Advancing Hernia Solutions

Hernia surgeries are often considered to be prosaic.  At academic medical centers, for example, they are rarely discussed, compared to the attention paid to higher level tertiary and quaternary cases like transplants and Whipples.  But they are important procedures for the patients who need them.  They are also rife with complications, both short-term and long-term.

Bruce Ramshaw, at Advanced Hernia Solutions in Daytona Beach, FL, believes there are two reasons for this.  First, these procedures often fail to receive the kind of rigorous analysis and review that others do.  For example, there are dozens of kinds of mesh that can be used, but there is no clear evidence as to which type of mesh works best for which kind of patient.  Some varieties of mesh have been in use for decades without ever having to demonstrate clinical efficacy, in that they were grandfathered from approval by the FDA.

Second, there has been little effort to apply the use of effective teams to deliver person-centered care in this arena.  He notes:

Person-centered care is embodied by care teams, with the person who is the patient and family at the center, and with the care team all working for the best interest of the patient, learning and improving to provide value for the patient and for the overall system.

It is this model that Bruce and his colleagues have constructed at their clinic.  In addition to surgeons, the team includes patient care managers--who get to know the patients and families intimately and are on call to assist them 24x7.  Here you see Brandie Forman, director of patient care management, who arrived to work with Bruce in the medical world years ago after being a flight attendant.  There she learned and developed keen skills of personal interaction and service delivery.

The team also includes an engineer, Joe Johnson (left), who evaluates the systems issues around the delivery of care as well as technical issues that arise from the equipment being employed.  Joe arrived with no medical background, but with a sound foundation in systems design and process analysis.  There is also a materials scientist on call.  That person concentrates on the issues surrounding the durability and effectiveness of different types of mesh.

Bruce and his colleagues take seriously the idea of patient and family input, and they have created an advisory panel with whom they review their plans, their educational materials, and other aspects of the clinical pathways.  As demonstrated in a meeting I attended today, the participants are out-spoken, thoughtful, and extremely experienced in other fields that they are keen to apply to the "boring" world of hernia surgeries.

These patients and spouses know, of course, that the issues surrounding hernia repairs are not boring at all.  They have experienced such surgeries--sometimes successfully and sometimes not--and they are prepared to offer advice and assistance to Bruce's group as it develops and expands its program.

As we come to the end of the year and look forward to the inevitable lists of "great medical advances of 2012"--the usual assortment of still-in-the-clouds technological innovations--it is good to remember that the real medical advances are those occurring on the ground.  It is by the kind of thoughtful hard work and planning demonstrated by Bruce and his colleagues--and by his patient and family partners--that the quality of life is being enhanced and that lives are being saved today.  Let's rank them and similar groups among the greatest medical advances of the year!

"What" before "Why"

As the Lean Coaching Summit drew to a close, John Shook, head of the Lean Enterprise Institute, offered a summation that included the slide above.  Although I have been practicing and/or coaching Lean for many years, it made a big impression on me.  Let me explain.

One of the techniques used in Lean and other process improvement approaches like Six Sigma is to employ the "5 Whys."  Wikipedia explains:

The 5 Whys is a question-asking technique used to explore the cause-and-effect relationships underlying a particular problem. The primary goal of the technique is to determine the root cause of a defect or problem.

The premise is that the root cause is often hidden and requires inquiry beyond the simple first answer.  Wikipedia goes on to give an example:

• The vehicle will not start. (the problem).

1. Why? - The battery is dead. (first why)
2. Why? - The alternator is not functioning. (second why)
3. Why? - The alternator belt has broken. (third why)
4. Why? - The alternator belt was well beyond its useful service life and not replaced. (fourth why)
5. Why? - The vehicle was not maintained according to the recommended service schedule. (fifth why, a root cause)

Lean practitioners spend a lot of time on the 5 Whys, and John's slide properly incorporates the "why" portion of a problem solving.  But he also reemphasizes the need to understand "what" happened.  As he said to me before the talk, we often do not spend enough time at the site of the problem to comprehend fully its characteristics and nature.  Failing to know what happened means that the root cause analysis can be off track, and the designed solutions therefore will not offer a complete or sustainable solution.

