Dr. Fitzpatrick offers optimism for World AIDS Day

I was very pleased to be invited to address the Board and senior managers of United Medical Center in Washington, DC, earlier this week.  UMC is located in the Southeast section of the city.  It is the safety net hospital for indigent people and serves a population with a variety of complex and difficult conditions, including hypertension, diabetes, and HIV/AIDS.  The hospital is facing severe financial challenges as a result of changes in Medicaid and Medicare payment regimes, and there are also interesting questions of ownership and governance that will need to be resolved over the coming years if it is to carry out the community mission which is so essential.

I was not surprised to meet a dedicated group of Board members and staff people.  One of those was Dr. Lisa Fitzpatrick, an infectious disease specialist, who has created a multidisciplinary clinic to help HIV/AIDS patients.  On the occasion of World AIDS Day tomorrow, Lisa has published an article in the Huffington Post entitled, " Getting to Zero AIDS Cases in America -- Can We Do It?"  She notes:

No one should ever die of AIDS. Unfortunately, many people arrive at my office for their first visit because they have become sick or begun to show symptoms of HIV. A few have even waited until it was too late and died of HIV. What kept most of these people out of my office is the shame and embarrassment of contracting HIV. This shouldn't be. HIV is a preventable and treatable disease. It is certainly within our power to address this public health scourge. We can do it. But we must become educated about the disease, its prevention and treatment.

It would be a shame if one of the unintended consequences of Obamacare is a change in funding to safety net hospitals that removes some of their ability to carry out the functions Dr. Fitzpatrick has eloquently set forward.  Maybe UMC--an important component of the District of Columbia health system--can help send that message to Congress over the coming months.  On this matter, the Board and the medical staff should be united, along with other safety net hospitals throughout the country.

Heroes at MITSS

It was an evening of unabashed hero worship on my part as I attended the annual dinner for MITSS (Medically Induced Trauma Support Services).  Recall that the purpose of the organization is to create awareness, promote open and honest communication, and to provide services to patients, families, and clinicians affected by medically induced trauma.  Seen above is Lucian Leape, from the Harvard School of Public Health, who is generally acknowledged as one of the founders of the patient safety and quality of care movement.  He was greeting USCF's Robert Wachter, the keynote speaker for the evening, whose contributions to quality and safety are legend, including his recent book, Understanding Patient Safety.

Earlier I had run into patient advocate Pat Mastors, accompanied by daughter Elizabeth (above), and Dr. Stephen Pratt and Martha Hayward (below), who have worked tirelessly to enhance the role of patient advocates in the health care system.

But the final treat was to encounter Patty Skolnik (below).  My regular readers might recall the story of her son Michael and the tragedy that ensued as a result of an improper consent process and medical errors.  Patty is now the voice for Citizens for Patient Safety, traveling the world to tell the stories of her son and others and to give clinicians, insurance companies, the legal community, and consumers the impetus and tools for improving the quality and safety of patient care.

@drsusanshaw couldn't do it. Could you?

Dr. Susan Shaw practices intensive care medicine in a hospital in Saskatoon and also chairs the province's Health Quality Council. She understands the importance of hand hygiene as well as anyone in the world.  Yet, when her daughter was being treated in a hospital, Susan noticed:  "I didn’t see anyone wash their hands before or after they cared for my daughter."

She continues:

And I couldn’t get out the words “Excuse me, would you please wash your hands for us?” I’ve thought long and hard about why I didn’t say anything.

Read further to see her explanation and offer your own thoughts on the matter. Susan asks:

Have you as a patient ever asked a healthcare worker to wash their hands? What did it feel like and what was the response? Have you, as a healthcare worker, ever been asked to wash your hands by a patient?  How did it feel? What did you learn?

@JustinHOPE and @mbismark show HEART

Congratulations to Dale Ann Micalizzi and Marie Bismark on the publication of their article "The Heart of Health Care" in Pediatric Clinics of North America.  An open access full text version is here. The abstract:

Behind the wall of silence in health care are the unanswered questions of parents whose children experienced harm at the hands of their caregivers. In an industry where information and communication are crucial to quality, parents’ voices often go unheard. Although that has begun slowly to change, providers could benefit from following the HEART model of service recovery, which includes hearing the concerns of patients and their families, empathizing with them, apologizing when care goes wrong, responding to parents’ concerns with openness, and thanking the patient and family.

Scholarship funding for patient safety camps

@dmayer33 David Mayer notes:

Through the generous support of The Doctors Company Foundation and MedStar Health, we have scholarship funding to bring 40 medical student and 20 nursing student leaders this coming summer to engage with leaders, educators, and advocates in patient safety for the Ninth Annual Telluride Patient Safety Educational Roundtables and Student Summer Camps.

The vision:

To create an annual retreat where experts in patient safety and health science education can come together with patients, residents and students in a relaxed and informal setting to discuss, develop and refine health science education that supports a culture of patient safety, transparency and optimal outcomes in patient care.

Check it out.  A great opportunity!

A proposed exception to malpractice coverage

Did you know this?

The Joint Commission Board of Commissioners originally approved the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery™ in July 2003, and it became effective July 1, 2004 for all accredited hospitals, ambulatory care and office-based surgery facilities.

Implementation of this standard was observed in the breach for some time. One article notes:  "The rate of wrong-site surgical procedures before and after implementation of the Universal Protocol mandate was not significantly different."

