Thursday, October 08, 2015

Shared baselines as a guide to protocols

There have been some interesting and important discussions flying across the web in recent days on the issue of protocols in helping to reduce variation and reduce the incidence of harm to patients.  My mistake in the debate was assuming that medical leaders would be reasonable about how protocols should and should not be used.

A doctor friend, highly committed to patient safety, notes:

My point about the protocols is that I have been chastised for not following them in situations where it was blatantly obvious that they did not apply. ("The protocol is there for a reason.")

The chastisement comes not from hospital administrators, but from clinician leaders in the doctor's own department:

We just got another email scolding us for not following the "colorectal pathway" sufficiently. One of the provisions of that pathway, for example, is strict limitation of iv fluids, sometimes difficult to "comply" when patients are severely dehydrated from their bowel preps, particularly the elderly.

The initial goals were to decrease opiate use and decrease PACU LOS, both worthy goals, but we're all annoyed at being beaten over the head with them and getting our hands slapped if we deviate, even with good reason.

It's ironic that on the one hand we are extolling the virtues of gene-based individualized therapies, but on the other hand we are trying to pigeonhole every patient into a standardized protocol. 

This is disappointing in so many ways, but especially because the solution is in the hands of the profession.  Brent James discussed the sensible application of protocols to clinical process improvement, as employed in the Intermountain Health system, several years ago:

The concept of “shared baselines” came to rule:

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

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

I guess my friend's experience is one example of the Law of Unintended Consequences.  I think the rigid approach being employed in that doctor's hospital and elsewhere is the result of little or no training in clinical process improvement in medical schools and in graduate medical education. We have often been told by residents, during our Telluride patient safety workshops, that they get more exposure to matters of clinical process improvement and high reliability systems in four days than in their seven previous years of medical training.

Brent expressed hope back in 2011:

Brent is optimistic because he has seen this philosophy of learning how to improve patient care extend to more and more doctors and hospitals around the country.  He views it as providing the answer to the rising cost of care, and he is excited about the potential.  He concludes that this is a “glorious time” to be in medicine because it is the “first time in 100 years” that doctors have a chance to institute fundamental change in the practice of medicine.

Thus far, such change only exists in certain islands of excellence, and it clearly takes energy and thoughtfulness to sustain it even in those places.

Tuesday, October 06, 2015

An error about mistakes

There are few neurologists I admire more than Martin Samuels, chief of service at Brigham and Women's Hospital in Boston.  So it truly pains me to see him engaging in a convoluted approach to the issue of mistakes.  Read the whole thing and then come back and see what you think about the excerpts I've chosen:

The current medical culture is obsessed with perfect replication and avoidance of error. This stemmed from the 1999 alarmist report of the National Academy of Medicine, entitled “To Err is Human,” in which the absurd conclusion was propagated that more patients died from medical errors than from breast cancer, heart disease and stroke combined; now updated by The National Academy of Medicine’s (formerly the IOM) new white paper on the epidemic of diagnostic error.

No, the obsession, if there is an obsession, is not about perfect replication and avoidance of error.  The focus is on determining the causes of preventable harm and applying the scientific method to design experiments to obviate the causes.  The plan is, to the extent practicable, implement strategies to help avoid such harm.

[T]here is actually no convincing evidence that studying these mistakes and using various contrivances to focus on them, reduces their frequency whatsoever.

Yes, there is convincing evidence (from Peter Pronovost's work on central line protocols, for example) that the frequency of errors that lead to preventable harm can be dramatically, and sustainably, reduced.

For example, there is absolutely no reason to believe that a comprehensive medical record will reduce the frequency of cognitive errors, whereas it is evident that efforts to populate this type of record can remove the doctor’s focus from the patient and place it on the device.  

Well, here's one place we agree! EHRs might actually increase the chance of cognitive errors. But why would you pick that one example, Martin?

We all try to avoid errors but none of us will succeed. This is fortunate as errors are the only road to progress. Focusing on the evil of errors takes our attention away from the real enemy, which is illness. We should relax and enjoy the fact that we are lucky enough to be doctors. 