As in many things related to Lean, this kind of advice can either appear to be self-evident and simple, or too nerdy or techy for real-world situations.  But it is neither.  It represents a codification of an essential aspect of process improvement, an aspect often observed in the breach.

How often have you been in an organization where a supervisor learns of a problem, does a cursory review, and then decides what has happened without a full understanding of important factors and details?  I know I have been guilty of this flawed approach in every leadership position I have had.  It occurs because we are creatures of habit, and the framework we use in viewing problems or defects has developed over the years based on experience, anecdote, and impressions.  It takes real insight to overcome our habitual view of the world and have the clear vision to see a problem and fully comprehend its characteristics.

It also takes a lot of practice to learn how to see a problem and to fully comprehend its characteristics.  An essential aspect of leadership training should be to create comfort in spending time on the front lines, where the work is done and value is delivered to customers.  Beyond physical presence, leaders have to be taught to quietly observe the work patterns of the front-line staff, and especially to see how the staff people create work-arounds to overcome obstacles to the tasks they are trying to carry out.  Excellent coaching is required to teach leaders the observational skills they need to answer the question, "What happened here?" 

Double-Lean focus on coaching

The Lean Enterprise Institute and Lean Frontiers joined together to create the Inaugural Lean Coaching Summit, a collaborative and hands-on learning environment to address coaching in companies and institutions that have adopted the Lean process improvement philosophy.  As noted by the hosts:

“Most lean practitioners have heard the principle ‘Before we make product, we make people.’ This embodies respect for people and describes the two responsibilities of every leader: Get work done and develop people. To accomplish these as separate activities is difficult, if not impossible. So the lean leader’s solution is to develop people through getting the work done. Easy to say, but what does it take? It takes coaching.” 

I was pleased to be invited to deliver the keynote address, based on the coaching themes and stories from my book Goal Play! But as usual in these sessions, I learned a lot of new things.  There was one bit of history from the original Toyota Lean work several decades ago.  They employed a four-part mantra that could apply to any organization today that hopes to become a learning organization:

Build people before cars;
Establish mutual trust;
Lead as if you have no power;
No problem is problem.

Billi joins MIT SDM for Lean webinar

The MIT System Design and Management webinars are generally excellent, but I predict that one of the best of the series is about to occur.  On December 10 (noon, Eastern time), Jack Billi from the University of Michigan Medical School will offer the topic: "Lean Thinking in an Academic Medical Center — The Beat Goes On."

This is the real thing, a major health system that has made a full fledged commitment to the philosophy and implementation of Lean process improvement.  For those interested in the potential to "bend the cost curve" while also improving quality and safety, this is a story from the front lines.  If you have never heard Jack before, you are in for a treat.  If you have, here's your chance to get a useful progress report and update.

Here's a summary:

The University of Michigan Health System (UMHS) has been on the lean journey for the past seven years, creating the Michigan Quality System. UMHS has over 20,000 faculty, staff, and trainees. The goal is to create 20,000 problem solvers who are finding and fixing root causes of problems they face daily. This webinar will briefly recap UMHS' initial approach, results of early experiments, what leaders learned, and how UMHS adjusted. The webinar will cover their current set of experiments, including the transition from scattered projects led by coaches to an integrated approach that incorporates People Development into Process Improvement.

Here are the details.

Nomenclature inflation strikes again

A few weeks ago, I presented an example of nomenclature inflation from the HR field, where "recruiter" had become "talent acquisition manager."  Today, another example appeared at Logan International Airport.

What would you call a person who assist patrons in wheelchairs, like the man above?  In US hospitals, we call them transporters.  In UK hospitals, they call them porters.

At Logan?

