Creativity in reducing falls among the elderly

#qualitysummit The Health Care Quality Summit in Saskatoon has had a number of break-out sessions with "Saskatchewan Stories."  I attended one entitled, "Engagement of front line workers in falls prevention at a long term care facility," conducted by Michelle Gould and Jodie Irving at Extendicare Parkside.

The issue was how to help avoid falls among a group of elderly patients with dementia.  The rate of falls was very high, with over 35% of the patients suffering from fall.  The usual generic methods of preventing falls were not successful, and so the staff decided to be creative, tailoring approaches to the characteristics of individual patients.  One success story involved this gentleman, who regularly fell, usually when experiencing stress.  The staff noticed that the man enjoyed being engaged in small motor physical tasks and also being near the staff.  In fact, when both occurred, his stress levels were noticably lower.

So the staff invented a task for the man, repeatedly putting pennies into a cup, and they arranged for him to be in frequent proximity to the staff.  In the months since they organized this approach, he has had no falls whatsoever.

Elderly ICU care and quality of life

#qualitysummit The Health Care Quality Summit in Saskatoon has full round of expert speakers, break-out sessions with "Saskatchewan Stories," but also a poster session showing some recent research in the field.  An anaesthesia and critical care fourth year resident named Adam van der Merwe (seen here) was interested in questions surrounding the efficacy of care in intensive care units.  But instead of focusing on the medical care, per se, he looked into the issue of the extent to which ICU care affected the patients' quality of life after their hospitalization.

In this chart, he compares various quality of life indicators for a control group representing the general population of Canada with elderly people who had visits to the ICUs.  Perhaps not surprisingly, the patient group shows markedly lower level of quality of life indicators after hospitalization.  Adam concludes, "The domains most affected are role limitations due to emotional and physical problems which impact independent living.  Low physical functioning scores also indicate that basic things like bathing and dressing might be a concern."

Governing quality and safety in Saskatoon

I am in Saskatoon, Saskatchewan, Canada to attend and speak at the annual health care quality summit of the Health Quality Council, an independent agency that measures and reports on quality of care in the province, promotes improvement, and engages its partners in building a better health system.  In advance of the summit, I was invited to attend a meeting of the Quality and Safety Committee of the Saskatoon Regional Health Authority.  This is the board committee charged with governance review of safety and quality, covering hospitals but also community-based health facilities throughout the province.

I was tremendously impressed with the expertise and commitment of the staff and board members.  (Committee chair Doug Finnie is seen here with Petrina McGrath, VP for quality and interprofessional practice.)  The conversations were thoughtful and probing, demanding accountability, but also with a heavy dose of positive reinforcement from the board members.

Here you see Barb Evans, pharmacy manager, giving a report on on medication reconciliation and documenting steady progress in this domain.  That was one of several reports today, including one on fall prevention in long-term care facilities and another on pathology lab process improvements.

A different kind of malpractice

Malpractice lawsuits are a necessary evil in our society.  At times, they are frivolous, often resulting from a patient’s or family’s anger at a result that was not what they had hoped.  Some are actually designed just to try to get a financial settlement.  When doctors are sued for malpractice, it is a searing process, isolating and painful.  I have known several excellent doctors who have given up established practices so they will never have to go through the possibility of another lawsuit.  That is a real loss to society.

But our legal system is also designed to protect patients.  Malpractice lawsuits can be justified when a doctor acts negligently or makes a decision that is clearly outside of the bounds of the accepted standard of care.  

One of things we know about quality and safety lapses in hospitals, though, is that they are often the result of systemic problems in those organizations.  It is not that a doctor or nurse has intentionally committed a clinical error.  It is that the way work is organized in the hospital causes errors to occur.  For example, many hospital-related infections arise this way, and people die or are harmed as a result.  This raises a question as to whether it should be possible to sue for malpractice when a hospital fails to act to correct systemic problems.

Anne Carroll, now retired, has graduate degrees in information science and public health.  She raised the question this way recently in a recent health care quality and safety chat room (reprinted here with her permission.)

Here is a not-so-hypothetical case:  In an organization where the "systems errors" are generally known (subsequent to root cause analysis after RCA after RCA analyzing the same errors and the same processes), and the "normal human errors" are generally known, and the solutions to the systems errors and normal human errors are evidence-based and generally known--and no organizational processes have been redesigned to include barriers and forcing functions and other known process improvements to prevent errors from reaching patients; no policies and procedures have been rewritten and improved;  no staffing improvements have been implemented; there is no communication from top management about patient safety as a priority--and the organization's patient safety and health outcomes have not improved--how long should that organization and its personnel be given a pass?  If not negligence and incompetence, what should it be called?

