Friday, November 21, 2014

What's up with the residency programs at St. Elizabeth's?

I've written about the financial difficulties leading to the closure of Quincy Medical Center and have suggested that these almost inevitably resulted from the business model employed by the private equity firm that owns this hospital system.  But are there other somewhat hidden consequences of this style of ownership?  One worth reviewing might be the system's commitment to residency training programs.

St. Elizabeth's Medical Center is the major training hospital within the Steward Health Care System.  How is it doing with regard to the long-standing and clinically important graduate medical education program that resides there?

Not so good.

The ACGME is the governing body that accredits residency programs.  It has a public website on which the status of each program is listed.  As we go through the site, we see the following programmatic problems at St. Elizabeth's in three of its largest training programs.  (The fourth, Anesthesiology, is currently accredited but up for renewal soon.)


Internal Medicine


Getting a warning or probationary designation is a very big deal.  For example, of the 9,527 programs that were ACGME accredited in 2013-2014, only 279 programs (under 3%) received such designations.  Here's the chart:

A warning is serious, but probationary status is applied when the ACGME concludes, following a site visit and review, that a program or sponsoring institution has failed to demonstrate substantial compliance with ACGME requirements. 

What's behind the St. Elizabeth situation? While the details behind these designations are not published, in general, the largest number of such citations come from persistent violations of the ACGME duty hours requirements.  Recall that, several years ago, the ACGME imposed strict limits on the number of hours per week that residents were permitted to work. These rules came about from Congressional pressure and an acknowledgement that it was not healthy for the residents, patients, and members of the public for trainees to get too little sleep (resulting in "impaired neurocognitive performance, including reduced memory consolidation, and deterioration of waking performance marked by increased rates of attentional failures.")

I have a hypothesis that when a hospital like St. Elizabeth's suffers from financial distress, there is an inclination to use residents as low-cost labor (relative to nurse practitioners and physician assistants) and assign them to extra hours of work in taking care of patients.  I'd be happy to have this hypothesis disproved, but that would require disclosure by St. Elizabeth's of the reasons for the warning and probationary ACGME designations.  The hospital is very unlikely to provide that to me!

But is there any inclination on the part of the Attorney General, the state official with authority to monitor the performance of the Steward Health system, to look into this matter?  If residents are, in fact, violating duty hours, there is the potential for harm to the public.  If residents are being assigned to cover the work that would otherwise go to paid staff, is that consistent with the employment promises made during the take-over of the system from its previous owners?

(There is also another possible reason for poor reports from the ACGME--a lack of training opportunities.  For example, if the volume of patients is too low, surgical residents don't get enough cases on which to practice. Might that being going on at St. Elizabeth's, too?)

It is too late to save Quincy Medical Center, but it is not too late for the state to review these matters and intervene.

Lean is not a program

Over two years ago, I wrote a post saying, You don't "do Lean."  Beyond suggesting that there should be a form of medical malpractice lawsuit against those consulting firms that promise hospitals that they will teach them how to "do Lean," I summarized the main point:

Lean is not a program.  It is a long-term philosophy of corporate leadership and organization that is based, above all, on respect shown to front-line staff.  There are two essential aspects, training front-line workers to be empowered and encouraged to call out problems on the "factory floor," and training managers to understand that their job is to serve those front-line workers by knowing what is going on on the front lines and responding in real time (when problems are fresh) to the call-outs.

A recent article by Emmanuel Jallas takes this theme a step further, based on a visit to a manufacturing facility.  Excerpts:

Fake Lean can be very smart. Or rather, I should say convincing at first glance.

I was visiting a facility of a great manufacturer with well known and respected products. I was told by my host, a manager at this facility, that every problem reported by associates is fixed by the team itself within five days, or by the support team under supervision of the facility manager. It all sounds impressive, right?

Maybe not.

While my guide left me alone to go speak with the factory manager, I took five minutes to just watch a team member working in this facility. At the end of this time I had 10 kaizen ideas, least four of which had to do with this person’s safety. She was bending her torso backwards every 20 seconds in order not to hit a screen with her head. She twisted her body 180° several times per minute in order to discard plastic bags in a trash bin which was right behind her. She was raising her shoulder over its normal height because of the length of her screw gun. And so on. Maybe things weren’t going so well after all.

So what is happening in this factory?

Upon further reflection and discussion with its leaders, it occurred to me that Lean was "put in place" here without any consideration for or effort made toward creating a lean culture.

The team member I observed has no chance to speak with leadership about her true problems. Not only this, she hasn’t been helped with how to see and understand them. As a result, she’s focusing less on her work and more on not hitting her head several times per minute.

He summarizes:

Taiichi Ohno was famous for asking managers to "step inside the circle" in order to develop problem- seeing, not just problem solving. Steven J. Spear has written in greater detail about this kind of skill development for managers in "Learning to Lead at Toyota" at Harvard Business Review, but coaching others to help them learn to see problems is really what this lean stuff is all about. No matter how much an organization boasts about their lean practices, or your own company does, it’s this ability to see problems that you really want to be looking for.

Wednesday, November 19, 2014

The die was cast for Quincy Medical Center in 2011

I wish I could say that it was unexpected, but the current story around the closing of Quincy Medical Center in Massachusetts, after its purchase by a private equity company several years ago, was so predictable.  Short version:  The Attorney General is powerless in making the company stand by its original promises.  She can "offer to negotiate" and other elected officials can bluster all they want, but the closure is done.

Here's the original prediction:

So your private equity firm offers to buy the property, making promises to regulators and stakeholders in the community.  Few objections are raised and the deal is approved.  The private equity firm, new to health care, gives an unprecedented level of authority and autonomy to the CEO.  He rewards your confidence by executing the key elements of the business plan.  Assets are sold for short term gain, with little concern for the downstream costs: After all, the hospital properties will be flipped in a few years anyway.  The hospital system's laboratories are sold to a private laboratory service company, in return for a long-term contract to use that company.  Real estate is sold and leased back.  The system agrees to a front-end-loaded risk-based reimbursement contract with the largest private insurer, one that calls for substantial reductions from the trend of medical expenses in future years.  Physician practices in the community are purchased at above-market prices to create an increased flow of referral business to the hospitals. 

