tag:blogger.com,1999:blog-320533622024-03-18T06:27:54.384-04:00Not Running a HospitalThis is a blog by a former CEO of a large Boston hospital to share thoughts about negotiation theory and practice, leadership training and mentoring, and teaching.Paul Levyhttp://www.blogger.com/profile/17065446378970179507noreply@blogger.comBlogger4646125tag:blogger.com,1999:blog-32053362.post-85229281493579378422016-03-15T17:35:00.000-04:002016-03-15T17:35:57.148-04:00--30--<div dir="ltr" style="text-align: left;" trbidi="on">
With 4646 blog posts dating back to August 2006, it's time to end this adventure. After over 9-1/2 years of almost daily output, I will cease adding new posts to this blog.<br />
<br />
Why? The main reason is that it is simply time to move on to other pursuits. The time and effort spent conceiving, researching, writing, and editing articles has pushed off other projects that I've had in mind for several years. I'd like to focus on those.<br />
<br />
I'm deeply appreciative of my loyal and engaged readers. They commented directly on the blog over 22 thousand times, and many have also sent private emails with their observations. The readers have been polite, respectful, attentive, and thoughtful, and I cherish the time we've spent together.<br />
<br />
I'm also grateful to members of the Fourth Estate with whom I have corresponded on many of the topics covered here. Sometimes we have sourced one another, sometimes we have collaborated, and sometimes we have offered mutual support in the face of harsh criticism from the subjects of our articles. I've generally found that the business pressures faced by the media have not eroded the diligence of reporters in this field, and their commitment to the First Amendment is powerful and lasting.<br />
<br />
As to those in the health care world, as I said in <a href="http://runningahospital.blogspot.co.uk/2006/08/running-hospital.html">my first blog post</a>:<br />
<br />
<i>I have never worked in a place where people are so consistently caring
and devoted to alleviating human suffering caused by disease. It is, in
many ways, a beautiful place to work. But many of the forces facing
hospitals, doctors, nurses, and others make it really hard to do the job
well.</i><br />
<br />
That dedication persists, but the corporatization of the health care world weighs heavily on these well-meaning people. They need our support and encouragement, and they deserve to be led by leaders who understand the value they bring to society.<br />
<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgkcumZp3trdi739O-TpMVL1U_4cB3LrYAIaeUWGFJeRoTavKyCFTnf2ttY_qGrTfRcKDjnoIskx854lsblM9z7MUhGNe9eagB9pfsqkDyyRW5KJMetqSiH4h-1tc-9GYTrMYXXqA/s1600/team.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="163" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgkcumZp3trdi739O-TpMVL1U_4cB3LrYAIaeUWGFJeRoTavKyCFTnf2ttY_qGrTfRcKDjnoIskx854lsblM9z7MUhGNe9eagB9pfsqkDyyRW5KJMetqSiH4h-1tc-9GYTrMYXXqA/s200/team.jpg" width="200" /></a></div>
Finally, a tribute to those who have mattered the most in making this blog worthwhile, the hundreds of girls I have coached in youth soccer over the course of over two decades. They've taught me immensely important leadership and teamwork lessons, and I've done my best to impart those lessons to you.<br />
<br />
I'll leave the blog up for those who might like to use it as a reference. A note: Do not use the search box within the blog page. It is not well supported by Google (even though Blogger is a Google product.) If you want to search for a topic, conduct a search from the main search engine you prefer on your browser--using "runningahospital [item]"--and you'll be more likely to be successful and get a more complete listing.<br />
--30--</div>
Paul Levyhttp://www.blogger.com/profile/17065446378970179507noreply@blogger.com128tag:blogger.com,1999:blog-32053362.post-6691777893479704032016-03-15T01:42:00.001-04:002016-03-15T01:42:52.153-04:00How to get patient opinions: Ask.<div dir="ltr" style="text-align: left;" trbidi="on">
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg_MWCVl5yAij6RvtRJVi38atmOSUWQoqAMf7idqHc6lSXWnqRWUOQTAzxO_O_YiEZkKGYG8hh5nByFU4rnVPyCT2efpfDT_7Fu499C6fq3H7oeszKzFcNZfc7v6-CLLWxed1n6uQ/s1600/PO.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg_MWCVl5yAij6RvtRJVi38atmOSUWQoqAMf7idqHc6lSXWnqRWUOQTAzxO_O_YiEZkKGYG8hh5nByFU4rnVPyCT2efpfDT_7Fu499C6fq3H7oeszKzFcNZfc7v6-CLLWxed1n6uQ/s1600/PO.jpg" /></a></div>
Michael Greco and his mates at <a href="https://www.patientopinion.org.au/">Patient Opinion</a> have developed a simple and useful way to collect opinions about medical care from patients and provide a lovely forum for interactions back and forth with the hospital and providers. The purpose is simple: To enable and enhance issue resolution, relationship restoration, and improvement. An easy-to-use website makes it possible.<br />
<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgLy0KGORz9HGQzsHJ-rB0Gk0DhltRq2coP6AEWzaFa6IPJHVMQvaT8sdoimdIyTZRfAKCdl2RXshIXNqjX-ol_W5UhmO8dGxjkiVgJh99NPGBnfAT55CnkeQMVBdS3mcZO9sFqHA/s1600/story.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="125" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgLy0KGORz9HGQzsHJ-rB0Gk0DhltRq2coP6AEWzaFa6IPJHVMQvaT8sdoimdIyTZRfAKCdl2RXshIXNqjX-ol_W5UhmO8dGxjkiVgJh99NPGBnfAT55CnkeQMVBdS3mcZO9sFqHA/s320/story.jpg" width="320" /></a></div>
The folks at <a href="https://www.easternhealth.org.au/">Eastern Health</a> in Victoria have had PO in place for some time. Here are some stories from their health system. As you can see, things go in both directions in a helpful, direct, and friendly fashion. In fact, <a href="https://www.patientopinion.org.au/opinions/61899">this first story</a> is actually an apology from a patient to the staff. An excerpt:<br />
<i><br /></i>
<i>I was upset and not in the mood to talk much nor was I paying attention
to what was being said, as a result I presented as being rude. When the
descending red misty haze had finally settled, remorse set in. I regret
deeply if I had offended this person and caused them to perform their
duties to other patients in a non satisfactory manner.</i><br />
<br />
<i>If you have any idea as to who the unfortunate recipient of my bout of
bad manners was, could you please forward my most sincere apologies to
him.</i><br />
<br />
The response from the hospital chief executive was empathic:<br />
<br />
<i>Thank you so much for sharing your story on Patient Opinion and I do
hope that you are feeling better for having communicated your apology to
us. Please be reassured that we understand how these things happen and I
hope that you have relieved a burden which I imagine you have been
carrying for a while.</i><br />
<br />
<i>Please be reassured that I will do my best
to identify the person . . . and be
sure to send on your apology to him.</i><br />
<br />
<i>Look after yourself and
thanks again for getting in touch - no doubt, if I can identify who this
person is, your apology will make his day.</i><br />
<br />
Here's <a href="https://www.patientopinion.org.au/opinions/61870">another story</a>, in which a mother expressed concerns about her daughter's care. An excerpt:<br />
<br />
<i>There have been a number of issues that I am concerned about and I believe need to be addressed, these are:</i><br />
<br />
<i>1.
My daughter should never have been discharged from the Angliss as she
was in pain, nauseous & unwell. Surely an indicator that something
was seriously amiss!</i><br />
<i>2. This damage to her bladder has been devastating for her & us as a family.</i><br />
<i>3. No phone communication from nursing staff when I rang as the phone rang out.</i><br />
<i>4. There appears to be a shortage of staff? Why are there not more ward clerks?</i><br />
<i>5. I am not the sort of nuisance person who makes complaints just for the sake of it.</i><br />
<i>6.
I am very disturbed at how my daughter has been treated and I feel
angry she has had to endure so much pain and an operation that went so
terribly wrong!</i><br />
<br />
<i>I suggest the issues I have pointed out require investigation & rectifying to avoid further insult & pain to others.</i><br />
<br />
<i>I
also hope you take note of the staffing in your hospitals and that more
thought is put into place regarding the discharge of patients.</i><br />
<br />
Here are excerpts from the response from the chief executive:<br />
<br />
<i>First of all, let me say how sorry I am to read about your daughter’s
experience at Angliss Hospital. I understand that you would be upset
about this and I am alarmed too when I read the detail.</i><br />
<br />
<i>Secondly,
at the outset, I want you know that we will work with you to resolve
these issues and importantly, learn from your experience so that we can
prevent a recurrence.</i><br />
<br />
<i>You have raised a number of issues related
to lack of care and I can’t imagine why this has happened. . . . Then, when I
read that you have made contact with Eastern Health and we have not
responded, I am even more concerned. We really do pride ourselves on
responding to all feedback and share this with our staff as part of our
process of feedback for improvement.</i><br />
<br />
<i>I would like to arrange a
full investigation into the issues which you have raised as well as the
matter of sending a letter and an email without a response from us.</i><br />
<br />
<i>Based
on the facts which have been raised, I can indeed have very general
discussions and piece little pieces of information together but it would
be even better and more targeted if I could have a conversation with
you and discuss a plan of action. </i><br />
<br />
<i>I would welcome your contact
and if you could email me privately . . .</i><br />
<br />
After some personal contact, the mother responded:<br />
<br />
<i>Thank you Mr Lilly,</i><br />
<br />
<i>It was very reassuring to hear
from you and that the issues mentioned will be followed up. It is not
about blame merely that more thought should be put into place when a
patient says something is wrong....we as humans know our own bodies.</i><br />
<br />
<i>I
would not like to see this happen to another person. We are only human
and things happen however it just goes to show we need to listen. . . . I thank you sincerely for your
compassion and concern. </i><br />
<br />
Michael notes that many stories have been viewed by the public hundreds of times. That all of these conversations are public makes them even more
powerful--in terms both of process improvement in the hospital and the messages and information that is provided to other patients and families.</div>
Paul Levyhttp://www.blogger.com/profile/17065446378970179507noreply@blogger.com0tag:blogger.com,1999:blog-32053362.post-48001540548330888942016-03-14T00:15:00.000-04:002016-03-14T00:16:17.896-04:00Callahan tells about stories<div dir="ltr" style="text-align: left;" trbidi="on">
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With a plethora of books about the value and importance of storytelling, we might wonder if another could offer any value. Well, the answer is yes, emphatically.<br />
<br />
Shawn Callahan's about-to-be released book
<a href="http://www.anecdote.com/putting-stories-to-work/"><i>Putting Stories to Work: Mastering Business Storytelling</i></a>, is a must-have for your actual or digital library. It is available now on pre-order and will be on the "bookshelves" on March 20.<br />
<br />
Shawn is the founder of <a href="http://www.anecdote.com/">Anecdote</a>, the world’s largest business storytelling company. His book is engaging and wise, and yes, replete with useful stories. His advise is concise and helpful, and--unsurprisingly--he has a way with words! Let me provide some excerpts. First, this teaser:<br />
<br />
<i> Natural as it is for us to tell stories, as soon as we enter a meeting,
begin a presentation or start a formal conversation with a colleague,
all our stories disappear. We bring forth our most authoritative voice
and opine away, saying things like: ‘There are three key points here...’
and ‘I think that...’ and ‘It’s my view that...’ But as we’ve seen, the
problem with this approach is that it’s mostly forgettable. You need
to inject some storytelling into business proceedings to get the right
balance of argument and narrative. And to do this effectively as a
leader, you need to concentrate on what I call small stories.</i><br />
<br />
<i>Big ‘S’ storytellers
apply plot structure, character development, beats, scene design and
myriad other storytelling principles and practices—they’ve probably
read Robert McKee’s fabulous book </i>Story: Substance, Structure, Style,
and the Principles of Screenwriting.<i> At the other end of the spectrum
is little ‘s’ storytelling, where we find the stories we tell on a daily
basis in conversations: anecdotes concerning real-life experiences. </i></div>
<br />
<i>We can certainly improve our storytelling by applying some of the techniques
used by the best screenwriters, playwrights and novelists. But beyond
a certain point, your storytelling will drop into the Uncanny Valley,
at the bottom of which your efforts will seem artificial, forced and
unappealing. And that’s fatal for business communications. </i><br />
<i> </i>
<br />
<div>
And some basic rules:<br />
<br />
<i>It’s been proven that the real efficacy of storytelling
lies in three standout features of stories that can help us do our jobs
as business leaders:</i><br />
<br />
<i>They're memorable—There’s no point in saying something if it’s
forgettable.</i><br />
<br />
<i>They convey emotion—People are inspired to act when they feel
emotion.</i><br />
<br />
<i>They’re meaningful—
In the complex environment of work, people
need to be able to make sense of what’s going on and how they fit in.</i><br />
<br />
I could go on with more, but you can download a free sample <a href="http://www.anecdote.com/pdfs/PuttingStoriesToWork_excerpt_2015.pdf">here</a>. Reading this book once will be well worth your time. And, then you will come back to it many times over the years.</div>
</div>
Paul Levyhttp://www.blogger.com/profile/17065446378970179507noreply@blogger.com0tag:blogger.com,1999:blog-32053362.post-38113153960454300752016-03-13T23:52:00.001-04:002016-03-13T23:52:55.126-04:00US News rankings reward transparency<div dir="ltr" style="text-align: left;" trbidi="on">
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Regular readers will know that I am no fan of hospital rankings and have been quite critical over the years at the ones at <i>US News and World Report</i>. But let's give credit to where it is due:<br />
<br />
Check out <a href="http://health.usnews.com/health-news/blogs/second-opinion/articles/2016-03-04/methodology-change-will-credit-hospitals-for-transparency-reduce-reputation">this news release</a>. Excerpts:<br />
<br />
<i>Patients and families who've used our rankings tell us they want
more from hospitals. What they want is meaningful transparency.</i><br />
<br />
<i>U.S. News will implement two closely related methodology changes
this spring that could drive broader transparency. Both will affect only our
rankings of Best Hospitals in Cardiology & Heart Surgery. In that
specialty, we will award credit to hospitals that publicly release their own performance
data via one or both of two clinical registries, the Society of Thoracic
Surgeons' (STS) Adult Cardiac Surgery Database and the American College of
Cardiology's (ACC) National Cardiovascular Data Registry. In the case of the
ACC data, two constituent registries will be considered: CathPCI and ICD. ACC
and its participating <a href="http://health.usnews.com/health-news/blogs/second-opinion/2015/11/18/cardiologists-begin-voluntary-public-reporting" title="Link: http://health.usnews.com/health-news/blogs/second-opinion/2015/11/18/cardiologists-begin-voluntary-public-reporting">cardiologists
began voluntary public reporting</a> from CathPCI and ICD in November.</i><br />
<br />
<i>Of approximately 700 hospitals evaluated for the heart rankings,
more than half already publicly report through STS. (Their performance can be
freely accessed at <a href="http://www.sts.org/adult-public-reporting-module" title="Link: http://www.sts.org/adult-public-reporting-module">STS.org</a>.) Many STS reporters publicly report
through ACC as well. In addition, some hospitals that haven't yet opted into the
STS reporting program, which began in 2010, have already elected to participate
in the ACC's program. (ACC data can be found at <a href="https://www.cardiosmart.org/Heart-Basics/Find-Your-Heart-a-Home/" title="Link: https://www.cardiosmart.org/Heart-Basics/Find-Your-Heart-a-Home/">CardioSmart.org</a>.)</i><br />
<br />
<i>
</i><i>Slightly more than 300 of the hospitals in the U.S. News cardiovascular-care
analysis, however, have not yet opted to be transparent through either
registry. That deprives patients of an opportunity to assess the holdouts' quality
of care.</i><br />
<br />
<i>To accommodate the new transparency measures, U.S. News will reduce
reputation's scoring weight in Cardiology & Heart Surgery from 27.5 percent
to 24.5 percent. </i><br />
<br />
Well done! This is an excellent step. I hope it will be expanded to other specialties over time.<br />
</div>
Paul Levyhttp://www.blogger.com/profile/17065446378970179507noreply@blogger.com0tag:blogger.com,1999:blog-32053362.post-90028986033553515632016-03-12T22:12:00.001-05:002016-03-12T22:19:42.420-05:00Meanwhile, back in Massachusetts<div dir="ltr" style="text-align: left;" trbidi="on">
It's been some time since I commented on issues of market dominance in Massachusetts, but <a href="http://commonwealthmagazine.org/health-care/ballot-question-spurs-unusual-hospital-alliance/">a recent story by Bruce Mohl</a> at <i>Commonwealth Magazin</i>e caught my interest. He writes about a petition being supported by a health care union, SEIU, and Steward Health Care that would mandate a flattening of rate disparities among the state's hospitals.<br />
<br />
The Massachusetts Hospital Association opposes the ballot question. Mohl notes:<br />
<br />
<i>All but one of the hospital association’s board members head
institutions that would benefit financially from the ballot question,
but nevertheless they have formed a united front against it. Their
reasons vary. Some are wary of government price regulation; others don’t
think a ballot question is the best way to set health care policy.
