that is required is for a nurse or doctor to remember to ask, "Is there anything else I can do for you?"  We know that in other service industries -- from hotels to stores to restaurants -- people make a practice of this.  Why can't those folks who work in hospitals?  Hint: It is not because we are too busy.  Or that we don't care.

My son Matthew lives with Autism Spectrum Disorder and a moderate intellectual disability.  About 5 years ago he was also diagnosed with Cyclic Vomiting Syndrome (sometimes known as an abdominal migraine).  Essentially, something triggers Matthew to throw up and he can’t stop without the support of intravenous medications. When he has an episode it’s not uncommon for him to go the ER three or four times within a two day period.  A couple of years ago, he was having quite a bad spell with episodes happening every two to three weeks.  Matthew became quite well known in the Pediatric ER with many of the nurses and doctors greeting him personally and giving him very thorough and kind care.  But could I (or Matthew) say the care was truly patient centred or exceptional?  Once we could – here’s why.

When an episode starts, Matthew’s communication completely shuts down – in part due to the incessant vomiting and second (we think) because of the pain or consequence of the migraine.  The only way he really prefers to communicate during this time is with hand signals. One afternoon in the ER, with Matthew semi-resting following the administration of the pharmaceutical cocktail that helps appease the vomiting, the pediatrician in charge came by and sat on the corner of Matthew’s bed.  We had established a bit of a relationship with her in part because she’s treated Matthew a number of times and she has been involved in some quality improvement efforts in the Pediatric ER (and knows I work in a quality improvement organization).

On that day, we were talking about patient experience surveying (and the results within her hospital) and I asked her how she would know when a patient has received exceptional care, and to make it easier, I suggested we use Matthew’s current experience as an example.  She thought about that for a moment and then began to offer a list of what I would say were very legitimate and contributing factors to an exceptional experience – the team provided very clear explanation about the condition and what they were doing (including checking and naming the medications before they were administered, what the medications were for, etc), she demonstrated active listening, ensured I understood what to do upon discharge, etc.

I agreed these were all wonderful things and I (and Matthew) really appreciated them.  I then asked her if there was anything else she would do.  She replied she didn’t think so but was curious enough to ask, “Do you think there’s something else?”  To this I replied, "Why not let Matthew have the last word (if he chooses)" -- since neither of us were sure he would speak but noticed see he was awake.

So she asked “Matthew is there anything else I can do for you today?”  Quietly and croakily Matthew replied, “Popsicle.”  After throwing up more than a couple dozen times, can you think of anything more relieving or soothing?  For Matthew, this is what exceptional meant.  I knew it and so did the pediatrician.

Matthew’s health has improved considerably and it’s been quite a while since he’s had an episode.  I can’t help but wonder whether that curious, thoughtful pediatrician still asks the patients she sees (or their parents if they can’t respond) the same question she asked Matthew that day.  I hope so because that’s the kind of care everyone deserves, every time.

Wednesday, April 18, 2012

Sarah Patterson informs about Lean

#qualitysummit  Another featured speaker at the Saskatchewan Health Care Quality Summit was Sarah Patterson, executive vice president and chief operating officer of Virginia Mason Medical Center, the leading adopter and proponent of Lean (or Toyota Production System) process improvement in hospitals.  Her presentation was a masterpiece of description and discussion of the Lean philosophy.  If it is posted on the web, it will be well worth your time.  In the meantime, as I did for the Jim Easton talk, I am going to post my live Twitter feeds to give you a sense of her major points.

Patterson: Using Lean provides a common language for process improvement. Small size of province offers oppty to experiment.

We understand the important role of leadership, throughout the organization.

Other orgs often talk about inability to sustain progress. Frustration of lack of stability.

Would like Va Mason org to operate like an aircraft carrier. How to run a complex business safety.

Aircraft carrier= an airport on top of a nuclear power plant comprising a bunch of 19 year olds!

Aircraft carrier needs complete alignment with the mission. If not done well, puts others at risk.

Aircraft carrier requires an incredible commitment to adoption of standard work. Relentless focus on training.

Aircraft carrier requires enforcement of accountability.

Create jobs that are doable. Train people to do them. Hold people accountable to them.

Virginia Mason story begins in 2000, looking for way to improve and assurance of accomplishing that.

Adopted TPS=customer first, highest quality, obsession w/ safety, staff engagement, successful economic enterprise

Declaration of zero defects was unheard of in health care. Essential aspect of TPS (Lean).

"Elegant" staff engagement system is inherent in Lean.

Lean 4Ps=philosophy; process; people and partners; problem solving. Not a program! A long-term philosophy.

TPS focus on process, not on the outcomes. Build key features into processes that are waste free, continuous flow.