I don't know who came up with the name "mobility assistant," but it seems a bit bureaucratic to me.  (It is also a term that is used by relocation firms for the folks who make arrangements when people change jobs from one city to another.  Also, certain robots have been assigned that name.)

In raising this issue, I don't mean to take away at all from the skill and judgment it takes to be a good transporter.  Indeed--whether in the hospital setting or in public facilities like airports--a transporter has a key role.  In fact, in hospitals, transporters actually have more contact with patients than any other staff members and are often the source for really good ideas about how to make care better.  Look at this posting for a wonderful example of that.  But we didn't think, and they didn't think, that they needed to be called anything other than "transporters."

But maybe the airport folks have a reason for the term.  Feel free to comment if you know it.

Let's go for autonomy, mastery, and purpose

(Please read this in conjunction with the post below.)

A number of regular readers were appalled the other day when I asked for comments about an idea, that malpractice insurance should not cover cases in which surgeons failed to conduct time-outs and therefore harmed patients.

One person said:  "As Wachter and others have indicated, the balance between a just culture and individual accountability is a very difficult subject."

Another argued:

I suspect that such a measure would result in 100% of DOCUMENTATION of the use of the Universal Protocol. As we all know, this is not the same thing as the cultural commitment to the underlying ideas of respect for the patient that leads to this thoughtful pause and confirmation. I suspect, however, that rate of wrong site surgeries would not fall appreciably. Unfortunately, there is no shortcut to the culture that is committed to eliminating patient harm. In some ways, regulation of good behavior IMCO has led to the illusion that this is possible.

I had hoped that my straw-man proposal would provoke some controversy, and I think these comments join the issue perfectly. We want to create a learning organization, one that cherishes mistakes and near-misses to undercover systemic problems.  Yet, we also want to know that we can rely on personal accountability to comply with protocols that reduce variation and enhance proven standardized approaches.

My blog post set forth the classic regulatory type of solution to this problem:  Impose a "contingent motivator."  If you do A, the consequence is B.

In this TED talk, Dan Pink explains the problem with such incentives.  You can watch the whole thing, but the main point is that it has been demonstrated that contingent motivators do harm.  They tend to "narrow our focus and concentrate our minds," just the opposite of what is needed in a learning organization.  He calls this "the lazy, dangerous, and crazy industry of carrots and sticks."  Indeed, I have set forth just that kind of argument with regard to financial penalties related to rates of readmissions.

Instead, research has shown that ideas develop and organizations improve when the environment is structures to give autonomy, mastery, and purpose to people.

But wait, isn't that the problem in medicine? Doctors are taught to be individual players, relying on their judgment, experience, and good intentions in taking care of patients.  The result is a high degree of variability, producing uncertain clinical outcomes, causing preventable harm to patients, and unnecessarily costing a lot of money.

Brent James and others offer the answer, one that is ideally suited to the personalities and abilities of the people who become doctors.  He says that we want to provide mastery in the use of the scientific method in clinical process improvement.  We want to allow autonomy, but within the context of that scientific method.  Purpose will carry us the rest of the way.  When Brent received an award last year it was:

[F]or his pioneering work in applying quality improvement techniques that were originally developed by W. Edwards Deming and others, in order to help create and implement a “system” model at Intermountain, in which physicians study process and outcomes data to determine the types of care that are most effective.

I summarized the Intermountain approach here:  

1 -- Select a high priority clinical process;
2 -- Create evidence-based best practice guidelines;
3 -- Build the guidelines into the flow of clinical work;
4 -- Use the guidelines as a shared baseline, with doctors free to vary them based on individual patient needs;
5 -- Meanwhile, learn from and (over time) eliminate variation arising from the professionals, while retain variation arising from patients.

Note that this approach demands that doctors modify shared protocols on the basis of patient needs.  The aim is not to step between doctors and their patients.  This is very different from the free form of patient care that exists generally in medicine.  Notes Brent, “We pay for our personal autonomy with the lives of our patients.  This is indefensible.”  The approach used at Intermountain values variation based on the patient, not the physician.

