Big events in health care next week

While the world at large focuses on the Supreme Court arguments about the national health care law, my neighbors will get to hear a thoughtful discussion hosted by the Newton-Needham Chamber of Commerce on the topic, "What you need to know about cost control, quality and value in health care".

The event is on March 28 and features three knowledgeable folks, Dr. Michael Jellinek, President, Newton-Wellesley Hospital; Andrew Dreyfus, CEO of Blue Cross Blue Shield of MA; and Charles Baker, Principal at General Catalyst Partners and former CEO at Harvard Pilgrim Health Care.  More information is available at this website.

Hopefully, an uneventful visit

Reported to me by a friend, who accompanied her pregnant friend (6th month) to visit a sick patient today at a Boston area rehab hospital.  Having visited before, they first went towards the previously assigned room, and a staff person recognized them, and directed them towards a single room instead of the previous double room.  While visiting the patient, at least three staff members came in and engaged in conversation, all making notice of the pregnancy of the visitor.  In the course of the visit, the visitors held the hands of the patient.  A fourth staff member came by and said, "You know you should really be wearing gowns, as the patient has an extremely contagious intestinal infection."  It appears that this may have been the reason the patient was moved to a single room.  The visitors left the room, put on robes, and returned. 

Later the patient informed the visitors that she had C. diff, a very contagious bug. No one on the staff told the guests that C. diff is not killed by the Purell sanitizer, that it takes soap and water cleansing.  Fortunately, the guests were aware of that precaution.

I haven't found any literature to suggest that pregnant women are especially susceptible to C. diff infections, or that the fetus will get the disease if the mother gets it.  I guess there is something to be said for an enforced weight loss (!) from the diarrhea, but I don't think most pregnant women would choose that path to weight control.  Also I have read that, if the infection is persistent and antibiotics must be administered to the mother post-partum, it could be inadvisable to breast feed the baby.

Given the circumstances, this all seemed to me to represent a very casual approach to infection control.  Are there any reactions from doctors and nurses out there?

How to use an iPad

The best ever:

You don't have to speak German to understand this. The woman asks her father if he's figured out how to use the iPad she gave him, which he affirms without question.

Spring in Boston!

Winter never came this year, but Spring has arrived!

Expanded contest eligibility

Process improvement in a hospital, company or other organization is a lot like process improvement on a sports team.  As I have set forth in my book Goal Play!, the coach has an important role in both settings.

Along those lines,  the other day I announced a contest for boys and girls to send in a poem or essay about their best soccer coach.  I said:

I, along with a small group of coaches and referees, will judge the entries, and we will pick a winner from among the girls and another winner from among the boys.  The two winning entries will then be posted on my companion blog, Goal Play!, for the world to read.  In addition, I will make a personal contribution of $50 each to a sports-related or education-related non-profit designated by each the two winners. 

Susan Day submitted this comment on my other blog:

I understand that you are running a competition for youth soccer players to comment on the best coach that they have had and why. My daughters were never into soccer and instead choose to pursue other athletic pursuits where they have had their share of great, mediocre and those best un-named types of coaches in their activities. Why can’t they share the best coaching practices that they have seen so that others may hear what works in other youth sports and learn from that?

After some thought, I replied:

Great idea, Susan. I was being too limited. We’ll open this up to all sports, but let’s still hear only from kids between 11 and 14 years old.

So, please spread the word to children who play baseball, lacrosse, hockey, or whatever other sport.  The topic is:

My favorite coach ever is or was [name].  Let me tell you why.

The deadline for entries is Saturday, March 24 at 9pm Eastern Daylight Time.  Please see my earlier post for all the rules.

We don't make the rules

There is no comment more infuriating to a customer than when you ask for a reasonable accommodation from a service attendant, and when s/he turns you down and you ask, "Why?" and s/he says, "We don't make the rules."

I had a quick round trip between Boston and New York today and used my accumulated Delta Airlines frequent flier miles to acquire the tickets on the Shuttle. Before leaving Logan, I asked a gate agent if it would be all right to take an earlier flight home than the flight I had reserved. She looked it up and noted that, while I had a certain class of seat, it would be no problem to switch to an earlier flight, especially as the plane was likely to be quite empty. So I expedited my business in New York and arrived a LGA in plenty of time to catch the 2:30 plane instead of the 3:30.