Grow leaders. Respect, develop, and challenge your people, but also vendors (who are partners.)

Problem solving, knowing what is going on on the front lines, when problems are fresh.

AT VM, still have problem implementing and sustaining standard work, e.g., in primary care.

92% of Rapid Improv. Event results sustained after 2 months. Not good enough. Would drop further after 6 months.

Could this be because of current management system? Too much reliance based on superheroes? Great crisis mgrs?

Sterile processing superhero, knew everything, went on vacation! Surgeons left unserved!

VMason had to go back to TPS training. What did we miss?Hadn't given middle mgrs enough training about new roles.

Middle mgrs viewed TPS as an add-on, additional work with new tools. Need comprehensive mgmt system.Back to school!

Need regular management presence where the work happens. A transparent environment. Clear and complete goals.

Mgmt by policy + daily mgmt + cross-functional mgmt = world-class mgmt system.

Management by policy = long term vision, 5 year plans, annual goals.Reflection.Share environmental scan with all.

Mgmt by policy: One stage is "Catchball." Draft of policy shared deeply in the organization. Get feedback.

Catchball staff engagement, shared with 1000 people last year. Next year, 5000.

Deployment. Need process for negotiating what is effective work, resources required, and people's commitment.

More careful scoping of projects is an imp discussion to have in the organization. Signoff by key people.

Multiple executives responsible for projects. E.g., CFO responsible for safety improvements!

Regular mtg for check and review. Short updates. Who needs our help?

Cross-functional work is essential. Where creativity really happens. Blame for silos lies with the top leaders.

(Me) Review what she says to see a fundamentally different role for leaders.

Daily mgmt: Know at a glance status of work. Satisfying customer demand? Std work being followed? Engaging staff?

If our front line staff are telling us it is bad, do we know this? Are we acting to help fix it?

Leaders' 2 jobs. 1 -- Run your business, while ensuring stability. 2 -- Improve your business.

Start with understanding your demand; and knowing your supply; standard work developed and posted.

Track your business on a HOURLY basis, or you can't understand process flaws and improvement opp'ties.

Everybody on the floor needs visual cues as to status of work and meeting customer demand. In real time!!!

Every hospital needs in-the-room nurse-to-nurse bedside handoff. Every time.

Toyota cord-pulls, happens often. 30 second response by leader to be on worker's side.

In hospitals, too, need real-time ID of problems and responsiveness by leader. At the work station!

Elements of daily management = leader standard work + visual controls + daily accountability process + discipline.

Whoa! Leader standard work, too! What a concept. Can't be "too busy" for this!

With leader standard work made visible, staff now know, "Oh that's what leaders do!"

Visual controls focus on the process and make it easy to compare expected with actual performance.

At Virginia Mason, patients can see the visual controls in the waiting rooms -- e.g., MD-specific delays.

If MD gets behind by more than 10 minutes, resources are brought to bear to provide support and get back on sched.

Other visual cue examples.Note: Not sophisticated computer reports.Just white boards with stickies! In real time!

Gives list of foundational elements of hospital nursing care. Every unit, every day. Auditing process, too!

Choreographed and sequenced system of daily accountability. All units have daily huddle.

Daily accountablity. PeopleLink Board used for 30 minute stand-up meeting once a week.

Senior leader regular gemba rounds to view one aspect of standard work.

"I'd rather have no board rather than an out-of-date board. They have to be real."

Email from Amy, "I'm just a biller, but I look forward to every Thursday morning at 7:30."

Amy, "We have a common purpose and a common language."

Audience Q:  Recruitment. Didn't want people who had all the answers. Looked for curiosity. Learners. Communication skills.

Created leadership development curriculum to develop competencies, but look for innate characteristics.

Audience Q: How to take current work off the plate? A: Take things away (reports) that are needed. But don't wait.

Things that used to take leaders a lot of time don't take time, because of connection to staff, issues tracking.

"Just tell them to do it. Don't be afraid. It won't be perfect. Try it. Fail. Try it. Change. Keep going."

Jim Easton inspires

#qualitysummit Jim Easton, national director for improvement and efficiency of the National Health Service, was the keynote speaker last night at the Saskatchewan Health Care Quality Summit.  (You see him here with Bonnie Brossart, CEO of the Health Quality Council.)  His was one of the most engaging and inspirational speeches I have ever heard on the topic.  I think it might be available on line in the future, but I wanted to present a summary here.

I think I'll do it, though, by just reposting my Twitter comments as the speech was delivered.  (You can also see them by searching using the hashtag above.)  While not doing full justice to Jim's eloquence, you'll get the drift.

Jim Easton tells Sask that they are doing great work - truly remarkable. But that's just the beginning. It's hard work!