But then the money falters.  Revenues take a tumble and days in accounts receivable grow during an extended transition to a new centralized billing system that was designed to take the place of the billing systems run by each hospital.  The risk contract with the insurer starts to limit annual price increases.  Medicare and Medicaid rates are constrained by the federal and state government.  Top line revenues fall, EBIDTA falls, cash flow falls.  Finally, the private equity partners are nervous. 

They turn off the spigot and impose cash constraints on the system.  Normal maintenance of building systems is deferred.  Medical equipment expenses, too, are kept to a minimum.

The only place to save money is on staffing.  He must make dramatic cuts in the upper management levels but will also be forced to make other cuts in the clinical support and lower administrative staff. Band-aid capital spending will be permitted when unsafe conditions exist, but the hospitals will start to fall behind on upgrades of important medical equipment and devices.  He will be in a race against the clock.  Can he hold it together long enough to permit the investors to get a return in the flip?  Finally, he will realize that closing one of the hospitals has to be part of the answer.  Investors will be relieved when he does so, but the community and governmental constituencies that supported the initial acquisition will get worried. 

[It] would be around this time that regulators would begin to understand that the corporate guarantees that might stand behind the private equity firm's acquisition of the hospital system are a nullity.  The owners' resources are legally separated from those of the hospital system.  It would take years of litigation to pierce that corporate veil.  Thus, the commitments that have been made to the governmental and private constituents in the community are supported solely by the financial resources of the hospital system itself.  But that hospital system faces high debt service costs and obligations, other long-term cost commitments, and increasingly difficult revenue restrictions.

One f***ing tree!

Image by Simon Stevens
Thanks to Janice Lynch Schuster for forwarding me this terrific article about stereotypes, in this case visual stereotypes about Africa.  The story is emblematic of our country's lack of understanding of other parts of the world.  I encountered this from friends and colleagues before, during, and after my recent trip to South Africa.  The lede:

Last week, Africa Is a Country, a blog that documents and skewers Western misconceptions of Africa, ran a fascinating story about book design. It posted a collage of 36 covers of books that were either set in Africa or written by African writers. The texts of the books were as diverse as the geography they covered: Nigeria, Zimbabwe, South Africa, Botswana, Zambia, Mozambique. They were written in wildly divergent styles, by writers that included several Nobel Prize winners. Yet all of books’ covers featured an acacia tree, an orange sunset over the veld, or both.

In short,” the post said, “the covers of most novels ‘about Africa’ seem to have been designed by someone whose principal idea of the continent comes from The Lion King.”

Like most Americans, book designers tend not to know all that much about the rest of the world, and since they don’t always have the time to respond to a book on its own terms, they resort to visual clich├ęs. 

The diagnosis:

We’re comfortable with this visual image of Africa because it’s safe. It presents ‘otherness’ in a way that’s easy to understand.   

Change comes slowly. One day, Mendelsund [Peter Mendelsund—who is an associate art director of Knopf] predicts, there will be a best-selling novel by an African writer that happens to use a different visual aesthetic, and its success will introduce a new set of arbitrary images to represent Africa in Western eyes. “But right now, we’re in the age of the tree,” he says. “For that vast continent, in all its diversity, you get that one fucking tree.” 

Millions of healthier lives on WIHI

Madge Kaplan writes:

The next WIHI broadcast — 100 Million Healthier Lives by 2020 — will take place on Thursday, November 20, from 2 to 3 PM ET, and I hope you'll tune in.
Our guests will include:
  • Soma Stout, MD, MS, Executive External Lead for Health Improvement, Institute for Healthcare
    Improvement (IHI)
  • Erin Healy, JD, Director, Knowledge Sharing, Community Solutions
  • Kevin Barnett, DrPH, MCP, Senior Investigator, Public Health Institute
  • Ninon Lewis, MS, Director, Triple Aim for Populations, IHI
Enroll Now

When IHI first introduced the framework of the Triple Aim in 2008, we couldn’t have imagined how much it would resonate with health and health care improvers all over the world. Six years and much on the ground experience later, this pursuit of better experience of care, better health, and lower costs, is taking a new, exciting turn and we want to tell you about these developments on the November 20 WIHI: 100 Million Healthier Lives by 2020.
The title of the show reflects the ambitions and visions of a new Guiding Coalition that was launched this October by IHI and some 30 founding partners with the goal of making a demonstrable improvement in the health of communities on a global scale… starting in the US. One of the driving principles behind the effort  which over 200 individuals and organizations from across public health, community health, health care, policy, and more have already signed on to — is to learn from and support community innovations and initiatives that are right now having an impact on people’s health. Millions stand to gain if what’s effective is better understood and spread. 
But how does change of this sort happen in measurable ways…especially to achieve the goal of improving the health of 100 million people over the next five years? And, how can hospitals and health care organizations not just say they want to support and strengthen community efforts around health, but actually become part of the fabric and infrastructure and two-way learning that makes it possible? That’s where our guests come in. From direct experience, each has a piece of the picture of the steps needed, fueled by the belief that the time has come to put health care and health together in one strategic frame to achieve results on an entirely new level. 
Your thinking and experience and participation in this effort are needed, too! Soma Stout, Erin Healey, Kevin Barnett, Ninon Lewis, and WIHI host Madge Kaplan look forward to engaging with you on the November 20 WIHI. 
You can enroll for the broadcast here. We'd also appreciate it if you would spread the word about the show via Twitter.

Integrating art into patient quality and safety

Well, I discovered a veritable treasure trove of health care quality and safety advocates here in Melbourne, some of whom I have "known" for years on social media and some new encounters.  We all had lunch together, organized by Marie Bismark, and I was brought up to date on some of the things happening here.  I'll just mention a couple for now, with more to follow.

Catherine Crock (seen here with Marie) heads up the Australian Institute for Patient and Family Centred Care.  As noted on their website:

The Australian Institute for Patient & Family Centred Care brings patients, families and healthcare professionals to the table together, to transform people’s experience of healthcare. We aim to achieve this through a three-fold approach:
  1. Develop partnerships between patients, their families and health professionals
  2. Create a culture that is both supportive and effective
  3. Improve healthcare environments through high-quality integrated art, architecture and design.