Whatever their motivation, the united front benefits Partners
HealthCare, the one association member who would take a big hit if the
ballot question becomes law.</i><br />
<br />
Mohl notes that under the proposed legislation:<br />
<br />
<i>Lowell General Hospital would receive $27 million. Cambridge Health
Alliance would get $22 million. CareGroup, which owns Beth Israel
Deaconess and Mount Auburn Hospital, would pick up a total of $17
million. Baystate Health and Lahey Health would each receive $10
million, New England Baptist would get $7 million, Boston Medical Center
would recover nearly $4 million, and Tufts Medical Center nearly $3
million.</i><br />
<br />
He also reports:<br />
<br />
<i>A source familiar with the board’s discussions said Partners wields
enormous power within the association, since it supplies 20 to 25
percent of its revenue. The source said the hospital association has
pledged $14 million to the ballot question fight, with $12 million
coming from Partners and $2 million from the association’s other
members. The Rasky Baerlein firm is being enlisted to run the ballot
campaign, the source said.</i><br />
<br />
What more evidence do you need of the power and intimidation that Partners can wield among the insiders of the Boston health care market? <br />
<br />
Some in the MHA find inimical the prospect of regulation of hospital pricing by the state. Oddly, some of those very people are among the first to complain that the market-power-based rate-making system current employed by Blue Cross Blue Shield and the other insurers is unjust. Now, when they could act, they adopt an ostrich-like pose. Do they really think that "a hospital association subcommittee headed by Michael Widmer, the former
head of the Massachusetts Taxpayers Foundation" will find ways to
address the pricing differentials? Over the course of the last decade, two Attorneys General have documented the disparities problem and its untoward effect on overall health care costs in the state, and the MHA has failed to do anything about it.<br />
<br />
Meanwhile, Steward's support for the petition is humorous. That system has always bragged about being a "low-cost" alternative to the pricey academic medical centers. It now seems to realize that it is not really "low-cost" but simply "low-paid." Meanwhile, for years it sent its tertiary referrals to Partners' Massachusetts General Hospital, the highest paid tertiary center--a move that undercut the profitability of the global payment based system Steward has chosen to sign with insurers.<br />
<br />
In short, everybody seems to want to have it both ways. Except Partners. Which has is (again) their way. Bravo, Partners! Well done.</div>
Paul Levyhttp://www.blogger.com/profile/17065446378970179507noreply@blogger.com2tag:blogger.com,1999:blog-32053362.post-58739113298771894792016-03-12T07:07:00.000-05:002016-03-12T07:16:46.041-05:00Getting past denial in Victoria<div dir="ltr" style="text-align: left;" trbidi="on">
You have to be willing to acknowlege your problems before you can remedy them. If I were to characterize the state of public and private hospital care in the state of Victoria, Australia, I'd have to say that this first step is lacking. Both the public and private hospital systems and the goverment regulators who oversee them are in a state of denial with regard to the level of harm being caused to the public by inadequate attention to quality and safety deficiencies. The health system as a whole, also, is characterized by an uwillingness to engage patients and families in the appraisal and improvement of care.<br />
<br />
The question is when and if the body politic and hospital governing bodies and clinical and administrative leaders will overcome their denial of the extent of the problem.<br />
<br />
On the public side of the hospital system, the Victoria Auditor-General is about to issue an important report on patient safety in Victoria hospitals, <a href="http://www.audit.vic.gov.au/work_in_progress/audits_in_progress.aspx#patient">described as follows</a>:<br />
<i><br /></i>
<i>Clinical incidents in healthcare settings cause, or have the
potential to cause, unexpected harm to patients. They include
falls, pressure sores and medication errors and may result in near
misses, adverse events where harm has occurred or sentinel events
resulting in serious harm or death. It has been estimated that
around one in 10 hospitalised patients suffers preventable harm and
an adverse event related to care. The number of near misses, the
accuracy of reporting of patient safety incidents, and the
effectiveness of subsequent investigation are not known. The audit
will determine whether public hospitals are managing risks to
patient safety.</i><br />
<br />
If this study is rigorous and accurate, as I have reason to believe it will be, it will confirm <a href="http://www.theage.com.au/victoria/hospitals-error-levels-revealed-20110817-1iyb2.html">a previous analysis</a> about the public hospitals:<br />
<br />
<i>A study published in the journal Health Policy showed there were almost 20,000 adverse events - or incidents that cause harm to patients - in Victoria in 2005-06.</i><br />
<br />
<i>The
data showed for the first time the extent of errors and complications
in Victoria's hospitals and highlighted how little the state government
reports such problems. It discloses only the most serious problems, or
''sentinel events'', each year.</i><br />
<div class="ad adAlignRight" id="adspot-300x250-pos3">
<i><br /></i>
</div>
<i>
</i><i>In 2005-06, the same year as the study, it disclosed only 91 serious adverse events, including 29 deaths.</i><br />
<br />
<i>The study, led by Katharina Hauck of the Imperial College London's
centre for health policy, found that adverse-event rates varied greatly
between hospitals - from 6.8 per cent to 30.1 per cent for elective and
from 3.6 per cent to 25.7 per cent for emergency patients.</i><br />
<br />
Many believe that quality and safety problems occur mainly in the rural
hospitals, but it is clear that they exist even in the most reknowned
academic tertiary care institutions.<br />
<br />
From all I can see, this study has been ignored by the body politic. After a brief flurry of interest by media, attention to the issue evaporated. Will the same happen to the Auditor-General's report? Concerns about the public health system tend to focus on budgetary matters, <a href="http://www.pressreader.com/australia/the-age/20160311/281745563488208">sometimes with sniping between federal and state officials</a> that distracts from the level of harm being caused to patients.<br />
<br />
There is a tendency among Victorians to extol the virtues of the devolved model of health care organization that exists in the state--as distinct, say, from the more centralized approach employed in New Soulth Wales. In that state, a Clinical Excellence Commission is directly charged with designing and disseminating improvements in patient care into the state's hospitals.<br />
<br />
There is no inherent advantage in one system versus another. After all, a devolved system can be a fecund environment for innnovation and creativity. But when it comes to the saftey and quality of care, there is scant evidence that such is the case in Victoria. An <a href="http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/Devolved-governance-Victoria-Kings-Fund-November-2015.pdf">October 2015 study by the King's Fund</a> is notably silent about any such advances. Apparently looking for positive remarks, the best the authors could say was the following:<br />
<br />
<i>The picture that emerges is of a health system performing well.
Available data shows that Victoria delivers good results in comparison
with other parts of Australia, being at, close to and sometimes above the
average on many indicators. Underpinning Victoria’s performance is a
well-understood governance model that gives the boards running health
services at a local level considerable autonomy within a state-wideframework of priorities.</i><br />
<br />
Putting aside the fact that benchmarking a system to "the average" is meaningless, the following remarks undercut the validity of even this conclusion:<br />
<br />
<i>The transparent reporting of data on performance is another area for
improvement. Not only would this strengthen accountability to the
public, but also it would support health care providers to compare their
performance with others and identify areas in which they can improve.
The ‘disinfectant of sunlight’, as it has been dubbed, is being used
increasingly in other health care systems, including within Australia,
and it could be a powerful means of providing an early warning of
performance problems. Increased transparency on safety and quality
would also provide boards with the information they need to discharge
their responsibilities.</i><br />
<br />
In short, the basic information that devolved boards need to carry out their responsibilities is simply not available.<br />
<br />
All of the above is about the public hospitals, but I have now heard and seen enough to believe that similar patterns exist in even some of the most highly regarded private hospitals. During the last three months, I did not seek stories of safety and quality lapses in the private system, but I've had many reported to me. One hospital system, for example, has a clear and persistent pattern of mis-identifying patients under their care--sometimes from failing to attach identifying name bands to patients admitted through their emergency room--resulting in near misses as patients were sent to the wrong procedure rooms or were about to be administered the wrong medications.<br />
<br />
As in the case of the public hospitals, as dearth of reporting about hospital acquired infections and other sources of harm impedes public debate about this important adjunct to the state's health system. A lack of transparency allows reputation and market power--rather than quality--to form the basis for the relative rates charged to private medical insurers.<br />
<br />
I have discussed before the high level of <a href="http://runningahospital.blogspot.com/2016/02/towards-zero-on-roads-in-oz.html">communitarian behavior</a> in much of Australia society, and this is a marvelous thing. I have also pointed out the <a href="http://runningahospital.blogspot.com/2016/03/staff-at-work.html">notable personal commitment</a> of many clinicians to providing patient- and family-centered area. This too is admirable. But general evidence of communitarianism and caring do not make a safe and high quality health care system. Unless there is a high-level and sustained commitment to reducing harm by Government, by boards, and by clinical leaders; unless all parties embrace transparency of clinical outcomes; and unless patients and family engagement is made an institutional requirement of care design and delivery, Victorians will be put at unnecessary risk during their visits to public and private hospitals in the state.</div>
Paul Levyhttp://www.blogger.com/profile/17065446378970179507noreply@blogger.com3tag:blogger.com,1999:blog-32053362.post-85839704820776422302016-03-09T18:19:00.000-05:002016-03-09T18:19:22.333-05:00Time for a "no dickheads" rule<div dir="ltr" style="text-align: left;" trbidi="on">
In his wonderful book about the All Blacks, <a href="http://www.amazon.com/Legacy-James-Kerr/dp/147210353X"><i>Legacy</i></a>, James Kerr reminds us that a key to the success of this remarkable rugby team is an unbreakable social contract, "No dickheads."<br />
<br />
I'm beginning to think that the body politic needs a similar approach. If we view each country as having an implicit social contract, we can see that its tenets have an ebb and flow--from inclusive to exclusive, from sharing to selfish, and so on. It appears that we are now heading, in several countries, to the end of the spectrum that is dysfunctional.<br />
<br />
Martin Flanagan sets forth this thought in his book about Australia, <i><a href="https://www.bookdepository.com/Sunshine-or-Shadow-Martin-Flanagan/9780330363709">In Sunshine or in Shadow</a>.</i> Although written several years ago, I have found his observations to be apt today in many ways. A country whose philosophy was based on "<a href="http://runningahospital.blogspot.com.au/2016/03/mateship.html">mateship</a>" has moved. He writes:<br />
<br />
<i>I ask my father-in-law--what does it mean to be Australian? He looks out the window and says, "Giving the bloke beneath you a hand up." This ethic is directly at odds with the political ideology of our day. known in this country as economic rationalism, it is a glib brew of post-modern capitalism and social Darwinism that has no meaningful notion of culture and no respect for the local except as a marketplace. </i><br />
<br />
Ari Shavit, in <a href="http://www.amazon.com/My-Promised-Land-Triumph-Tragedy/dp/0385521707">My Promised Land</a>, describes a similar phenomenon in another young country that came into being on a wave of mutual support and social justice. A friend of mine there in Israel, looking at the current political leadership, behavior, and social trends, says, "I don't feel I am living in my own country anymore."<br />
<br />
And in the United States, well, what can we say about the current campaign in one of the two major parties? <a href="http://www.vox.com/2016/3/1/11127424/trump-authoritarianism">This article</a> notes:<br />
<br />
<i>Much of the polarization dividing American politics was fueled not just
by gerrymandering or money in politics or the other oft-cited
variables, but by an unnoticed but surprisingly large electoral group —
authoritarians.</i><br />
<br />
<i>This trend had been accelerated in recent years by demographic and
economic changes such as immigration, which "activated" authoritarian
tendencies, leading many Americans to seek out a strongman leader who
would preserve a status quo they feel is under threat and impose order
on a world they perceive as increasingly alien.</i><br />
<br />
There was never a more important time for people of influence and status to speak up for the more positive social contract that has worked to make nations great. But, not only those people. With the rise of social media, everybody has a forum they can employ for similar messages. It's really time to use the resources at our disposal to encourage and support a "no dickheads" rule, a culture of respect, openness, understanding, empathy, and mutual support--one that welcomes the diversity within but also the inflow of new citizens seeking gratefully to participate in a productive and free society.<br />
<br />
But it is just that freedom that, without diligence, diminishes us all.<br />
<br />
If not, we best remember the quote from Martin Niemöller:<br />
<br />
<i>When the Nazis came for the communists,<br />
I did not speak out;<br />
As I was not a communist. </i><br />
<br />
<i>When they locked up the social democrats,<br />
I did not speak out;<br />
I was not a social democrat.</i><br />
<br />
<i>
</i><i>When they came for the trade unionists,<br />
I did not speak out;<br />
As I was not a trade unionist.</i><br />
<br />
<i>
</i><i>When they came for the Jews,<br />
I did not speak out;<br />
As I was not a Jew.</i><br />
<br />
<i>
</i><i>When they came for me,<br />
there was no one left to speak out.</i></div>
Paul Levyhttp://www.blogger.com/profile/17065446378970179507noreply@blogger.com2tag:blogger.com,1999:blog-32053362.post-45684941997708478622016-03-09T12:51:00.000-05:002016-03-09T13:09:11.776-05:00Mateship<div dir="ltr" style="text-align: left;" trbidi="on">
You can't be here in Australia for very long before hearing about the concept of "mateship." Here are some explanations:<br />
<br />
<a href="https://en.wikipedia.org/wiki/Mateship">Wikipedia says</a>: <span class="st" data-hveid="42">"Mateship is an Australian cultural idiom that embodies equality, loyalty and friendship."</span><br />
<br />
<span class="st" data-hveid="42">But it goes further than that. This government <a href="http://www.australia.gov.au/about-australia/australian-story/mateship-diggers-and-wartime">site</a> says:</span><br />
<br />
<i><span class="st" data-hveid="42">'Mateship' is a concept that can be traced back to early colonial times.