It is tough to change attitudes and practice. Despite the commitment of people, a paradox.

Universal system really matters to UK and Sask. We need to remind people that we are protecting that. A leadership responsibility.

Improvement of health delivery system is the most important task in society. 

Cost reduction. Quality revolution. Patient empowerment. Three aspects of paradigm shift.

We the people running health care are killing it (costs) so we have responsibility 2 change it.

We have a responsibility to fix the unsustainability of the health care system

Easton aiming to save 20 billion pounds by 2014 for NHS! 

The cost problem is an ethical issue. Money is medicine.

Quality revolution. Examples of success exist but health care is still not a self-improving industry.

Shameful not to share clinical quality information.

Quality improvement driven by front-line is powerful. But we need to improve the improvement, to make it better.

We have ethical obligation to share information about how well health care system is performing.

We need to spread and increase the rate of improvement. Rate of both is 2 slow.

We love to hear from patients when they praise us! Easton. But we need to hear criticism better.

Criticism can be attributed to "difficult people." We are still early in this journey of listening.

How 2 accelerate change? Need to use all levers in a coordinated fashion. Leadership for change is one. Need skills.

Leadership is not an amateur sport! Need disciplined development.

Two: you need a plan for spreading innovation.

Three: have an improvement method like Lean. Common language. Skills will spread.

Four: engagement to mobilize. Communication. Have to tell the story of change right.

Tell the story over and over. 100 percent of ur time. Relentless communication.

Five: use system drivers and align with the desired changes. Money, salaries, investment. People spot those things.

Six: transparent measurement. Morally right. Powerful tool for change.

Seven: rigorous delivery. E.g. Waiting time. Link this to quality improvement.

Need to improve ourselves as leaders. Be intolerant of mediocrity, to hate it. Reject normative levels of harm.

It is not ok to be in the middle of the distribution of the number of people we are killing.

It is uncomfortable to be the person saying we are not doing well enough.

Easton says he's been called bully for saying good enough isn't good enough when it comes to quality, safety.

Be a personal champion of spread.

Harness the good difficult people. Deal with the bad difficult people. Don't allow blockers to block. Tackle this.

Staff always responds well in a crisis. Need to give value to calm ordered care.

Runs of routine success are what matters.

Reward ordered routine care.

Improving ourselves as leaders: This is hard. Get support.

Physician Breakfast Club

#quality summit Where do doctors go for a safe place to try out ideas?  That was the topic of a breakfast meeting this morning at the Saskatchewan Health Care Quality Summit.

A couple of years ago, a few Saskatoon-based doctors decided that they would start a physician breakfast club to provide an informal venue for people interested in quality and safety improvement to share stories and provide mutual support.  Although a small group, they applied a thoughtful discipline to their approach.  They decided ahead of time what their goals were; limited the group to seven or eight people; committed to a meeting interval of six to eight weeks, scheduled for a year in advance; decided that a quorum of two people at any given meeting was acceptable; engaged a non-physician helper to organize the sessions and prepare minutes; and adopted a policy of summarizing and critiquing each meeting at its conclusion.

Today, the core group of the breakfast club presented this concept to doctors from throughout the province, offering it as a potential model to be replicated and/or adapted.  Here you see, Mark Wahba (right), an emergency room doctor, explaining the idea.  He told the story of an idea he had to obtain feedback from his ER patients after discharge, something that is often lacking.  When he presented his thoughts to his ER colleagues, they were not supportive.  But when he brought it to the breakfast club, people were less judgmental and offered suggestions that led to his plan being implemented.

Also shown in the picture is Debra-Jane Wright, who serves as organizer and scribe for the group.  Beyond being a note-taker, she summarizes and consolidates the thoughts of the group session.  In the words of Dr. Susan Shaw, another group member, "She makes us sound really smart!"

The conversation this morning taught me something about doctors, too, the sense of isolation they feel in their profession, particularly as they are promoted to leadership positions.  "As soon as you are made a department or section head, you are 'on the other side,'" was the way one person put it.  "Your physician colleagues make you feel more lonely and isolated.  Meanwhile, the administration also feels that you are not one of them."