So penalties were imposed.  Wrong-site surgeries were declared "never" events. As such, doctors and hospitals cannot be paid when they occur.  How effective has this been at reducing the number that occur?  Not much or at all.

Understanding that rule-based failures--actions that match intentions but do not achieve their intended outcomes due to incorrect application of a rule or inadequacy of the plan--are always possible, it still makes sense to pursue universal application of the "universal" protocol.

Here's an additional idea that could be implemented immediately by all of the malpractice insurance companies in the country: Any surgeon who has carried out a wrong-site surgery who did not follow the universal protocol for a time-out would not be covered for malpractice claims on that procedure.  Any anesthesiologist who was attending such a surgery likewise would not be covered for malpractice claims on that procedure.

Maybe this would finally start to make a difference in the frequency of wrong-site surgeries.  What do you think of this idea?

Health care for Australian Aborigines

Please check out this fascinating story by Edward Small in The Atlantic, entitled "For Australian Aborigines, the Health Problems of Westernization."  An excerpt:

About three years ago, McKenzie had to move to the central Australian town of Alice Springs -- around 300 miles from Mutitjulu -- for a reason that has become increasingly common among Australia's indigenous population: dialysis. His kidneys were failing, and if he did not get treatment to replace the blood cleaning work that they used to do, he was not going to survive. 

In other words, he moved to stay alive. But he was not too happy about it.

"It's tough in Alice Springs," he says. "Nobody comes out and talks to me. I'm by myself. Lonely, you know?" 

McKenzie still spends the bulk of his time in Alice Springs, as the medical treatment he needs is much more available there than it is in remote aboriginal communities like Mutitjulu. However, thanks to a mobile dialysis unit that the corporation Western Desert Nganampa Walytja Palyantjaku Tjutaku (the name means "making all our families well" in the aboriginal language Pintupi) launched in 2011, he at least has some opportunities to come back and visit.

Mr. Small just joined the staff The Boston Courant, a neighborhood newspaper here that has been branching out lately to take on some very interesting health care stories.  As their neighborhood includes the Longwood Medical Area--home to Harvard Medical School and School of Public Health and several hospitals--expect some new insights about issues facing Boston and beyond.

Goal Play! audiobook is in the works

I have been heartened by the response to my book Goal Play! over the last nine months, and many people have asked if and when an audiobook version will be available.  I am happy to report that the day is fast approaching.

Here's a tantalizing tidbit, a screen shot of the image of me reading one of the chapters.  There are also some guest appearances by several other people, and I know you will enjoy the production.  Stay tuned for details.

In the meantime, here's an Authors@Google video from a recent appearance I made at that company's headquarters in Mountain View, CA.  If you can't see the video, click here.

 

A sign of the times

Can you guess what was deleted from the top of these three signs at the Logan Airport Hilton Hotel? It used to point to the public telephones.  If you look closely, you can see the shadow of the old letters.

Now look down the corridor to where they used to be:

Clearly, with virtually everyone carrying a cell phone, there is no longer a need to provide this capability to the guests.

Just talk to each other!

@Lucienengelen at Radboud University Nijmegen Medical Center @umcn is passionate about how to apply the tools of social media to help patients participate in their care, and also about how to enable doctors to work better together to help make that happen.  A recent advance from his REshape Center carries out the convergence of those functions in an elegant and simple manner.

It's called FaceTalk, and you can find a description here.  It might be simplest to think about this as Skype on steroids.  First, several people can join in a conversation simultaneously and see and hear each other.  But the discussion can be supplemented by the visual presentation of test results, images, electrocardiograms, and the like.  Further, the images can be manipulated by any of the participants.  Want a closeup view of a CT scan that has been been presented by your colleague across town (or across the country)?  Just spread it wide like a photo on your iPhone.

The whole thing also has significant privacy protections and meets US HIPAA standards and the equivalent European standards.

FaceTalk is offered on a subscription basis to doctors for a modest fixed fee per month.  Any subscribing doctor can invite anyone else to be part of his video exchanges.  The whole thing works on any platform on any computer or smart phone.  Lucien has negotiated with the Dutch insurance companies to consider FaceTalk visits reimbursable, just like office visits would be.

Here's a short video of a news story on the project.  (Click here if you cannot see the video.)


FaceTalk kort EN from UMC St Radboud on Vimeo.

Read this story about treatment of children with cleft lips or palates.  Previously, they had to travel many hours to visit the hospital for periodic checkups.  Now they, are sent an inexpensive webcam and are able to present the doctor with a view of their physical features.  Doctor Stefaan Bergé explains:

Our patients come from every corner of the Netherlands. An online consultation via FaceTalk saves them a lot of time. They no longer need to travel to Nijmegen for a check-up. There are various stages to treating children with a cleft lip or palate. It starts between birth and four years old, and continues between the ages of ten and thirteen years. They need several surgical procedures, so the children have to come to hospital on a regular basis. These are the periods when we really need to see them.

But between four and ten-years-old and twelve and eighteen-years-old, we only need to check their progress. These consultations only take a couple of minutes and can be carried out perfectly well via FaceTalk. The webcam allows us to look into the patient´s mouth and if we are in any doubt, we ask them to come to the hospital.