There are errors that lead to progress and there are errors that lead to death and other harm. The flaw in Martin's article is not so much what he says, as the extrapolation he makes from what he says.  A friend sent me a note summarizing the case nicely:

While I agree that we’ll probably never achieve zero errors in healthcare for a number of valid reasons, there is ample evidence that a systematic approach based on the scientific method can significantly reduce harm to patients.  Yet, there is no reference to the great work done by so many of his colleagues, e.g., Peter Pronovost, Lucian Leape, Donald Berwick, John Toussaint, Robert Wachter and Gary Kaplan, just to name a few.  Nor is there any empathy toward the patient and the impact of avoidable harm on his or her life

Monday, October 05, 2015

"Protocols are for nurses."

Every now and then you hear something so dramatically stupid that you have to wonder.

One such example was a couple years back, when someone said: "I only text on the highway."

The latest example comes from a resident who was being "trained" by an attending doctor.  The resident was about to administer a drug using the protocol developed by that hospital's clinical department--one based on evidence produced as a result of systematic clinical evaluations.

The attending doctor interrupted the trainee and said, "Don't do it that way. I've been a doing this for over 20 years, and that way is stupid."

The resident replied, "But I've been told that this is the protocol."

The rejoinder, "Protocols are for nurses. Do it the way I say."

Which is worse, the pedagogy that has been employed or the practice of medicine that is being carried out?

After several years of participating in resident quality and safety workshops, I can report that we hear stories about this kind of thing quite often. Each time, the resident is put in an untenable position. Each time, a patient is put in jeopardy.

Sunday, October 04, 2015

Marty teaches about mathematics and learning

My buddy Sam came home from back-to-school night at Wellesley Middle School inspired by his son's math teacher, Marty Wagner.  He related Marty's message to the parents, that mathematics is about taking risks and making mistakes.  He said, "If your kids aren't frustrated when they come home, I'm not doing my job."

In my undergraduate days at MIT, an esteemed mathematician named Gian Carlo Rota taught freshman calculus and put it this way when we were having trouble grasping a new concept: “Learning is overcoming your prejudices.” He understood that people are not really good at getting past their old frameworks of viewing things and in so doing have to work through the discomfort of adopting a new view of a topic.

Afterwards, you experience the joy and satisfaction of having learned the new item and find yourself on a new plane. At that point, as noted by Cynthia Copeland Lewis, "As soon as you understand 2 x 4 you can't believe there was a time when you didn't understand it."

A key attribute of a good teacher is to have sufficient empathy with his or her students to understand where they are in the learning cycle--the initial interest, the distress of overcoming prior conceptions, and the pleasure of success.  In an email Marty sent to parents many years ago, he displayed that empathy and helped the parents understand how he was trying to teach their children.

We did do a lot of cross-country skiing this vacation, but having two pre-adolescent boys means that we also did a lot of downhill skiing. At this point it is clear that my two boys (9 and 11) are definitely better skiers than I. They kept going through the glades on ungroomed and extremely bumpy trails, in and out of trees, and kept pushing me to do the same thing. I would have been perfectly happy to stay on nice, groomed, cruising trails.

 Frankly, it's hard for me to get over the fear of falling. I don't like to put myself in a position where I might fall.

I think that many 7th graders are in a similar position. They are being asked to accomplish more than they think they can. There is more content, more homework, more tests, more new thinking than they feel comfortable with. As a teacher, my job is to push students to go down the hill, support them when they fall, and tell them that they need to go right back and do it again.

After skiing this week, I can really appreciate how scary that is. I have extra respect for the courage of students who do fall-- who can't quite figure out the homework, or maybe even get failing scores on tests, but then come right back, get help when needed, and figure out what they need to know to do well on their next test or quiz. 

We can expand on Marty's construct to the corporate and institutional environment.  If a key job of a leader is to help his or her place become a learning organization, a full understanding of the stages of learning is essential.  The key attribute of the leader, then, is to have sufficient empathy to understand where his charges are in the learning cycle. He or she can then adopt strategies that will help them move to the next stage, both individually and collectively.

