SaferPatients

Most of the time, folks in health care think of their job as a set of tasks or actions that take place in a —> [box] <—.

It turns out, though, that if they go upstream and alter the stuff that comes to them in their box, it’s a lot easier to do great work, that is safer and of better quality.

And if they go downstream and work with the people that take care of their patients after the patient leaves their box, the final product is better as well. Now, it’s more of a –> [   box   ] <–. (Note the box is now bigger - with more room to manuever.

A surgeon can consider his work as only being in the box of the operating room. But if he works with the wider perioperative team to systemize the processes to make sure EVERYTHING (antibiotics, equipment, H&P, implants, charts, imaging, etc…) is in order before the patient comes in, his results are better. If he will work with the team to systemize processes for the patient after the patient leaves the OR, same thing.

Too often, surgeons take the attitude that that kind of work on systeminzing processes and improving the collaboration among the wider team is work only for administrators. “Call me when you get it right,” he thinks to himself.

If that surgeon could only see what I see at institutions where we have helped physicians and staff improve processes both upstream and downstream. What a better place to practice medicine it creates. What a better “box” to work in. Cases start on time - every time. Cases go as scheduled. The team is better. Preference card systems work. Equipment is always on hand and no one is rushing out of the core to find missing stuff. Cases are uneventful - they go as scheduled. Little slips and potential mistakes are caught before they become a crisis.

The challenge lies in convincing physicians that spending the effort on the upstream and downstream parts of the work, instead of always assuming that their [box] is just what happens inside the OR, or as a direct result of their actions with a scalpel in their hand. But it is a challenge that can be overcome. and when it is, magic happens in our box.

�

It is just about time for March Madness, the NCAA college basketball playoffs. This national tournament reminds us that competition is everywhere, even in health care -  although we sometimes forget to notice it.

Examples:

There are ten hospitals in town that provide services in particular medical specialty. One hospital has made an investment in teamwork training and standardized work for its nurses and staff in that specialty. Consequently, the community-based physicians in town that practice in this specialty always have efficient, standardized, high performing teams to work with when they provide care in that hospital. Physicians can get in, and get out - providing great care efficiently. Which of the 10 hospitals has won the competition for attention from the community’s physicians?

There are six ASCs and day surgery centers in town that patients can choose for surgery. One invests in its safety with a real culture-changing safety initiative, has a focus on the patient experience, recruits its patients and their families to be a part of the safety team, and makes its safety and quality statistics available on its web site. Others are muddling through, arguing about the business case for safety, factoring in mistakes and adverse events as part of the cost of doing business in health care, hiding their results under the cloak of secrecy, and doing business as usual. Which one will ultimately command a higher premium for its services while also doing the right thing for its patients?

You have fifty openings for nurses or other staff. You are competing with 8 other hospitals in town for qualified personnel. The working hours and pay rates are about the same all over town. Your nursing turnover rates are the lowest in town. Your employee satisfaction surveys are the highest in town. Your safety climate surveys are the best in town. Your culture of interactive communication between physicians and staff is the most collegial in town. Your core measures are the best in town. Your HCAHPS survey results are the highest in town. Which hospital has the most number of nurses wanting to interview with it?

There are ten new jobs in town for the superstar mid-level administrator who is looking for a new challenge. One hospital offers a culture of accountability where the staff speak up and hold one another to the standards of performance they have all agreed to. It has a commitment to standardized work and is not constantly re-inventing the wheel. All of the managers are committed to giving and receiving objective, specific, detailed, non-defensive performance feedback from one another. It has a history of giving its physicians a seat at the table when new procedures and systems are implemented; it never struggles finding physician champions for its projects. It gives its managers the tools and the freedom to work on interesting projects that improve the safety and quality of care. Where does she choose to apply?

We don’t have to like competition but we must understand that it exists. While certainly not the only initiative available to win the competition, effective patient safety programs give physicians, nurses, staff, administrators, and patients a very compelling reason to pick you and your organization.