The harsh environment in which convicts and new settlers found
themselves meant that men and women closely relied on each other for all
sorts of help. In Australia, a 'mate' is more than just a friend. It's a
term that implies a sense of shared experience, mutual respect and
unconditional assistance.</span></i><br />
<br />
<span class="st" data-hveid="42">And <a href="http://www.abc.net.au/local/stories/2015/01/23/4167572.htm">this article</a> notes: "</span><span class="st" data-hveid="42">It is a term that conjures images of young men providing unconditional support for one another amid the toughest of conditions."</span><br />
<br />
<span class="st" data-hveid="42">But what I've found is that the term also often implies demonstrating that loyalty with a panache of machismo, sometimes--in the view of others--to the the extent of foolishness. Martin Flanagan tells a story in his book <a href="https://www.bookdepository.com/Sunshine-or-Shadow-Martin-Flanagan/9780330363709"><i>In Sunshine or in Shadow</i></a>:</span><br />
<br />
<i><span class="st" data-hveid="42">Just after the Rocherlea turn-off, I stopped for a hitchhiker, a young man in his twenties, who looked to be in pain. He was holding his groin and got into the car with difficulty. He told me he had picked up a pup belonging to his mate's dog, a half bull terrier bitch, which had responded by leaping up and biting him in the testicles. I asked if he struck the animal or kicked at it to get away. He looked at me as if I hadn't heard him correctly, and said, a second time, more slowly than the first, "It was the mate's dog."</span></i><br />
<br />
<i><span class="st" data-hveid="42">When I told Bob Brown [a Tasmanian environmental activist] this story, he laughed till he cried, big sodding drops that fell on his shoes, and I knew he loved this poor silly bastard and the foolish splendour of his male pride.</span></i><br />
<span class="st" data-hveid="42"><br /></span>
<span class="st" data-hveid="42">The term is also exemplified in the 1890 iconic epic poem by A. B. "Banjo" Paterson, "<a href="http://www.middlemiss.org/lit/authors/patersonab/poetry/snowy.html">The Man from Snowy River</a>." When I heard the musical version by </span><span class="st" data-hveid="42">Wallis & Matilda from <a href="https://youtu.be/r-MzfmPo5j4">their album "Pioneers,"</a> I remarked that the difference between this story and America is that the guys in the American Old West would not necessarily have come to the aid of one of their fellow horse owners to go after the colt. Here they did, to be helpful for sure, but especially for the sport of the difficulty in retrieving it. Here's the poem. [Sorry, I can't get the formatting exactly right here, so go to <a href="http://www.middlemiss.org/lit/authors/patersonab/poetry/snowy.html">the original</a> to see all the words.] Note the description of the pony in the third verse--the perfect horse for this mate:</span><br />
<br />
<pre>There was movement at the station, for the word had passed around
That the colt from old Regret had got away,
And had joined the wild bush horses - he was worth a thousand pound,
So all the cracks had gathered to the fray.
All the tried and noted riders from the stations near and far
Had mustered at the homestead overnight,
For the bushmen love hard riding where the wild bush horses are,
And the stockhorse snuffs the battle with delight.
There was Harrison, who made his pile when Pardon won the cup,
The old man with his hair as white as snow;
But few could ride beside him when his blood was fairly up -
He would go wherever horse and man could go.
And Clancy of the Overflow came down to lend a hand,
No better horseman ever held the reins;
For never horse could throw him while the saddle girths would stand,
He learnt to ride while droving on the plains.
And one was there, a stripling on a small and weedy beast,
He was something like a racehorse undersized,
With a touch of Timor pony - three parts thoroughbred at least -
And such as are by mountain horsemen prized.
He was hard and tough and wiry - just the sort that won't say die -
There was courage in his quick impatient tread;
And he bore the badge of gameness in his bright and fiery eye,
And the proud and lofty carriage of his head.
But still so slight and weedy, one would doubt his power to stay,
And the old man said, "That horse will never do
For a long a tiring gallop - lad, you'd better stop away,
Those hills are far too rough for such as you."
So he waited sad and wistful - only Clancy stood his friend -
"I think we ought to let him come," he said;
"I warrant he'll be with us when he's wanted at the end,
For both his horse and he are mountain bred.
"He hails from Snowy River, up by Kosciusko's side,
Where the hills are twice as steep and twice as rough,
Where a horse's hoofs strike firelight from the flint stones every stride,
The man that holds his own is good enough.
And the Snowy River riders on the mountains make their home,
Where the river runs those giant hills between;
I have seen full many horsemen since I first commenced to roam,
But nowhere yet such horsemen have I seen."
So he went - they found the horses by the big mimosa clump -
They raced away towards the mountain's brow,
And the old man gave his orders, "Boys, go at them from the jump,
No use to try for fancy riding now.
And, Clancy, you must wheel them, try and wheel them to the right.
Ride boldly, lad, and never fear the spills,
For never yet was rider that could keep the mob in sight,
If once they gain the shelter of those hills."
So Clancy rode to wheel them - he was racing on the wing
Where the best and boldest riders take their place,
And he raced his stockhorse past them, and he made the ranges ring
With the stockwhip, as he met them face to face.
Then they halted for a moment, while he swung the dreaded lash,
But they saw their well-loved mountain full in view,
And they charged beneath the stockwhip with a sharp and sudden dash,
And off into the mountain scrub they flew.
Then fast the horsemen followed, where the gorges deep and black
Resounded to the thunder of their tread,
And the stockwhips woke the echoes, and they fiercely answered back
From cliffs and crags that beetled overhead.
And upward, ever upward, the wild horses held their way,
Where mountain ash and kurrajong grew wide;
And the old man muttered fiercely, "We may bid the mob good day,
No man can hold them down the other side."
When they reached the mountain's summit, even Clancy took a pull,
It well might make the boldest hold their breath,
The wild hop scrub grew thickly, and the hidden ground was full
Of wombat holes, and any slip was death.
But the man from Snowy River let the pony have his head,
And he swung his stockwhip round and gave a cheer,
And he raced him down the mountain like a torrent down its bed,
While the others stood and watched in very fear.
He sent the flint stones flying, but the pony kept his feet,
He cleared the fallen timber in his stride,
And the man from Snowy River never shifted in his seat -
It was grand to see that mountain horseman ride.
Through the stringybarks and saplings, on the rough and broken ground,
Down the hillside at a racing pace he went;
And he never drew the bridle till he landed safe and sound,
At the bottom of that terrible descent.
He was right among the horses as they climbed the further hill,
And the watchers on the mountain standing mute,
Saw him ply the stockwhip fiercely, he was right among them still,
As he raced across the clearing in pursuit.
Then they lost him for a moment, where two mountain gullies met
In the ranges, but a final glimpse reveals
On a dim and distant hillside the wild horses racing yet,
With the man from Snowy River at their heels.
And he ran them single-handed till their sides were white with foam.
He followed like a bloodhound on their track,
Till they halted cowed and beaten, then he turned their heads for home,
And alone and unassisted brought them back.
But his hardy mountain pony he could scarcely raise a trot,
He was blood from hip to shoulder from the spur;
But his pluck was still undaunted, and his courage fiery hot,
For never yet was mountain horse a cur.
And down by Kosciusko, where the pine-clad ridges raise
Their torn and rugged battlements on high,
Where the air is clear as crystal, and the white stars fairly blaze
At midnight in the cold and frosty sky,
And where around The Overflow the reed beds sweep and sway
To the breezes, and the rolling plains are wide,
The man from Snowy River is a household word today,
And the stockmen tell the story of his ride.</pre>
<span class="st" data-hveid="42"><br /></span>
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Paul Levyhttp://www.blogger.com/profile/17065446378970179507noreply@blogger.com0tag:blogger.com,1999:blog-32053362.post-16118231065027445372016-03-09T06:05:00.000-05:002016-03-09T06:38:21.443-05:00What can I do? May Wong answered the question.<div dir="ltr" style="text-align: left;" trbidi="on">
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<br />
The most common question I get--worldwide--after I give a talk or seminar on creating a learning organization to improve clinical processes in hospitals is: "I really like what you are saying, but what can I do if those above me in the organization have not adopted the philosophy you espouse." I respond by saying, "Start small, and just try to get something fixed in your area, working with other like-minded people. Maybe the ideas will spread organically. Maybe they won't, but at least you will have made things better for some."<br />
<br />
Well, May Wong from Sydney didn't need my advice. My buddy Sarah Dalton at the New South Wales Clinical Excellence Commission told me the story:<br />
<br />
Several years ago in her intern year, the thing that most frightened May was having to participate in a resuscitation. To alleviate part of her anxiety, she checked the resuscitation trolley ("code cart" in our region) in her ward to be intimately familiar with the location of every device or supply she might need if an emergency arose.<br />
<br />
A few weeks later she was working in another ward, and a code was called, and she found to her dismay that the trolley on that ward was organized differently, and she had difficulty finding the airway equipment.<br />
<br />
She said to herself, "This is ridiculous. Shouldn't every cart be organized the same way?" And she decided to get the problem fixed.<br />
<br />
She started knocking on doors. Her registrar (senior resident) said, "That's the way things are." Her consultant (attending physician) said, "That's not my problem." The nurse manager said, "It's not a problem. All of our nurses know how to find what they need."<br />
<br />
Eventually, someone suggested that she should talk to the Director of Clinical Governance. She searched around to find out who the DCG was and where to find him, and he said, "Oh, is that a problem? I didn't know." He said, assemble a team, collect data, construct a statement of aim, come back to me, and suggest the change concepts you want to implement.<br />
<br />
So she did. She brought the issue to the Resuscitation Committee, gathered other junior medical offices, invited the nurses from several wards, and even engaged the medical head of the ICUs. And she got it done. By the end of her intern year, all of the resuscitation trolleys in the hospital were organized in the same way.<br />
<br />
But things didn't stop there. May went on to work with other house staff to create a regular forum in which they could compare their quality and safety improvement ideas and progress and help one another with suggestions. It is now a regular part of the hospital's culture.<br />
<br />
What can you do? May has provided you with the path to your answer with her thoughtful actions. </div>
Paul Levyhttp://www.blogger.com/profile/17065446378970179507noreply@blogger.com3tag:blogger.com,1999:blog-32053362.post-6195089340703251812016-03-04T00:29:00.001-05:002016-03-04T00:29:46.157-05:00Staff at work<div dir="ltr" style="text-align: left;" trbidi="on">
One of the great pleasures of being ex-CEO of a hospital is to visit other places around the world and see the staff in action. Whatever you might have heard about the stresses and problems faced by doctors and nurses and others, there remains an underlying sense of purpose and commitment that often shines through.<br />
<br />
Here's a example, from the theatre in which young patients at Royal Children's Hospital receive lumbar punctures and bone marrow tests to receive chemotherapy and/or to assess their progress with regard to leukemia treatments. I offer the explanation totally in pictures, which pretty well tell the story. The only one warranting a bit of explanation is the one showing Steve, the anaesthesia technician, driving a small toy car as the patient enters the room--to distract and engage the child!<br />
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Paul Levyhttp://www.blogger.com/profile/17065446378970179507noreply@blogger.com1tag:blogger.com,1999:blog-32053362.post-2312124604635251592016-02-29T07:08:00.000-05:002016-02-29T07:08:06.107-05:00What will their legacy be?<div dir="ltr" style="text-align: left;" trbidi="on">
A danger of being "<a href="http://www.deakin.edu.au/research/story?story_id=1610">Thinker in Residence</a>" for several months here in the state of Victoria, Australia, is the danger of diagnostic anchoring--too quickly reaching conclusions about the state of the health care system--followed by confirmation bias--valuing only those observations that support the conclusion you've reached, while ignoring other data. With cognitive errors of this sort, the best defense in avoiding them is to be aware of their existence. So, I've tried assiduously to be careful during my visit here. But the time has come to offer my considered view on several matters.<br />
<br />
In <a href="http://runningahospital.blogspot.com.au/2016/02/towards-zero-on-roads-in-oz.html">a recent blog post</a>, I noted that the extensive program of traffic safety run by the Transport Accident Commission is an example of the strong sense of communitarianism that pervades this society. I suggested that a future column would explore whether this communitarian view within Victorian society carries
over into health care--whether there is a comparable commitment "towards
zero" with regard to preventable harm in hospitals.<br />
<br />
I conclude, with some sadness, that the answer is "no." <br />
<br />
At a meeting with a high government official, I was asked how the the situation with regard to quality and safety in this state compares with other jurisdictions I've visited around the world. I answered that the situation was comparable. The offical seemed satisfied with that answer. I was too polite to point out that satisfaction was not the appropriate response. As I often note, there is no virtue in benchmarking yourself to a substandard norm. In most of the developed nations, the situation with regard to quality and safety can best be described as islands of excellence in a sea of mediocrity. That such is also the case in Victoria should be no cause for contentment--for the simple reason that this state has the potential to do better.<br />
<br />
What's behind the failure to act decisively in the communitarian manner exemplified by the TAC in the transportation arena? A hint was given in a meeting with a senior official in a private hospital system, when I asked if there were any efforts to share advances in quality and safety among the region's hospitals:<br />
<br />
"We won't share what we learn about quality and safety improvement
because that information gives us a competitive advantage, e.g. with
regard to reducing lengths of stay, which has a direct impact on our finances."<br />
<br />
I was shocked by this statement, but several of my more knowledgeable colleagues were not when I mentioned the reply to them.<br />
<br />
Contrast this attitude with that of several pediatric hospitals in the Midwest United States: "We compete on everything, but we don't compete on quality and safety."<br />
<br />