Another doctor in the Netherlands helped a patient in Egypt:

The diagnosis of my patient had previously been made in Egypt. The mother wanted to consult with me about whether additional treatment would be required for her child and whether she would have to come to the Netherlands for this treatment. They are Dutch, but are living in Egypt as ex-pats. At that point, I thought about FaceTalk; I had heard about it previously and wanted to try it myself. I told the mother that we would be able to have a video consultation, but if this was unsatisfactory then she would still have to purchase the airline tickets. However, the video consultation worked very well, so this was unnecessary.

Lucien demonstrated the system to me recently when I was in Nijmegen.  It is as easy as Skype and Facebook combined.  Within seconds, we had a three-way conversation going on around a conference table:  One of us on one computer, and the other on two!

There are a lot of people working on complicated inventions to improve health care.  This one is elegant and inexpensive and works.  It can truly be transformative in the delivery of care.

Joris explains CRM in the PICU @UMCN

I recently cited an excellent article about the use of Crew Resource Management (CRM) in intensive care units.  Now I have had a chance to visit a place where they are trying it out.  Joris Lemson, MD PH.D., is medical director of the pediatric intensive care unit at Radboud University Nijmegen Medical Centre in the Netherlands. Joris and his colleagues (strongly supported by Professor Johannes G. van der Hoeven) have been testing out CRM principles in their unit for over a year.

You might recall from the article that there are several aspects of this approach.  When people are trained in CRM, the key subjects in the syllabus are: Situational awareness and recognition of adverse situations; Human errors and non-punitive response; Communication and crosscheck techniques; Giving and receiving performance feedback; Management of stress, workload and fatigue; Creating and maintaining team structure and climate; Leadership; and Risk management and decision-making.

The crews in airplane cockpits often have a written set of protocols on hand as they carry out the aspects of CRM.  Indeed, there and in places like Navy submarines, it would be unthinkable to carry out certain procedures without the written checklist on hand.  The PICU folks decided that a similar approach might have value as an awareness and decision-making guide, and so they produced this laminated card to be an aide-mémoire.  In one sense, this is standard checklist items for intubating a patient--items related to equipment, the patient's position, the staff, and the procedure itself (including a pre-procedure briefing.)  On the other side, there is an elaboration of the briefing procedure, a description of the post-procedure debriefing, and a list of required supplies.

But, as Captain Sullenberger has said: "A checklist alone is not sufficient. What makes it effective are the attitude, behavior and teamwork that go along with the use of it."

I think many ICU doctors and nurses reading this would find most of the items in the Radboud procedure to be routine.  I think, though, that most would have to admit that their process is not as standardized as that found in this PICU.  I bet, too, that most of them would not have a written guide to follow.  I am most sure, however, that very, very few would have a debriefing.

In case you are having trouble with the Dutch, here's a translation of the debriefing elements:
Results versus plan. 
Execution: What went well. What went less well. What will we do differently next time. 
Summary by leader.

If we are to adopt the scientific method in clinical care improvement, a real-time review of the effectiveness of reducing variation is essential.  How otherwise to evaluate whether the protocol was effective and to decide if it should be modified?

Joris is honest about the progress of this effort in his PICU.  He notes improvement and general compliance with the approach and procedures, but he also notes lapses.  For instance, sometimes the leader will forget to conduct the debriefing.  That's all right, but not if the other crew members forget to remind him/her when it happens.  A tenet of CRM is mutual responsibility and authority:  If the chief forgets to carry out part of the protocol, the others are required to point this out.

Why did Joris devote his personal time and energy to implementation of CRM in his intensive care unit?  He explains that he once gave the wrong instructions to a nurse, who followed them blindly, with almost disastrous results for a patient.  Later, when he and she talked about the case, she said, "If it had been a resident, I would have questioned the order.  But you are a senior doctor, and I therefore hesitated to question you."  It was at that moment that Joris realized that even the best doctors need protection from their own errors.  Every person in the clinical setting needs to understand that he or she has the responsibility and authority to express concern if things appear to be going awry.

As Sully mentions, CRM is "a compact, with defined goals and responsibilities. These are not soft skills. They are human skills. They have the potential to save more lives than new medical technologies."

The Waiting Room in Boston

Please join me as I moderate a special discussion with The Waiting Room director Pick Nicks and producer Bill Hirsch after the 6:45 screening on December 1 at the Kendall Square Cinema in Cambridge.  Can't make that showing?  The movie will be at Kendall Square from November 30 through December 6.  Info here.

The film has been nominated for Best Documentary of the Year by the Gotham Independent Film Awards. It has also been nominated for a Film Independent Spirit Awards and an Golden Eye Honors Awards.  Previous runs in the Bay Area--Oakland, San Francisco, and Berkeley--as well as San Jose, San Rafael, and Sebastopol were extended because of the demand.  Don't miss this!

Dr. Englander excels at home, too.

My regular readers may recall dispatches from my friend Dr. Honora Englander, when she was involved in caring for people in Uganda.  Well, I am pleased to report that the American College of Physicians has named her as one the top ten hospitalists of 2012.  The ACP particularly cited Honora's Care Transitions Initiative (C-TraIn). "The program is noteworthy not only for its success with helping poor and uninsured patients transition between hospital and outpatient settings, but also for garnering the financial support of the hospital."