I was recently at a hospital where the CEO said directly to his senior management and clinical leaders that his goal was to be “just above average” when it came to quality and safety metrics.  I was stunned because I know the effect of setting such a low target.  In my former hospital, we established a target of eliminating preventable harm; we implemented scores of process improvements; we rewrote policies and procedures; we made it clear that the top leaders and our board of trustees viewed reduction of harm as a priority.  Once we did all that, we were able to avoid the deaths of dozens, maybe hundreds, of patients per year.  The CEO who has chosen not to do that has, in essence, said that the loss of hundreds of lives at his institution is acceptable.

Anne raises the issue of whether a hospital that takes a passive approach like this should be vulnerable to malpractice lawsuits.  She suggests that the scope of the standard of care in medicine has changed.  It is no longer just a question of whether the doctor has made reasonable decisions in the care of the patient.  It is a question of whether the hospital has affirmatively engaged in systemic process improvement to avoid harm.

I am not one to encourage malpractice lawsuits, having seen the effect of them on individual doctors who are unjustly accused of an act of commission or omission.  On the other hand, I have sympathy for the patient who has died or been harmed unnecessarily because of the failure of a hospital to try to improve its delivery of care.

I am not suggesting that every instance of harm should prompt an institutional malpractice lawsuit.  Even the best hospitals in the world, the ones focused intently on improving care, will have such events.  Rather, I am suggesting that if a hospital has not demonstrated a good-faith effort to adopt proven techniques and approaches to improving quality and safety, it is not carrying out its public service responsibilities.  In such a case, I think it is quite fair to raise the question in court as to whether the institution should be held legally responsible for avoidable harm.

Ohio children's hospitals set the standard

I have made previous mention of the progressive attitude and approach to patient quality and safety that exists in Ohio.  The annual Central Ohio Patient Safety Conference, for example is organized by a number of hospitals in the area who decided years ago that "we compete on everything, but we don't compete on safety."  Likewise, Cincinnati Children's Hospital Medical Center has long had a goal of "pursuing perfect care" and has an an extensive commitment to transparency of clinical outcomes.

Now comes a group of children's hospitals that has established a truly audacious goal -- eliminating all serious harm in Ohio’s children’s hospitals.  The coalition, called Solutions for Patient Safety, is described here.  Their vision is to make Ohio the safest place in the nation for children's care.

But this is no mere slogan.  Supported by Cardinal Health Foundation, the group will focus on eliminating Serious Safety Events (SSEs) in Ohio children’s hospitals.  Complete transparency is an important element of this effort, and they are committed to inter-institutional data sharing to foster an "all teach all learn culture."  The group is developing a patient harm index to capture all elements of harm occurring at children’s hospitals across the state.  Here are the participants:

The group has a top-to-bottom philosophy:

I can't begin to tell you how exciting and admirable all this is.  These folks are adopting, in a collaborative learning environment, audacious goals, process improvement techniques from other industries, and transparency of clinical outcomes.  There is nothing they are doing that every hospital in the country cannot adopt -- given sufficient leadership.  There is nothing they are doing that cannot be accomplished by consortia of hospitals in other regions.  They are not being forced to do it by government regulators or insurers.  They are doing it because they want to hold themselves accountable to the standard of care in which they believe.

Let me include this excerpt from a press release about the Ohio program to give more information about what is possible if people decide to "just do it":

To achieve the network’s goals, participating hospitals will be learning from high reliability industries - such as nuclear power and aviation – that achieve high levels of safety in the face of considerable hazards and operational complexity. In addition, participants will focus on transparent sharing of data; development and use of standardized pediatric measures and process bundles; and the use of common tools and techniques to address organizational culture. Specifically, the network will be working to reduce harm in 11 healthcare acquired conditions, including:

• Adverse drug events (ADE)
• Catheter-associated urinary tract infections (CAUTI)
• Central line-associated blood stream infections (CLABSI)
• Injuries from falls and immobility
• Pressure ulcers
• Surgical site infections
• Ventilator-associated pneumonia (VAP)
• Preventable readmissions
• Obstetrical adverse events
• Venous thromboembolism
• Serious safety events (SSE)

OCHSPS will also be leading the network’s efforts to develop definitions for the above mentioned pediatric domains of harm that will be considered for use by The Centers for Medicare and Medicaid Services (CMS) as national definitions for pediatric harm measures.

When you see this kind of thing, all of the arguments raised by naysayers and skeptics about the potential for safety and quality improvement in America's hospitals, and the accompanying efficiency and cost improvements, drop away.  But we have to ask:  Where are the boards of trustees in other hospitals in America?  Where are the CEOs?  Where are the clinical leaders? Where are the medical schools?

I'll tell you.  Unfortunately.  They live in a self-satisfied, sometimes arrogant world, where they have decided that "these things happen."  They have implicitly committed themselves to the idea that it is all right to continue to kill and maim hundreds of thousands of people per year.  In other venues, that would be considered a criminal act.  In these venues, it is, quite simply, a tragedy of national dimensions.

Thank you for riding the billboard, er, the T

Our local transit system here in Boston, which we lovingly call the T, is -- again -- in deep financial trouble, mainly the result of inaction by the Legislature in solving its structural problems.  They are experts in kicking the can down the road, putting off real solutions.

