SaferPatients

Typically, it takes about six to nine months for a hospital to decide if it wants to do training to improve the communications between its physicians and nurses. Nine months from the time the executive team and Board of Trustees has decided that it can not  allow any more sentinel events in its hospital.

One hospital I worked with had a series of several serious wrong surgeries. After the third one, and in desperation they called me, asking for an immediate call back. They knew their culture was broken. They knew their checklists weren’t being used correctly, if at all.

It took over 24 months for them to decide to take the steps to fix it.

You don’t need more time, you just need to decide.

Read the history of the original Mac and you’ll be amazed at just how fast it got done. Willie Nelson wrote three hit songs in one day. To save the first brand Seth Godin was responsible for, he redesigned five products in less than a day. Seth says It takes a team of six people at Lays potato chips a year to do one product redesign.

The urgent dynamic in patient safety is to ask for signoffs from your executive team and to push forward, relentlessly.

Keep telling your leaders, “I can make this happen. I’ve got it.”

Seth Godin, one of the best project innovators out there says you can feel this relentless move forward happening when you’re around it. “It’s a special sort of teamwork, a confident desperation… not the desperation of hopelessness, but the desperate effort that comes from being hopeful.”

Your patients are hopeful that you are relentlessly improving how you provide care. Are you?

What’s happening in your unit?

In the just-released 2013 Industry Survey: Strategic Imperatives for an Evolving Industry, a survey of health executives reveals that the 3 biggest priorities for hospitals are 1) patient experience, 2) clinical quality 3) cost reduction.

Chief Financial Officers for surveyed hospitals estimated the percentage reduction of operating costs for the next 3-5 years.

The average was set at 11%.

How are hospitals going to do this? Lean + TeamSTEPPS. Lean for process improvement to drive out the waste. TeamSTEPPS (or CRM) to create a culture of accountability to make sure the waste stays driven out.

We typically see an average ROI on Lean process improvement work of 4 to 1. One dollar spent on improving processes return $4 on waste reduction and volume increases.

Unfortunately, you only keep that $4 improvement every year if you have an operational culture where peers hold one another accountable to adhere to the new waste-free, efficient process. Otherwise, your organizational culture will eat your process improvement efforts for lunch. This is one of the true values of an effective TeamSTEPPS program. Tt creates a culture of cross-check, accountability, stop-the-line when standardized work is ignored.

Everyone has processes. Everyone is doing Lean. Everyone has bundles (CLABSI, CAUTI, VAP, SCIP, etc..). Everyone has protocols. Everyone has checklists. Everyone has medical expertise and training. What everyone doesn’t have is “culture.”

Culture is what separates the profitable and on-going, from the broke and going-out-of-business. What are you doing today to change your culture? If the answer is nothing, be prepared to be looking for new employment by 2015.

Allstate Insurance had a great ad during the Super Bowl - showing all the mayhem that has happened throughout history after Eve ate the apple in the Garden. Watch the video here.

Mayhem does happen. Even if we don’t want it to. Just look at the amount of patient harm in our nation’s hospitals.

Allstate won’t prevent that harm. But you can - with a really great system of care that has high reliability processes and a culture of safety that holds everyone accountable to use those standard processes.

Mayhem happens. You have the tools to stop it. Time to get busy.

At the Weill Cornell College of Medicine, new doctors-in-training are learning communication and teamwork skills right alongside their medical skills. Cornell has integrated simulated practice and role-plays into their medical education and training. Students learn to effectively use human factor skills when communicating with patients because numerous studies have shown that the better physicians can create rapport with patients, the more effectively the patient will follow their medical advice.

In the learning center where simulations occur, a central observation area is outfitted so that faculty can observe students practicing with the actor-patients; there are one-way mirrors and the technology to support wireless headsets so that instructors can change the audio channels to observe several rooms simultaneously. Rooms are also outfitted with AV equipment and microphones so that every interaction is recorded. This creates a longitudinal database so that students and professors can track their progress and ensure that practice has a positive outcome on student performance in medical school and beyond. This is an important point - practice sessions are taped for study and learning.

Football coaches have long analyzed game tape, but taping practice is actually more important. Part of building a culture of practice is videotaping practice; it sends the message that improvement through practice matters.

Cornell uses the lens of practice and feedback for all aspects of their program.

After each training session the actor-patient breaks out of the role and, using a detailed checklist, gives the medical student three pieces of very explicit feedback. Following feedback from the actor-patient, each student debriefs with faculty for more performance feedback. Finally, the students go through the very painful process fo watching their own video tape. (I know this is painful because this is the exact process we followed when learning how to present new material when I was an instructor at TOPGUN. Fellow instructors played the role of students in a classroom listening to our presentation, and after getting their feedback we received feedback from our instructor on the new material, and finally, we had to watch a video tape of the whole presentation.)

What these new medical students are learning is priceless for success in the new world of health care:

1. Medical skill is not enough. Every clinician must know how to be an expert communicator and how to operate as part of a highly functional team.
2. Practicing together and exchanging feedback builds isolated individuals into an expert collaborative team.

TeamSTEPPS, done well, is high value to hospitals, and ideally suited for the challenges facing American health care– patient care quality/safety coupled with financial pressures.

The challenge for any hospital wishing to implement a truly effective TeamSTEPPS program is that although the documented impact of TeamSTEPPS is desirable, the installation of TeamSTEPPS in hospitals can’t be cost-free, (it can’t be done by downloading free materials from the AHRQ web site) and therefore competes with other hospital (survival) priorities for precious diminishing financial resources.

This is the main reason hospitals should implement the powerful combination of Lean (Toyota Production System) and TeamSTEPPS.