“To ensure integration with hospital efforts and increase program sustainability, Honora pursued hospital funding rather than grants,” said Rebecca Harrison, MD, OHSU's section chief for hospital medicine who co-nominated Dr. Englander as a Top Doc. “That she developed a quality and business case and developed new clinical partnerships that bridge hospital and community care demonstrates her desire to solve substantive problems.”

I particularly like this characterization, which comes as no surprise to those of us who know her:

“Honora is a remarkably humane person and this comes through in how she treats her patients, colleagues from all disciplines, and also how she treats the work of systems change itself,” said Dr. Kansagara. “I think people naturally want to work with someone who has an action-oriented vision for improvement, and who is always keeping the ball moving forward.”

Engage With Grace

@engagewithgrace #blogrally12 Once again, a group of us (including Matthew Holt, Alexandra Drane and our friends) are launching the Engage With Grace blog rally to coincide with Thanksgiving weekend. As in previous years, we’re suggesting that people who want to join the rally simply post the attached “ready made” blog content starting tonight, November 21, and leave it up through the entire weekend (consider it a much-deserved break from blogging for a couple days).

One of our favorite things we ever heard Steve Jobs say is… ‘If you live each day as if it was your last, someday you'll most certainly be right.’

We love it for three reasons:

1)      It reminds all of us that living with intention is one of the most important things we can do.

2)      It reminds all of us that one day will be our last. 

3)      It’s a great example of how Steve Jobs just made most things (even things about death – even things he was quoting) sound better.

Most of us do pretty well with the living with intention part – but the dying thing? Not so much. 

And maybe that doesn’t bother us so much as individuals because heck, we’re not going to die anyway!! That’s one of those things that happens to other people….

Then one day it does – happen to someone else.  But it’s someone that we love.  And everything about our perspective on end of life changes.  

If you haven’t personally had the experience of seeing or helping a loved one navigate the incredible complexities of terminal illness, then just ask someone who has.  Chances are nearly 3 out of 4 of those stories will be bad ones – involving actions and decisions that were at odds with that person’s values.  And the worst part about it? Most of this mess is unintentional – no one is deliberately trying to make anyone else suffer – it’s just that few of us are taking the time to figure out our own preferences for what we’d like when our time is near, making sure those preferences are known, and appointing someone to advocate on our behalf. 

Goodness, you might be wondering, just what are we getting at and why are we keeping you from stretching out on the couch preparing your belly for onslaught? 

Thanksgiving is a time for gathering, for communing, and for thinking hard together with friends and family about the things that matter.  Here’s the crazy thing - in the wake of one of the most intense political seasons in recent history, one of the safest topics to debate around the table this year might just be that one last taboo: end of life planning. And you know what? It’s also one of the most important. 

Here’s one debate nobody wants to have – deciding on behalf of a loved one how to handle tough decisions at the end of their life. And there is no greater gift you can give your loved ones than saving them from that agony.  So let’s take that off the table right now, this weekend.  Know what you want at the end of your life; know the preferences of your loved ones.    Print out this one slide with just these five questions on it. 

Have the conversation with your family.  Now.  Not a year from now, not when you or a loved one are diagnosed with something, not at the bedside of a mother or a father or a sibling or a life-long partner…but NOW.  Have it this Thanksgiving when you are gathered together as a family, with your loved ones.  Why? Because now is when it matters. This is the conversation to have when you don’t need to have it.  And, believe it or not, when it’s a hypothetical conversation – you might even find it fascinating.   We find sharing almost everything else about ourselves fascinating – why not this, too?   And then, one day, when the real stuff happens?  You’ll be ready. 

Doing end of life better is important for all of us.  And the good news is that for all the squeamishness we think people have around this issue, the tide is changing, and more and more people are realizing that as a country dedicated to living with great intention – we need to apply that same sense of purpose and honor to how we die. 

One day, Rosa Parks refused to move her seat on a bus in Montgomery County, Alabama.  Others had before. Why was this day different?  Because her story tapped into a million other stories that together sparked a revolution that changed the course of history.

Each of us has a story – it has a beginning, a middle, and an end.  We work so hard to design a beautiful life – spend the time to design a beautiful end, too.  Know the answers to just these five questions for yourself, and for your loved ones.  Commit to advocating for each other.  Then pass it on.  Let’s start a revolution. 

Engage with Grace.   

Musings from Ostia Antica

Before I take a blogging pause for the (US) Thanksgiving holiday week, I want to pause and reflect on some items.  I was able to spend a bit of time in Rome this past week. As always "the Eternal City" is remarkable, but I was especially caught up by a visit to Ostia Antica.  This was the port of Rome in the 2nd and 3rd centuries AD, a city of over 75,000 people with active commerce and culture.  As the river shifted course, its use as a port facility ended, and its abandonment was helped along by a malaria epidemic.

Today, there are fairly well preserved ruins.  Notable features include mosaics spread throughout the city.  The ones along the Piazzale delle Corporazione--a town square surrounded by market stalls--are most revealing in that they symbolized the trades or services being offered in each shop (see above).

Near the theater we see decorative statues displaying some of the emotions one might experience in the productions of Greek and Roman dramas and comedies.

 
In another part of town, the funerary area, we find depictions of scenes from the underworld, giving hints of the activities of the gods and sea creatures.

Elsewhere, there are a number of statues, including this elegant woman or goddess.