Thursday, October 01, 2015

Two books

I'm often asked to read books and post reviews here, and I thus find my bookshelf overly full.  I just can't get to them all.  (Indeed, I just donated a few dozen books--some read and some never opened--to one of our local hospital management degree programs!)

I recently received two requests, and frankly, I was hesitant.  For one thing, I am friendly (in the internet virtual kind of way) with the authors, and when friendship is involved little good can come of an honest review. For another, the topics were troublesome and likely to be a bit timeworn--yet another book styled as a guide to personal health and yet another autobiography about the trials and tribulations of being a doctor.

Well, what a relief!  They are both very good, and I am pleased to recommend them to you.

An Illustrated Guide to Personal Health

Tom Emerick and Robert Woods, with some important help from illustrator Madi Schmidt, offer 40 common sense steps to improving your health.  Don't worry.  You don't have to adopt all 40, but you might like to.  As the authors note:

Alas, medical care can really only deal with about 20 to 25 percent of the things that cause you to die before your time.  The remaining 75 to 80 percent [other than genetics] of health risks come from . . . factors . . . you alone can control.

With good humor the authors warn:

As you read this book, you will see a lot of repetitive redundancy, over and over.  Why? We are trying to inculcate you with certain principles.

Much of what we have written here is documented science.

Some of what we wrote here is less science than a merger of philosophy and personal observations.

And then the final disclosure:

Some people do almost everything wrong their entire lives, and we mean everything, and live to be age ninety. 

I'll let some of the chapter headings titillate your interest. To find out more, buy the book. Don't worry.  It's short.

Avoid Hand Dryers in Public Restrooms

Avoid Antibacterial Soaps and Gels

Let Kids Play in Dirt

Don't Take Multivitamins

Envy is a Killer

Brush and Floss Your Teeth Regularly

Retirement Can be Bad for Your Health

Medicine Man, Memoir of a Cancer Physician

As first glance, Peter Kennedy is the stereotypical overly intelligent young man who dives into his medical school textbooks to learn everything so he will never face the possibility of not knowing something important that he might face in the classroom or the clinic.  There not much hint of emotional intelligence as we read that chapter.  Later, too, we see his impatience with colleagues, administrators, and regulations, and we are set on believing that he is overly hard-driving and arrogant.

Why on earth would we consider his life to be interesting? Simply, because we watch him grow as a human being and as a doctor.

It turns out that this fellow is deeply dedicated to his patients. We like to talk about patient-centeredness today, as though it is a new concept.  Decades ago, Peter walked the walk, sometimes literally.  Here are some excerpts from his fellowship period:

The work [of taking care of indigent patient's in the Ben Taub cancer service] was long and rarely exciting.  On those occasions where I couldn't quite understand a patient's difficulty with immediate family or home issues, I ventured into the Fifth Ward (Houston's ghetto district) to visit patients at night in their homes. It was plain stupid to go alone. I had seen hundreds of the wounded from that region, more than enough to make me wary, but I was never approached or threatened on those visits.  It was at those times that the total impact of a patient's journey to improvement or death upon his family became reality to me.

As I talked with patient and family . . . I felt something in the room change. And as I explained a mother's medical status, her husband, her children, and any extended family present would calm down and give me all their attention.  Some of the free-floating anxiety, and the suspicion and wariness about a physician in their home at nine p.m. began to dissipate.

I pushed past my own hesitation a little further.  Patient and family were presented with a gentle reboot of sorts, a statement of data rather than information mixed with hysteria or bias. . . . They became active participants in their own disease and its treatment.

[He'd say:]

"When I am sure you understand all of this, and you must try very hard to do so, we'll talk about what can be done to reverse, stop, or cure this cancer.  I'll tell you about treatment, warts and all.  Nothing will be held back"

"Then we'll use this information to decide what we as a team think is best."

And then Peter offers this confession to the reader:

As I became more deeply involved in it, I began to impart a quality I did not know I had--true empathy.

I had been trained originally to use evasion and misdirection as tools to maintain hope. 