At the ticket desk in New York, the agent said: "That change will be an additional $50."

Me: "But the flight is empty, it is the same routing, and your Boston agent told me I could switch if I got here early."

"We don't have any of that class of seats available."

"It is really annoying to be treated this way when I am a loyal customer."

"We don't make the rules."

You see above a picture of my airplane shortly before takeoff, so you can it was quite empty.  It cost Delta nothing to let me take the earlier flight.

Upon returning to Logan, I went back to the ticket counter and talked with a very friendly "red jacket" person -- the supervisor of the gate agents -- who in turn talked to three or four other people on the phone. None were able to help her to get me a refund or otherwise solve my problem. Finally, she gave me an 800 telephone number; the chain of phone prompts -- dial 800-335-8241, option 8, option 2, option 8, option 6, and ask for a live agent -- and instructions of what to say.  I called, and an equally pleasant person answered, told me that she would need to confer with her supervisor, and, while unable to refund the extra charge, gave me a $50 voucher towards a future flight.

So, let's review this and pick up some lessons. In doing so, let's compare this experience with what would have happened at a place like the Gaylord Palms Resort in Florida.

First, no one at the Gaylord would have said to a customer, "We don't make the rules."  If, indeed, there were strict rules, there would have been a logical explanation given to the customers for the rules.  Second, the associate would never have let the customer leave the front desk without offering something to make the customer satisfied and wanting to come back again.  Third, in contrast to the "red jacket" person's need to talk to three people on the phone to remedy the problem, at the Gaylord she would have been empowered to have refunded the money or issue a voucher on her own.  Fourth, a person of her rank would never have left the customer alone to call an 800 number to find a fix.  She would have gotten on the phone with me and made sure that the person at the other end was responsive.

So, the upshot is that, although I had satisfactory outcome, the process for getting there was clumsy and wasteful.  It took time from at least six Delta employees to work on my issue.  No one was empowered to solve the problem.  I think this reflects a lack of trust on the part of the company towards its people.  Finally, of course, the experience did not serve to make me a more loyal customer (beyond the $50 I will someday use on another flight!)  That I had to spend an inordinate amount of time trying to solve the problem was troubling in itself.  But what was more disconcerting was the initial comment to me:  "We don't make the rules."  It was dismissive and unfeeling.  Moreover, it made me feel that the person who said it did not himself have loyalty to the company.  If an employee does not, why should I?

It is not March madness: U Mass can be first

The announcement that John G. O’Brien will step down as president and chief executive of UMass Memorial Health Care in early 2013 is bittersweet.  John is among the best of health care executives in the region, but, as he realized, ten years is enough for anyone running a major hospital system.  Now it turns to the U Mass Memorial trustees to find a successor.

I have a proposal for the trustees as they seek to fill this job. Normally, hospital trustees focus on finding someone with the business background to keep a hospital in the black. That’s fine, but this hospital can be something more. It can be the hospital in the region that takes on the challenge of being the safest hospital in the nation. It can be the hospital that, together with U Mass Medical School, sets the standard for medical education that trains doctors to engage in patient-centered care and process improvement. It can do all this while achieving financial stability and health. And it can do so in a way that sets an example for those Boston-based hospitals and medical schools that like to claim they are the best but often shy away from actions and from the transparency that would truly make them the best.

In 2010, the Lucian Leape Institute at the National Patient Safety Foundation reported that U.S. “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.” The report comes approximately 10 years after the Institute of Medicine’s landmark 1999 report “To Err Is Human,” which found that 98,000 Americans die unnecessarily from preventable medical errors. “Despite concerted efforts by many conscientious health care organizations and health professionals to improve and implement safer practices, health care remains fundamentally unsafe,” said Lucian L. Leape, MD, Chair of the Institute and a widely renowned leader in patient safety. “The result is that patient safety still remains one of the nation’s most solvable public health challenges.”