Like many other countries, increasing health care costs vis-a-vis available public tax-generated money and private health care premiums are big issues here. There is a tendency for those in government and those in the industry to list financial issues as the primary ones facing the health sector. That, in turn likely leads to the kind of comment made above about competition.<br />
<br />
But such competitive forces and the narrow priorities drawn from them are not compatible with the underlying purposes of the hospitals and people working in them. Nor are they compatible, if the public understood fully, with what would be the expectations and demands of the populace.<br />
<br />
In his marvelous book <i>Legacy</i>, James Kerr writes about the greatest rugby team on earth, and notes:<br />
<br />
<i>In answer to the question, "What is the All Blacks' competitive advantage?", key is the ability to manage their culture and central narrative by attaching the players' personal meaning to a higher purpose. It is the identity of the team that matters--not so much what the All Blacks do, but who they are, what they stand for, and why they exist."</i><br />
<br />
What happens when hospital leadership focuses so intensely on money and competitive standing? A former trainee from Boston put it this way:<br />
<i><br /></i>
<i>The
absence of a sense of purpose of this kind is toxic. For instance,
if you have an advertising campaign that emphasizes our kindness or humanity,
but we have no policies or practices that distinguish our kindness or goodness
from anyone else's, it may be persuasive to our market as a branding tactic,
but it's actively alienating to those of us who work within this system. </i><br />
<br />
Kerr paraphrases Jim Collins' <i>Good to Great</i> by noting that "When enthusiastic and rigorously adhered to, a dramatic, compelling purpose is a fundamental driver of the companies that go from good to great."<br />
<br />
So an irony is that, while many health care institutions seek competitive advantage, they will not achieve what is possible even on that front because they fail to focus sufficiently on the public good aspects of their business. They give their doctors and nurses insufficient reason to have a fulfilling sense of purpose that could in turn make a huge difference on the commercial front.<br />
<br />
Here, of course, the penalty for a lack of purpose is worse than the commercial consequences. People are dying and are being harmed in Victoria's hospitals to a greater extent than is necessary.<br />
<br />
As noted earlier, the TAC is not content with even 300 traffic fatalities per year and instead helps the people of the state move that number towards zero. In contrast, in the health care arena, the number is far greater and yet there is a systemic failure to acknowledge the problem. Government agencies fail to cooperate on solving it to the extent commensurate with the public health hazard. No one proposes a standard of zero preventable harm for the Victoria hospitals. Instead, the focus is solely on <a href="http://www.theage.com.au/victoria/dozens-of-victorians-die-in-blunders-as-hospitals-feel-the-squeeze-20140521-38p56.html">sentinel events</a>, which are <a href="http://www.theage.com.au/victoria/hospitals-error-levels-revealed-20110817-1iyb2.html">just the tip of the iceberg</a> with regard to preventable harm.<br />
<br />
Hospitals themselves fail to work together on the issue. The various colleges representing the doctors' specialty groups have not addressed it in a meaningful way. The medical schools, likewise, do not work together on making longitudinal training quality and safety and clinical process improvement part of a shared curriculum.<br />
<br />
It may be that that the nascent patient quality and safety movement in Victoria will grow and help nudge government and health sector leaders to make elimination of preventable harm a priority activity comparable to eliminating traffic deaths. In the meantime, unfortunately, self-satisfaction reigns and harm persists. The people of Victoria deserve better.</div>
Paul Levyhttp://www.blogger.com/profile/17065446378970179507noreply@blogger.com1tag:blogger.com,1999:blog-32053362.post-57172859708761549852016-02-27T16:26:00.000-05:002016-02-27T16:37:43.903-05:00Hear me. Do you know me? <div dir="ltr" style="text-align: left;" trbidi="on">
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgpi0aYAn8fos2DonjYM4BtwjFKDYUfK4fywhY7SEsgsg0vncZGHgbRVgFhk5-2lOQl7zeAetMKPLsjncIONjmgRCJL9rTbY3GFn6yQpO7AN2HamC6Mmj1iuPYqVEeWDH7UI8TnDw/s1600/cath.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgpi0aYAn8fos2DonjYM4BtwjFKDYUfK4fywhY7SEsgsg0vncZGHgbRVgFhk5-2lOQl7zeAetMKPLsjncIONjmgRCJL9rTbY3GFn6yQpO7AN2HamC6Mmj1iuPYqVEeWDH7UI8TnDw/s320/cath.jpg" width="248" /></a></div>
It isn't often that I can report that I was honored to see a play, but such was the case recently when I was invited to view the showing of a short four-person drama at <a href="http://www.wghg.com.au/wghg">West Gippsland Hospital</a> in Warragul and especially because I was permitted to attend the staff discussion that followed the performance. Here's the background:<br />
<br />
The <a href="http://www.aipfcc.org.au/">Australian Institute for Patient and Family Centred Care</a> was established a few years ago by Catherine Crock and colleagues to promote just what its name implies. As noted:<br />
<br />
<i><span style="font-size: 100%;">We aim to </span><span style="font-size: 100%;"><span style="font-size: 100%;">to transform people’s experience of healthcare</span> through a three-fold approach:</span></i><br />
<ol><i>
</i>
<li><i><span style="font-size: 100%;">Develop partnerships between patients, their families and health professionals</span></i></li>
<i>
</i>
<li><i><span style="font-size: 100%;">Create a culture that is both supportive and effective</span></i></li>
<i>
</i>
<li><i><span style="font-size: 100%;">Improve healthcare environments through high-quality integrated art, architecture and design.</span></i></li>
</ol>
One medium used by the AIPFCC is to commission short plays on key themes in health care delivery and present them, upon invitation, to hospitals throughout the country. The hospital plays a small fee for the show, and the balance of the cost is covered by donations to the Institute. The plays have now been seen in dozens of health care institutions by thousands of people.<br />
<br />
Two plays are offered, <i><a href="http://www.aipfcc.org.au/assets/files/About%20Hear%20Me.pdf">Hear me</a></i> and "<i><a href="https://www.youtube.com/watch?v=JRAxkgBXV5o&feature=em-upload_owner">Do you know me?</a></i> The first deals with medical error, disclosure, apology, and communication. The second deals with care of the aging population.<br />
<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEid0Cn4BW0a99Aih6qbImFbi4u0iffRV3AcY4eDdPsdnhZppnvcce2w6Pl719B82LricNb7YQBRyXpAfaGC1SXfheOdE1fLcVjDiFETVQR5ENQ0caFGdRf33LxN6CausBsmrFCfuA/s1600/one.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEid0Cn4BW0a99Aih6qbImFbi4u0iffRV3AcY4eDdPsdnhZppnvcce2w6Pl719B82LricNb7YQBRyXpAfaGC1SXfheOdE1fLcVjDiFETVQR5ENQ0caFGdRf33LxN6CausBsmrFCfuA/s200/one.jpg" width="133" /></a></div>
We viewed the latter play in Warragul. It was organized and supported by CEO Dan Weeks. The audience of doctors, nurses, and trainees were deeply affected by the performance and the themes raised. Afterwards, Dr. Crock facilitated a discussion, and the honesty and vulnerability displayed in the comments was truly extraordinary.<br />
<br />
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The actors had permitted people to reach into their experiences--whether with their own family members or with patients--and share observations that will help bring a better sense of clinical teamwork in the hospital and empathy with patients and families.<br />
<br />
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I was particularly pleased to see that medical students and more advanced trainees were permitted time away from their ward-based clinical activities and were invited to attend. They, too, were active participants in the discussion and clearly benefitted from the experience.<br />
<br />
Meanwhile, the actors stayed and listened, no doubt enhancing their own ability to offer even more engaging performances in the future.<br />
<br />
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Paul Levyhttp://www.blogger.com/profile/17065446378970179507noreply@blogger.com0tag:blogger.com,1999:blog-32053362.post-19286457967330369312016-02-27T05:53:00.000-05:002016-02-27T06:09:08.158-05:00Towards zero on the roads in Oz<div dir="ltr" style="text-align: left;" trbidi="on">
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<br />
In America, drivers don't try to kill other drivers. In Australia, drivers try not to kill other drivers.<br />
<br />
After almost three months here, I've decided that this difference in attitudes is the biggest thing that separates these two cultures.<br />
<br />
America was built on a culture of individualism, sometimes called "rugged individualism." In Australia, society is characterized by a much greater degree of communitarianism.<br />
<br />
The place of traffic fatalities in the two countries provides a nice example.<br />
<br />
There are about 32,000 traffic-related fatalities in the US per year, about <a href="https://en.wikipedia.org/wiki/List_of_motor_vehicle_deaths_in_U.S._by_year#Motor_vehicle_deaths_in_U.S._by_year">10 per 100,000 population</a>. I think if you were to ask most American drivers about this figure, they would probably answer, "These things happen." There is virtually no concern in the general population about these deaths, and there is certainly little or no evidence that road dangers influence the manner in which people drive.<br />
<br />
In Australia, there are about 1200 deaths per year, or about <a href="https://bitre.gov.au/publications/ongoing/road_deaths_australia_annual_summaries.aspx">5 per 100,000 population</a>.<br />
<br />
A two-fold difference is pretty significant, and Australia would certainly be entitled to rest on its laurels. But folks here understand that there is no virtue in benchmarking yourself to a substandard norm. Instead, as illustrated by the a program of the Victorian Transport Accident Commission, they've set an objective of zero. The agency <a href="https://www.tac.vic.gov.au/road-safety/tac-campaigns/tac-latest-campaigns/towards-zero">explains</a>:<br />
<br />
<i>At the heart of Towards Zero is the belief that human health is
paramount to all else. It acknowledges that, as people, we all make
mistakes. However, when mistakes happen on our roads they can cost us
our lives or cause serious injury. That's because our bodies aren't made
to absorb the forces of high impact speeds. We are fragile, and there's
only so much physical force we can withstand and this is why we need to
build a safer road system. Improving the safety of our roads, our
speeds, our vehicles and our people will improve safety for everyone. The move Towards Zero is a collaborative
effort between everyone in the community. Together, we can build a safer
road system and help change road safety for the better.</i><br />
<br />
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<br />
A campaign is just a campaign if it does not take hold in the minds and behavior of the target audience. I'm here to report that as I drive on the highways and streets of Victoria, I see it in action. When you are on the highway, and the speed limit is 100 km/hour, people go at 100 km/hour. In the US, when the speed limit is 60 mph, the expectation is that you will go above that. In Victoria, you don't see people engaged in a "Grand Prix" form of driving, weaving in and out of lanes to pull ahead of cars in front of you. As a result, automobile travel is a lot less stressful and more comfortable, not to mention safer.<br />
<br />
In talking with friends here, they acknowledge that very strict enforcement of the speed laws--and high penalties--keeps your mind on doing the right thing. But they also follow up by saying that they are pleased that such is the case. Why, they say, should people die when they don't have to.<br />
<br />
In the US, if we think about the issue at all, we tend view those who might die as "somebody else," and we feel no sense of responsibility towards those potential victims. In Australia, when they think about the issue, they view those who might die as a member of their community, and they feel a great sense of responsibility in minimizing the potential for harm.<br />
<br />
In a future column, I will explore whether this communitarian view of Australian society carries over into health care--whether there is a comparable commitment "towards zero" with regard to preventable harm in hospitals.</div>
Paul Levyhttp://www.blogger.com/profile/17065446378970179507noreply@blogger.com2tag:blogger.com,1999:blog-32053362.post-16213355154528530422016-02-22T15:52:00.000-05:002016-02-23T06:14:40.161-05:00Ultimate advice<div dir="ltr" style="text-align: left;" trbidi="on">
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiyJ8z83ScNhPGU_v0Zyb0VxnaJDwin9VSdJjrjuYeXsrcGF7s1V5yaiTg3tpNgG9ZlJMqhq30van_qmLo0U9k5EIDkoBD5VnJ-OsH_lKi_6K2tUZNB-rxg9HuaGfGly-Q1ZhPjbw/s1600/michelle.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiyJ8z83ScNhPGU_v0Zyb0VxnaJDwin9VSdJjrjuYeXsrcGF7s1V5yaiTg3tpNgG9ZlJMqhq30van_qmLo0U9k5EIDkoBD5VnJ-OsH_lKi_6K2tUZNB-rxg9HuaGfGly-Q1ZhPjbw/s320/michelle.jpg" width="320" /></a></div>
<br />
When I was growing up, ultimate (originally known as ultimate frisbee) had <a href="https://en.wikipedia.org/wiki/Ultimate_%28sport%29">not yet been invented</a>. While we played with frisbees, it was mainly just a lot of tossing them around. Since then, the sport has developed and highly skilled players and teams compete worldwide.<br />
<br />
I've had a forced sabbatical from playing soccer here in Melbourne (no one plays during the summer apparently), but have been lucky to be invited to join a local co-ed division three ultimate team. It's been great fun to play a sport which in which the rules are self-enforced, i.e., without referees, and where the "spirit of the game" is the dominant culture.<br />
<br />
Nonethless, there remains a role for a team leader, often a player-coach, and in this case we are blessed to have Michelle Phillips, a world class player, as ours. Off the field, she and I have traded stories about leadership, and I've also had a chance to watch her skills in that regard during games and her post-game advisories to the team. The latest one struck me as having lessons well beyond the playing field. Here's an excerpt:<br />
<br />
<i>There's a tendency in teams (whether sporting or otherwise) to try
to 'fix' everything, to try to have the strategy perfect, to try to get
everything absolutely right.</i><br />
<br />
<i> It's not possible. More importantly,
trying to do this is actually detrimental to the overall performance of
a team. Let's have a look at why, and at what we can do instead.</i><br />
<br />
<i>
When we try to correct every non-perfect action out on field, we crowd
our minds with more information than we can process. What that looks
like is multiple voices in the circle, talking about strategic points
while we're on the line, and tacking extra pieces of information onto
the main message. Doing this means that not only do we not remember all
the little things we've been told to do, but we forget the most
important things that we started with. </i><br />
<br />
There's a direct parallel between these points and about achieving process improvement in hospitals and other organizations. Improvement in efficiency, quality, safety, and customer satisfaction occurs one small step at a time, within an overall strategy. If you try to change too many things at once, the effort usually fails, and because you've changed too many things, you don't know how to analyze the cause of the failure.<br />
<br />
Now, let's get back to Michelle's summary as she discusses a leadership (and the followship) issue:<br />
<br />
<i>A leader's job is not to fix everything. A leader's job is to filter all
the information they receive, decide what is most important for the
team, and direct the focus there. If you're leading (and we all do, at
different times) you need to be able to give your team one clear set of
directions out of the hundreds of possible actions that could be taken.