There are two programs of note that I'd like to share.  One is Hear Me, a 40-minute HealthPlay written by playwright Alan Hopgood.  The play focuses on the importance of patient and family involvement and empowerment as partners in their own health care.  AIPFCC makes the play available to requesting health care institutions and performs it for them.  Catherine notes:

There is enormous potential for improving the quality and safety of healthcare by encouraging communication and partnerships between patients, families and health professionals and fostering an employee empowerment culture. The play can have a significant and novel role in the education of patients, families and staff.

Following the performance, the audience participates in a stimulating facilitated discussion forum (30 minutes), led by a trained facilitator, on team communication, clinical incident disclosure and patient centred care. The forum is a critical component of the play, allowing for debrief, practical application and ideas for change. 

The play has been performed in many locations in Victoria, with excellent reviews.

The other program is called Hush, and comprises a series of musical pieces. Catherine introduced music into The Royal Children's Hospital in Melbourne, to reduce the stress of hospital procedures for the children, Catherine recognised the effectiveness of involving patients and their families in the treatment program.  Now, a large number of CDs (some shown above) are available for people to use in their own settings.

Tuesday, November 18, 2014

Product placement, to a new level

Speaking of Intuitive Surgical, do any of my readers find anything wrong with this announcement?

Intuitive Surgical (Nasdaq:ISRG) has awarded technology grants to five top U.S. medical centers to increase training opportunities in minimally invasive surgical techniques. Dartmouth-Hitchcock Medical Center, Duke University, Oregon Health & Science University (OHSU), University of Texas Southwestern and Washington University School of Medicine in St. Louis will each receive a da Vinci System console and Skills Simulator™ equipment for one year. 

I do.  It's this: The line between academic inquiry and education and commercial strategies has become so blurred as to be meaningless.

A bit like killing a fly with nuclear weapons

Not all publicity is good, even if you are Intuitive Surgical, the publicity-seeking makers of the daVinci robot.  They must go nuts when they see allusions like this about their machine:

The surgeons also plan to remove his gallbladder, full of painful stones, although given the routine nature of that procedure they admit that using the robot is “a bit like killing a fly with nuclear weapons.”

“People accept robotics in their life all the time,” Moser told the Herald ahead of Clauss’ surgery. “We have drones — robots blowing up enemies, robots flying planes."

"Government efficiency" is an oxymoron

I always appreciate and pay attention to the thoughtful observations of Sachin Jain, and this article in the Journal of General Internal Medicine is no exception.  It's called "Big Plans, Poor Execution: The Importance of Governmental Managerial Innovation to Health Care Reform."

Here's the introduction:

The Affordable Care Act (ACA)'s implementation failures including the launch of and delays of several key provisions of the legislation have threatened continued support for the law. At the core of the public's misgivings is trust in whether government agencies can effectively implement programs of importance on massive scale. The ACA rollout has exposed deep flaws in the ways in which federal agencies manage the implementation of legislative efforts. For these reasons, we strongly believe that health policy reform must occur alongside innovation and reform of the managerial processes of the Department of Health and Human Services (HHS) and its constituent agencies. In this paper we draw on experiences implementing significant health care policy legislation to explore the fundamental management challenges that have hampered the implementation of the ACA, and threaten the future viability of government-led health care reform.

The authors go on to itemize the problems:

The first is the overly burdensome and bureaucratic process of soliciting, vetting, and awarding con- tracts. Initially designed as safeguards against kickbacks, regulations have evolved to the point where contracts are awarded to firms with the most experience in navigating the federal procurement process, rather than those with the most experience and skills in the content area.

Second, the operational units within each agency responsible for managing contracts and implementing reforms are too far removed from the procurement process.

Finally, the rigidity encountered early in the contracting process is mirrored in constraints around termination.

These problems are compounded, say the authors, because "federal agencies often struggle to attract and retain appropriate, competitive talent."

After recommending changes, they conclude:

Implementation is the ultimate test of any legislative effort,a difficult reality currently facing the supporters and architects of the ACA. Challenges with the ACA have uncovered fundamental flaws in the federal government's managerial structures for executing complex legislative agendas. If we expect our federal health agencies to take a frontline role in reforming health care, so too must we pay attention to reforming these institutions. 

Well, many of these points are so true, and their impact has been felt over the years in defense and non-defense governmental programs.  (The one with which I would disagree, for the most part, is the one about attracting talented people.)  The recommendations made are thoughtful and appropriate.

But the truth of the matter is that the basic structures underlying federal procurement will not change much.  As noted by the authors, many were designed to prevent corruption: In so doing, Congress made an explicit trade-off between obtaining efficiency and preventing crime. Other federal procurement rules were frankly designed by lobbyists for entrenched government contractors: There is a whole industry of inside-the-Beltway firms that have survived and grown off of federal largess.  Their core competence is influencing the body politic to protect their interests.  Other firms do not have the time or interest to engage in the influence-peddling business and wisely choose to spend their time serving the private sector.

Every well-meaning Administration comes into office thinking that it is going to introduce more "business-like" procedures into the federal government.  Some succeed to a certain extent, but most fail.  It is not an activity that generates public support or political rewards.

So, in my opinion, what is required is a more sophisticated and thoughtful approach to writing the law when you are hoping to invent a new program or policy.  The ACA was an immensely complicated piece of legislation.  Many components relied on having an effective, efficient, and timely procurement plan.  It may have been naive to expect that implementation would be successful.

In addition, whatever problems existed at the procurement regulatory level of the government were aggravated by the fact that the high-level managerial structure, support, and oversight put in place by the President and his Secretary of Health and Human Services were inadequate.  The recommendations contained in this article are thoughtful, but no amount of bureaucratic redesign can survive against incompetent leadership.

Monday, November 17, 2014

Learning from Smart Patients

Roni Zeiger, Gilles Frydman, and colleagues have been successfully plugging away for some time in the development of Smart Patients, "an online community where patients and caregivers learn from each other about treatments, clinical trials, the latest science, and how it all fits into the context of their experience."