 
As the Lucian Leape Institute has noted, though: 

Medical schools are not doing an adequate job of facilitating student understanding of basic knowledge and the development of skills required for the provision of safe patient care.

I am not sure we should be optimistic yet, but there is some movement on the education front.  Medstar's David Mayer likes to say, "Educate the young. (And on occasion, regulate the old.)" While that still leaves unstated how and where to "regulate the old," it puts the emphasis where it needs to be.  The current system of care has evolved over decades.  It is unlikely that we will effectively use regulation to bring about change.  Years ago, I suggested that change must come from within.  It will, when we give mastery and autonomy to rising doctors to practice their craft in a way that is consistent with their underlying purpose.

What could he do?

I was talking recently with one of the world's experts on patient quality and safety--you would recognize his name--about another world expert, who has written widely and elegantly on the topic--you would also recognize his name.  I said, "Isn't it ironic and a shame that the author's own hospital has failed to adopt many of the practices he so eloquently sets forth?"  The response, "Well, what can you expect him to do?"

I think he was suggesting that it is very hard for a doctor (particularly a junior faculty member) to make waves in his own academic medical center when the senior administrative and clinical leaders have chosen not to make patient quality and safety a strategic priority and when they have not endorsed the importance of clinical outcome and cost transparency in support of process improvement.

W. Edwards Deming said of process improvement:  "Long-term commitment to new learning and new philosophy is required of any management that seeks transformation. The timid and the fainthearted, and the people that expect quick results, are doomed to disappointment."

Our writer is not the only person facing this issue.  Of all the questions I receive around the world after talking with doctors, nurses, respiratory therapists, and others, the one most often heard is, "I believe in what you are saying: How do I get my CEO (or chief of service, or division head) to buy into this and let us move forward?"

I am told that Deming's answer to this question was that you should quit and find a new job if the organization was not committed to the kind of learning environment he described.  While that might be good advice for some, others have constraints that make this remedy unsuitable.  So, what could you do?

Our patient safety author is devoting his efforts to systematically analyzing process improvement approaches, reporting on his experiments at other hospitals, and proselytizing through his writings.  There is certainly something to be said for that.  The bully-pulpit, after all, is powerful.

But it is only a matter of time before credibility is weakened by a lack of performance of the host institution.  After all, if you can't walk the walk, you won't long be able to talk the talk.  And, indeed, such observations among clinical leaders are already being made.  Simply put, people have seen that leadership in implementation of quality and safety improvements is regularly and modestly occurring elsewhere.  Many of the world-renowned academic medical centers are being left in the dust.  Nonetheless, they persist in arrogantly believing that they are "the best in the world" and even "God-given gifts to society."  (Yes, those are the actual terms used.)

My advice to those nurses and doctors who want to make progress in their hospitals is to find like-minded people on their floor, their unit, or other departments and slowly and quietly conduct some experiments in redesigning work.  Don't look for large global changes.  Just find some small area where an obstacle has arisen and, instead of inventing a work-around, try to do a root cause analysis of the problem and design an possible solution.

Deming called this "Plan-Do-Check-Act."  The idea is that a multitude of incremental improvements is a more effective way to enhance the work environment and give better service to the customer.  You make one small set of changes to go from the "current state" to the "future state."  Then, the future state becomes the new current state, and you move on from there.

While administrative and clinical leadership is essential to nurture and support these measures, sometimes--just sometimes--a clever administrator or chief of service will notice that his or her staff has quietly and effectively been producing measurable improvements in quality, safety, and efficiency.  It may actually be possible to "manage up" and teach that person what you and your colleagues need to do the job right and to become a learning organization.

It is worth a try, whether you are a world famous author or a junior nurse or intern on the night shift.  If you don't think it is possible where you work, you really should do what you can to find a place where your skills and abilities and commitment are better put to use.