What comes across to me in this setting is how similar the ancient Romans are to us today.  Whether engaged in commerce or the arts, or wondering about the meaning of life and death, these folks had the same kinds of interests and questions that we do.  It turns out that the passage of about 2000 years does not make much of a difference in underlying concerns.

Yet ancient Ostia fell away.  No society is guaranteed permanence.  Thinking of my home town of Boston as an example, are we still in the ascendant, or have we begun our decline?  We are too close to the situation to know, just as the Ostians of 200 AD could scarcely have known that their city would be shutting down 200 years later.

Is it unthinkable to hypothesize that a great city could become irrelevant in the course of a couple of centuries?  How could the home to great universities, hospitals, museums, and businesses wane in influence and prosperity?  Beyond environmental hazards, the key threat is a deterioration in sense of community.  If complacency, arrogance, and ad hominem attacks take the place of intellectual modesty, respectful curiosity about the other person's point of view, and manners, the kind of selfless behavior that is necessary for a community's well-being takes flight.

Whether you live in Boston or elsewhere, please take time this Thanksgiving to give thanks for the opportunity to live in a safe and vibrant place, but please recommit, also, to the virtues and behaviors that will provide the basis for its growth and sustenance as a caring community.

Babbitt lives on in the HR world

Sinclair Lewis, in Babbitt, (1922) made fun of the fact that real estate brokers changed their name to realtors to make themselves sound less like salespeople and more like professionals.  George Babbitt notes:

“Makes me tired the way these doctors and profs and preachers put on lugs about being ‘professional men.’ A good realtor has to have more knowledge and finesse than any of ’em.”

"We ought to insist that folks call us ‘realtors’ and not ‘real-estate men.’ Sounds more like a reg’lar profession."

His convention speech on the subject is a hit:

After the meeting, delegates from all over the state said, “Hower you, Brother Babbitt?” Sixteen complete strangers called him “George,” and three men took him into corners to confide, “Mighty glad you had the courage to stand up and give the Profession a real boost.

I think I just noticed the same thing happening 90 years later.  Someone asked to be connected to me on LinkedIn.  Her job, at a great local university, was "Talent Acquisition Manager."  Whoa!  Isn't that what we used to call "recruiter?"

Well, Recruiter.com tried to set me straight, noting:

The job title of Talent Acquisition Manager and even the use of the term Talent Acquisition, is quite new.

It goes further and says:

Corporate recruiting may be one of the few examples where a name change means something.  Recruiting has gone through a process of upheaval and transformation over the past ten years which might explain the need for a changing nomenclature. Talent acquisition now comprises a very broad field, since recruitment channels have multiplied and the scope of the recruiters’ job has broadened. Talent Acquisition Managers now head up employment marketing initiatives, branding campaigns, internal referral programs, and develop employee engagement metrics and retention programs. It’s a broad set of responsibilities that cover more internal policy and external communications than individual corporate recruiter jobs did in the past.

Sorry, I don't buy it.  Good recruiters and their directors in good human resource departments* often did much of this stuff in the past. Even if the job has expanded, the key function and purpose remains recruitment.  We don't need three words to say what one represents.  Especially when the new term uses the pompous "talent" to refer to "qualified people" and when the verb moves into the greedy realm of "acquisition" as opposed to the respectful concept of "persuasion."

I think this is a simple case of nomenclature inflation, to make it sound like there are substantially different professional attributes required.  Sinclair Lewis would be amused, I think.

---
* (aka personnel departments, but we'll let that pass for now!)

Health Foundation research tenders

I am forwarding this along to those who might be interested:

The (UK) Health Foundation is seeking experienced providers for two pieces of research: a spotlight report on healthcare-associated infections and a review of the best evidence on mobilising community assets in health and care services. The invitations to tender for both pieces of work have recently been published, and are available on our website. 
 

The spotlight report on healthcare-associated infections will bring together evidence from a range of sources on the best means of preventing and controlling infections, taking account of difficulties in measurement and recent success stories. We expect bids in a range of £100k-£120k. 

 

The best evidence review on mobilising community assets in health and care services will bring together evidence on the effectiveness of asset-based approaches to community development in health and care, drawing on models and lessons from the literature and case studies. We expect bids in a range of £55k-£70k. 

Applications for both projects close in the first week of December 2012. Full guidance on both projects and information on how to submit a tender can be found on the Health Foundation website.

CRM in intensive care settings

The use of Crew Resource Management is well known in areas like airline cockpits.  CRM, when properly implemented, maintains certain aspects of the hierarchy that is required in a command situation, but it also empowers all members of the crew to behave in a way that satisfies safety and quality concerns--even if the pilot is failing to do his or her job correctly.  An article by Haerkens, Jenkins, and van der Hoeven in the Annals of Intensive Care provides support for the proposition that CRM might make a difference in clinical settings.  No subscription is required (yay!), so please read it here.

I like some of the observations:

The majority of current interventions focus on implementing safety tools such as event-reporting systems, quality and safety dashboards, evidence-based guidelines and checklists. Even though the results of a comprehensive unit-based safety program (CUSP) are promising, introducing more stringent rules potentially increases the gap between procedure and practice. Therefore, the question remains if these tools can be truly effective in the traditional hospital climate, where highly trained professionals tend to focus more on individual performance than team effectiveness. Moreover, the typical culture in which junior members of the ICU staff should not question the decisions made by senior members adds to the challenge.