A sign of the success is that a growing number of doctors and other clinicians have been asking if they might join Smart Patients to learn what the patients and caregivers are saying.  Roni and Gilles have been designing a way of allowing this but that still is respectful of a strong desire to keep the space devoted to the patients and caregivers.

So now, they are launching Learn from Smart Patients, to create learning materials based on conversations in Smart Patients--but the curated conversations are de-identified and used with patient permission.

Three health care institutions have signed up so far:

The George Washington University School of Nursing is piloting the service with Nurse Practitioner students studying the role of caregivers. 

Physicians at Allegheny Health Network (AHN) will use the new service to better understand the needs of cancer patients. 

At Cincinnati Children’s Hospital Medical Center (CCHMC), clinicians who care for patients and families affected by cystic fibrosis are reviewing and discussing issues that arise in the Smart Patients cystic fibrosis community. 

I'm hoping other centers decide to sign up, as I am really excited to see where this all leads.  I have a feeling it is going to lead to helpful insights and stronger partnerships between clinicians and families--consistent with my hope for more patient-driven care.

Sunday, November 16, 2014

“Deny and defend” has become an indefensible approach to medical error.

Please check out this excellent article by Bruce L. Lambert and Timothy B. McDonald.  Key excerpts:

In our research on communication and resolution approaches to malpractice, patients and families who have been victims of medical errors tell us that without hearing an explanation or apology, every hour that passes after the initial harm event feels like an additional injury.

Fortunately, there is now a viable alternative.

Several hospitals around the country, notably the University of Michigan and the University of Illinois at Chicago, have adopted the so-called communication and resolution approach to unexpected patient harm.

This approach emphasizes rapid reporting of harm events, rapid communication with patients and families, and rapid investigations to identify possible system failures and to determine whether or not the patient was harmed by inappropriate care.

When an investigation reveals inappropriate care, the health professionals who were involved meet with the patient and family, admit liability, describe in detail what happened, apologize and offer emotional support, and maintain contact for ongoing communications.

Depending on the nature and severity of the harm, the hospital will often waive fees and charges related to the care that caused the harm, waive fees for subsequent care to remedy the harm, and offer financial settlements to compensate patients and families for pain and suffering and for the cost of ongoing care — all without litigation.

Research shows that communication and resolution programs have many benefits. Those include fewer claims and lawsuits, increased reporting of near misses and errors, more rapid settlements for patients, lower malpractice insurance costs, lower legal fees and expenses for hospitals, and less defensive medicine being practiced by physicians.

More importantly, telling the truth to patients after they have been harmed by medical errors is the right thing to do. It is more just, equitable, and humane.

It is better for providers too, who are often traumatized by unintentionally harming the people they were trying to heal, and who are prevented from apologizing, and even speaking, to patients and families.

“Deny and defend” has become an indefensible approach to medical error. The time has come to abandon it.

In Katoomba

A weekend break between health care presentations in Sydney and Melbourne: Some views of the Blue Mountains and local flora west of Sydney, Australia.

Thursday, November 13, 2014

If we were on the Serengeti, we would not be the lions.

I have often viewed hospitalists as "the real doctors" in a hospital, people whose inclination, geographic location, and practice patterns allow them to be fully engaged in creating a partnership between the clinical staff and patients and families.  But this view is not always widely adopted by other medical specialties.  Brad Flansbaum offers this essay about the status--perceived and real--of hospitalist doctors vis-a-vis other practitioners in hospitals.  He titles it, "Do I look like a PGY?"

I engaged my team in a short non-scientific exercise. I asked them to plot their impression of how the world at large, defined broadly, views the worth of various specialties versus how they see them.  They assessed the following four disciplines: intensivists, cardiologists, palliative care docs and hospitalists.

He wryly notes:

Do you notice a pattern? If you don’t, let me make it easy: if we were on the Serengeti, we would not be the lions.  

Beyond the humor, there are serious questions raised about the profession:

Now I could speculate about how any specialist might rate themselves and the biases each would bring to the table. I could also speculate proceduralists and physicians engaged in high tech care have deeply embedded cultural advantages in U.S. medicine—and no matter how we spin the story, docs without toys will always drop to the lower rungs of the ladder.

However, I think our station has much to do with our need to mature as a field, and how the public (and HM) views a young, unassimilated specialty.

Many of us still lack confidence. 

An interesting call to arms of sorts for a group of doctors who, in my mind, have shown that they can be at the forefront of clinical process improvement.  Brad's article suggests that more can come, and should come, from this dedicated group.

Wednesday, November 12, 2014

TOP 5 is tops!

As noted below, I've been having a wonderful time meeting with folks at the New South Wales Clinical Excellence Commission.  This is an agency with a broad-ranging agenda to improve the safety and quality of patient based care in Australia's largest state.

The CEC has a slew of initiatives, and I thought I would share one with you from their Partnering with Patients program.  The overall objective of PwP is to include patients and family as care team members to promote safety and quality.

The particular program I present here is called TOP 5.  It is lovely in its simplicity and low cost . . . and in the power of its results. It could be replicated anywhere there is a will. 

The idea is to come up with strategies to help caregivers who are responsible for dealing with people with dementia--and particularly the anxiety and agitation that can characterize this disease in the presence of certain environmental factors.  As described by the CEC, "TOP 5 is a simple process that encourages health professionals to engage with carers to gain non-clinical information to help personalise care. This information is then made available to every member of the care team, thus improving communication."

5 strategies are developed after consultation between staff and the carer to ensure they are workable in the ward setting. The agreed strategies are recorded on an identifiable TOP 5 form and included in the patient's bed chart notes, enabling all staff to access this information and support the care provided. Up to five strategies may be recorded, however, in some cases there may only be one or two relevant strategies.

Dr. Karen Luxford, Director, Patient Based Care, and Anne Axam, the project coordinator, kindly gave me some examples, which I summarize here:

One gentleman had been a paramedic.  All the "bells and whistles" that are typical in a community hospital setting only escalated his anxiety:  He felt he needed to jump into action at a each "emergency." The strategy that was developed was to speak to him as if he were member of the team--using professional terminology--and advise him that "another car is responding." He would then become settled. 