So, what we end up with is increasing ugly approaches to raise revenue.  Check out these new ads on the turnstiles, of all places.  As you approach, you actually have to focus to realize the turnstile is still there.

Lisa Gualtieri offers courses at Tufts

Professor Lisa Gualtieri is offering two great courses at Tufts University School of Medicine.  She is a fine teacher and always attracts an interesting, diverse, and creative group of students.

Mobile Health Design, May 23 - June 20, 2012
This 4-week online course examines the impact and potential of mobile devices for health at a national and global level. Using systematic design methodologies, professionals will learn to conceptualize and design health apps that incorporate evidence-based guidelines and capitalize on the unique capabilities of smartphones and tablets. The class project, in teams, is designing a weight loss app for Consumer Reports.

4th Tufts Summer Institute on Digital Strategies for Health Communication, July 15 -20, 2012
This one-week, intensive course prepares professionals to develop, formulate, and implement a comprehensive strategy to enhance their organizations’ online presence. Participants will learn practical skills for planning and executing effective health initiatives using the most current web, social media, and mobile technologies. The class project, in teams, is devising a new digital strategy for the CDC.

Payment discussion at MHDC

I was honored to join Charlie Baker, former CEO of Harvard Pilgrim Health Care, and Carey Goldberg, of WBUR's Commonhealth, for a discussion at a seminar entitled "Payment Reform: Achieving the Three-Part Aim?" held by the MA Health Data Consortium.  We were preceded by an opening address from Dr. Robert Galvin of Blackstone Consulting.

Dr. Galvin provided an overview of issues surrounding payment reform, integrated health care delivery, and the like.  He set forth two possible scenarios for the various market areas.  One would be where integration would lead to improved outcomes and lower costs.  And the other would be where consolidation would lead to higher prices and unchanged outcomes.  He noted that the Federal Trade Commission does not have the resources and that the federal administration does not have the desire to intervene to prevent the latter scenario.

He wondered about the possibility of the "too big to fail" phenomenon occurring in health care, where because provider organizations become the economic engine of a given area, the normal forces of cost control do not take hold.

He set forth a warning, too, about two aspects of payment reform that could cause backlash.  The first related to those he termed the real losers -- providers who will ask, "Where did my income and autonomy go?'  The second was about perceived losers -- consumers/patients who will say, "No one told me I couldn't have everything."

Galvin suggests that the extent to which payment reform should be adopted and could be successful depends on using distinctly different approaches to different kinds of markets.  "We need to map payment archetypes to market archetypes," is the way he put it.

He concluded by suggesting that evolution, not revolution, would be the way things should and will move:  "Reorganizing the delivery system is unbelievably resource-intensive and fraught with unintended consequences."

Charlie and I then began our panel discussion, moderated by Carey. Regular readers of this blog will have a sense of my discussion about payment reform, its limitations and difficulties, and how it distracts us from other priorities for the health care system.  Charlie was sailing along a similar tack, to the point that Carey noted that our talks were more likely to result in a debate with the audience than between the two of us.

A few of Charlie's points bear repeating.  First, he noted that 90% of health care spending is concentrated in the care of 10% of the population.  Why, then, create an overburden of a payment change policy for the whole population?  Citing studies by the MA Attorney General, he reminded people that utilization is not driving up the cost of health care in the state.  "It's the unit cost."  Further, the Attorney General demonstrated that control of costs is not tied to particular payment methodologies.

Although we both discussed transparency, Charlie nailed the political point by saying, "You can't build will if no one knows what the current state of play is."  Absent real-time presentations of relative prices charged by providers and of quality metrics of those providers, there will not be public support for the kind of cost containment that could result from limited networks and other varieties of insurance products.

Nominations due for Schwartz Center award

My friends at the Schwartz Center remind me that the May 4 deadline is approaching for nominations for the annual Compassionate Caregiver Award.  Nominations from all of the New England states can be submitted by mail or on-line.  Here's more information.

To inspire you a bit, I want to take you back to this marvelous speech delivered by Dr. Amy Ship when she received the award.

With Warner Slack and his students

For several years running, I have been invited to present at a class at Harvard called "The Quality of Health Care in America."  Professor Warner Slack is currently in charge of the class, but in previous years he was joined by other health care luminaries in Boston:  Don Berwick, David Blumenthal, and Howard Hiatt.  For those readers not familiar with Warner, I point out that for over 40 years he has been a leader in the use of computers to improve communication, and specifically to empower both patients and doctors to deliver better health care.  (Check this CV if you have any doubts!)

I need to be a little careful -- but not too careful! -- when I say that Warner is unusual in the Boston medical establishment in his modesty, his respectfulness of others, his candor, and his gentleness.  I stereotypically attribute that to his training in the Midwest.

But whatever the reason, it is always a privilege to be asked to join his class of undergraduates.  As usual, I promised students that their pictures might show up on this blog if they asked a particularly good question or gave an incisive answer.  You see some of those students here.