ICUs with a “team-oriented culture” have shorter lengths of stay, lower nursing turnover, higher quality of care and can better meet family members’ needs.

Human Factors account for the majority of adverse events in aviation as well as in clinical medicine. The current safety paradigm is still based on ways to limit human variability in otherwise safe systems, promoting stringent procedural guidelines. CRM focuses on improving interprofessional cooperation and team performance and thus patient safety. Even though evidence of CRM on medical errors and patient outcome is still scarce, the parallels between the critical processes in aviation and Intensive Care suggest that a well-adapted medical CRM training has potential for the ICU environment too. 

Readmissions on WIHI

November 15, 2012: Reality Knocks with Reducing (Hospital) Readmissions
(2:00 – 3:00 PM Eastern Time)

Featuring:
Patricia Rutherford, RN, MS, Vice President, Institute for Healthcare Improvement; Co-investigator, STate Action on Avoidable Rehospitalizations (STAAR)
Elizabeth H. Bradley, PhD, Professor of Public Health (Health Policy and Management), Yale School of Public Health; Faculty Director, Yale Global Health Initiative

Of all the improvement issues facing health care, reducing avoidable hospital readmissions may well be the one that finally breaks down traditional silos — and allows promising changes to realize their full impact. Why? In order to prevent patients from bouncing back into the hospital, front-line staff must create robust care coordination strategies across multiple health care settings, as well as the home and the community — taking a fundamentally broader view of the patient journey and the reforms needed. However, doing the right thing ​— keeping patients out of the hospital — often hurts a hospital’s bottom line.

So far, anyway. In the US, the Centers for Medicare & Medicaid Services (CMS) has now imposed fines on some 2,200 hospitals for higher-than-average readmission rates, as part of new federal policy. This latest move won’t make the financial piece any easier, but it does put hospitals on notice that there’s “nowhere to run, nowhere to hide.” If you want to reduce readmissions, you have no choice but to fundamentally redesign what you’re doing now. We'll explore this on the next WIHI on November 15: Reality Knocks with Reducing (Hospital) Readmissions.

What are the most promising ideas and strategies to look to and build upon? WIHI is pleased to convene two important leaders and thinkers on reducing readmissions and care coordination that, between them, have a comprehensive view of what’s working, what’s challenging, and where we go from here. Elizabeth Bradley is the lead author of a recent article in the Journal of the American College of Cardiology (the title page is shown above) that examines the all-too-persistent gap between best intentions and uneven execution of known best practices. Dr. Bradley is eager to discuss the study findings and what can be done to help health care organizations follow through on their own robust policies. In her role as Co-Principal Investigator of IHI’s STAAR initiative, Pat Rutherford has been deeply involved with hospital leaders and officials in three states that have taken to heart the challenge of reducing readmissions, with results to show for it. Pat Rutherford also carefully tracks the work of multiple initiatives in the US, including Project BOOST, Project RED, and Hospital to Home (also known as H2H).

WIHI host Madge Kaplan scheduled Dr. Bradley and Pat Rutherford because their insights are crucial and couldn’t be more timely this fall. The two improvement leaders are keenly aware of the ways in which policy and reimbursement changes surrounding readmissions are giving hospitals that want to do the right thing a jolt. They’d like to share what they’re learning, and to learn from you, on the November 15th program. Please join us!

To enroll in the broadcast, please click here.

MBAs say: This place can't exist

As the years go by, I like the Midwest portion of the US more and more.  There is a palpable sense of community in that region. Here's an example from Jeff Thomspon, CEO of Gundersen Lutheran Health System in La Crosse, WI. 

Jeff was recently interviewed by some management and compensation experts who asked what the structure of the leadership and executive incentive bonus program was.  He summarized the interview in a note sent to his staff:

I pointed out that there was no structure, we had no program.  They corrected me and pointed out that of course our salaries and benefits would follow the market, but they wanted to hear about the incentive program because at their graduate business school it was understood as sure as water flows downhill that to run a high performing organization you needed 15, 30 or 40% of compensation to be delivered in incentive bonus program.

I pointed out that all of our staff deserve to be paid fair wages, good benefits, a long term pension program that is secure, an environment with a consistent set of values, and trust that they will be treated well.  But the amazing success of the organization is not related to large financial payouts for anyone.  Still exasperated, one consultant said, “So what is the incentive?”  I said the incentive is we have a large number of people who genuinely believe in the mission of the organization.  They believe by focusing on the greater good, we can accomplish a greater good.  We all want to be paid fairly and have good benefits, but many of our staff turn down opportunities for just more money because they also value delivering excellence in patient care, education and research and improving the health of our community.

Another person then asked, “So is there nothing at risk?”  I said everything is at risk; the well-being of our patients and their families, the well-being of the community – they are at risk every time we touch a patient or family.  As for the staff, most look at it as an opportunity – the opportunity is to work with others with a high set of values focused on something bigger than any of us individually.  I pointed out that we do have part of our pension plan at risk, but everyone is in that, there are no exceptions.  We will all either get a little less, historical normal or a little more.

The consultants left shaking their heads wondering how this place gets along on a system that their college professors don’t seem to believe exists.

Thanks for all your efforts…all through the days and all through the nights…to serve something bigger than any one of us individually.