Progress is slow because medical schools and teaching hospitals have not trained physicians to follow safe practices, analyze bad outcomes, and work collaboratively in teams to redesign care processes to make them safer. These education and training activities, the report states, need to begin on Day 1 of medical school and continue throughout the four years of medical education and subsequent residency training.

“The medical education system is producing square pegs for the delivery system’s round holes,” said Dennis S. O’Leary, MD, President Emeritus of The Joint Commission, a member of the Institute, and leader of the initiative. “Educational strategies need to be redesigned to emphasize development of the skills, attitudes, and behaviors that are foundational to the provision of safe care.”

Even the University of Michigan Health System, an exemplar in many respects when it comes to quality improvement, has found that a substantial majority of its 22 residency training programs do not provide systematic didactic training with project experience.  A researcher at that medical system concluded that there is a need for active institutional involvement to encourage and facilitate the development of such training, and specifically to develop faculty leaders and to share pedagogical materials across all the residency programs.

On the clinical care front, as GoLocalWorcester reported last week, the Commonwealth Fund recently found that Worcester ranked in the lowest 25% of the percent of patients who reported hospital staff always managed pain well, responded when needed help to get to bathroom or pressed call button, and explained medicines and side effects.  As I noted in that article, this is a symptom of the fact that nurses are forced to spend too much of their time away from patients, filling out paperwork and fetching medicines and other supplies. We have great nurses in the region, but hospitals need to improve their work flows to make it easier for them to respond to basic patient needs.

Changing these patterns requires a leadership commitment, a CEO who is an advocate for patient-driven care, eliminating preventable harm, transparency of clinical outcomes, and front-line driven process improvement.  University of Michigan Health System CEO Ora Pescovitz recently wrote to her staff:

Health care is a human system, and humans are fallible. There is not and never will be a perfect person or a perfect hospital. The most educated, experienced and well-intended people make mistakes, and the most prestigious health care organizations make medical errors. That is why a culture of safety requires processes and systems that minimize human error.

While it may be impossible to be perfect, we most certainly can be exemplary.

I am proud of the University of Michigan Health System. But, to be a leader in safety, we must demand excellence from ourselves every single day. Because we can never be perfect, we must be resolute in our commitment to continuous improvement. I know that this Health System has what it takes to be the safest hospital in the nation. I call on all of you to engage, to recognize the important role you play and to be more diligent than ever in pursuit of this foremost goal.

We need a CEO at U Mass Memorial who displays this kind of leadership commitment, and leaves U of M in second place in this version of the Final Four!

Are you Mrs. Smith? Well, it doesn't really matter to me.

It is so simple and so important:  Identifying a patient before administering medications, taking vital signs, extracting blood, or engaging in other care procedures.  But this new article by Etienne Phipps and others suggests that it just doesn't happen the way it should.  The abstract says:

Findings:  Although residents and nurses viewed PT ID as crucial to patient safety, they cited time pressures; confidence in their ability to informally identify patients; and a desire to deliver personal, humanistic care as reasons for not consistently verifying patient identification. Nurses expressed concern about annoying, offending, and/or alienating patients by repeatedly checking wristbands and asking date of birth, in the belief that excessive patient identification practices could undermine trust. Residents relied on nurses to check ID and preferred to greet the patient by name, a practice that they viewed as more consistent with their professional identity. Referring to patients by their room number and location was cited as a commonly used practice of PT ID and a contributor to errors in identification.

Conclusions:  Nurses and residents are aware of the importance and requirements to verify PT ID, but their adherence is mitigated by a variety of factors, including assessment of necessity or risk, impact on their relationship with the patient, and practices in place in the hospital environment that protect patient privacy. 

Oh, please tell me this isn't so. This is the simplest of all safety measures.  These are terrible excuses for non-compliance.

I remember one day when I was CEO of the hospital, and I had to have some blood drawn. The tech, knowing who I was, used the opportunity to talk to me for ten minutes about hospital-related issues and then said, "OK, it is time to draw some blood.  What is your name?  What is your birth date?"  I congratulated her for following the proper procedure.

Building capacity for patient-centered care

Here's a nice idea, supported by The King's Fund and the Health Foundation, to help build capability for more patient-centered care in the United Kingdom.