Another example was Mr. G, a very gentle and proud man, who would become very agitated after his shower. "A discussion with his wife helped us learn that he became very upset if he did not have his watch on his wrist. She always made sure it was replaced as soon as possible." The strategy that was developed was that, during his shower, the staff would reassure Mr G that they would put his watch back on after he was dry, and then they would put his watch back on as soon as possible. With his watch on his wrist he did not become agitated. 

A third example.  A gentleman (Bob) without a primary carer was admitted to the service. He used to get very agitated each morning at 4:30 and was very difficult to settle. One day a visitor came into the room and recognised Bob. The staff asked the visitor if he knew anything about Bob that might explain his daily agitation. He was able to shed some light on the situation: Bob used to manage a delivery yard and part of his job was to get the trucks on the road by 4:30am. The strategy adopted was for the staff to just say, "Bob, the trucks are all gone" and he would settle down. 

Beyond this reduction of anxiety, which is reason enough to run the program, I look forward to learning more about the possible clinical benefits of TOP 5.  The program reminds me of a similar approach adopted in Saskatchewan to help avoid falls among the elderly with dementia. One success story involved a 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.

I'm willing to bet that we'll hear similar results from the CEC, and I look forward to their future reports on this program and other initiatives.

Getting acquainted with clinical governance in Sydney

I've been having a wonderful time meeting with folks at the New South Wales Clinical Excellence Commission.  This is an agency with a broad-ranging agenda to improve the safety and quality of patient based care in Australia's largest state.  Today's audience were principally the Directors of Clinical Governance, the people responsible for enhancing clinical care in the 17 local health districts spread across the state.  Also attending was Kim Oates (left), Director of Undergraduate Quality and Safety Education for the CEC.

My primary topic was on leadership approaches that help bring about the cultural change necessary to reduce harm in hospitals, drawing especially on lessons from my book Goal Play!

Following this, we engaged in a negotiation module using one of my favorite exercises, Michael Wheeler's "Win as Much as You Can."  Here you see some reactions of the participants as they experienced relationship changes with some of their colleagues as the game progressed.  It was an important lesson in considering the structure, context, and people engaged in a negotiation, all with an eye to creating sustainable negotiated agreements that can bring value to the parties.

Tuesday, November 11, 2014

Now this is leadership!

Now this is leadership, from the Board of Trustees who approved the plan, to the CEO and his folks who conceived it, to everyone who played a role.  What a model for other hospitals!

The email is from Jeffrey Thompson, CEO of Gundersen Health System in Wisconsin, to everyone in the system.

Dear colleagues:

Today we will make a big announcement about our energy program. We are accomplishing something no one else in healthcare has done. This is really a big deal around the country. This is a common theme for us, but others are amazed. The point of this note is to help you understand the why and the how so it is easier for you to understand how it fits into our mission and easier for you to answer questions.

The accomplishment is we have had several days where we produce more energy than we use. October 14th was the first day that we hit this mark. This means instead of paying millions in natural gas and electric bills we are producing our own. We will extend this to many more days, then weeks, then months. We are using natural gas from landfills and cows, hardwood chips from local sawmills, wind, geothermal wells, and very importantly, conservation.

Why we embarked on this journey has many parts. We believed:
·         it will decrease the pollution we were producing that adds to the health burden of our region and nation,
·         it will save the organization money that can be spent on patient care, staff salaries, or used to keep our prices down,
·         it will boost our local economy, instead of coal from Wyoming (for electricity) and natural gas from Texas ( for heat) – what we do spend  is on local sources
·         it helps define us as an organization, a strong corporate citizen, concerned about the broad health and well-being of our region; both physical and economic health.
Where did the money come from to do all this?  Funding for our conservation projects came out of our regular operating funds. And it was a great bargain. We spent $2 million dollars one time on conservation and reduced our energy costs by $1.2 million every year after; a much better return than any of our personal saving accounts or checkbooks. For other big projects we took money out of savings, not the salary or benefit pool, and used it to invest in these long term projects. Because of our timing and innovation we also received 11 million in state and federal money that would have gone somewhere else in the country if we had not won it.

The effects of this work (in addition to saving money, decreasing pollution and boosting the local economy) has been increased staff pride, enhanced recruiting, community inspiration, as well as national and international recognition for Gundersen and La Crosse.

Has this effort decreased our other important objectives? The best data would say our quality, service, and financial health is as good as it has ever been.

Are we done? Not yet. There is still plenty of waste you can help us decrease. We also have many opportunities to expand our sustainability and waste management programs. Beyond that, it is to help other staff and other communities understand, that a great healthcare organization needs to take care of patients, their families, and our whole community, and that is what we are trying to do every day .

Thanks for your help to make us better, and to help lead our communities.

Pause to remember

As we celebrate Veteran's Day in the US and Remembrance Day in the Commonwealth nations, I recall being in Toronto on this date a few years ago.  A report on the radio noted that at 11am on November 11, the demand for electric power in the province suddenly dropped by 350 megawatts as people stopped using their computers, their washing machines, many industrial machines, and other power-draining activities for a few minutes of silence and contemplation.  The announcer pointed out that this was an amount of power sufficient to serve the entire city of Burlington, Ontario!

Fantastic Voyage is showing in New South Wales

Dr. John McGhee is a researcher and senior lecturer based at UNSW Art & Design. Here you see him taking a virtual voyage through an artery, twisting and turning as he goes through to look for plaque that has been created and watching pieces break off like ice calves from a glacier.

John's passion is to take real data generated from patients and create a three-dimensional dynamic representation that can be viewed by the patients and their families.  He brings to this the kind of techniques that are used in computerized gaming, but his purpose is to allow patients to examine inside of their own body, created from their own radiological images.  This visualization will help them better understand what is happening in their bodies.

The current experiments involve stroke patients.  With the patient's neurologist, John is able to help instruct the patient and family as to the nature of their disease--much more so so than is possible  by viewing the images as CT or MRI slices on the wall. He hoping this visualization "will be a normal thing to request when you go to get feedback on your scan."

I view this technique as an opportunity not only for a patient's understanding, but also for a closer partnership with the doctor.  The virtual reality view is such that he doctor and patient can jointly examine the patient's blood vessels, discussing together what they see and the diagnositic and therapuetic implications.