If you've passed information onto a leader and they haven't acted on it,
realise that they have made a decision not that it isn't valuable, or
true, but that it isn't the message that the team needs in that moment.
Trust that they are storing it away, and when the time is right it will
be packaged up and delivered.</i><br />
<br />
Finally, we return to the relative importance of strategy versus implementation:<br />
<br />
<i>And let me tell you a secret. It's way less about the strategy than we think.</i><br />
<br />
<i>
If it was all about strategy, the underdogs would never win. If it was
all about strategy, team sport results would be far more predictable
than they are. If it was all about strategy, the state of your athletes
wouldn't matter - only the state of your coach.</i><br />
<br />
<i> Games are won by the team that controls the mood.</i><br />
<br />
I don't think people think much about this concept of mood in a hospital or an industrial or service organization, but it is key. We might use another word, like "morale." Having now visited thousands of places, I can usually tell within 15 minutes whether a place is a
true learning organization--one described by my late friend and colleague Donald Schön
(1973), as one that is “capable of bringing about its
own transformation."
You can see it in the faces and demeanor of
staff as they walk down the corridors. You can feel it in how they
interact with one another on the front line. Call it mood, morale, or a
shared sense of purpose and mutual support. I described this in my book <a href="http://www.amazon.com/Goal-Play-Leadership-Lessons-Soccer/dp/1469978571/"><i>Goal Play!</i></a><br />
<br />
<i>The girls who play soccer in our town’s league in Eastern Massachusetts are among the luckiest kids in the world. They get to go out and play a beautiful game with their friends in a safe environment with terrific coaches and parents who support them. But there is an additional bit of magic that occurs during a game.<br /><br />As the girls play, they unconsciously adapt to one another’s strengths and weaknesses, creating a seamless web of teamwork. As a coach, when you see this happen, all you can do is smile. You know you had something to do with it, but you also know that something has happened among the girls themselves. It is a marvelous thing. They will remember it all their lives, but they may not entirely understand what they are remembering. <br /><br />They will think their fond memories of the season had something to do with friendships or other social relationships or new skills acquired or the team’s exceptional record. But there is something even more important that made the season so memorable. It is an elemental statement about the human condition: We are born to work and play together in teams. Many people do not get to experience that sense of ensemble, which requires giving enough of ourselves to let the filaments connect. That the girls discover it for themselves is very, very special. They are, indeed, the luckiest kids in the world, and we are likewise blessed in being able to share this time with them.</i></div>
Paul Levyhttp://www.blogger.com/profile/17065446378970179507noreply@blogger.com1tag:blogger.com,1999:blog-32053362.post-10825989362490574242016-02-17T04:02:00.001-05:002016-02-22T15:52:35.117-05:00Sea spurge, compacts, and other descendants of Wipe off 5<div dir="ltr" style="text-align: left;" trbidi="on">
Today's story is about how to implement a cultural change among a large group of people. Stick with me, as this will take a moment.<br />
<br />
Back in 2001 the Victoria Transport Accident Commission wanted people to slow down just a bit while driving. They understood that "Speeding just 5km/hr over the speed limit can mean the difference between a close call and a serious accident." The question was how to get people to do it, and do it consistently. Of course, you could have police and traffic cameras trying to enforce the speed limit, but that is resource intensive and can never be pervasive enough to hold thousands of drivers accountable to this standard. It would be better if people would internalize the message and hold themselves accountable.<br />
<br />
What resulted was the <a href="http://www.tac.vic.gov.au/road-safety/tac-campaigns/speed/wipe-off-5">Wipe off 5 campaign</a>. TAC employed a simple statement of principle and combined it with an easily understood and remembered action that every driver could take.<br />
<br />
The fact statement was pretty straightforward and incontrovertible:<br />
<i><br /></i>
<i>Each year about 100 hundred people die on our roads every year in
crashes where speed was a contributing factor. The TAC spends about $1
billion every year on support services for those affected by road trauma
and accepts about 19,000 claims each year from people injured in
crashes.</i><br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjMwniQfRZX6FAWUOtijakJi8iHVZ-edwFPgLEZ8DGNn4Xo02rThaUh071IeQ-79ziRbex8TQQ4lBrOzl4Am47fP-J3Ec2vkny4y3YxC8Vf23tjl3ye4rTcVI2_xrD7zRmpRbqyqg/s1600/5.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="175" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjMwniQfRZX6FAWUOtijakJi8iHVZ-edwFPgLEZ8DGNn4Xo02rThaUh071IeQ-79ziRbex8TQQ4lBrOzl4Am47fP-J3Ec2vkny4y3YxC8Vf23tjl3ye4rTcVI2_xrD7zRmpRbqyqg/s320/5.jpg" width="320" /></a></div>
<br />
The ask from the public was widely publicized in forums that were frequented by people--standard media and social media. Highly respected advocates (Footy stars!) <a href="https://youtu.be/KCre0eHbOUc">lent their names and images</a>.<br />
<i><br /></i>
<i>Low level speeding is the target of this latest TAC campaign -
the aim to make people aware that travelling only 5km/hr over the speed
limit can have disastrous results.</i><br />
<br />
<i>
</i><i>Throughout the month of August, the Wipe off 5 message will be spread
through social media, a Statewide roadshow that will tour Victoria
and the commercial featuring famous AFL number 5’s, Carlton's Chris Judd
and Collingwood's Nick Maxwell.</i><br />
<br />
The results were both immediate and sustained:<br />
<br />
<i>Over time there has been a change in community attitudes towards
speeding and also in behaviour. According to Sweeney Research, people
who report they speed most, or all, of the time has dropped from 25% to
11%.</i><br />
<br />
<i>
</i><i>Market research surveys show that the Wipe off 5 concept is generally
understood by Victorian motorists and is having a positive affect on
their driving behaviour. Since the campaign began, Vic Roads has
reported a drop in average travel speeds in 60km, 70km and 80 km/h speed
zones.</i><br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi3PqkcAizIpRQZv4JQ3tI2Pk4M-X1xTqxSxPSzWms7HXUJvmBjObtunQZXQCUUfV4JsebbHpVhFqtauaF0opPE72oN2Y7cSLQxFF4Erqm7dRiSfQ-KHfH2zUnX3r3LUD1hv_J4rg/s1600/IMG_0311.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi3PqkcAizIpRQZv4JQ3tI2Pk4M-X1xTqxSxPSzWms7HXUJvmBjObtunQZXQCUUfV4JsebbHpVhFqtauaF0opPE72oN2Y7cSLQxFF4Erqm7dRiSfQ-KHfH2zUnX3r3LUD1hv_J4rg/s320/IMG_0311.jpg" width="203" /></a></div>
<br />
Now another story, this time from the beach. There is an invasive plant species, sea spurge
(<i>Euphorbia paralias</i>), that has taken over many of the dune areas in Australia beaches. As noted <a href="http://www.environment.nsw.gov.au/pestsweeds/SeaSpurge.htm">here</a>:<br />
<br />
<i>Sea spurge can produce up to 5000 salt-tolerant seeds. These seeds can
survive for a number of years on ocean currents that spread them from
beach to beach. Once established, a sea spurge colony can spread
rapidly, displacing the native vegetation and changing the structure of
the beach. This can disrupt many native species including the endangered
shorebirds (hooded plovers, little terns and oyster catchers) that use
open sand spits for nesting.</i><br />
<br />
Although the plant is not unattractive, its displacement of local
species is troubling, and a number of people in the Cape Paterson region
have banded together to try to remove it from the dunes in their area. Work parties go out periodically to carefully pull up the plants. (It has to be done carefully or, as seen above, the remaining root structure will spread into dozens of new plants.)<br />
<br />
But two or three dozen stalwart volunteers alone cannot maintain several kilometers of beach front, and so the group has been encouraging other folks who use the beach to pitch in--to be part of the culture of removing the invaders. But the trick was to make the job memorable and approachable, so that each person would take personal accountability to help out. Rod Phillips, one of the organizers, suggested that the team adopt a take-off of the Wipe off 5 campaign, and "Take out 10" was born! As people walk along the beach, they can easily pitch in by pulling up ten of the plants and walk on, knowing they have helped. There are now several sections of the beach that remain remarkably free of the plant.<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjyrwfpv2Bu6LgglRd3ESdWIVr_jfNginpxvgbUFEjUhs8WK69SxRLtn2lnMlP64sgL2UMP-sc0XqydVdzTQYLpViUXQjEOv9UNn_ttCx0WoB0rayP-Ua4ErRgyz-ldCsWwgtoJgA/s1600/IMG_0361.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjyrwfpv2Bu6LgglRd3ESdWIVr_jfNginpxvgbUFEjUhs8WK69SxRLtn2lnMlP64sgL2UMP-sc0XqydVdzTQYLpViUXQjEOv9UNn_ttCx0WoB0rayP-Ua4ErRgyz-ldCsWwgtoJgA/s320/IMG_0361.JPG" width="320" /></a></div>
<br />
Finally, let's turn to a story that is in its early stages. A group of senior administrators and clinicians at Royal Children's Hospital in Melbourne have spent several months engaging staff in the construction of a compact between and among the medical and managerial staff. Hundreds of people have spent thousands of hours constructing this document, which is meant to reflect the values that should govern behavior in the hospital.<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiAnchJ6F5iQVjtRCloh72uv6czkdxPureiK-M4YmB-6mADLywWJ3yKylWQmSk6oHSnfUM9w-uojajICIZfWBlT-zv06ZAN7uIWFycnF7l-bjPCESBZil4Iy_6neFp1E0IhYU_pKg/s1600/IMG_0356.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiAnchJ6F5iQVjtRCloh72uv6czkdxPureiK-M4YmB-6mADLywWJ3yKylWQmSk6oHSnfUM9w-uojajICIZfWBlT-zv06ZAN7uIWFycnF7l-bjPCESBZil4Iy_6neFp1E0IhYU_pKg/s320/IMG_0356.JPG" width="320" /></a></div>
<br />
The compact represents a personal commitment of those who sign on to it. There is no enforcement mechanism. It is the exemplar of self-accountability. The as yet unanswered question is whether is will make a difference in changing the culture of RCH.<br />
<br />
As one staff member noted: "Getting the words down is just the first step. It's all about the deeds."<br />
<br />
Another, analyzing behavior patterns in the hospital, said: "We need to look at ourselves as a tribe, not at the tribes within the hospital."<br />
<br />
Another noted that there is "a need to call out bad behavior in real time" in a way that is viewed as positive and constructive.<br />
<br />
The best summary of one desired outcome was: "We need to stop saying this is <i>my</i> patient and instead say that this is <i>our</i> patient."<br />
<br />
And finally, the clincher: "We should look after each other."<br />
<br />
So the question for RCH and other institutions that seek to raise the level of kindness in their delivery of medical care is how to translate excellent words into excellent action. And it is here that perhaps the lessons of "Wipe off 5" and "Take out 10" might offer assistance.<br />
<br />
If staff members at the RCH focus their efforts on the global behavioral change that is envisioned in the compact, the task may seem overwhelming. There are so many sentences and so many words. Which should get priority? How should this affect my daily life? Viewing such a large task might even be paralyzing. Instead, what if the hospital were to implement the compact by adopting an analogy to a simple mnemonic, a daily standard that could be incorporated into each person's work flow and interactions?<br />
<br />
I'm not clever enough to know what might work, but perhaps something like "Show five types of caring each day." Or, "Offer ten kinds of kindness." The point is to make the desired task clear, compelling, and practical--allowing each person to go home at the end of the day claiming success in helping to instill the culture so eloquently set forth in the compact.</div>
Paul Levyhttp://www.blogger.com/profile/17065446378970179507noreply@blogger.com4tag:blogger.com,1999:blog-32053362.post-82691536595750861622016-02-14T07:28:00.000-05:002016-02-14T07:28:45.111-05:00Correlation ≠ cause and effect<div dir="ltr" style="text-align: left;" trbidi="on">
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhYzAj9jxYYyaLe6AvApv6poIddN4EpHmheYfLf06RoEYTbORHIE2x1ndXs1bJLVgjVb9QgaxELUCzfXK81o1Syz7EH3QFEd-c2H1jIa3woryNXXK3oNgqDFN4FqzotlFIEghF9VA/s1600/411IFeFe13L._SX328_BO1%252C204%252C203%252C200_.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhYzAj9jxYYyaLe6AvApv6poIddN4EpHmheYfLf06RoEYTbORHIE2x1ndXs1bJLVgjVb9QgaxELUCzfXK81o1Syz7EH3QFEd-c2H1jIa3woryNXXK3oNgqDFN4FqzotlFIEghF9VA/s200/411IFeFe13L._SX328_BO1%252C204%252C203%252C200_.jpg" width="131" /></a></div>
I was recently directed to a lovely example of how an observation of correlation can be misinterpreted with regard to cause and effect.* It comes from <a href="http://www.amazon.com/Mind-Raven-Investigations-Adventures-Wolf-Birds/dp/0061136050"><i>Mind of the Raven</i></a> by Bernd Heinrich. Here's the excerpt:<br />
<br />
<i>At dusk on September 7, 1997, a cougar crept up on Ginny Hannum as she was working at the back of her cabin at the head of Boulder Canyon in Colorado. The cougar crouched low among the rocks, facing her from about twenty feet, and it was ready to pounce. </i><br />
<i><br /></i>
<i>Although Mrs. Hannum was unaware of the cougar's presence, she had become "somewhat annoyed" by a raven "putting on a fuss like crazy. The noisy raven kept coming closer, having started its commotion twenty minutes earlier from about three hundred yards away. Was this raven trying to say something? She started to listen more closely.</i><br />
<i><br /></i>
<i>The cougar was ready to make its kill, but the raven was close, and it made pass over the woman, calling raucously, then flying up above her to some rocks, where she finally saw the crouching cougar. As the cougar glared down with yellow eyes locked onto hers, Hannum quickly backed off and called her three-hundred-pound husband. The surprise attack had been averted. She had been saved. "That raven saved my life." The event was declared a miracle in the news.</i><br />
<i><br /></i>
<i>A miracle is any event the natural cause of which we do not understand. Why did the raven call? To the religious Hannums, it seemed a miracle that a raven would go out of its way to deliberately save a human life. To me, raven behavior is still a miracle, although I have faith that this raven's behavior was within the realm of what ravens normally do. They are alert to predators that could potentially provide them with food. Perhaps the raven had been luring the ion to make a kill, alerting it to a suitable target. If the lion had feasted, so would the raven. That is, both would have benefited, as expected in communication.</i><br />
<br />
After presenting some more evidence, the author concludes:<br />
<br />
<i>Everything I know about ravens, as well as folklore, is congruent with the idea that ravens communicate not only with each other, but also with hunters, to get in on their spoils.</i><br />