By the way, you might find it interesting to learn that, if you are appointed full professor at Harvard, and you do not have a degree from Harvard, you are granted an honorary master's degree from the school. Really. Check Warner's CV to see that this is so. It is as if (1) such an honorary degree has any meaning, and (2) that it is somehow a necessary condition to join the pantheon of Harvard professors.  I guess his Princeton and Columbia degrees just didn't make the grade.

Is this a little incestuous?

The Society of General Internal Medicine has established a "National Commission on Physician Payment Reform" to:

Assess how and how much doctors get paid, as well as potential impacts of proposed healthcare payment models such as accountable care organizations, patient-centered medical homes and value-based purchasing.  The panel will identify solutions that help constrain costs and optimize care.

The Commission is funded in part by the Robert Wood Johnson Foundation, the California Healthcare Foundation, and the Sergei Zlinkoff Fund for Medical Education and Research.

Well, OK.  Can't hurt, I guess.  But there seems to be a requirement for membership, some kind of connection to Harvard, Boston, Stanford, or California.  Even the sole consumer representative is from Boston, working for an organization funded in great measure by Boston-based health care institutions and insurers.  Last I looked, there were a lot of great people born and bred and trained in other places.  Couldn't those foundations have pushed harder for a greater diversity in background?

How to alter the flow of the Mississippi

A very thoughtful commenter on a post below, noting the slow pace of change in hospitals with regard to quality and safety improvement, said, 

For all the talk of disruption, isn't it time that we actually witnessed a little?

So, who will break this dam between knowledge and candor? It isn’t that we don’t know what to do. We just won’t do it. It will require: (1) a centralized, protected anonymous log of harm and near misses observed, experienced, and performed; (2) visual social penalties to the very highest (rather than next in line, middle or lowest) in the priesthood for poor reporting; and, (3) elevation of substantial contributions to institutional safety performance as requisite to all levels of physician and managerial promotion.

One of these would alter the flow of the Mississippi. Two would alter the tides. Three would be an entirely different universe of patient care.

These are excellent thoughts, and let me add a possible input into how these steps might be accomplished, a more rigorous accreditation process that included the elements above as part of the standard of hospital operations -- accompanied by unvarnished transparency in that accreditation process.  Elements of the first part exist, but need bold expansion and refinement.  The Joint Commission offers a framework of expert and peer review of hospitals as it conducts periodic surveys of institutions.  While many of the metrics used by The Joint Commission are based on archaic and misplaced CMS requirements imposed upon it, The JC has tried to do better than that over the years and has focused more and more on processes, procedures, and standards that make sense.  That transformation is not over, but at least the capability exists -- if the will is there -- to include items likes those mentioned by my commenter as part of the accreditation requirements.

But the Joint Commission fails mightily on the issue of transparency, both in its actions and in its role as advocate for quality improvement.  In terms of actions, I have been and remain highly critical of The Joint Commission's failure to make widely available its library of best practices -- and of CMS' failure to force this to occur.  These are stories of quality and safety successes from the nation's hospital's, accumulated by The Joint Commission during its survey activities.  Those survey activities are carried out in its role as a designated agency of CMS.  In essence, they result from a public function.  Yet, the Joint Commission persists in holding those useful stories close to the vest, precluding their view by thousands of clinicians and administrators throughout the country, and also from patients and families who might want to engage in collaboration --or activism -- with hospitals to encourage adoption of these best practices.

A recent position taken by The Joint Commission is even more reflective of a terrible misunderstanding of the role of transparency in nudging along quality and safety improvements.  Last September, I reported on an effort by Dr. Kevin T. Kavanagh and many others to change the federal law to make public the content of accreditation surveys.  This was opposed by The Joint Commission.  As explained in a letter to Kevin, President Mark Chassin said: 

I would like to point out that there is no prohibition on hospitals releasing Joint Commission accreditation reports to whomever they decide is appropriate. Nonetheless, The Joint Commission does not itself provide survey reports directly to the public for the critical reason that we want to maintain an open and honest dialogue with hospitals in the various stages of review over survey findings.  Under our relatively new process, hospitals which are found to be out of compliance with accreditation requirements that rise to the level of an accreditation citation must generally come back into compliance within 45 days of the end of the survey or they will start moving down a path toward non-accreditation.  During this time, The Joint Commission works with hospitals to ensure an appropriate plan of correction and enters into dialogue with the hospitals over the nature and scope of the cited areas. We believe strongly that this ability to engage hospital leadership in the early stages of review should be protected and kept confidential.  By establishing a safe environment for give and take, we promote the attainment of higher levels of quality improvement and faster resolution of any deficiencies found at the time of survey. This philosophy of having a protected dialogue is consonant with similar arguments made by many diverse stakeholders, including some consumer advocates, that there should be a safe environment for health care organizations to report and vet issues about adverse events.  In fact, this broadly held concept led to the enactment of the Patient Safety Organization Act of 2005 which encourages protected reporting of patient safety events.