We are inviting applications from NHS provider organisations that have demonstrated commitment to transforming patient experience.

The King's Fund and the Health Foundation would like to invite your organisation to consider applying for the Patient and Family Centred Care programme. This is a development and support programme, using tried and tested techniques to help NHS organisations make significant improvements in patients' experiences.

It's breaking new ground in improving the experience of care for patients and their families, and the working lives of staff. We are currently looking for NHS provider organisations to participate in the next phase of this exciting work.

Our goal is to develop a small number of exemplary NHS provider organisations and a team of professional staff and managers who can demonstrate their achievements to others, and bring sustainable improvement in patients' experience.

We want to allow patients to:

• feel confident that the care they receive will be consistently high quality
• participate in their own care and feel confident working in collaboration with healthcare professionals
• feel that their care has been designed in a way that acknowledges its place within their broader lives.

The programme will provide leadership development and on-site support for your teams, and include a series of learning events and rapid improvement days, supported by expert coaching and mentoring.

The programme offers you the opportunity to:

• make a reality of policy commitments to improve patient-centred care
• build your organisation's reputation for high-quality, compassionate care
• receive ongoing support from the Health Foundation and The King's Fund, with input from our experts
• access expertise on how to bring about successful change, with an emphasis on sustainability and reach
• showcase your work and become a leader in the field.

Your contribution

Successful applicants will be expected to commit to the programme for two years and have active sponsorship from your board to support your participation.

The cost to participating trusts is £5,000 (+VAT) per year. This will help to pay for learning events and support for your teams.

Applications now open

For an informal discussion about the programme please call Bev Fitzsimons, Programme Manager at The King’s Fund, on 020 7307 266 or email b [dot] fitzsimons [at] kingsfund [dot] org [dot] uk.

The deadline for applications is 30 April 2012. For more information and to download the application form, please visit our website: www.health.org.uk 

We don't think in ounces. We think in pounds.

The scene:  Our local Peet's Coffee shop.  At the request of friend who needs it for his St. Patrick's Day party tonight, I go to the counter and ask the young lady for 12 ounces of Major Dickason's Blend®.  She pleasantly and unhesitantly starts to fill the order.  The surly young man at her side says, "Next time you're here, please ask for 3/4 of a pound instead of 12 ounces.  We don't think in ounces here.  We think in pounds."

New contest for young soccer players

Let's see if we can all get together to counteract the kind of behavior we see in the post below and also milder versions of the same.  We'll try to make a dent with a new contest that I am announcing.  Only youth soccer players between ages 11 and 14 (inclusive) are eligible to participate.  Children from all parts of the world are welcome to participate.

Once a month during the soccer season, I will announce a topic for a guest blog post.  If you have a son or daughter who plays the sport and meets the age limits above, he or she is eligible to submit an entry of 700 words or fewer on the topic I have set forth.  The entry can take the form of an essay or a poem.  The entry MUST be submitted by the child's parent or guardian, saying that they approve of the child's participation in the contest.

I, along with a small group of coaches and referees, will judge the entries, and we will pick a winner from among the girls and another winner from among the boys.  The two winning entries will then be posted on my companion blog, Goal Play!, for the world to read.  In addition, I will make a personal contribution of $50 each to a sports-related or education-related non-profit designated by each the two winners.  I may also, from time to time, quote entries from other participants on my blogs, articles, and books and in my speeches.

Here's how you play:  Send the entry by the designated date to this email:  goalplayleadership [at] gmail [dot] com.  The parent must include the following message, and provide a phone number in case any questions arise:

"This essay or poem is being submitted by my son/daughter [name] in response to your topic.  I certify that my child is [number] years old.  I understand that, if this essay or poem is chosen as a winner, it will be posted on your blog Goal Play!  If my child's essay is chosen as a winner, s/he would like you to donate $50 to the following non-profit organization:  [Name, address].  I understand that the judges' decisions are final.  I waive all copyright rights of my child's submission, whether or not it is chosen as a winning entry."

The first topic is this:

My favorite coach ever is or was [name].  Let me tell you why.

The deadline for entries is Saturday, March 24 at 9pm Eastern Daylight Time.

Good luck to all of our young players!