<i><br /></i>
<i>Whatever else these to incidents illustrate, they show the difficulty of interpreting communication and how much communication can depend on the mind-set of the receiver. To make sense of communication, the first relevant questions to ask are: What are the costs and the payoff to the givers and potential receivers of the signals given.</i><br />
<br />
All in all, this is an excellent example that shows the dangers of making quick assumptions from a few observations without applying rigorous thinking to possible underlying causal factors.<br />
<br />
--<br />
<br />
Many thanks to <a href="http://www.melbournepaediatricspecialists.com.au/profile/dr-rod-phillips/">Dr. Rod Phillips</a>.</div>
Paul Levyhttp://www.blogger.com/profile/17065446378970179507noreply@blogger.com3tag:blogger.com,1999:blog-32053362.post-57593362488351291712016-02-11T15:38:00.000-05:002016-02-11T16:09:04.294-05:00"A good way for doctors to let patients know they are antiquated and unfriendly"<div dir="ltr" style="text-align: left;" trbidi="on">
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg3YKfWCU0OG_mwyU7qd7YYmunQSK3M44niC0UGoE7vNyIOg0thp_aXn1BlBoIaMOuNpftJgjT3bRPrfKFSKQfbA1TXKO2BoVMvXq9VaAV_md50jQTM6rlgpPR9EJi8FU5CT5FLmw/s1600/IMG_0306.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg3YKfWCU0OG_mwyU7qd7YYmunQSK3M44niC0UGoE7vNyIOg0thp_aXn1BlBoIaMOuNpftJgjT3bRPrfKFSKQfbA1TXKO2BoVMvXq9VaAV_md50jQTM6rlgpPR9EJi8FU5CT5FLmw/s320/IMG_0306.JPG" width="240" /></a></div>
<i>A friend here in Melbourne visiting a doctor in the community took this picture from the bulletin board in the doctor's waiting room. I posted it on Facebook with the comment:</i><br />
<br />
<i>"I know some doctors feel frustrated about this issue, but even if they
do, is the waiting room a really good place to put up a sign like this?"</i><br />
<br />
<i>Within hours, I received a slew of comments, and I repeat a few of them here.</i><br />
<br />
<span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"></span></span>Condescending, much?</span></span><br />
<br />
<span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody">Gotta
fight snark with snark! My search engine spends more than 2 minutes
with me, doesn't disregard my input, and is available for follow up...so
it'd be hard to confuse with a real doc. </span></span></span></span><br />
<br />
<span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody">It is offensive to put that in a waiting room. Period. </span></span></span></span></span></span><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody">I would turn right around and walk out.</span></span></span></span></span></span></span></span><br />
<br />
<span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody">I'd turn around and walk right out too, if I could. Great example of an ego-based practice!</span></span></span></span></span></span></span></span></span></span><br />
<br />
<span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody">Yikes, not at all appropriate for posting in a waiting room.</span></span> </span></span> </span></span></span></span></span></span></span></span><br />
<br />
<span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody">Don't confuse your medical degree with human empathy.</span></span></span></span></span></span></span></span></span></span><br />
<br />
<span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody">We
have had some great doctors lately so have respected my need to
research - but I respect their degree and experience. There is a fine
line between research for understanding and research used for self
diagnosis. It also is hard because anyone can publish anything on the
net so weeding thru it to find truth is challenging. I thought the sign was funny but could see how many would be offended.</span></span> </span></span> </span></span></span></span> </span></span> </span></span><br />
<br />
<span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody">The number of doctors I have witnessed Googling (and Wikipedia reading) while I've been in waiting rooms...</span></span></span></span><br />
<br />
<span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody">Doctors are too sensitive.</span></span></span></span></span></span><br />
<br />
<span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody _1n4g">I totally understand doctors' frustration at Doctor Google. And equally think
doctors need to get a grip and recognize this is the 21st century!
Hello? Savvy consumers ARE GOING TO GOOGLE. Medicos need to develop
ways of dealing with the information, and likely also the
misinformation, that patients and carers may find.</span></span></span></span></span></span></span></span><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"> </span></span> </span></span> <br />
<span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"></span></span></span></span><br />
<span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody">They
are ignorant of empowered, educated patients, sophisticated websites
and instant crowdsourcing within correct parameters. It's a mark of an
older generation of doctors, perhaps used to dealing w LILE (low income,
low education) patients.</span></span></span></span></span></span><br />
<br />
<span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody">Knowledge is Knowlege.</span></span></span></span></span></span></span></span><br />
<br />
<span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody">With
one in ten misdiagnoses, and that estimate is very low because
diagnostic error isn't tracked or reported except by malpractice claims,
you bet I'm doing my own research. How am I supposed to engage in
shared decision making if I don't educate myself? I go to medical school
websites, medical academy and society websites, disease organizations
and more for my info. Google gets me there.</span></span></span></span></span></span></span></span></span></span><br />
<br />
<span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody">Physicians
need to take a look at why patients feel the need to google their
symptoms and diagnosis. Then they could have a constructive
conversations of how to change the patient experience. This poster is
just highly offensive and just supports the old notions of dr.s being
narcissistic jerks.</span></span></span></span></span></span></span></span></span></span></span></span><br />
<br />
<span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody">Worst kind of paternalism.</span></span></span></span></span></span></span></span></span></span></span></span></span></span><br />
<br />
<span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody">Wow.
Not an appropriate sign for a waiting area. Why not work with the
patient and thank them for being so proactive. Your knowledge can
outweigh any Google search. The patient is only scared.</span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span><br />
<br />
<span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody">Patients
should be involved with their care and ask questions. We do it for
many other products that we consume in our life. Health care should be
no different.</span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span><br />
<br />
<span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody">I would never confuse the two. Google is much better.</span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span><br />
<br />
<span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody _1n4g">I
actually went undiagnosed for years with a rare kidney disorder. I
mentioned to my doctor on several occasions what I thought was going on
and got the "don't self diagnose on the Internet" lecture. I agree, it
can be frustrating to doctors who spent
years in medical school to have patients act like they know more.
However, nobody knows their body better than the one living in it and
when a patient says "this is not right" they should keep a open mind. I
did get a profuse apology from my doctor and she said that she learned
to leave her ego at the door and to listen to her patients.</span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span><br />
<br />
<span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody _1n4g"><span data-ft="{"tn":"K"}"><span class="UFICommentBody">
I like it! It's a good way for doctors to let patients know they are
antiquated and unfriendly. I'd rather know that in the waiting room than
find out in the exam room.</span></span> </span></span> </span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span><br />
<br />
<span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody">If
this is how they are choosing to respond to the digital era then its
time to find another doctor. Giving such a clear sign is a societal and
individual benefit.</span></span> </span></span> </span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span><br />
<br />
<i><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody _1n4g">And then this dialogue:</span></span></span></span></span></span></span></span></i><br />
<br />
<span data-ft="{"tn":"K"}"><span class="UFICommentBody">[Kathy] Epitome
of arrogance! You'd better believe I will be googling my diagnosis and
symptoms. I only go to the doctors office if I need "physician
ordered" medicines, diagnostics or treatments.</span></span><br />
<br />
<span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody">[reply from Eric] After
you spend endless hours debunking the mindless nonsense people read on
line you may look at this differently. A little knowledge is very
dangerous.</span></span></span></span><br />
<br />
<span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody">[reply from Kathy] But,
that knowledge may be what the doctor does not know! Patients engaging
in their own care and learning about their bodies and illness makes
them safer, not dangerous (to anyone).</span></span> </span></span> </span></span><br />
<br />
<span data-ft="{"tn":"K"}"><span class="UFICommentBody">[reply from Eric] </span></span><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody">Spend
a day in my shoes where people clamor for inappropriate tests and
drugs. I believe we should all be proactive but what I see on an almost
daily basis is nuts.</span></span></span></span><br />
<br />
<span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody">[reply from Kathy] </span></span></span></span><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody">Some
of those people are right on with what they need. I am a nurse and I
have worked in doctors offices. I have also been a patient who knew my
diagnosis and what I needed. I didn't get it and as a result I got
kidney damage. There are two sides to every story.</span></span></span></span></span></span><br />
<br />
<span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody">[reply from another person] </span></span></span></span></span></span><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody">Patient
empowerment can come from many places and should. I can understand
frustrations with time and teaching and getting more time with patients
(nurses and doctors) a solution to many problems. This sign is extremely
arrogant and provocative. A power struggle for status and status is
something WE can use wisely or unwisely and this is of the latter.</span></span></span></span></span></span></span></span><br />
<br />
<span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody">[and from another] </span></span></span></span></span></span></span></span><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody _1n4g">I
am a trained scientist with a PhD and I do a lot of research before and
after I go see my doctor and also for my friends and family. I
actually pick my doctors after asking them their opinion of patients
like me who want to make informed decisions, and
I WILL most definitely find a different doctor if they give me such
attitude. I respect that it can take extra time to deal with the cases
where a little knowledge is a dangerous thing but if the doctor wants me
to stay ignorant and treat their individual opinion as infallible, I am
outta there. Just my 2 cents on this issue.</span></span></span></span></span></span></span></span></span></span><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"></span></span></span></span></span></span></span></span></span></span></span></span></span></span> </span></span></span></span><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody _1n4g"></span></span></span></span></span></span></span></span></span></span><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"></span></span></span></span> <br />
<span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody"><span data-ft="{"tn":"K"}"><span class="UFICommentBody _1n4g"></span></span></span></span></span></span></span></span></span></span></div>
Paul Levyhttp://www.blogger.com/profile/17065446378970179507noreply@blogger.com2tag:blogger.com,1999:blog-32053362.post-85618829366680407312016-02-09T11:15:00.001-05:002016-02-09T11:15:42.017-05:00Ask, instead, why they would want to leave<div dir="ltr" style="text-align: left;" trbidi="on">
It isn't often that I am surprised in a negative way by something relating to an Ohio pediatric hospital. Indeed, the hospitals in that state have been at the forefront of working together to enhance quality and safety for their patients.<br />
<br />
But <a href="http://www.dispatch.com/content/stories/local/2016/02/07/nationwide-childrens-hospitals-non-compete-clause-for-doctors-stretches-100-miles.html">this recent story</a> in the <i>Columbus Dispatch</i> caught my eye. An excerpt:<br />
<br />
<i>Non-compete agreements built into contracts help ensure that doctors can’t join a hospital’s
crosstown rival or enter private practice across the street — at least for a while.</i><br />
<br />
<i>
</i><i>The choice to relocate elsewhere to practice medicine is especially limited for pediatric
specialists employed by Nationwide Children’s Hospital.</i><br />
<br />
<i>
</i><i>The Dispatch reviewed a non-compete agreement that shows that Nationwide Children’s pediatric
specialists risk being sued if they take a job within 100 miles of the hospital within two years of
leaving it.</i><br />
<br />
It turns out that other Ohio hospitals have similar, if slightly less restrictive clauses. The rationale:<br />
<br />
<i>Recruiting and hiring require a significant upfront investment, Thornhill said. “It’s a classic
business practice of protecting the investment.”</i><br />
<br />
Well, maybe it is--although courts have sometimes tossed out such agreements if they are too wide in scope,. As noted <a href="http://www.the-hospitalist.org/article/physician-noncompete-clauses/">here</a>:<br />
<br />
<i>In states where noncompetition clauses for physicians are enforceable,
the provision must: 1) protect the employer’s legitimate business
interest, 2) be specific in geographical scope, and 3) have a narrowly
tailored durational scope. If
the language in the clause is vague or does not clearly describe the
exact terms of the restrictions on practice, the clause might be
unenforceable or open to greater interpretation than either party
anticipated.</i><br />
<br />
But I have a different concern, especially for places like Nationwide, Cincinatti Children's and others that put great stock in engaging their staff in ongoing process improvement. From the point of view of those leading a learning organization--one focused on constant improvement from within--it is far better to figure out why someone would want to leave you than to inhibit them from doing so.</div>