The Joint Commission is not subject to the Freedom of Information Act (FOIA) because the Act does not apply to non-governmental agencies. We do not support opening the FOIA to accrediting bodies simply because their evaluations are recognized by the government. A critical difference exists between the roles of a governmental body only performing certification activities and an accrediting organization which also seeks to help organizations succeed in achieving compliance with ever increasing levels of quality for the services and care they deliver. To that end, The Joint Commission has many additional standards, safety goals, and requirements beyond those of CMS. But most importantly, such a change to FOIA could have very broad implications well beyond accrediting bodies. 

Dr. Chassin unfortunately misses the point.  He confuses (appropriate) peer review protections for adverse events with (inappropriate) secrecy concerning accreditation results.  He obfuscates by focusing on release of interim survey findings compared with release of final findings.

Further, relying on FOIA as an argument misses the point that the proposed bill would allow the Department of Health and Human Services to release the survey results.   As Kevin noted to me, "This requires repeal of a portion of the social security act.  Also, we asked for modification of the Freedom of Information act to allow TJC (and other accrediting agencies) as a Governmental contractor to be subject to it."

Dr. Chassin's use of existing law to argue against a change in existing law reminds me of a true story from my days in Arkansas, when the Legislature was considering a bill to establish a state lottery.  One legislator pronounced that he was against the proposition because "gambling is illegal in Arkansas."

Influential women discuss aging

Here is an announcement for a great sounding forum and webcast this Friday, April 13, from 2:00 to 4:30pm, sponsored by the Altarum Institute, entitled "The Last Word: Influential Women Discuss What Matters When Loved Ones Face Aging."  A summary:

Altarum Institute invites you to a unique gathering of prominent and influential female authors, each of whom has written about their personal experiences caring for a loved one in the final phase of life. Combining elements of an informal book club meeting and an intriguing policy seminar, guest authors Eleanor Clift, Muriel Gillick, Jane Gross, Susan Jacoby, and Joanne Lynn will speak about their work, experiences and compelling stories that led to publications with profound implications for public policy. Their books range from practical, hands-on advice for caregivers, patients, and families to discussions of the political, social, and cultural ramifications of a fragmented health and social service system. Pulitzer Prize-winning columnist Ellen Goodman will moderate the panel discussion.

This will be at the Pew Charitable Trusts Conference Center in Washington, DC.  But you can also join by webcast.  Register here.

Pursuing quality at Carilion Clinic

I am just returning from a very satisfying visit to Carilion Clinic, headquartered in Roanoke, Virginia.  The main event was to give a talk at the system's Leadership Forum, with people from throughout the system, focusing on issues of quality and safety improvement.  Carilion, led by CEO Nancy Agee, has a strong commitment to these matters, along with an attempt to create a more integrated care regime among their multitude of physician practices and hospital facilities.

Earlier in the day, I had a change to meet privately with smaller groups, including this group of three: Dr. Stephen Morgan (CMIO); Paul Davenport (VP for emergency medicine); and Shirley Holland (VP for strategic development.  The three are AHA fellows, spending a year of professional development in a series of sessions around the country.

Somehow (!), the topic always returns to children's soccer, and Paul shared this photo of him and co-coach Doug Kidd, along with their indoor tournament champions from this past winter's season.

How to get better at harming people less

Every day, a 727 jetliner crashes and kills all the people on board.  Not really.  But every day in America, the same number of people in American hospitals lose their lives because of preventable errors.  They don’t die from their disease.  They are killed because of hospital acquired infections, medication errors, procedural errors, or other problems that reflect the poor design of how work is done and care is delivered.

Imagine what we as a society would do if three 727s crashed three days in a row.  We would shut down the airports and totally revamp our way of delivering passengers.   But, the 100,000 people a year killed in hospitals are essentially ignored, and hospitals remain one of the major public health hazards in our country. 

There are a lot of reasons for this, but I’d like to suggest that one reason is a terrible burden that is put upon doctors during their training and throughout their careers.  They are told that they cannot and should not make mistakes.  It is hard to imagine another profession in which people are told they cannot make mistakes.  Indeed, in most professions, you are taught to recognize and acknowledge your mistakes and learn from them.  The best run corporations actually make a science of studying their mistakes.  They even go further and study what we usually call near-misses (but perhaps  should be called “near-hits.” ) Near-misses are very valuable in the learning process because they often indicate underlying systemic problems in how work is done.

If you are trained to be perfect, it is very hard to improve.  David Rosen, an accomplished educator and administrator, and many years ago the Director of Education Services at Jobs for Youth in Boston, watched my TEDx talk and was prompted to say:

Your concern that doctors’ need to be perfect, to make no mistakes, leads me to a (just coined) adage: "perfect is an enemy of good...and also better."