Here's a video.

There are possible applications beyond strokes, including GI and other imaging.  John is looking for collaborators from other clinical settings around the world, and he is also searching for funding to expand the scope of  his research.

Sunday, November 09, 2014

Making time for griefwork

All kinds of cross-connections become evident as you work with people to try to improve the quality and safety of patient care, as we seek to eliminate preventable harm.  But I never expected a psychiatrist's book about combat trauma to offer an insight.  The book (recommended by Budd Shenkin), is Jonathan Shay's Achilles in Vietnam, Combat Trauma and the Undoing of Character.  And a powerful book it is, a must-read to understand the devastating long-term impact on personality that can result from wartime situations.

The first section of the book deals with the impact on troops when their commander betrays the trust of his troops.  The context:

The mortal dependence of the modern soldier on the military organization for everything he needs to survive is as great as that of a small child on his or her parents.  No single English word takes in the whole sweep of a culture's definition of right and wrong; we use terms such as moral order, convention, normative expectations, ethics, and commonly understood social values.  The ancient Greek word that Homer used, themis, encompasses all these meanings.

When a leader destroys the legitimacy of the army's moral order by betraying "what's right," he inflicts manifold injuries on his men.

I don't mean to minimize in any way Shay's application of this concept to the battlefield, but as I read it, I saw an analogy to health care.  Let's see if you appreciate and agree with my extension of the concept.

At our Telluride Patient Safety Camp, it is not uncommon to see evidence of trauma in the faces and stories of our residents and medical students.  A common theme is that they had witnessed a senior physician engaging in a practice that harmed a patient, followed by (at best) a lack of disclosure and (at worst) a lack of acknowledgment that such harm had actually occurred.  The young doctor's shock is exacerbated by the feeling of guilt that he or she had not intervened in the procedure to stop the harm from taking place.  Whether or not the resident had been required to participate directly in the actions being taken or was simply observing was not necessarily germane to the reaction.

What has happened? An idealist young doctor, who only recently had solemnly taken the Hippocratic Oath to "do not harm" at the behest of senior educators, was witnessing a betrayal of "what's right."  This observation is a searing experience. Combined with a feeling of powerlessness to intervene, to use Shay's words, the event "taints the lives of those who survive it."

Each resident or student who has the experience reacts and behaves in a different way afterwards, employing his or her own coping mechanism.  The damage often remains in the form of guilt.  For the vast majority, I suggest, the trauma teaches them a very, very bad lesson:  "Hide your mistakes.  Rationalize them away.  In any event, never acknowledge or disclose to the patients and family members."

The whole effect is compounded by another aspect of such events, the silence that surrounds them. Shay explains:

There is a growing consensus among people that treat PTSD that any trauma, be it loss of family in a natural disaster, rape, exposure to the dead and mutilated in an industrial catastrophe, or combat itself, will have longer-lasting and more serious consequences if there has been no opportunity to talk about the traumatic event and those involved in it, or to experience the presence of socially connected others who will not let one go through it alone.

Griefwork encompasses the whole range of formal and informal social exchanges that soldiers at Troy and Vietnam practiced after a death.

We have seen evidence of the power of such griefwork at Telluride.  Those of us who were present on one session's first day, June 11, 2013, will never forget Michelle Espinoza's story, when she related witnessing a serious medical error in the treatment of an obstetric patient, with the resulting death of the baby. To make it worse for Michelle, she realized the error was occurring as it took place but felt that she, as a trainee, could not intervene.  That trauma, in the form of guilt, had lived with her for months.

As she told the story to the residents and faculty, the group's engagement and empathy were highly evident, from the shared tears to the incredibly supportive comments from all in the room.  Equally evident was gratitude on the part of other young doctors that Michelle had shared her story.  She was not alone in her experience:  Similar stories from other trainees began to flow.

What was the effect of this?  A reaffirmation for Michelle and the others that they could go on and pursue their dreams, consistent with their Hippocratic Oath.  Here are her words:

Today’s experience was life changing. Today it was reaffirmed to me why I had decided to make medicine my vocation. You see for me, Medicine is not just a career, it is a God-anointed life calling. To be here in Telluride is truly a blessing, and to be surrounded by such knowledge, talent, wisdom and passion is AMAZING.

Today I learned that I am not alone in thinking our hospitals are one of the most dangerous places for patients. That my internal conflict regarding my concerns for residency training is not isolated to my hospital, and that there are people who not only believe this is wrong, but have dedicated their lives to making a change. It’s divinely inspiring and I can’t wait to see what the rest of the week brings.

Let's consider the generalizable lesson.  Our society selects the most well-intentioned young people to be physicians, and we invest years of effort and huge financial resources in their training.  We then expose them to betrayal and trauma when their leaders and mentors fail to acknowledge the harm that is being meted out to patients and families. We follow this betrayal with silence, rather than empathy and support.  We leave no time for griefwork.

As Linda Pololi notes, this destructive behavior not only occurs in clinical settings.  It is endemic to the environment of medical schools themselves:

Our data show that the way medical schools are structured and the norms of behavior among faculty can create huge barriers to effective relationship formation . . . a medical school environment that could at times negatively impact patients and our system of health care as a whole.

There is a parallel between disconnection and emotional detachment among medical school faculty and ineffective communication between doctor and patient.

Research shows that physicians remember for decades mistakes they have made, feeling guilty and humiliated and isolated in their shame. Only by creating transparency, so they can discuss mistakes openly, can these destructive feelings be relieved. Equally important, open discussion enables the physician and others to learn from these mistakes and prevent them from recurring.

A similar call for griefwork was offered by a young doctor, Pranay Sinha, in a recent op-ed:

We need to be able to voice these doubts and fears. We need to be able to talk about the sadness of that first death certificate we signed, the mortification at the first incorrect prescription we ordered. . . . . A medical culture that encourages us to share these vulnerabilities could help us realize that we are not alone and find comfort and increased connection with our peers.

Often overlooked in discussions of the Hippocratic Oath is its imperative to teach.  In that regard, let's consider that Shay's work reinforces an observation I made a few years ago:

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.