It is unusual for an author to display the vulnerability that Peter offers, not just on these clinical matters, but with regard to his personal life.  (I'll leave those sections to you.)  His story is a compelling one. It is a privilege to be asked to read it. I am pleased to recommend the book to medical students, clinicians, administrators, and patients.

Wednesday, September 30, 2015

Building resiliency

What's the secret of building resiliency, the ability to withstand unexpected challenges, into your organization?  Lots of leaders I know take this attitude: "When the crunch comes, we'll deal with it. I'll explain that we have a burning platform, and the team will respond."

Well, yes, they will, but to the extent that you succeed in handling the crisis?  If so, will the team respond in a way that creates the potential for future success, or will the effort just get you through the crisis?

A recent story [subscription required] in the UK Health Service Journal shows what happens when an administrative fiat is issued to deal with a budget shortfall.  Excerpts:

The financial ‘stretch targets’ and emergency measures imposed by NHS regulators will fail to make significant inroads into the total provider sector deficit, analysis by HSJ reveals.

Providers had forecast a combined year-end deficit of £2.1bn at the start of 2015-16, which prompted Monitor and the NHS Trust Development Authority to order them to revisit their financial plans for the year in August.

Emergency measures were announced, such as a recruitment freeze for non-clinical roles, while many trusts were asked to work to new stretch targets or control totals.

[HSJ[ findings revealed that at least 13 of these organisations were not given stretch targets, while at least seven have declined to alter their plans. For three organisations, their positions deteriorated.

Contrast that experience with the one at my former hospital when we faced a budget crunch in 2008-9 because of the financial crisis.  For several years, we had built a culture to support a learning organization, one in which the staff felt empowered and engaged and encouraged to redesign work flows.  When the bad numbers hit, we asked people to consider whether they would be willing to make sacrifices to save the jobs of others.  They did, willingly and enthusiastically.

Brian, from finance, said:

Obviously, I want to keep this job. I’m sure I echo most people’s thoughts when I say that no one wants anyone else to be laid off, and we are all willing to do whatever is necessary to make sure that as few as possible actually lose their jobs.

Catherine, a nurse, offered:

I would be more than happy to forgo a pay raise and reduce my earned time if that would mean another person in the hospital could keep their job. I think this is a great idea and I hope my colleagues feel the same.

And Bernice, an MRI technician, agreed:

I would rather take the loss of my yearly raise than see a fellow employee laid off.

And another:

I know the next few months will be extremely difficult for all of us. But it is so comforting to know that the people I work with are not just sitting back and letting things happen.

After this afternoon’s meeting, we had our own “post-town meeting meeting” to review what you had said, and to toss around suggestions. I know those little meetings are happening all over the medical center. I have never been prouder of the people I work with and the hospital I work for.

The challenge also enhanced our internal sense of community.

Lois, a manager in our Department of Medicine, said, “I think we will learn much from the process. I even dare to believe that we will become a community of healing for one another, just as we are for our patients.”

The end result of this entire process was that we were able to balance the budget with hardly any layoffs. And much to our amazement, we achieved national renown for our hospital. Readers emailed a Boston Globe story by Kevin Cullen detailing the events to over 14,000 other people around the world. The story was also posted on the Yahoo home page for an entire day, viewed there by hundreds of thousands of people. ABC news, NBC news, and PBS all came to do feature stories, seen by millions of viewers.

The pride among our staff was palpable. Patients, too, felt a part of the story and helped spread the word. Here’s a note from Bob, who had had cardiac surgery at our hospital:

I just watched the NBC clip about the employees of BI. I must tell you how much I appreciated the care that I received from all of the folks who attended to me while I was recovering from my surgery. This is most true of the ‘low-level’ employees. The folks who helped me wash, brought me my meals and took me for my x-rays were all professional and courteous. For this reason alone, I am so glad to hear of the efforts all of the BIDMC employees to ensure that everyone can keep their jobs.

About a year and a half later, we were able to restore the salary and benefits to our staff, and even pay a small bonus when our business improved. Jerry wrote a typical response: 

I’m sure you were inundated with thank you emails for this bonus, but I felt the need to add mine to the list. I also wanted to mention that when I told my wife about this she said, “What a wonderful place to work. That would have never happened at my company.”