He goes further and discusses one of his former employees:

When I first worked with Mary she was a perfectionist.  It was driving her crazy.  As we were creating the JFY competency-based GED curriculum, one day she said "Does everything I write in this curriculum have to be excellent, or are there some things that just need to meet a more basic standard?  I don't think I can do everything perfectly. I need to know from you, as my supervisor, which things need to be excellent and which just need to pass." 

Mary taught me -- as a wet-behind-the ears supervisor -- everything I know about good supervision.

Let’s now take this a step further and consider the role of punishment in such an environment.  At my former hospital, we had a case in which an orthopaedic surgeon mistakenly operated on the wrong leg of a patient. It was quite clear that the hospital’s “time-out” protocol, which was designed to avoid precisely this kind of error, had not been properly carried out. In the weeks following this disclosure, a number of people asked me if we intended to punish the surgeon in charge of the case, as well as others in the OR who had not adhered to that procedure.  Some were surprised by my answer, which was, “No.”

I felt that those involved had been punished enough by the searing experience of the event.  They were devastated by their error and by the realization that they had participated in an event that unnecessarily hurt a patient.  Further, the surgeon immediately reported it to his chief and to me and took all appropriate actions to disclose and apologize to the patient.  He also participated openly and honestly in the case review.

My reaction was supported by one of our trustees, who likewise responded, “God has already taken care of the punishment.”  He pointed out that it would be hard to imagine a punishment greater than the self-imposed distress that the surgeon already felt.  He had taken a professional oath to do no harm, and here he had, in fact, done harm.  But another trustee said that it just didn’t feel right that this highly trained physician, “who should have known better,” would not be punished.  “Wouldn’t someone in another field be disciplined for an equivalent error?” he asked.

This was a healthy debate for us to have, but a wise comment by a colleague made me realize that I was over-emphasizing the wrong point (i.e., the doctor’s sense of regret) and not clearly enunciating the full reason for my conclusion.  The head of our faculty practice put it better than I had, “If our goal is to reduce the likelihood of this kind of error in the future, the probability of achieving that is much greater if these staff members are not punished than if they are.”

I think he was exactly right, and this was the heart of the logic shared by our chiefs of service during their review of the case.  Punishment in this situation was more likely to contribute to a culture of hiding errors rather than admitting them.  And it was only by nurturing a culture in which people freely disclose errors that the hospital as a whole could focus on the human and systemic determinants of those errors.

Check yes or no, not both!

I am giving a keynote presentation about reducing medical errors at the annual Health Care Quality Summit of the Saskatchewan Health Quality Council in a couple of weeks and was asked to fill out the usual forms beforehand.  In so doing, I inadvertently demonstrated one of the dangers of checklists.  As a nurse colleague once said to me, if you create a checklist, people will check it.

Indeed, in the wrong side surgery I have discussed from time to time, the circulating nurse actually checked the portion of the patient record indicating that a pre-surgical time-out had taken place, even though it had not.  Why did she do that?  Well, she had left the OR briefly, and when she came back the procedure had started.  Therefore, she assumed that the time-out had taken place and checked off the box in the patient record to document the "fact."  (The new protocol makes that not possible:  The nurse has to witness the time-out.)

In short, unless there is a thoughtful work process underlying a checklist, it can still permit failure.

In my case, no harm was done.  My host gently wrote:

I was just reviewing the contract that you signed and noticed you checked both boxes (as included in the image below).  Could you clarify which one you are consenting to?  Can we video record you to make parts of your presentation available online? You are keeping us on our toes!

Opaque, not transparent

Where does this fall on the spectrum from transparent to opaque?

A doctor friend in a Midwest hospital, who devotes his life to quality and safety improvement, writes:

I am getting my ACL repaired a week from Monday.

I have been unable to get my hands on any data regarding which surgeon has fewest complications, let alone best outcomes – and I have some knowledge of the system.

Heck, I don’t even know our institutional data for outcomes/complications for ACL repairs. 

To make the point further, he referred me to this recent article on Forbes.  Here's the lede: 

Hospitals across the country are using near-total discretion in the way they disclose infections that occur as a result of surgeries, cause over 8,000 deaths annually in the U.S., and cost an additional $10 billion per year to the healthcare system, a new study underscoring the need for public reporting standards has found.

The report, published in the Journal for Healthcare Quality, and authored by researchers at Johns Hopkins University School of Medicine, shows that only 21 states currently have legislation that requires monitoring and public reporting for surgical site infections. Of those, only eight states actually make the data publicly available, and only a total of 10 procedures – out of 250 possible types of surgeries - get reported.

In memoriam: Sonya Nelthropp

My friend Sonya Nelthropp died this week on her beloved island of St. Thomas. I received the news while in Holland, but have not had a quiet moment until now, as I write this onboard my flight back to Boston. Hardly any of you, dear readers, knew Sonya. But may I ask you to read on anyway, for two reasons? First, there are aspects of her story that will resonate with many of you, and will move some of you. Second, for my own selfish reasons, I want you to feel that you know her, so you can join me in missing her. This is longer than usual, so please bear with me.