Margaret Mead reportedly said, "Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it is the only thing that ever has."

Arlo Guthrie put it in different terms (in a very different context):

You know, if one person, just one person does it they may think he's really sick. And if two people, two people do it, they won't take either of them. And three people do it, three, can you imagine, they may think it's an organization. And can you, can you imagine fifty people a day. And friends they may thinks it's a movement.

@waitingstories waits for you in Boston

It was a treat to join director @petenicks and producer Bill Hirsch (seen here with student @AdamJJoseph) for a special discussion of The Waiting Room last night at the Kendall Square Cinema in Cambridge.  The auditorium was full, and many appreciative people stayed for quite some time after the show to ask these fellows why and how the movie was made and what they hoped to accomplish.

Couldn't make that showing?  The movie will be at Kendall Square through December 6.  Info here.  There is reason to believe that the film might be on the list of Oscar contenders this year.  It has already won some great awards.  If you go now, you will be able to brag that you were smart enough to see it before it became famous!

Neither accountable nor caring nor organized

Almost two years ago, I quoted Dartmouth's Elliott Fisher facetiously remarking that we could not be sure whether accountable care organizations (ACOs) would actually be accountable, caring, and organized.  A year later, I warned about the dangers of industry consolidation, quoting from Federal Trade Commissioner J. Thomas Rosch:

“The net result” of ACOs, says Rosch, “may therefore be higher costs and lower quality health care—precisely the opposite of its goal.”

Events since that time should cause us concern.  Julie Creswell and Reed Abelson report in the New York Times about a consolidation and market share battle going on in Boise, Idaho.

Regulators expressed some skepticism about the results, for patients, of rapid consolidation, although the trend is still too new to know for sure. “We’re seeing a lot more consolidation than we did 10 years ago,” said Jeffrey Perry, an assistant director in the F.T.C.’s Bureau of Competition. “Historically, what we’ve seen with the consolidation in the health care industry is that prices go up, but quality does not improve."

In an earlier Washington Post article, author Steven Pearlstein explained his concerns.  He noted:

Because there are often hospitals in each region that insurers must have in their networks to attract subscribers, dominant hospital chains are able to demand monopoly-like prices for their services. Insurers have responded by merging with other insurers in the hope of gaining negotiating leverage by becoming as indispensable to the hospitals as the hospitals are to them. To maintain their leverage, hospitals in turn have consolidated into bigger and bigger chains.

This arms race has produced repeated waves of consolidation that, rather than having led to lower prices, have led to higher prices, declining quality and less competition.

Look, what is going on in hospitals is similar to what has happened in other industries--telecommunications, banking, electric utilities.  The first refuge of corporate executives who face structural changes in their industries is to arrange mergers to gain market power and reduce risk.  I know of no industry in which unregulated market dominance has led to lower costs or greater customer choice.  Monopolies, after all, behave like monopolies. Neither Republicans nor Democrats have chosen to address these market power issues in the health care sector.

Dr. Fitzpatrick offers optimism for World AIDS Day

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

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

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

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

Heroes at MITSS

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

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

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

@drsusanshaw couldn't do it. Could you?

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

She continues:

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

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

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

@JustinHOPE and @mbismark show HEART

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

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

Scholarship funding for patient safety camps

@dmayer33 David Mayer notes:

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

The vision:

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

Check it out.  A great opportunity!

A proposed exception to malpractice coverage

Did you know this?

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

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

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

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

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

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

Health care for Australian Aborigines

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

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

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

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

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

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

Goal Play! audiobook is in the works

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

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

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

 

A sign of the times

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

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

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

Just talk to each other!

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

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

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

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

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


FaceTalk kort EN from UMC St Radboud on Vimeo.

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

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

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

Another doctor in the Netherlands helped a patient in Egypt:

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

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

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

Joris explains CRM in the PICU @UMCN

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

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

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

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

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

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

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

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

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

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