I’m sure the five hundred dollars will come in handy, but the fact that our leadership even thought of this is what makes BIDMC such a great place to work. We came together when times were tough, and now we are sharing the wealth as finances improve. To me this sounds more like a family than a workplace.

Tuesday, September 29, 2015

In appreciation: Vivian Li

The worth of a city can be measured in part by the caliber of the people who devote themselves to its improvement.  By that measure, Boston has much to credit from the engagement of Vivian Li as long-time head of the Boston Harbor Association, created to promote a clean, alive and accessible Boston Harbor.  Many have considered her the unofficial mayor of Boston's waterfront for the last quarter century, and that would not be a bad summary.

She's now off to new adventures in Pittsburgh, and there is a farewell celebration for her tonight.  For today, I'll skip her many accomplishments but rather focus on her approach and demeanor.  

I don't know of anyone in this city who has worked with Vivian who doesn't admire her and consider her a friend and colleague.  Those of us who worked at the Massachusetts Water Resources Authority certainly viewed her in that light. Invariably pleasant and respectful in her dealings--even in the most contentious disputes--she has approached her job with intelligence, judgment, and good humor. Her objective has always been to achieve the public good.  But her other objective has been to achieve a coalition for the public good, to build the institutional and community infrastructure to support the wise use of the waterfont resource. In that regard, her legacy will outlast her tenure at TBHA.

I join thousands who know her in wishing her well and happiness.  Pittsburgh, you've landed a gem!

Sunday, September 27, 2015

Will no one rid me of this priest?

As we consider the leadership failures that led to the current debacle at Volkswagen, we can take a lesson from English history.

Henry II, facing a disagreement with Archbishop of Canterbury Thomas Beckett in 1164, is reported to have shouted out in frustration, “Will no one rid me of this troublesome priest?” Four knights heard what Henry had shouted and interpreted it to mean that the king wanted Beckett dead. They rode to Canterbury and did the deed.

This story exemplifies the term myrmidon. From this source, we get the following definition: "A loyal follower; especially: a subordinate who executes orders unquestioningly or unscrupulously."

One of the dangers for a CEO is the tendency for your subordinates to take what you say and execute it to a degree you never intended.

Now, let's take a quick look at the VW story, courtesy of the New York Times:

Martin Winterkorn, Volkswagen’s chief executive, took the stage four years ago at the automaker’s new plant in Chattanooga, Tenn., and outlined a bold strategy. The company, he said, was in the midst of a plan to more than triple its sales in the United States in just a decade — setting it on a course to sweep by Toyota to become the world’s largest automaker.

“By 2018, we want to take our group to the very top of the global car industry,” he told the two United States senators, the governor of Tennessee and the other dignitaries gathered for the opening of Volkswagen’s first American factory in decades.

One way Volkswagen aimed to achieve its lofty goal was by betting on diesel-powered cars — instead of hybrid-electric vehicles like the Toyota Prius — promising high mileage and low emissions without sacrificing performance. 

The determination by Mr. Winterkorn, the company’s hard-charging chief executive, to surpass Toyota put enormous strain on his managers to deliver growth in America.

Volkswagen officials now state that Mr. Wintrerkorn knew nothing of the regulatory cheating that his engineers had designed into the company's engines.  Some are skeptical:

“For something of this magnitude, one would expect that the CEO would know, and if he doesn’t know, then he’s willfully ignorant,” said Jeffrey A. Thinnes, a former Daimler executive who works as a consultant for European companies on compliance and ethics issues.

We may never know.  But what we can be sure of is that the myrmidons at VW thought they were carrying out the intent of the CEO.

Friday, September 25, 2015

Part of the school day

For several years, I've had the pleasure of expanding my role as referee of youth league soccer games to officiate in high school games.  Although covering some of the same age groups, there is a different feel to these school games.  School loyalties are different from town team loyalties.  Coaches are more often professional and paid rather than being volunteer parents.