Paul Levyhttp://www.blogger.com/profile/17065446378970179507noreply@blogger.com5tag:blogger.com,1999:blog-32053362.post-90250688613165990862016-02-08T23:27:00.000-05:002016-02-08T23:28:31.783-05:00In memoriam: The Boston Courant<div dir="ltr" style="text-align: left;" trbidi="on">
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhX3bxsqASuEtVnCoGQEaKiYkJp6EH-sw8fhDgbdKAbfa2sbcsnYvtllYHvfL-R5EbXsm9b9dUTrDRAaURmfW3pLQLWiyIKSs-kxLPaTQ8j9aMN_5Y3E_c_yz_IvVck5h_RJ__fyA/s1600/courant.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="269" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhX3bxsqASuEtVnCoGQEaKiYkJp6EH-sw8fhDgbdKAbfa2sbcsnYvtllYHvfL-R5EbXsm9b9dUTrDRAaURmfW3pLQLWiyIKSs-kxLPaTQ8j9aMN_5Y3E_c_yz_IvVck5h_RJ__fyA/s320/courant.jpg" width="320" /></a></div>
In the end, <i>The Boston Courant</i> did not shut down because of the oft-discussed pressures on the print media. No, it was because of legal fees and a judgment made against the newspaper from a former employee's lawsuit.<br />
<br />
David Jacobs and Gen Tracy and their loyal crew worked hard to provide neighborhoods of Boston with relevant, current news--well written and clearly presented. Advertisers rewarded the paper with their business because it was widely and consistently read.<br />
<br />
The owners and staff deserve to feel proud about their contribution to the City, which will be diminished by the absence of their newpaper.</div>
Paul Levyhttp://www.blogger.com/profile/17065446378970179507noreply@blogger.com0tag:blogger.com,1999:blog-32053362.post-53634454294108914862016-02-08T17:02:00.001-05:002016-02-08T17:02:33.313-05:00Cruelty and enlightenment<div dir="ltr" style="text-align: left;" trbidi="on">
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhPi-IfQNK_Waqm01xlSABRdu4o6ApNVSfIT7B2yHHIkyvgXiLZ6QeRo6p6AjWTXUfcF29mw7N9u2YZAqJy6vD1bM4Q8i4bJsAERgF0I6NLO_rTu-WMa3H8opbMyi-OsLvFyVAFxw/s1600/factory.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="110" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhPi-IfQNK_Waqm01xlSABRdu4o6ApNVSfIT7B2yHHIkyvgXiLZ6QeRo6p6AjWTXUfcF29mw7N9u2YZAqJy6vD1bM4Q8i4bJsAERgF0I6NLO_rTu-WMa3H8opbMyi-OsLvFyVAFxw/s320/factory.jpg" width="320" /></a></div>
I don’t know if the following observations are profound or trite or somewhere in between. They are prompted by a recent visit to the <a href="http://femalefactory.org.au/">Cascades Female Factory</a> in Hobart, Tasmania.<br />
<br />
Every country, it seems, has something to be ashamed of in its history. Certainly, among other things, the US bears blame for its treatment of native Americans, slaves imported from Africa, and forced detention of Japanese descendants during World War II.<br />
<br />
And yet, those same countries have often made contributions to political systems that are truly noteworthy in the advancement of human society. Think of the principles espoused in the Mayflower Compact, the Declaration of Independence, the Constitution, and in the practice of civil disobedience against injustice, a philosophy that stemmed from the writings of Thoreau and others. <br />
<br />
These contradictions between eras of cruelty and shame and periods of enlightenment may be irreconcilable. Or perhaps there is some underlying theory of the advancement of the human condition that posits that the bad must occur to bring about the good. Political philosophers of greater wisdom than I have surely offered their hypotheses.<br />
<br />
I think, though, that part of the process of societal development depends strongly on exposing the bad times with stories about normal human beings who were caught up in the antisocial maelstroms of their time. We seem to be emotionally insulated from general histories about thousands or millions of people who were harmed during the cruel eras. It is hard to pursue political action based on such broad-based summaries. But when we hear the stories of individuals who were treated badly, we are able to identify with them and then perhaps step back and build a political coalition for change.<br />
<br />
It was in that light that a recent visit to the Female Factory was so powerful. This facility was opened, ostensibly, to punish and help redeem women who had committed crimes in Great Britain. The crimes could be as simple as stealing a handkerchief or food for a starving family. Poverty was viewed as a sin, caused by the ethical character of the poor person, not by the society in which they lived. <br />
<br />
“Transportation” was the name for forced passage across several oceans in cramped and unhealthy ships to Tasmania, where women were locked up to serve their time. <br />
<br />
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<br />
The prison bureaucrats were careful to record the arrival of each woman, assigning her such descriptors as they felt were appropriate. A sample is shown above, an indication of the dehumanization already being experienced by these women.<br />
<br />
But the system was actually designed to provide women to help serve and populate the British colony. While in the factory, the women would do manual labor in support of the community of Hobart. Laundry was handled here. Women were also tasked with “making oakum,” disentangling the caustic, tar-laden strands of ship rope into fiber that was used as caulking to fill the cracks between boards for ships. <br />
<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjxCYLgvgQTnYn0VayRwGWkX0Pe3AH-MtO447HB3VlfgxpU_R8s43GFlZp-8KIcnqrtBMIEZwKqrQCdotsIjSovAWocTk_4lpFs4A9boScKtscfk5HYJ_OQLlA8xTSXnzao4coLlQ/s1600/Oakum.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="196" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjxCYLgvgQTnYn0VayRwGWkX0Pe3AH-MtO447HB3VlfgxpU_R8s43GFlZp-8KIcnqrtBMIEZwKqrQCdotsIjSovAWocTk_4lpFs4A9boScKtscfk5HYJ_OQLlA8xTSXnzao4coLlQ/s320/Oakum.jpg" width="320" /></a></div>
<br />
Babies were forced to be weaned from their mothers at 6 months, then to have a diet of bread and water from the polluted rivulet next to the factory. Many died from dysentery. At 3, the children who survived were taken to live in their own orphanage-prison, perhaps to be reunited several years later when their mothers’ terms of servitude were completed.<br />
<br />
Later, “transportation” was transformed to “probation.” Upon landing, women would be sent out to work and live on farms throughout the island in slave-like conditions until they could earn their freedom. If they failed to do their work well or became pregnant, they would be returned to the factory.<br />
<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj-67nWc_U5xeoDTfinE8EHBRknrpvt75YOBRxiTsKGZn6C_kDnLjQqTwJkTDbv1ARKteAEqpVTRR4GRQQtCDT7BUILBOo1oKyCW5YArdgno-cAeEf8w0676fAipHbT8jwSfMEIow/s1600/Names.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="129" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj-67nWc_U5xeoDTfinE8EHBRknrpvt75YOBRxiTsKGZn6C_kDnLjQqTwJkTDbv1ARKteAEqpVTRR4GRQQtCDT7BUILBOo1oKyCW5YArdgno-cAeEf8w0676fAipHbT8jwSfMEIow/s320/Names.jpg" width="320" /></a></div>
<br />
At the museum, there is this simple exhibit on which women’s names are listed. They remind us that each one had her story of loss and suffering. With luck there could be survival and freedom. Indeed, there was a lovely photographic exhibition of modern day descendants of some of these women, who live proud lives notwithstanding their “convict” ancestors.<br />
<br />
(By the way, there were other types of awful treatment awaiting the male convicts in <a href="https://en.wikipedia.org/wiki/Van_Diemen's_Land">Van Diemen’s Land</a>—many of whom, too, committed minor crimes and were sent as a work force by the British Empire to squeeze out possible colonization by other European powers.)<br />
<br />
I was reminded as I watched the movie <i>Suffragette</i> that Australia was the second country in the modern era (after New Zealand) to grant women the right to vote—well before Great Britain. Was there something about the earlier history of cruelty and oppression that led to a greater sense of egalitarianism in Oz? Is it possible that the treatment of men and women convicts created a communitarian culture that led to this and other social advances? A number of my friends and colleagues here have made this connection. How ironic it would be if one era of such cruelty helped herald another period of political enlightenment. If so, the women at the factory would have left a legacy for their adopted country that they never could have imagined.</div>
Paul Levyhttp://www.blogger.com/profile/17065446378970179507noreply@blogger.com2tag:blogger.com,1999:blog-32053362.post-14455803302001637802016-02-07T08:01:00.000-05:002016-02-07T08:01:06.591-05:00There is no Holy Grail, just small chalices<div dir="ltr" style="text-align: left;" trbidi="on">
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</div>
Given the stakes to society and the persistent growth in
health care delivery costs throughout the developed nations, there is an
understandable desire to achieve the “breakthrough” technological solutions
that will result in a substantial disruption in diagnostic and treatment
practices and patterns that have evolved over the decades.<span style="mso-spacerun: yes;"> </span>Well intentioned and intelligent people with
thoughtful ideas are focused on ways to achieve these solutions.<span style="mso-spacerun: yes;"> </span>Investors, seeing the large (and growing)
percentage of each nation’s GDP that is devoted to health care, likewise hunger
for the opportunity to grab even a small portion of that wealth.<br />
<br />
As I noted in a blog post <a href="http://runningahospital.blogspot.hk/2015/01/in-pursuit-of-big-data-holy-grail.html">last year</a>, an area that
consumes tremendous energy is the search for the Holy Grail of decision support
products that would mine health care “big data.” People are looking for the
algorithms that could help doctors—in real time—analyze the condition of
patients and put in place more efficient and efficacious diagnostic regimes and
treatment modalities. I explained in
that blog post why these efforts will fail. Let me summarize:<br />
<br />
1 -- The data that is collected is not reliable enough to
draw connections between patient characteristics, clinical decisions and
outcomes.<span style="mso-spacerun: yes;"> </span>It is not reliable for two
reasons.<span style="mso-spacerun: yes;"> </span>First, it is simply not
reliable.<span style="mso-spacerun: yes;"> </span>Much data that is collected
and/or coded in hospitals and physician practices is done so poorly, or in a
format that is not clinically accurate.<span style="mso-spacerun: yes;">
</span>Second, it is likely to be characterized by such wide standard
deviations as to make it unsuitable for predictive purposes.<br />
<br />
2 -- It is unlikely that the algorithms that are designed to
produce work rules will be trusted by doctors. In part, this is due to the standard deviation problem noted above. That is, the models will not be sufficiently
rigorous in their predictive capacity. Maybe more important, there is a general lack of trust on the part of doctors
with regard to using formulaic approaches in their practices. While doctors are the victims of many kinds of
cognitive errors—diagnostic anchoring, confirmation bias, and the like--they are often not trained to reflect on and catch
these biases. They are trained instead
to trust their own judgment and take personal responsibility for their
patients. It would be but a small
minority of doctors who would be able to overcome those biases and that
training to use big-data-driven decision support tools—even if such tools were
able to overcome the statistical difficulties mentioned above.<br />
<br />
3 – The process for selling such systems into the hospital
market is complex and almost infinitely slow. The sales cycle will kill off all but the most highly capitalized
firms. Even excellent products will
often wither and die on the vine.<br />
<br />
Does this suggest that there is no potential for disruptive technologies
that can improve health care delivery at a reduced cost? No, but it suggests that there is not a Holy
Grail, but rather a group of smaller, potentially jewel-encrusted,
chalices. Targeted innovation is the way
to go. Think small, think focused, and
think about how to achieve quick results that benefit the doctor, the patient,
and the hospital.<br />
<br />
Wait, did I just put the doctor first on that list? The Ptolemeic health care system has the doctor at the center of the
solar system, and it will be that way for a long time to come. Unless your product helps the doctor feel
that they are doing a better job and can fit into their work flow, it’s not
worth pursuing.<br />
<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjZrgjg1HLsamMppA5odcKE9g0IohJDsdQTrRCTr7amWvoIXr-l-y-Y6uvBoPvnOSvvaemL8WczrRdm163vZZ99SDrMMTMoYN8DMthycWbhg0MmFyGNFcwX4TyZ2e_hIXuDxHDtBA/s1600/logo.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="78" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjZrgjg1HLsamMppA5odcKE9g0IohJDsdQTrRCTr7amWvoIXr-l-y-Y6uvBoPvnOSvvaemL8WczrRdm163vZZ99SDrMMTMoYN8DMthycWbhg0MmFyGNFcwX4TyZ2e_hIXuDxHDtBA/s200/logo.png" width="200" /></a></div>
I’ll provide an example that originated in Melbourne,
produced by a firm called <a href="http://www.globalkineticscorporation.com.au/">Global Kinetics</a>. The
approach is described in <a href="http://theconversation.com/watch-and-learn-a-new-tool-for-measuring-parkinsons-disease-14706">this article</a>. A
Parkinson’s patient wears a simple device on their wrist for a week or
two. The accelerometer contained in the
device correlates the extent of the patient’s movement disorder with the drug
dosages they have taken. (The “watch”
also, by the way, provides the patient with a reminder to take the drug at the
specified times, leading to a higher level of adherence and providing a higher level of precision to the experiment.) The
report is transmitted to a standard hand-held device, using a patient code that
is fully privacy protected.<br />
<br />
The technology and the reports produced by this approach do
not substitute for the judgment of the neurologist. Rather that judgment—previously based on
trial and error--is enhanced by a real-time, patient specific experiment. The process can be repeated as often as the
doctor deems necessary--more often for a patient suffering a rapid
deterioration from the disease, and less often for a more stable patient.<br />
<br />
The device is not bought by the hospital, and so it bypasses
the highly competitive capital budgeting process. Rather, the product is provided as part of a
service offering, the test result that is provided to the doctor. The fee for each report is well within the
normal operating budget of the neurology department, requiring no special
allocation of funds. In short,
acceptance simply requires a decision by the doctors themselves.<br />
<br />
I offer this as a perfect example of a jeweled chalice. Simple hardware and software technologies;
easily incorporated into the doctors' workflow; enhancing their ability to
exercise professional judgment; and offered in a sales process that does not
create competition among hospital factions and is consistent with normal budget
processes. It is by this path that
technology can disrupt health care—one carefully designed step at a time.