The St. Croix newspaper printed this obituary. It is accurate and gives hints of an unordinary life. It starts with her teaching science at the local high school in Charlotte Amalie. Then, what’s this about going to school to be a seaman engineer in the merchant marine, one of very, very few women to so do? And, then a change of heart to get a master’s degree in education at Harvard? Then, a stint helping to train people to run the sewage treatment plant in Boston Harbor? (That’s where we met.) Then, a return to St. Thomas to be the force behind setting up the Virgin Islands wastewater management authority. And, then dying at age 62.

Let me fill in some details, starting near the end. In the winter of 2010, when I was still CEO of Beth Israel Deaconess Medical Center, Sonya called me to say she was in Boston for some tests. Biopsy results received on a Friday afternoon indicated two forms of cancer. She was in a turmoil. The people at one of Boston’s most distinguished cancer centers had given her this verdict and then told her they would set her up to meet with a medical oncologist in ten days.

Ten days? You give a woman test results showing two forms of serious cancer; she is over a thousand miles from home, staying alone in a hotel; and the best you can do is get her an appointment ten days hence? It is hard to imagine a more cruel act. We had dinner the next night, and she told me the story. I said, “We will do better for you.” I took her medical records and sent an email at 10 pm that night to several doctors at BIDMC, asking them to think about how we could help.

I called Sonya the next day, Sunday, at about 1pm, saying that someone was likely to be in touch. She replied, “Dr. Awtrey [our gynecological oncologist] already called me. He spent two hours on the phone with me this morning telling me what to expect and possibilities for treatment and promising to coordinate my care with the other departments. His secretary will pick up my medical records from your office tomorrow morning.”

The next morning, Chris Awtrey’s secretary came by the office, and I asked her to express my appreciation to him for reaching out to Sonya on a Sunday. She looked at me with great seriousness and said, “Oh, there is no reason to thank him. Dr. Awtrey believes that the most important part of his job -- before performing any treatment -- is to spend as much time as necessary with a woman to help her be less anxious about her disease. That is the way he is. I can’t think of a more admirable person. It is such a privilege to work with him.”

Over the following weeks, the BIDMC team went to work -- surgery, radiation, chemotherapy. All aspects of care were well coordinated among several departments, leaving Sonya feeling like a queen. She understood that they had bought her some time, probably not a lot of time, but she was tremendously grateful for all that had been done. She was even more grateful for the degree of humanity shown to her by the doctors, nurses, radiation therapists, transporters, food service workers, and others during her stints as an in-patient and out-patient.

She went back home to the islands, undertaking follow-up care as needed, and then returned to BIDMC for a check-up in August of 2011. “The PET scan lit up like a Christmas tree,” she reported to me. “They’ve told me I have six months to a year to live. I might be able to extend it by a month or two with chemotherapy, but I don’t want to live that way. I’m just going to go home to St. Thomas and live well till the end.”

I went to visit her twice, once in November and again in January. We had a ball, touring St. Thomas, looking at places where our relatives might have known each other, accompanying me as I bought custom made sandals at Zora’s, heading to beautiful beaches (her to read, me to swim), playing backgammon, relishing in killing mosquitoes with an electric swatter, playing with the dogs, eating well and, yes, drinking well, too!

We talked plainly and openly about end-of-life issues. I expressed concern about her being far from her closest friends and family, who live in the US. Would she want to have hospice care at my house in Boston, or elsewhere near to people who could help out. We sat discussing this on her balcony: “How can I leave this?” she said, pointing out over the sparkling water, the neighboring islands, and the vegetation, as birds and peeper frogs sang in the background. “This is paradise. This is my home.” And so she stayed.

Sonya was immensely proud of her late parents. They were a tremendous influence in her life. She showed me items from the family archives, and I translated some of them into this blog post about her father. Unlike her mother, who had died fairly recently and whose obituary was in the online edition of the local newspaper, her father had died before the Internet, and so there were no images of him to be found on the web. I published a picture of him and her in my blog post. The next morning, I said, “Look at this!” I had done a Google image search, and the photograph of her father and her was already available for the world to see.

Not being very savvy in the ways of social media, she gasped, “That’s amazing. How did that happen, and so quickly!” Mainly, though, she was so grateful that I had told his story in a setting that could be seen widely by others.

A bit about that stint as a cadet in the merchant marine. Why Sonya wanted to be a seaman engineer was a simple, “I thought it would be interesting.” Why did she stop? “I was on a training cruise in the Suez. A fuel leaked developed in a diesel engine. As the cadet, I had the least seniority, so I was assigned to go under the engine and repair the leak. I had to lie on my back fixing the problem with a welder. It was 140 degrees under there. I finished the task and realized that I never wanted to do anything like that again. When I got back to port, I shipped out and figured it was time to get back to teaching and applied to Harvard for the master’s program in education. I never looked back.”