On the pitch, we can all do better than this

As we go into our spring soccer season here in the Northeast US, it is instructive to view this disturbing Under-12 boys match from Hong Kong.  While the boys misbehaved, the coaches and parents did not help things, and the referees chose to be powerless.

Ora defines leadership

In response to my post below about work needed to be done to improve the residency program at the University of Michigan health system, CEO Ora Pescovitz wrote me:

Thanks for shining a bright light on UMHS and the work we do……we appreciate this both when we are proud of our efforts and when we recognize that we have room for improvement. It is part of the culture we are attempting to instill.

If you want to see more about what real leadership in health care is about, check out this blog post by Ora.  Excerpts:

Lately, I’ve been thinking a lot about what it means to have a culture of safety.

With a population of 22,000 employees and more than two million patients, visitors and guests coming through our doors each year, the University of Michigan Health System is a vibrant community unto itself. And in an organization of this size and complexity, things will go wrong, mistakes will be made and accidents will happen. What is most important is how we deal with and learn from our mistakes, problems and accidents to make sure we are always striving to create the safest environment possible.

Creating a culture of safety means many things, including:

• Admitting our own errors and mistakes when they occur, and feeling empowered and supported to speak up when we see another’s;
• Respecting each other’s professional input and checking our egos at the door so  that we always remain focused on our number one priority – patient safety;
• Continuously evaluating our processes and procedures to identify areas for improvement and then implementing these improvements;
• Engaging patients and families in health care decisions and keeping them informed throughout the course of care;
• Holding people accountable for their work and their actions;
• Learning from errors so that we don’t repeat them.

Health care is a human system, and humans are fallible. There is not and never will be a perfect person or a perfect hospital. The most educated, experienced and well-intended people make mistakes, and the most prestigious health care organizations make medical errors. That is why a culture of safety requires processes and systems that minimize human error.

While it may be impossible to be perfect, we most certainly can be exemplary.

I am proud of the University of Michigan Health System. But, to be a leader in safety, we must demand excellence from ourselves every single day. Because we can never be perfect, we must be resolute in our commitment to continuous improvement. I know that this Health System has what it takes to be the safest hospital in the nation. I call on all of you to engage, to recognize the important role you play and to be more diligent than ever in pursuit of this foremost goal.

U of M searches deep to evaluate QI training for residents

We have talked below about the importance of training residents to improve clinical quality, safety, and efficacy.  Professor Van Harrison, a social scientist at the University of Michigan Health System, is one of several people at that institution who are passionate about this topic.  You would think that this health system, given its leadership position in implementing Lean and its stellar record of clinical improvement, would also be at the top of its game when it comes to such training.

But after spending some time evaluating the institution's 22 training programs, Van and his colleagues found that "the substantial majority of programs did not provide systematic didactic training with project experience."  Further, each program independently decides whether and what types of quality improvement training to provide.  For example, only five programs had a faculty member leading the effort; and only six had formal didactic sessions about quality improvement; and only half the programs had all residents participating in quality improvement training.

Van and friends concluded that there is a need for active institutional involvement to encourage and facilitate the development of such training, and specifically to develop faculty leaders and to share pedagogical materials across all the residency programs.

In a note to me, Van also observed that "here at least, residency program directors interact and learn more from other residency program directors in their specialty at other institutions than from program directors in other specialties within their institution."  He also found that interest and experience in quality improvement varies by specialty.  He reminded me of something I have seen, too, that the published examples of resident training in quality improvement tend to come from Internal Medicine residency programs, while little has been reported for a number of other specialties.  I note that in previous decades, such work might have been more noticeable in departments of anesthesiology, where much of the excellent early work in clinical process improvement took place.

Van's colleague and Lean expert Jack Billi reminded me:

In light of the RRC [Residency Review Committees'] requirements for all residents to be trained in “system based practice” and “practice based learning”, why aren’t more departments doing more training and projects? Insights include: not enough time, no one to teach it, no ready-made training experiences, resident schedules don’t fit with timeframes of ongoing QI work.