One of the things drilled into the referees is that the matches are "part of the school day." We're told that the main value of the athletic endeavors is that they are part of the curriculum. The coaches, we are advised, have a teaching role, just like in the classroom. Indeed, many of the coaches are classroom teachers, too, during the previous hours in the day.  Our job is to defer to these teachers in matters of deportment and discipline (while of course officiating the game in a fair manner and one which helps ensure the safety of the teenagers.)

So, what happens to all that when the coach loses it?  When, in the excitement and stress of the match, he or she feels that calls are not going their way and when he or she loudly and persistently dissents from the calls made by the referees.

In youth soccer matches, the established ethic is that the coach shall not dissent, in word or deed, from the calls made by the referee.  Indeed, a coach can be disciplined--and even ejected--for doing so to excess.  Not so in the high school matches (except in very extreme cases.)  When the yelling begins, you maintain your composure as a referee and just continue to do your best.

I don't have a problem with that.  I personally have taken a lot more heat as a public official and CEO than I get from the sidelines of a soccer match.  I've had hundreds of people screaming at me in public meetings, death threats from aggrieved parties, not to mention really nasty commentators in the media.  I've learned to breathe deeply and go on.

No, the problem I have relates to the setting: The game is supposed to be part of the school day. The coach's role is that of a teacher.  What possible lesson is being taught to the students when the coach engages in obnoxious and disrespectful behavior to uniformed officials who main job is to use their judgment to maintain a fair and safe environment?  Who is there to remind the coaches that the circumstances of the game should not overtake their roles as mentors and role models for the children?

Wednesday, September 23, 2015

Blindfolds on? Good, let's lead.

My Australian friend Marie Bismark and colleagues published an article a couple of years ago about the role of boards in clinical governance in over 80 health service boards in the state of Victoria.  There was one remarkably revealing quote about the 233 board members who answered the survey:

Almost every respondent believed the overall quality of care their service delivered was as good as, or better than, the typical Victorian health service.

In an earlier article, Ashish Jha and Arnold Epstein found similar results:

When asked about their current level of performance, respondents from 66 percent of U.S. hospitals rated their institution’s performance on the Joint Commission core measures or HQA measures as better or much better than that of the typical U.S. hospital.  Only 1 percent reported that their institution’s performance was worse or much worse than the typical hospital. Among the low-performing hospitals, no respondent reported that their performance was worse or much worse than that of the typical U.S. hospital, while 58 percent reported their performance to be better or much better. 
Hospital Board Chairs’ Perceptions Of Hospital Performance, Compared With A Typical U.S. Hospital, On The Joint Commission Core Measures, 2007–08

Marie and her co-authors suggest:

A recognised cause of these so-called "Lake Wobegon effects" named after Garrison Keillor's fictional community in which all the women are strong, all the men are good looking, all the children are above average, is unavailability or underuse of reliable information on peer performance.

I'd go a step further. A couple of months ago, I recalled

a wonderful story from Amitai Ziv, the director of MSR, the Israel Center for Medical Simulation at Sheba Medical Center on the outskirts of Tel Aviv.  He relates how Israeli fighter pilots would return from their missions and debrief how things went.  The self-reported reviews of performance were very good.  Then, the air force installed recording devices on the planes, and it turns out that the actual performance was not nearly as good as had previously been reported.  The conclusion: It's not that people are poorly intentioned or attempt to mislead about their performance. It's just that we tend to think we are doing better than we actually are.  

I think the issue is not the unavailability of reliable information on peer performance.  I think the issue is a failure, in the first instance, to even measure one's own performance and to share that with one's own team. After all, the issue is not so much benchmarking.  That only goes so far.  As I've often said, there is no virture in benchmarking to a substandard norm.

So, the first step is to accurately collect one's own data and make it transparent to your own team. It is that transparency--more than benchmarking--that will establish the creative tension in an organization that will drive people to meet their own stated standard of clinical excellence.  A smart board does not have to apply pressure on its staff by drawing comparisons with others. Rather, they take governance steps to demand transparency, so that the deep sense of purpose that is inherent in the clinical staff is employed to stimulate the team to do better on their own.