How sad a statement!  But how accurate, I believe.  As noted by Dr. Kishore Visvanathan (left), to the extent this kind of breakfast club gives doctors a place to explore and crystallize ideas related to quality and safety improvement and to gain mutual support from their peers, the better off we'll all be.
You Can’t Improve What You Can’t Evaluate
Live from Paris at the
International Forum on Quality and Safety in Healthcare
April 19, 2012, 11:00 - 12:00 PM Eastern Time 

Donald Goldmann, MD, Senior Vice President, Institute for Healthcare Improvement

Dale Webb, PhD,
Director of Evaluation and Strategy, The Health Foundation, UK

Mary Dixon-Woods, BA, DipStat, MSc, DPhil,
Professor of Medical Sociology, University of Leicester, UK

Gareth Parry, PhD,
Senior Scientist, Institute for Healthcare Improvement
WIHI doesn’t need to travel all the way to Paris, France, to focus on challenges with the design and evaluation of improvement initiatives. But, four leading experts in this area are going to be sharing some of the latest thinking on this topic at the 17th annual International Forum on Quality and Safety in Paris this month. So, WIHI host Madge Kaplan, who’ll be at the IHI-BMJ Group conference, is going to grab the four presenters after their panel to share their observations with the WIHI audience.

Why should you tune in? Here’s just a sample of what Don Goldmann, Dale Webb, Mary Dixon-Woods, and Gareth Parry want to cover:  Despite best intentions and commitment, improvement initiatives don’t always yield hoped-for results. Why does this happen? It seems so obvious, yet it turns out to be much harder to spread successes in one setting to another even if, on the surface at least, the settings seem pretty similar. What can help this adaptation? Everything seems to be running smoothly, but then problems with the design of the work are discovered late in the process. How can problems and design flaws be detected sooner? Everyone is very excited about the results of some improvement work, but when it comes time to write it all up, there’s confusion and disagreement about which mechanisms are actually responsible for the changes. How can this be avoided?

One underlying theme is the need to integrate what one hopes to learn from an improvement initiative right from the start, and to build into the process a robust learning and evaluation system for every step of the way. These aren’t just abstract notions; you’ll hear from our WIHI guests about recent situations they’ve been part of or witnessed where “learning the hard way” has given rise to much better and clearer-eyed processes for the future.

Here are some other things the guests promise to discuss:

  • Developing a theory of change at the outset
  • Matching expectations to the intervention
  • Aspirational vs. evaluative goals
  • The conspiracy of enthusiasm
  • The importance of independent evaluation
The theme of this year’s International Forum is “Solutions for Tough Times,” and improvers in the US and globally face many challenges. Getting the nuts and bolts and the design right for improvement work couldn’t be more important and relevant. Please join the conversation, from Paris, on April 19th! 

To enroll, please click here.

A visit to gemba at Royal University Hospital

Regular readers know of my practice of going to gemba when I am visiting a hospital.  It is my way of looking at work processes in different places.  If you are interested in process improvement, you can never see enough examples of this.  In turn, I like to present summaries to you, my readers, not to draw negative conclusions about the institutions involved, but rather to demonstrate the common need for process improvement across the hospital world.

This week, while I was in Saskatoon for the Health Care Quality Summit, my hosts graciously arranged for me to spend some time shadowing Therese, a unit clerk in the emergency room of Royal University Hospital, an excellent institution operated by the Saskatoon Health Region.  The SHR, along with the rest of the province, has made a strong commitment to the Lean process improvement philosophy.  Lean will be rolled out over the coming years.  Given the early stages, it has not yet been fully adopted everywhere, and so I got to see the "before" view of things in the ER.

Therese is a dedicated and hard-working person who faces a large variety of tasks in the ER.  She handles telephone inquiries of all types.  She helps coordinate the collection of specimens and their delivery by pneumatic tube to the laboratory.  She compiles patient records.  (These are paper records, as an electronic system has not yet been put in place.)  She also takes care of linen changes and wiping down of the patient care bays in her section of the ER.

As I sat with Therese, I was amazed at her energy and sense of organization.  She truly holds the place together in many ways.  And yet the underlying work flows that she must carry out offer prime examples for the kind of redesign that will surely come when Lean arrives.

Here's an example.  When a patient is discharged from the ER, a copy of the patient's record -- known as the back copy -- is kept in the ER for two weeks in the event the patient returns.  If and when the patient returns, Therese flips through the accumulated stack, looking for that record, and then attaches it to the current patient file.  Also, if a bacterial culture has been taken for a patient, the lab result generally is returned after the patient has left.  Therese has to find the back copy, onto which she attaches the lab report, leaving it for a doctor to review in the event a change in treatment (e.g., a new anibiotic) is called for.

If Therese cannot find the back copy, she has to call to the medical records department and ask them to fax a copy to her.  The problem is that the back copies are stacked up in an unpredictable order, so Therese has to flip through them to try to find the correct patient record.  This ends up taking an inordinate amount of her time -- 2 to 3 minutes each time -- unless she is interrupted by a phone call or something else, at which points she has to start over again.  This little video gives you a sense of the current process.

When you add up those multiple 2-3 minute tasks and calculate how much cumulative time is spent on this alone, you can see how -- some Lean day in the future -- this and other parts of Therese's life in the ER will be improved.

If you cannot see the video, click here.