I don't think that Van's conclusions are unique to the U of M.  Indeed, many institutions are worse off in this arena than his place.  And the University deserves kudos for taking the time to evaluate these programs and for being honest and open about the current state.   Even that is quite unusual.  As with clinical improvement efforts, modesty and transparency will help things improve much more quickly than if things are covered over.

A software engineer and a surgeon walked into a bar

My fellow soccer referee Dick Williams sent along this note:  "I ran across this and thought of you. You might find it scary that health care is looked up to by a profession for its process improvement."

The "this" to which Dick referred was a keynote address by Edward Kit, founder and CEO of Software Development Technologies (SDT), entitled "What's surgery got to do with improving software practices?" at the ALM Expo 2011 conference.

I wasn't the least bit skeptical about the need for process improvement in the software world.  You just have to consider the experience of many hospitals and doctors with the computer programs that drive clinical and administrative systems to know that there are rampant flaws in many of these products.  (Aside for another day: Should electronic health record (EHR) software be subject to FDA approval?  Isn't that software as much of a medical device as the implements used in an operating room?)

Anyway, I was curious as to what Mr. Kit might have to say, and I found myself watching the whole presentation.  He started with a comparison of surgeon and software engineer personality types.  Showing this chart, he dared the audience to state which profession it described:

He then attributed the following self-description to software engineers:  "We're artists.  We're cowboys. Don't bring anything in that's going to restrict our creative freedom."  Some of us have heard the same thing said about doctors.

After explaining how germ theory was developed by Joseph Lister in the late 1800's.  He first noted how resistant the industry was to his ideas:

 He explained the things Lister did to gain acceptance:

But there was incredibly slow adoption of germ control in operating rooms in the United States.  It was only after the US medical community was embarrassed by their tortuous treatment of President Garfield after he was shot did they adopt the theories that had been around for some time (minute 35 of the video).

Referring to the software industry, he says at minute 36, "We haven't had this moment yet."

It is after this that we start to see additional parallels with process improvement in health care. The slogan for SDT is "real world testing done right." Kit describes going into companies as a consultant to help improve their software process, and he makes clear at minute 43 that doing so requires a commitment of senior leadership.  "If you don't get the senior leaders on board, you're not going to make these kind of changes."

Shortly thereafter, we see his menu for successful improvement in the process of writing software.  My regular readers will see remarkable similarities to the PDCA cycle inherent in Lean process improvement.

And in the parallel needs for both the health care and software industries:

If you cannot see the video, click here.

I really appreciate your hard work

When the son of blogger Anesthesioboist complained of stomach pains, they made a visit to Children's Hospital Boston, where he ultimately had an appendectomy.  You can read the whole story here.

As she reports:

My son never once forgot to say "Thank you" to his caregivers whenever they did something for him. Before I left for the night he even thanked me for bringing him to the hospital. I am grateful for his sweetness, and for the wonderful individuals who saw us through his first major ordeal. We owe them all a debt that I can only repay by trying to be for my patients what they were for us.

Well, that's not quite the whole story.  The final chapter was this note from the little boy to his doctor:

"Appropriate action" from Mt. Ida students and administration

The students of Mt. Ida College, about whom I have written twice before, persist in their habit of littering our fair city as they wait for the shuttle bus to take them to campus.  Here's the scenario:  They arrive at our village center by trolley or bus in plenty of time for their shuttle bus and go to Dunkin Donuts for a take-out cup of coffee.  Their shuttle bus arrives at the assigned parking lot, and the students leave their cups on the sidewalk.  As I picked up and threw the cups away today in the very convenient trash collector (something that is now part of my regular routine),  I noticed that many were partially full.  I am guessing the shuttle bus has a sign saying "no food or drinks permitted" -- probably to avoid littering inside the vehicle.

That these are very clever students is clear.  Look how thoughtfully this cup was balanced on the top of the steel pipe holding one of the parking lot signs.  There is time enough to do that but not to take five steps to dispose of the cup in the trash bin nearby.

I wrote to the Mt. Ida administration about this back in October and received the following note from the vice president for student affairs:

President Carluccio forwarded your blog and email to me. Thank you for bringing the matter to our attention as we take being a good neighbor seriously. We will look further into this and take appropriate action. 

Right.