Pronovost advises all boards and CEOs

Johns Hopkins' Peter Pronovost offers sage advice to the board of the troubled Parkland Memorial Hospital in Dallas as it searches for a new CEO.  Actually, though, his elegant advice could apply equally well to "untroubled" hospitals because most of them still are not fully carrying out their public trust--a task that requires a deeper view of how to deliver quality and safety to patients and families, to respectfully engage all staff in front-line driven process improvement, and to be transparent with the community about their successes and failures. Excerpts:

History may provide some guidance. Historian Rufus Fears [right] notes that great leaders — leaders who changed the world — have four attributes: a bedrock of values, a clear moral compass, a compelling vision and the ability to inspire others to make the vision happen. Parkland needs one of these great leaders.

The key values of the next CEO should be humility, courage and love — and these values must guide the leader’s behavior. Parkland will not be able to improve unless it acknowledges its shortcomings; this will take humility. Yet Parkland is a great organization with a rich past and bright future. The leader must honor the past and look forward. The leader must be able to live with the paradox of being humble yet confident.

To avoid a revolt and get staff passionate about the vision, the leader will need to transparently communicate where Parkland is going and why, how Parkland makes decisions and what those decisions are. Yet the next CEO will need to deftly dance between democracy and autocracy, between conversations and results. To make all the needed fixes, to bring Parkland back to where it needs to be, much needs to be done, and only with a passionate and engaged staff can real change happen.

Yet perhaps the greatest value will be love. Avedis Donabedian, one of the fathers of quality improvement, was interviewed on his death bed by a student. The student asked, “Now that you have been a patient and devoted your life to improving care, what is the secret of improving quality?” Donabedian told him, “The secret of quality is love. If you love your God, if you love yourself, if you love your patients, you can work backwards to change the system.”

This is what Parkland needs. The hospital’s doctors, nurses and administrators care deeply about patients; they do not want to harm them. They work with broken, underresourced systems. The next CEO must recognize this and seek to understand rather than judge, to learn and improve rather than blame and shame.

We shouldn't need a waiting room.

Our Lean workshops at Jeroen Bosch Ziekenhuis ended today with a session about the differences between batch and flow processing.  It turns out that many hospital settings are based on batches of patients or tests or procedures.  This is often less efficient than a flow-based process.  It is also a lot less customer-centric.

Frederieke Berendsen (above) started talking about this with regard to out-patient clinics, noting that the waiting rooms are often full of people who arrive in batches (or near-batches) and then often wait to be seen.  She noted that in an efficient system, "We shouldn't need a waiting room."

I immediately awarded her with the astute-observation-of-the-week prize, as she had codified one of the Lean principles in a simple declarative sentence.  I then related the story of Dr. Sami Bahri, the Lean dentist in Jacksonville, Florida, whose "clinic prides itself on minimizing the amount of time patients spend waiting -- whether for an appointment, sitting in the front area, sitting in the procedure chair, or whatever."

Brava to Frederieke--and also to the other people in our workshops--for their attentive participation and excellent observations during our sessions!

Coffee breaks demonstrate Lean essentials

The essence of Lean is to have a focus on the needs of the customer and, when problems become evident in the workplace, to think about the obstacles and apply the scientific method to invent incremental improvements.  Such change originates with the front-line staff, but it is the job of leaders to encourage an environment in which this is encouraged.

An example arose recently at Jeroen Bosch hospital in the Netherlands.  It was the brainchild of Jeanne Smith, whose job includes serving coffee to patients on the wards.  You see her here. 

Jeanne was hearing complaints from patients about the temperature of the coffee.  It was highly variable, ranging from properly hot to less so to just warm.  She conducted a root cause analysis as she walked through the wards and noticed that coffee stored in the larger thermos containers stayed hot longer than the coffee served from the smaller containers.  (The greater thermal mass of the larger container held the temperature better.)  So, the solution was simply to use the larger containers.

Immediately, the complaints disappeared, as the coffee was served at a uniform temperature throughout the wards.

Now, admittedly, this is not an item of high clinical importance, but it is an indication of patient satisfaction.  After all, if you are going to offer coffee, why not make sure it is the correct temperature?

Jeanne's improvement won first prize in the poster portion of the hospital's Quality and Safety Day last week. Her poster title was "Dit is andere koffie!"  ("This is different coffee!")  CEO Willy Spaan said, "This is just the kind of sense of initiative and constant improvement that we are trying to encourage."

Wesley and Ziko's fine Lean adventure

One goal of conducting Lean workshops at Jeroen Bosch Ziekenhuis was to create an archive of pedagogical material that could be used by the training staff in future sessions.  We decided to supplement the various games and exercises with a collection of pertinent video clips.  So we had two nice young film production students from Koning Willem 1 College join us.  You see them here, Wesley Martens and Ziko Assink. 

They followed several participants during the gemba walks and shadowing.

What they did not expect was the moment we had an odd number of students to participate in a game requiring an even number.  One of our film-makers found himself immersed in the 5-S game, learning to be Lean (while his partner looked on with amusement!)

Taking one for quality and safety

I want to try to provoke some sympathy from my gentle and caring readers by demonstrating that serving on the Quality and Safety Day jury yesterday at Jeroen Bosch hospital was hazardous duty.  As the jury convened to compare our individual rankings and reach a consensus, Kees Smulders, director of quality and safety, showed up with this plateful of Bossche bolls (one for each judge.)  The Bosch ball is a profiterole type of pastry the size of a softball, filled up fresh whipped cream, and covered with dark chocolate.