</div>
Paul Levyhttp://www.blogger.com/profile/17065446378970179507noreply@blogger.com2tag:blogger.com,1999:blog-32053362.post-17701815184318798712016-02-04T15:14:00.000-05:002016-02-04T15:14:35.629-05:00There is no billing code for compassion<div dir="ltr" style="text-align: left;" trbidi="on">
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhH6wn_Lmct2YNJpf54K9lMKzxoaHELImNN8tSrNk_3zMafnZj0rl-pjUtJWtp9BxZCxkVwGgIBs6BH8n85OfMEHeOr6fi13zXjdpo6DbsKvWSvrFXMCAi_NX03UcUh0Q-q2yX9Cg/s1600/unnamed.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="79" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhH6wn_Lmct2YNJpf54K9lMKzxoaHELImNN8tSrNk_3zMafnZj0rl-pjUtJWtp9BxZCxkVwGgIBs6BH8n85OfMEHeOr6fi13zXjdpo6DbsKvWSvrFXMCAi_NX03UcUh0Q-q2yX9Cg/s320/unnamed.png" width="320" /></a></div>
<br />
I am borrowing a line from Dr. Amy Ship, the 2009 recipient of the Campassionate Caregiver Award from the <a href="http://www.theschwartzcenter.org/">Schwartz Center,</a> to remind folks that nominations are now open for this coming year's award. The award recognizes health care professionals who display extraordinary devotion and compassion in caring for patients and families. It is open to health care professionals who work in any U.S. health care setting. The nomination deadline is March 31, 2016. <a href="http://www.theschwartzcenter.org/supporting-caregivers/nccy-award/nomination-form/">Here's the link</a>.<br />
<br />
There's no better way to express your appreciation to a friend, colleague, or caregiver than to nominate them for this honor.</div>
Paul Levyhttp://www.blogger.com/profile/17065446378970179507noreply@blogger.com0tag:blogger.com,1999:blog-32053362.post-20099524289858090882016-02-03T05:26:00.000-05:002016-02-03T05:43:25.552-05:00Plus ça change<div dir="ltr" style="text-align: left;" trbidi="on">
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhP1In1IQ214yPx1YVtvI18jARdqzut40yTcuatFh9aVofKPy73tNrfsHxax3nKfDRs0CtkYpLPfZ2pGRLJZieGSdtx_5enjo3OAzDhc4rQ7mzHzC1wafWKM6Uwbn4JflRA_VmdIg/s1600/crackdown.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="213" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhP1In1IQ214yPx1YVtvI18jARdqzut40yTcuatFh9aVofKPy73tNrfsHxax3nKfDRs0CtkYpLPfZ2pGRLJZieGSdtx_5enjo3OAzDhc4rQ7mzHzC1wafWKM6Uwbn4JflRA_VmdIg/s320/crackdown.jpg" width="320" /></a></div>
<br />
I mean no disrespect to my Australian hosts when I say that I've seen this all before. The details differ, but the same underlying themes emerge. And when stories are placed side by side, it can be confusing to the public.<br />
<br />
In Australia, the government strongly encourages private health insurance
coverage for a portion of the population, a policy that was designed to
reduce overcrowding in the public hospitals. There are a whole series
of regulations that influence both corporate and individual behavior in
this arena. These rules have essentially created the private health
insurance market in the country. <br />
<br />
As <a href="http://runningahospital.blogspot.com.au/2016/01/one-persons-costs-is-another-persons.html">noted just a few days ago</a>, the private hospitals in the country want to assure their investors that the demand for health care services will not diminish over the next several years. They cite underlying demographic factors:<br />
<br />
<i>In a strident statement Ramsay's Mr Rex said the report failed to
consider further utilisation growth linked to the ageing
population. "Macquarie's report incorrectly concludes that the modest
impact of ageing in the past means that the impact will be minimal in
the future," he said. "But it is the future impact of ageing – the baby
boomers moving into the 60-70 year bracket - that needs to be
considered... We have not yet felt the ageing impact – it is yet to
come."</i><br />
<br />
Those who provide private health insurance to cover patients for these services have understandably been increasing premiums to cover the costs. Look at this chart below:<br />
<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhcPgwvf2jJGIDq30WI71fHa9l1QmvByUWs6CBqSQH5s8ATbXqIz4b0mOUdwTuvYK2qjtKX1nJxr404eOtH9MDzw0PhVxFMWggXWg7Cfg0lqFs6Jx6lU8vrYEgzZuOinuq_UGkPLw/s1600/premiums.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="231" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhcPgwvf2jJGIDq30WI71fHa9l1QmvByUWs6CBqSQH5s8ATbXqIz4b0mOUdwTuvYK2qjtKX1nJxr404eOtH9MDzw0PhVxFMWggXWg7Cfg0lqFs6Jx6lU8vrYEgzZuOinuq_UGkPLw/s320/premiums.jpg" width="320" /></a></div>
<br />
Private health care costs are rising at about 8%, mostly due to higher utilization of the health care system (both number of visits and procedures per visit) and a bit (about equal to the consumer price index) due to hospital and doctor pricing changes. So the insurers have actually been able to hold premiums increases to something a bit less than the total cost increase. <br />
<br />
But that doesn't keep government officials from taking a strong stand against the current premium rate filings, saying they demand further review.<br />
<br />
The insurers then respond by <a href="http://www.theage.com.au/business/health-insurers-urge-action-on-costs-in-return-for-lower-premiums-20160131-gmhznk.html">pointing out</a> that part of the problem stems from the government's own policies. For example, the cost of prosthetic devices in Australia's private health care sector is dramatically above that found in other countries. Why? Because the government has made a pricing deal with equipment suppliers to keep the cost of such devices low to the public hospitals, subsidizing those facilities with higher prices to the private hospitals.<br />
<br />
<i>Health insurers . . . estimate that up to $800 million could be saved on prosthetics, such as hip and knee replacements, if a reference pricing system with Australian and international benchmarks was introduced.</i><br />
<br />
But let's get past this local detail. Even if it is true--and worthy of attention--it can distract from our overview. There is an old joke about gravity: "It's not just a good idea. It's the law." So, too, for anti-gravity in the health care world in developed countries. Those countries face common factors that are driving up costs. I summarized these <a href="http://runningahospital.blogspot.com.au/2009/08/primary-causes.html">back in 2009</a>. Number 8 doesn't apply here in Australia, but the others do to a greater or lesser extent:<i><br /><br />1)
Demographics. The huge cohort of baby boomers have now entered the age
at which they are seeking hospital care. Meanwhile, their parents are
living longer than ever and are coming to the hospital for both acute
and chronic care.<br /><br />2) Entitlement. The first cohort named above
expects and demands everything for themselves, and of the insurance
products they expect their employer to purchase. For their parents,
they often expect extraordinary end-of-life care interventions, paid for
by Medicare.<br /><br />3) New stuff. See #2 above. A knee that
previously would have remained sore in the past or be treated by
physical therapy becomes a target for arthroscopic surgery.<br /><br />4) The medical arms race. Physicians and hospitals feel compelled to buy the latest technology, even without proof of enhanced clinical efficacy.</i><i><br /><br />5) Defensive medicine. Yes, the threat of malpractice law suits leads to over-testing and other extra costs.<br /><br />6) Regional medical mythology. Thanks to <a href="http://runningahospital.blogspot.com/2008/04/more-from-brent-james.html">Brent James</a> for this insight. Local practice patterns often are just that, with no evidentiary basis.<br /><br />7) Preventable harm in clinical settings leading to extended hospitalization and bodily injuries.<br /><br />8)
Lack of access itself. If people don't have health insurance and can't
get proper early diagnostic and preventative care, they are a more
expensive burden on society when they get sick.<br /><br />9) The cottage
industry problem. The medical profession, both in physician practices
and hospitals, has failed to adopt process improvement approaches that
are common in other industries, that result in redesign of work flow and
systems to derive efficiency, quality, and standardization.<br /><br />10) A
sedentary and malnourished lifestyle for all age groups, leading to
obesity and other associated physiological problems that are the
precursors to major health issues.<br /> </i><br />
<i>... We can fix some of our inadequacies through
legislation, but many components of our problems lie deeper in society.<br /><br />P.S.
While there are pro's and con's of each country's health care systems,
similar cost pressures have become evident in much of the rest of the
world. Perhaps this suggests that a common organism underlies our
problems, homo sapiens and its curious ability to live longer and expect more. </i><br />
<br />
Putting aside the political trading that will inevitably take place, from what I've seen so far, Australia could do a lot by investing in changes to numbers 6, 7, and 9, above--and likely number 10. Places around the world that have done so have been able to counteract at least part of the anti-gravity tendency of societally driven health care cost increases.</div>
Paul Levyhttp://www.blogger.com/profile/17065446378970179507noreply@blogger.com0tag:blogger.com,1999:blog-32053362.post-74927402948093429522016-01-31T16:50:00.001-05:002016-01-31T16:50:13.693-05:00Mind the step!<div dir="ltr" style="text-align: left;" trbidi="on">
One of my "thinker in residence" sponsors here in Australia is VMIA, the Victoria state government insurance agency. I had just finished having a lovely cup of coffee and conversation with one of the agency's executives, where our topic had been risk assessment and mitigation.<br />
<br />
As I started to leave the coffee shop (not a state agency facility!), I stumbled and looked back to see a drop in the floor levels between two parts of the restaurant. While I can be clumsy (just ask my soccer buddies!), usually I'm pretty adept at walking out of restaurants without suffering harm. So, I looked back to reconstruct the situation.<br />
<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgmRHKGNNSGYnK-FMTJaT_DqA6-fTC1QJlt59cTay6rY62RGiNBCqy8n6_TKAk0_gH1QUf8mwG7kDjY-Kj9rMHOroKMiTtv7ojQsIySzmrKWz1DKlW5EPkZdzXWqNObL5d3nTV7yQ/s1600/IMG_0190.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgmRHKGNNSGYnK-FMTJaT_DqA6-fTC1QJlt59cTay6rY62RGiNBCqy8n6_TKAk0_gH1QUf8mwG7kDjY-Kj9rMHOroKMiTtv7ojQsIySzmrKWz1DKlW5EPkZdzXWqNObL5d3nTV7yQ/s320/IMG_0190.JPG" width="320" /></a></div>
<br />
Here's the broad scene. The waiter above has just stepped down into the lower portion of the shop. And indeed, there is a large sign up and to the right warning patrons of the drop in floor height.<br />
<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhSyW6U7_rZTYn83buZnHnOc4Zo8kpZdcl4dIds-5sOtDdUzqazzRZSmxLPUSEc_OrccSRDiIRt18oYJvxJtc60bYAG4EqaZSIDQtFqyT9YcRqcmrzVKG6iMAPRXy-ynLzMkACqgA/s1600/IMG_0189.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhSyW6U7_rZTYn83buZnHnOc4Zo8kpZdcl4dIds-5sOtDdUzqazzRZSmxLPUSEc_OrccSRDiIRt18oYJvxJtc60bYAG4EqaZSIDQtFqyT9YcRqcmrzVKG6iMAPRXy-ynLzMkACqgA/s320/IMG_0189.JPG" width="240" /></a></div>
<br />
The problem is a that there is a very eye-catching sign to the left, designed to draw your attention as you pass through this area.<br />
<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhosZakKhDyyOvb2zIUaWkVCSlQji2C6dt6fNZX2gUcfsigbCjLHJjEtqLSUnncWTQF3v3nOW6qffcR8UXSb35TBMm7fCvP12ltVp45yEvXZg-e4XOVEZvx9ttz0WMpxIQppeSF2Q/s1600/IMG_0188.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhosZakKhDyyOvb2zIUaWkVCSlQji2C6dt6fNZX2gUcfsigbCjLHJjEtqLSUnncWTQF3v3nOW6qffcR8UXSb35TBMm7fCvP12ltVp45yEvXZg-e4XOVEZvx9ttz0WMpxIQppeSF2Q/s320/IMG_0188.JPG" width="240" /></a></div>
<br />
So, I didn't notice the warning sign to my right. Also, the floor area is not well lit, and there is little color difference between the step and the floor below.<br />
<br />
Ok, that's the human factors set of circumstances. These are accidents waiting to happen.<br />
<br />
Now, let's turn to the people side. As I stumbled, a clerk behind the counter noticed and smiled knowingly, as if to suggest that I was not the first to have this experience. I went back to talk with another clerk and point out the problem. She was very apologetic and asked if I was hurt. I said I was fine but just wanted to point out the safety hazard. When she saw me taking pictures, she said, "You're not going to sue us, are you?" I said no, but I thought the shop might want to devise a better warning system. She acknowledged that the current arrangement was designed to warn people headed towards the right, i.e., going to the toilet, but not those who might be going to the left.<br />
<br />
I left confident that the problem would not be addressed in the future. Some day, someone will fall and be badly hurt, and the shop may, indeed, be sued.<br />
<br />
Think through similar circumstances in health care facilities and other service establishments, as well as industrial settings. Such patterns are highly prevalent--both in terms of the human factors issues and also in terms of the lack of empowerment felt by the front line staff.</div>
Paul Levyhttp://www.blogger.com/profile/17065446378970179507noreply@blogger.com2tag:blogger.com,1999:blog-32053362.post-5544798231209083972016-01-27T17:00:00.000-05:002016-01-27T17:00:05.649-05:00A canary in the coal mine?<div dir="ltr" style="text-align: left;" trbidi="on">
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How should we think about medical malpractice claims against doctors? Are they indicative of something about those doctors who've been sued? Are they a symptom of underlying quality and safety issues in a hospital, a kind of canary in the coal mine that suggests there might be deeper problems? These are long-standing questions.<br />
<br />
Perhaps part of the answer is provided in <a href="http://www.nejm.org/doi/full/10.1056/NEJMsa1506137">a new article</a> in the <i>New England Journal of Medicine, </i>"Prevalence and Characteristics of Physicians Prone to Malpractice Claims," by David Studdert and colleagues. (The article has a theme that is somewhat consistent to one <a href="http://runningahospital.blogspot.com.au/2016/01/when-is-doctor-like-bull-ant.html">I discussed a few days ago</a>, which reported that a small group of doctors in Australia accounted for many patient complaints.)<br />
<br />
The authors conducted an extensive review of US National Practitioner Data Bank information, analyzing 66,426 claims paid against 54,099 physicians from 2005 through 2014. They found that, over this 10-year period, "a small number of physicians with distinctive characteristics accounted for a disproportionately large number of paid malpractice claims."<br />
<br />
<i>Approximately 1% of all physicians accounted for 32% of paid claims. Among physicians with paid claims, 84% incurred only one during the study period (accounting for 68% of all paid claims), 16% had at least two paid claims (accounting for 32% of the claims), and 4% had at least three paid claims (accounting for 12% of the claims). In adjusted analyses, the risk of recurrence increased with the number of previous paid claims. For example, as compared with physicians who had one previous paid claim, the 2160 physicians who had three paid claims had three times the risk of incurring another.</i><br />
<br />
<i>Risks also varied widely according to specialty. As compared with the risk of recurrence among internal medicine physicians, the risk of recurrence was approximately double among neurosurgeons, orthopedic surgeons, general surgeons, plastic surgeons, and obstetrician–gynecologists. The lowest risks of recurrence were seen among psychiatrists and pediatricians.</i><br />
<br />
<i>Male physicians had a 38% higher risk of recurrence than female physicians. The risk of recurrence among physicians younger than 35 years of age was approximately one third the risk among their older colleagues. Residents had a lower risk of recurrence than nonresidents, and M.D.s had a lower risk than D.O.s. </i><br />
<br />
We could stop right there and conclude that the problem lies solely with the high-risk doctors. But, as the authors point out, these doctors practice in health systems, and those systems have the potential to intervene.<br />
<i> </i><br />
<i>All institutions that handle large numbers of patient complaints and claims should understand the distribution of these events within their own “at risk” populations. In our experience, few do. With notable exceptions, fewer still systematically identify and intervene with practitioners who are at high risk for future claims. Rather, the risk-mitigation initiatives that are in place — such as the educational and premium-discount programs that some malpractice-insurance companies offer — are generally offered en masse. Otherwise, insurers tackle the problem of claim-prone physicians primarily by raising premiums or terminating coverage. These strategies do not directly address the underlying problems that lead to many claims.<br /><br />In an environment in which a small minority of physicians with multiple claims accounts for a substantial share of all claims, an ability to reliably predict who is at high risk for further claims could be very useful. . . . If reliable prediction proves to be feasible, our hope is that liability insurers and health care organizations would use the information constructively, by collaborating on interventions to address risks posed by claim-prone physicians (e.g., peer counseling, training, and supervision). It could present an exciting opportunity for the liability and risk-management enterprises to join the mainstream of efforts to improve quality.</i></div>
Paul Levyhttp://www.blogger.com/profile/17065446378970179507noreply@blogger.com2