Food matters to patients, and others!

Thanks to Julia Robarts for reminding us that today is National Registered Dietitian Day; a day to give kudos to the nutrition experts who work to improve the health of the public.

She says:

If you know any RDs (besides me), give them a hug, a high five, or a thumbs up. They deserve it! If you’re curious to see what the career path for an RD looks like, check out this link at the website for the Academy of Nutrition and Dietetics!

This is a great profession, and I always enjoyed getting to know the dedicated young people who participated in our dietetic intern program at BIDMC.  They were engaged and involved with patients and loved to learn and serve (in both senses of the word.)

Stop smiling. It is not good enough.

Ok, call me a sourpuss, or call me a contrarian, but I am put off by the self-satisfaction evident in this graphic in the Boston Globe.  To be fair to the newspaper, its coverage reflects how the story about a reduction in the rate of central line infections was reported by the state Department of Public Health's Bureau of Health Care Quality and Safety.  That report presents data for the period July 1, 2009 through June 30, 2011.

The good news is that the rate of such infections dropped by 24% during that period.  The bad news is inherent in this description:

Central Line Associated Blood Stream Infections (CLABSIs): A central venous catheter (CVC), sometimes known as a central line, is a special type of flexible tube that is placed through the skin into a large vein in a patient’s chest, arm, neck or groin and ends in or close to the heart or one of the major blood vessels. . . . While central venous catheters are considered an essential part of providing critical care, their use also places patients at increased risk for infection. Central line associated blood stream infections (CLABSIs) are serious, costly, and most can be prevented by following accepted practices for inserting and caring for central lines (my emphasis).

A rate of one infection per thousand patient days, while a reduction from the previous period, is not equivalent to "most can be prevented."  According to the story, that rate of infection still represents about 200 cases annually in the state. This article from the Centers for Disease Control attributes a mortality rate of 12 to 25 percent for each infection.  So 200 cases of infections means that somewhere between 24 and 50 people died unnecessarily.  These people are anonymous in the state's report, but every one is someone's mother, father, sister, or brother.

The infuriating aspect of the Globe's chart is the inclusion of a so-called national baseline rate based on data from 2006-2008.  This was clearly prompted by the DPH report saying things like:

All ICU types has standardized infection ratios (SIRs) that were statistically significantly the same or lower than predicted when compared with both state baseline and national rates.

That kind of analysis has no probative value with regard to anything.  We might as well have said that a child's ability to do calculus increases by 100% between 3rd grade and high school -- such was the state of national medical attention to central line infections during the period in which the baseline rates were calculated.

There were a very few exceptions back in the early years of this century.  In January of 2011, it was reported that Peter Pronovost and his colleagues:

developed the checklist nine years ago (my emphasis), along with a training program that attempts to change the culture in hospitals so staff will speak up if patient-safety rules aren't being followed. The checklist ticks off five basic precautions, such as washing hands, to prevent the spread of germs.

The program got its first widespread tryout in Michigan, where Pronovost said 70 percent of the state's hospitals put it into practice starting in 2004.

"Prior to our study, the mortality rates in Michigan and surrounding states were quite similar," the researcher said. Those death rates diverged once Michigan hospitals began using the prevention program.

"It's breathtaking," Pronovost said. "With our program, patients are alive who wouldn't be if they were outside Michigan."

While Peter and his colleagues worked, most hospitals slept easily with the thought that these things happen.  Perhaps they were motivated by the complacency of  knowing that deaths from central line infections were not even considered reportable adverse events.  More likely, they were just doing things by habit.  A doctor once told me, "As residents, we didn't even bother putting on gloves during those procedures.  We did as we were taught by the previous class of residents."

As I have noted, too, such benchmarks are useless as tools in encouraging process improvement.   Catherine Carson, Director, Quality & Patient Safety at Daughters of Charity Health System put it well:

When the goal is zero – as in zero hospital-acquired infections, or falls – why seek a benchmark? A benchmark would then send the message  - that in comparison to X, our current performance level is okay, which is a false message when the goal of harm is zero.  So be careful when reporting benchmarks, because you are sending a message of acceptable performance.