Time to pass the baton

As this excellent summary by Robert Weisman and Scott Allen in the Boston Globe reveals, the basis for and the content of the proposed deal between the Attorney General and Partners Healthcare System are deeply flawed. 

A deal that once seemed almost a foregone conclusion [has turned] into one of the most contentious and closely watched hospital expansion pushes in the country.

Suffolk Superior Court Judge Janet L. Sanders, who will hold a hearing on the proposed expansion on Monday, said she’s never seen so much opposition to a negotiated agreement.

Given that the two proponents of the deal, the AG and the CEO of Partners, are both stepping down from their jobs, isn't withdrawing the deal the gracious thing to do?  Let their successors start over again and come up with something in the public interest.

It's a stupid rule. Well, no.

I serve as a mentor to our league's youth referees and get to watch a lot of little kids' games.  At one of yesterday's 3rd grade games, I noticed that one coach was hanging around the goal area, giving constant instructions to his team's goalie.  I went to the other coach of this team, who was on the sidelines in the appropriate place, and asked him to get the other one to move back to the sidelines.  He said, "Would you please tell him?" implying that he had failed in that task.

So I did so, and the coach gave me a very hard time.  "How can you expect the girl to learn if I am not there to explain things to her?"

I said, "You do that during practices.  She'll learn the rest by playing and thinking."

"That's stupid," he said, "This is a developmental program and she needs to be told what to do."

I said, "Well, actually no."

He said, "It makes more sense for me to do it from here rather than yelling from 30 yards away."

I said, "That's not such a good approach either."

"Well, if you tell me it's a league rule, I'll move, but it is a stupid rule."

He moved off, and guess what?  The little girl did just fine on her own.

The Dutch, who are excellent youth development instructors, often put it this way: "Let the game teach the game."

Kwan's messages from Liberia

Ebola is already off the front pages in American newspapers, consistent with the media's fifteen-minutes-of-coverage pattern, but the disease continues in force elsewhere.  Here's an excellent blog with front-line observations by Kwan Kew called Ebola in Liberia. An excerpt:

Seventeen-month-old Jackson, son of Fatu, spiked a fever and was readmitted to Suspected Ward to test for Ebola.  He was initially tested negative but was brought into the Confirmed Ward to be with his mother while waiting for a suitable caretaker.  Then Comfort, a nurse’s aide who recovered from Ebola a few weeks ago, cared for him until last night when he spiked a fever.  We retested him today and unfortunately he is now positive.

Fatu’s three-year-old Theresa, who had one of the highest Ebola titers in the county, died this morning, curled up in bed and her face puffy beyond recognition.  All morning long Fatu lying in the next bed did not realize her child was dead.  Struggling with bloody diarrhea and profound weakness, she barely could take care of herself. 

At the end of our morning round we approached her with the psychosocial nurse to let her know that her daughter had died.  At first there was disbelief in her eyes then despair, she quickly and fleetingly glanced at her daughter in the next bed.  Confirming the truth, she was overtaken with grief, her face dissolved into expressions of pain and deep sorrow, but she shed no tears.  We gently asked whether she wanted to touch her child, she shook her head.  At home news and images of people afflicted by Ebola often moved me to tears so much so that I knew I had to be here.  Seeing Fatu struggling with her loss this morning, for the first time since I came here, tears filled my eyes.  Grateful that no one could see my tears behind my goggles, they just innocuously mingled with my sweats.  As a mother I felt her deepest loss.

Because of the large number of sick patients in the ETU, I stayed again for close to three hours.  When finally my gloves were peeled off, my hands looked macerated as though they had been immersed in water for a long time.  Indeed they were, bathed in my own sweats. 

As if echoing the full moon, the Confirmed Ward was full by the end of the day.

Saturday, November 08, 2014

End of season rituals

I've come to hate this point in the soccer season, when we take a break after playing and working hard together with the 12-year-olds.  They've come a long way and have bonded to become a real team. The individual and collective development and growth is real and visible to all.  Being with them is the highlight of my week, and now I have to wait over four months till we start up again.

Good ending, though, winning 4-2 in a rubber match against the top team in our section.  Then, the required pizza party and this nice thank-you card.  Also shown above, our midseason ice cream party on a warmer day--my reward to the girls for a goal scored on a volley!

Words from the Southern Hemisphere

As a result of some recent presentations I made in Johannesburg, I was invited to submit a commentary piece to the widely read Mail and Guardian in South Africa.  Please take a look (and please ignore the typos).  The lede:

With the progress in the delivery of healthcare over the past several decades, one wonders where the next advances will arise. Will it be a new series of drugs developed by scientists and pharmaceutical companies? Will it be new generations of medical devices? Will it be a better understanding of the genetic determinants of disease? 

Certainly all of the above are likely to occur, but each comes with a high cost: years of research and employment of hi-tech approaches will necessarily require that corporations invest in, and protect, their intellectual property rights.  

But there is a hidden gem of intervention in the healthcare system that requires little or no investment, and little or no technological advancement, but has the potential to save more lives than most of the drugs and medical devices that will come to the market over the coming decade. That this intervention remains largely untapped results in the premature death of hundreds of thousands of people around the world.

What can this “miracle drug” be? Well, it is no miracle. Rather, it’s reorganising the way in which hospitals provide quality care . . .

Many people are harmed in hospitals or die from preventable medical errors. I do not refer to the occasional explicit error made by a surgeon during a complicated operation. I refer instead to the insidious presence of infections, missed test results and other similar events that occur in hospitals.  These do not happen out of negligence: rather they result from the manner in which work is organised in hospitals.

Friday, November 07, 2014

In memoriam: John Winthrop Sears

John Sears died this week, appropriately, on Election Day.  Appropriately, because he was a great public servant who held elective office and ran for other positions during his life.  He defined himself as "an old-fashioned, center-fielding Republican," and that's a good summary.

I loved spending time with John.  He was as public-spirited as anybody, a great conversationalist, and one of the last of the old New England "Yankees" to serve in public office.