�

A survey undertaken by the Institute for Safe Medication Practices last fall has shown that the current economic climate has forced staff cuts, reduced the amount of technology and equipment that hospitals can purchase, and negatively affected the culture of safety by reducing the amount of time staff members have to report errors. Nearly 850 people took the survey and of those, 41% said the economy had a large to moderate negative impact on medication safety in particular.

Some specific findings concerning medication safety include:

• Forty-two percent of respondents said the staff person who dedicates time to medication safety (either a medication safety officer or quality improvement specialist) has had hours cut or his or her position completely eliminated.
• Less attention is being paid to the purchasing of safe medication equipment, such as using multi-use vials instead of single-use.
• Caregivers are more apt to rush drug administration practices as well as have less time to educate patients about their medications.
• Pharmacists are less likely to have a clinical presence on patients’ units.

If not the economy, the stressor would be something else. Health care reform, reimbursement reductions, nursing shortages, and staff turnover all could easily replace (or add to) the economy as a stressor to your health care system. Nothing ever stays the same. It is not a question of “if,” but a question of “when” the next stressor will hit.

Despite the ever-changing gale-force winds of stress blowing their way, all high reliability organizations (HRO) have a solid safety system hardwired into their very foundation. They don’t depend exclusively on the extraordinary efforts of excellent staff to fend off errors. HROs give their capable staff an underlying safety system of accountability, leadership support, just culture, safety tools like checklists, and data scorecards that protect the integrity of their operations from the buffeting winds of change.

Do you have such a system?

If not, I predict more mistakes in the future of your organization.

In my last post, I talked about making an emotional connection with your colleagues when describing the goal of your patient safety initiative. Seth Godin made a wonder blog post on this very issue. He said,

“Relying too much on proof distracts you from the real mission–which is emotional connection.”

Read his entire post at this link.

It’s not only U.S. hospitals that are concerned with improving the safety and quality of health care. I recently returned from Malaysia, where there is great interest in creating a safer experience for patients. During my visit, I conducted workshops for 4 hospitals and the Malaysian Ministry of Health.

One of our first activities was to get to know one another, and for me to understand the competitive and regulatory landscape in Malaysia. So I began to ask them questions about reimbursement rates, Never Events, public transparency of safety and quality data, Sentinel Events, and malpractice lawsuits, etc…

What I disscovered about their country is that few of the patient safety “motivators” that exist in the States are present in that country. There is no govermental or regulatory pressure on local hospitals to improve patient safety. They are not concerned about pay for performance, or lower reimbursements for poor safety or quality. They do have malpractice cases, but the “sue anybody for anything” mindset is notably missing. They do not post their safety and quality data for the public to see. In short, there is no economic pressure on the Malaysians to improve patient safety.

Said another way, the lack of an improvement in safety will not put their business at risk.

Yet, there is clearly a national concern over doing a better job for those they serve, and for no other reason than it is the right thing to do.

Financial return on investment for safety activities is a secondary consideration, if it matters at all.

Honestly, I found it very refreshing to have the opportunity to work with medical professionals who want to do the right thing just because it is the right thing, and not because their actions were monetized, provided an ROI, or because they felt threatened by regulatory or economic consequences.

Another refreshing difference from stateside workshops was the number of practicing physicians in the room. In the U.S., it’s rare to see a practicing physician take time away from caring for patients to invest in patient safety improvements. Most of the workshops we do of this type are filled predominantly with nurses and administrators. In Malaysia, over 50% of the participants were physicians who were taking an active role in leading patient safety initiatives in their hospitals.

Having said that, as the workshoip progressed, it became clear that many of the barriers to organizational change that we experience in the States are identical to those in Malyasia. People are people everywhere - all subject to the universal resistant human reactions to change.