I know that I should praise the Massachusetts hospitals for their progress in this arena.  After all, less is better, and they do deserve credit for making the effort.  But, don't give kudos for beating a standard that is not a standard.   Let's not forget that the only intellectually defensible target in this arena is zero.

Coaching on the field and in the workplace

A friend writes, "It occurred to me that not everyone in the audience for your speeches may associate the term 'coach' with a positive experience."  I was taken aback, knowing the relationships I had with the children I have coached in soccer and with the staff in organizations I have run.  Not that I am a perfect coach by any means, but I know that I go into the job with the intent of creating a meaningful and fun-filled experience that promotes personal growth.

And then, another friend sent me a link to this video.  Much of it is about the relative advantages of spontaneous play versus organized sports for children, but if you start the clip at minute 17, you see the negative effects of bad coaching, leading to the frame presented above:  "70% of kids who play organized sport drop out by 13 citing burnout, exhaustion and the high pressure environment."

Then, I heard a presentation by Rebecca Manley to the board of our local girls soccer league.  She surveyed the girls and found the following themes for positive coaching experiences:

Gave positive feedback, high fives, told me individually that I did a good job;

Did not care about winning or losing, but cared about the quality of play;

Cheered for us;

Great communicator, felt comfortable asking questions;

Made practices and games fun;

Did not yell at us.

A typical verbatim comment:

My favorite coach was my favorite because he was passionate about the game and his players. I felt like I was playing as much for him as for myself because he truly cared about each of us.  He also had the most creative drills, and practice was always fun. He was sure to point out what each player was doing right, and not only when accompanied by constructive criticism, like some coaches do.

The key themes for negative coaching experiences were the following:

Yelled at us a lot;

Did not give encouragement, he couldn't tell when our feelings were hurt;

Did not connect with the players, didn't know my name;

Showed favoritism, playing time was not equal.

A revealing verbatim comment:

My least favorite coach never had a positive attitude, and only told us what we did wrong.  he was only satisfied if we won the game, and during the game would constantly be screaming at the team on the field, which sometimes distracted us.  It was hard because we were constantly being told what to do on the field, so we could never think for ourselves.

If you think, as I do, that the experience children have playing sports has an effect on self-image, growth, the ability to engage in teamwork, and the children's own leadership abilities, you can tie these reactions about interactions with coaches to the potential for success in schools and in the workplace.  I'm not saying that a child who has had bad experiences with coaches in youth sports will end up as a failure, a criminal, or a misanthrope.  I'm just saying that bad coaching represents a missed opportunity to help a child gain skills and perspectives that can carry over into their education and jobs.  In short, why not coach well rather than poorly?

Tovah at 14

This story about Tovah exemplifies that.  She now says, "That season was very meaningful to me."  She elaborated by telling me that my approach to an error she made on the field had taught her a great lesson, one that she was conscious of trying to apply in her personal and professional interactions today. She is now trying to “pay it forward,” offering others the same environment within which to improve.

Let's turn to adult life and specifically to health care, which is especially notable as  a "low praise zone."  Little wonder when you review Linda Pololi's research about the environment among faculty in medical schools. Note the similarity of Linda's conclusions to the comments of the young girl quoted by Rebecca above.

Two fundamental worrisome experiences . . . were a sense of disconnection and having few trusting relationships with colleagues and supervisors.

The system is designed to create barriers at all levels to collaboration and collegiality.
 
No attention was paid to what people were feeling. . . . [T]his refusal to engage them as individuals had a depersonalizing effect. The culture seemed to ignore the qualities that made them able to address human needs and show compassion and sensitivity to others.

We found little indication that medical schools cultivated appreciation of people's efforts. Rather, the focus was on finding fault.

If the training ground of American physicians works against a common sense view of the world, is there any doubt as to why we have such problems in patient care? Clinical and administrative leaders in hospitals must strive to undo the culture that is embedded in these centers of learning and help those who have devoted their lives to alleviating human suffering to start, first, to alleviate their own suffering and sense of loneliness and isolation.

It is an elemental statement about the human condition that we are born to work and play together in teams, but we have to give enough of ourselves to let the filaments connect.  The coach, more than anyone else on the field, has to be most giving.