On February 23, 1996, I interviewed him for a paper I was working on about the Metropolitan District Commission, the first great regional government agency in America, which used to run the Boston metropolitan area water and sewer system as well as an assortment of parks, parkways, and recreational facilities like swimming pools and skating rinks.  He was Commissioner of the agency from 1970-1975.  I wanted to learn how it had fallen from its glory days to a patronage-ridden embarrassment.

We sat in his book and newspaper strewn apartment at 7 Acorn Street on Beacon Hill. His observations included the following:

The [former] MDC commissioners were fairly hefty folk.  Hultman -- I think Hultman and Greenough were the two greats of us -- and Hultman built the aqueducts and sort of finished Quabbin [Reservoir]; and Charles Greenough was the great park MDC commissioner -- more of a road builder, a parkway builder.  But I think the agency was seriously politicized. The Yankee legislatures who came up to about 1956, who tended to be Republican, were unimaginative, reluctant to spend, but they weren't successfully corrupt.  They were succeeded by this flow of colorful folk who were willing to spend, but also wanted to send you a schedule.*  We got an annual list from the Ways and Means Committee of people to hire.

Q. Not just positions, you mean people?

Not just positions, people, names.  Micromanaging in the most awful way.  I resisted that, and caused a lot of trouble.  I even fired some people, and it took me two years to work that out.  When we had put the two zoo societies together -- this is a good sort of parable of what went wrong at the MDC -- I told the brand new Boston Zoological Society that they could go and find a good zoo director, and I would hire him or her and put the new director on the MDC payroll.  Well, all hell broke loose.

First, there was a painter foreman who said that he had seniority.  I carried out my part.  But they really went down kicking and screaming.  There are scars all over me from trying to work down through the politicization at every level in the MDC.

The intrusions of Michael Paul Feeney.   He was the dean of the House.  A charming man. We had a good relationship, but if there was ever a spare dollar, suddenly it would have a use attached to it.  [As a result,] there were something like eight little playgrounds in Hyde Park. It took a certain sense of humor and a certain amount of mischief in order to work one's way through some of this.

The MDC, at that date, was quite like a big, helpless giant.  It was the Corps of Engineers on the Massachusetts scale. Every legislator felt they could send us their nephews and then send us instructions to build a park or a pumping station.  Joe DiCarlo put a pumping station in Beechmont, which is still there, which pumps against the Atlantic Ocean. That's an unequal match, if I may say so.

There was a political engineering firm named Maguire, C. E. Maguire, and anytime Maguire ran a little short of work, all of a sudden the wheels would spin and orders would come over to do some real majestic engineering thing.

Speaker McGee.  We hired a terrific young veterinarian for the zoo.  He  said, "None of your animals are going to breed eating this rancid horsemeat that you're feeding them out there." I said, "Well of course, doctor, tell us what we should buy and we'll buy it." The Speaker of the Massachusetts legislature called me up and said that if we did not go on buying my horsemeat from West Lynn Creamery that he would do a number on our budget.

I said, "Tom, you know I'm going to do what the good doctor tells me, and I don't care at all where we buy it from.  If your friends in West Lynn would franchise this food the doctor says is better, I'll buy it from them gladly." he said, "To hell with you" -- and that isn't all he said -- and he took the salary of a little lady who had been in the sewer division for about 30 years and ravaged it in the budget.  He knew that was how to hurt me.  We managed to save her and put her in the construction division.

[This kind of interference] took a lot of time and patience to cope with.

 * A "schedule" was the list of approved jobs included in the yearly appropriation bill.

Wednesday, November 05, 2014

EHRs and safety on WIHI

Madge Kaplan writes:

The next WIHI broadcast — Optimizing Safety with the Electronic Health Record: The Latest on Glitches and Fixes from the Frontlines — will take place on Thursday, November 6, from 2 to 3 PM ET, and I hope you'll tune in.
Our guests will include:
  • David Classen, MD, CMIO, Pascal Metrics; Associate Professor of Medicine and Consultant in Infectious Diseases, University of Utah School of Medicine
  • Frank Federico, RPh, Executive Director, Strategic Partners, Institute for Healthcare Improvement
  • Ann Bisantz, PhD, Professor and Chair, Industrial and Systems Engineering, University at Buffalo, The State University of New York
Enroll Now
As the implementation of electronic health records (EHR) increases across health care, so has awareness of new patient safety risks that the technology has either introduced or exposed. The very same EHR being counted on to improve communication, safety, and continuity of care across multiple settings and providers turns out to have features that can have the opposite effect. Getting a good handle on where the vulnerabilities lie is the first step toward coming up with solutions, which is why we hope you’ll join us for the November 6 WIHI: Optimizing Safety with the EHR: The Latest on Glitches and Fixes from the Frontlines.

The list of problems is growing, but some of the most prominent concerns include EHR systems that generate so many online warnings that clinicians and staff complain of “alert fatigue” and have come up with workarounds to avoid them. To save time, practitioners have also developed the habit of updating a patient’s EHR with a lot of copying and pasting, often forwarding medical information that no one has recently reviewed and that may contain inaccuracies. Computer programs that allow doctors to open up and work on multiple electronic patient records at the same time is another accident waiting to happen, according to some. When combined with being interrupted or distracted, it’s not hard to imagine all the mix-ups that can and do occur.

Guests on the November 6 WIHI have a lot to contribute to our discussion. Dr. David Classen is nationally renowned for his work on safety and is one of the lead authors of a 2011 Institute of Medicine report on health IT and patient safety. Among other things, the report speaks to the need to understand new electronic tools in the context of a “larger sociotechnical system that also includes people  such as clinicians and patients — organizations, processes, and the external environment.” David will be joined by Ann Bisantz, who brings a human factors lens to our topic, crucial to analyzing how health care providers are being challenged by the EHR and health IT today and the need to develop habits consistent with safety goals and best care. IHI’s Frank Federico has been looking hard at the unintended consequences of a number of new health care technologies, including the EHR, and will work with WIHI host, Madge Kaplan, to guide our discussion.

We’re in the middle of a learning curve to ensure the EHR doesn’t bring new harm to patients and facilitates, rather than disrupts, an organization’s reliable processes and patient safety culture. I hope you will join us on November 6.

You can enroll for the broadcast here. We'd also appreciate it if you would spread the word about the show via Twitter.