The lesson learned here is that no mater what adversity or barrier you are struggling to overcome in your patient safety change initiative, someone, somewhere in the world is experiencing, or has experienced, the same thing. And, that means there is best practice available to overcome your challenge. We just have to find the best practice and learn from others.

My experience in Malaysia proves yet once again that there is very little new under the sun. When we realize that and seek out those who have already walked our journey, we learn and improve much faster.

I agree with most Americans that we need healthcare reform. As I travel around the country helping hospitals implement best practices in their patient safety programs, it is clear to me our present system has some major flaws. Costs, for everyone involved, spiral upward every year - yet most hospitals are “break even” businesses at best. In many states, more than half the hospitals are in the “red” and others limp by with 1% profit margins. And, too many of us don’t have access to the care we need.

Further, as a Christian and man of faith I would argue that, as a matter of responding to our moral imperative to take care of our fellow man, ensuring access to quality health care is a proper role for government and consistent with biblical teaching.

But, in their rush to reform healthcare as we know it, and in the face of growing opposition to their 1000 page bill, I believe Congress has created a reform package that needs serious rework. Here’s why.

First, Congress has rejected every amendment to protect the consciences of medical providers- doctors and nurses who, respecting the tenets of their faith, would choose not to participate in providing abortions or “end of life services.”

I do not argue with the right of patients to seek such services if they desire, nor the provision of those services by healthcare professionals who wish to provide them. But, I believe it to be unfair to make our nation’s physicians and nurses violate their conscience and their first amendment rights, or to make them choose between their faith and their careers.

Over the years I have worked with many Catholic hospitals and systems. Catholic facilities constitute 13% of our nation’s hospitals. How will these faith based institutions be affected by the current bill? Will the bill, as is, force them to perform such procedures? What percentage of them would choose to close rather than violate the tenets of their faith?

I have also seen first hand how Catholic systems take care of the poor and unemployed. What will be the effect on this safety net? Will government run healthcare be able to take up the slack?

Second, medical mistakes and errors. As I look at the error rates in single payer, government run systems around the world, the numbers of adverse outcomes due to medical mistakes seem to be on the rise - not decreasing. In the U.K, France, and Switzerland, for example, recent studies showing the effect of errors on their healthcare system are startling. I don’t see anything in this bill (like the FAA mandate of CRM training for the airlines) that really addresses the potential for an increase in error.

My next concern is fiscal responsibility. The Congressional Budget Office says the bill now in Congress would add $1 trillion to the federal deficit over the next 10 years. While we should move forward on reform, the process should consider the cost to our nation and future generations. What can we afford? What other programs should be cut? How can we, as a country, live within our means?

I don’t profess to have the answer to what healthcare reform should look like and how we should pay for it. But I do want reform. However, a bill that violates freedom of conscience, erodes the dignity of human life, or leads to a budget busting government takeover of healthcare is not the reform we need.

�

Here’s the account of a surgeon falling asleep in the OR during two successive surgeries. The story appeared in the Boston Globe.

“When Dr. Loren J. Borud began his first case at about 8 a.m., an operating room nurse noticed he looked tired and wobbly. She was so concerned, according to one account of the Friday last June, that she suggested Borud postpone his next patient.

Borud said he had been up all night working on a book, but he kept operating, starting a second case, during which he briefly fell asleep, according to a report from state investigators. The nurse again called him aside and suggested “maybe he should take a break,” according to her interviews with investigators, but he continued the surgery.

The operating room nurse called the plastic surgery department twice to report Borud’s behavior that morning and early afternoon, the report said, and the office nurse told her to “keep an eye on him.” But no senior surgeon or administrator ordered Borud to stop operating - even though there was widespread awareness of his history of drug and alcohol abuse, according to investigators. Read more »

With the advent of the World Health Organization (WHO) surgical safety checklist, a lot of facilities in the U.S. are trying to implement a checklist as a vehicle to accomplish the Universal Protocol (Time Out). Not everyone who tries it succeeds, and they seem very surprised when they don’t.  Why? Read more »