We went through dozens of file folders from her drawers, and she piled stuff about her life and her family in my suitcase. She gave me her stamp collection (another common interest): “I won’t be needing these.” She offered me her old leather backgammon set. “I’ll leave this here,” I said, “so we can play the next time.” “Right,” she said, with a wry grin. That was our private joke. We knew there would not be a next time. I would be off traveling for several weeks, and we both knew that the odds would work against another time together.

I called Sonya a few times in the following weeks. Her breathing had become difficult as the tumors spread and grew into her lungs. She added morphine to her daily routine. Then she added an oxygen generator. I shortened the phone calls because I knew it was hard for her to talk. The call I knew would be the last was a day or two before I left for Iceland and Holland on March 25. When you have worked in a hospital, you know when the end is near. She knew, too, and we hugged across the phone lines and expressed our love and our gratitude for the times we had had together.

I end with a poem Sonya wrote while a cadet in the merchant marine. It is about being assigned to be on watch. But being just a cadet, there also had to be a certified seaman on watch. So, as a cadet, you “watched the watch.” Here it is, the product of a young woman who lived a short life to the fullest.

A Cadet's First Watch

What do you do on your first watch?

You watch the watch
Who watches the gauges
and watches the pumps.
You watch the watch, watch his watch.

What do you do on your first watch?

You watch the wipers
You watch the DEMAC
You watch the watch, then you watch your watch.

What do you do near the end of watch?

You watch the watch
Fill in the log
Put up the coffee cups
Stretch his legs
And watch the ladder for the next watch.

Going to gemba at Jeroen Bosch Hospital

Knowing I was going to be in the vicinity after TEDx-Maastricht, I contacted my friends at Jeroen Bosch Hospital to ask if I could be of help as they pursue their impressive quality and safety journey.  The timing worked out that I would address a new leadership program for operations managers at the hospital, run by Miriam Casarotto (at left) and her colleagues.  The main topic was transparency, which I presented as a tool that assists process improvement.

I have been trying to go to gemba when I have speaking engagements like this, spending time on the floors of the hospitals I visit to get a sense of how work is organized.  Doing so also often provides some examples that make my talks more relevant.

A nurse named Kimmie, on one of the surgical wards, was kind enough to let me shadow her for a while.  (At first, she tried to keep explaining things to me.  I had to tell her that I just wanted to observe what her work life was like, and to try to forget I was there.  Why?  Well, if people keep interrupting their work to tell you what is going on, you don't get to see the normal flow of events.)

Anita Tucker at Harvard Business School has conducted studies of how nurses spend their time and has found that they often spend time overcoming obstacles they encounter.  Those work-arounds are effective in the short run, permitting the nurses to carry out the tasks at hand, but root cause problems are often left unsolved.  Over time, this has created an environment in which nurses are unlikely to spend more than 20% of their time taking care of patients, using the rest on administrative matters and, more likely, fetching or solving problems over and over again.  It is an environment ripe for systemic process improvement, but such improvement is often slow to occur, if it ever occurs.  This is certainly not the fault of the nurses, who are caring and well-intentioned.   The underlying problems lie elsewhere.

It is a remarkable thing, but within five minutes or so of starting to shadow a nurse in almost any hospital, you see this phenomenon.  Kimmie was working on discharging a patient and need to have a physical therapist visit the person before he was permitted to leave.  Here you see her faxing the PT order to the appropriate office.

But then, immediately after, she called the physical therapist to arrange for the visit.  After I had finished my shadowing, I asked her what that was about.  Well, she needed to have the PT visit occur today, and the fax order would not be viewed by the PT before the day was over.  Hence, she had to call the PT on the phone to put in that request.

So, Kimmie had to duplicate her work, taking up precious minutes of her time.  She also had to interrupt the therapist, wherever that person was located, wasting precious minutes of his/her time.  This particular instance of waste may not be that significant in the big scheme of things, but when it is multiplied by hundreds of other examples and by hundreds of people, you can see that there is a large cumulative impact.

An article about Professor Tucker's research put it this way:

By quickly and effectively solving the many small problems that came up throughout their shifts, the nurses Tucker observed continued to provide excellent care to their patients. 

The bad news, said Tucker, is that the root causes of the problems - from annoyances like supply shortages to potential dangers like unclear instructions - went unaddressed and thus continued. 

I later told this story to my seminar audience.  (Some physical therapists in the audience smiled knowingly.)  My point, of course, was not to critique this hospital.  Jeroen Bosch is a very fine place with excellent, well-intentioned people.  It just happened to be where I was when I went to gemba.  Check out your place, and you will find the same phenomenon, writ many times over.

Bossche bols are good for you. Right.

Believe it or not, these are miniature Bossche bols. They were served today during a meeting break at Jeroen Bosch Hospital, where I was giving a couple of seminars.  (More on that topic later.)

Wikipedia describes the full size one like this: It is effectively a large profiterole, about 12 cm/5" in diameter (i.e. somewhat larger than a tennis ball), filled with whipped cream and coated entirely or almost entirely with (usually dark) chocolate.