I could try to make an argument that this delicacy has great nutritional value.  After all, it contains at least three of the food groups--grain, dairy, and, er, chocolate.  But I fear you might see through that characterization.  The truth is that this is an outrageous dessert or snack, loaded with calories and fat.

So, I approached the challenge gingerly, knowing that I would have the will power to take just a bite or two.  I got off to a good start.

But there is a problem.  There is something about the mixture of the three flavors and textures that is absolutely irresistible.  The time-space continuum is disrupted, you lose consciousness, and in the blink of an eye, the thing practically disappears!

I awoke in the nick of time and stopped at this point.  One of my fellow judges, though, couldn't resist and cleaned his plate (below).  This just shows you how dangerous it can be to be involved in pursuing quality and safety improvements in the health care field:  A total lack of mindfulness takes hold if you let your guard down even for a moment.

Kinderwebsite wins the gold medal at JBZ

Today was the annual Quality and Safety Day at Jeroen Bosch Ziekenhuis in the Netherlands, and it was a marvelous opportunity for the staff and public to learn of initiatives taken by people in the hospital.  I was asked to be on the jury judging from among the top entries in the day's friendly competition.  Our six-member body quickly reached a consensus on the winner, the Kinderwebsite, or children's web site.

Please go and try it out here.  You come to a home page welcoming you to the hospital (see portion above), with noise of a playground in the background, and you are asked to click on or touch your age. (As you go over each button, it says the age aloud to help you.)  Click on age 9, for example.

When you get to the next screen, the background noise changes to that of a hospital, and you find the area you are interested in.  Let's say you have an operation coming up.  You click on operatie, and a series of short videos show up.  An age-appropriate child is featured, and each video accurately depicts what you will experience as you show up for pre-op, the operation, and post-op.  In video number one, you see the identification band being put on, the child walking down the corridor (still being permitted to hold her favorite stuffed animal), and her blood pressure being taken.  There is no sugar-coating of what will happen and what it will look like.  The idea is to present an accurate representation that can help a child and his/her family prepare for what otherwise would be a scary environment and uncertain set of procedures.

Activity on the site during its first few months, from April 1 to October 1, was 4,624 visitors, of whom 65% were new viewers and 35% were returning.  The average residence time for each viewer was 5 minutes and seven seconds, impressive for any website.

Our jury was asked to rank projects on the basis of patient-centeredness, the various dimensions of patient care, the value to the patient (and family), the sustainability of the project, and its creativity.  Kinderwebsite was the clear favorite, although all of the projects were very good.

Two of the brains on the team behind this website were Yvonne Pulles and Matthys Timmerman, and they were very excited when the announcement came that they had won the top prize.

Lean games in Den Bosch

We played a couple of my favorite games in the last two days at our Lean training workshops at Jeroen Bosch Ziekenhuis.  The value in using simple and amusing games is to remove the participants from their day-to-day frameworks and allow them to focus on exercises that reinforce Lean principles.

Yesterday's game was designed to illustrate the concepts of 5-S, fixing the workplace so it is conducive to easy acquisition or use of needed supplies by removing extraneous materials, organizing according to how often they are used, keeping the workplace neat, reducing variation across the institution, and ensuring that these practices are persistent.  The terms used to describe these steps are: sorting, setting in order, shining, standardizing, and sustaining.

The game is a simple number sorting game.  Teams of two are asked to look at a sheet of paper and tick off the numbers between 1 and 49, in order.  The first sheet starts with a jumble of numbers going up to 100 (top picture).  The next sheet, having been sorted, appears with no numbers after 49 (see above).  The next sheet places the numbers on a grid (see below), so it is easier to find the next one in sequence.  

The next sheet offers the numbers in sequence. The final two sheets require the players to perform a quality audit, as two numbers are missing.  First, they are all presented in a jumble.  Next, they are presented in sequence.  Our students quickly saw the value of the 5-S principles, and we later went up to areas of the hospital to see how it might be applied in settings like supply rooms.

Today's game, an all-time favorite, was Pig.  It is meant to demonstrate the value and power of standardized work.  In round one, participants are asked to draw a pig on a grid, following oral instructions.  The results, to say the least, are mixed!  Compare the drawings above and below this paragraph.

In round two, written instructions are provided, and things improve a bit.  In round three, a picture is provided along with the written instructions and there are high quality, consistent results (as seen below).

Beyond fun and games, the issue of standardization is a deadly serious concept when we turn to the problem of clinical variation.  We always want to leave doctors and nurses with the discretion to vary from protocols when necessary; but, for the most part, we want to remove creativity from the workplace with many clinical procedures.  Our class viewed this problem as we watched a video of two nurses carrying out a straight-forward, but important, procedure, cleaning a central line.  Even though a written protocol exists, it contains some ambiguity.  It might be that the ambiguity resulted in the nurses carrying out the procedure in slightly different manners; or it might be that they had committed the protocol to memory rather than reviewing the documentation each time; or it might be that they simply had habitual variations in how they conducted the procedure.  But the lesson was clear to our participants:  Achieving standardized work in the clinical setting is important but difficult.