Why? It is easier to gain and demonstrate the financial returns of Lean (see a few at this link). In effect, successful Lean projects fund the TeamSTEPPS implementation to improve the patient care quality/safety that is and should be at the core of every American hospital’s reason for existence.  Besides, the cultural approach of Lean is highly synergistic with TeamSTEPPS, so reinforcing and so compatible that doing both Lean and TeamSTEPPS will be seamless to hospitals.

Not everyone knows how to seamlessly integrate both. LifeWings does.

If you go to any meeting about patient safety or quality and say nothing, it would have been better if you hadn’t gone at all.

If you go to work and do only what you’re told, and never look for a way to do what you do better, you’re not being negative, but the lack of initiative you demonstrate costs the entire unit, because you’re using a slot that could have been filled by someone who would have added more value.

It’s tempting to work quietly, comply, and rationalize that at least you’re not doing anything negative to hurt your patients. But the opportunity cost to your hospital that must compete in a new world of safety data transparency, and ever more dangerous world of high-tech medicine complexity is significant.

Not adding value in patient safety is the same as taking it away. What will you do today to be more reliable, have less variability, and ensure things don’t fall through the cracks?

But how to get better?

If you are depending on individual clinicians to spectacularly rise, on their own, to the challenge of the massive changes in reimbursement (e.g. Value Based Purchasing) or quality data transparency, you will fail.

Doing what you did to get here, WILL NOT GET YOU THERE.

Sustained results will only come from a systems approach that hard-wires daily habits all of personnel. if you don’t know how to do this, it might be time to get some help.

At Brigham & Women’s Hospital in Boston, team-based inpatient care has resulted in dramatic reductions in inpatient mortality, significantly lower lengths of stay, and higher satisfaction for physicians and nurses.

Team-based care dissolves the hierarchical, traditional structure that exists among nursing, physical therapy, pharmacy and medical staff, social work staff and others to empower individual members of the team to contribute equally to the optimal outcomes for the patients.

At Brigham & Women’s Hospital and its sister Faulkner Hospital, a team-based model of care has been adopted for almost all general medicine units. This system replaces the “chaotic model,” in which residents, attending physicians and interns rotated on different cycles; physicians and nurses did not know one another; and the admissions department assigned patients to whatever beds were available.

Each unit now has a team made up of attending physicians, residents, interns and medical students, pharmacy students and a faculty supervisor, nurses, a social worker, an RN care coordinator and a physical therapist. All members of the team are assigned to work together on a specific unit for at least four weeks at a time.

Two other key changes were instituted: The admissions department assigns a patient to an intensive care unit team only if there is a bed available on its unit and interdisciplinary rounds are structured sequentially by nurse, rather than by room number.

Also, under a team-based care model the expectation is that you don’t discuss a patient until the nurse is present, Another expectation is that before a physician articulates the [patient's care] plan that you get the nurse’s input. The physician team leader will always address the nurse and ask, “Do you have anything to add about this patient?”

The perspective of other team members is equally valued, depending on the patient’s diagnosis and care plan. Sometimes the most important clinician is the physical therapist. The physician may be writing the orders and doing some of the direction, but under the team-based care model the physician does not work alone, but as part of a team.

This approach requires new standardized processes, extensive teamwork and communication training, and strong support and leadership action from top administrators.

Watch a Three-minute movie about LifeWings

Crew Resource Management, or team training, is not a new topic in health care. Health care has even adopted its own name for a CRM-based patient safety project - TeamSTEPPS. Whatever you call it, it’s the idea that health care as an industry can learn a lot from the aviation industry - specifically that many of the concepts used in creating a culture of safety in the U.S. commercial airline industry can be used in health care to improve patient outcomes.

The question is often asked “Where is the data that proves this approach?” A study that provides the data to back up this notion is reported in  American Medical News.

The research, published in the  Archives of Surgery, followed caregivers who had taken a course titled “Lessons from the Cockpit,” which attempts to relate errors in aviation with medical errors and teach how to avoid them. After studying 857 participants of the six-hour course since 2003, researchers concluded that teaching health care workers the principles of crew resource management has a positive effect not only on patient care, but on workers’ perception of the culture of safety and self-empowerment.

Some of the most striking results include the use of preoperative checklists (75 % of participants were using them in 2003, and by 2007 100% of participants were using them). Self-initiated incident reports rose from 709 in the first quarter of 2002 to 1,481 in the first quarter of 2008.

You can read more by checking out the American Medical News article.

The Patient Safety and Quality Health Care journal reports that 90% of hospitals include patient safety as an integral part of their strategic plan and, even in this difficult economic climate, 53% plan to spend more money on patient safety initiatives than they did last year.

I wonder, given the data that verifies the CRM approach, how many will invest in training their staff with the teamwork and communication skills used by all high-performance teams?

Here is an interesting blog post from Seth Godin, author of Linchpin and Poke the Box (two of my favorite books). Seth says…

“Thousands of doctors have signed up for a service that, among other things, they can use to try to prohibit patients from posting reviews. You can read a bit about it here.

In Iowa, in a surprisingly similar move, the state government is moving ahead with a law that will make it a crime to take or possess videotapes of factory farming that might harm the commercial interests of the farmer.

In both cases, an organization is trying to maintain power by hiding information from the public. Can you imagine being arrested for possession of a photo of a pig?

It’s easy to argue that from the public’s point of view, laws like this are a bad idea. The public certainly benefits from the outing of bad doctors and from the improved hygiene of factory farms. In that sense, it’s unethical for doctors and legislators to subvert their responsibilities by ordering the un-empowered to shut up.

I think it’s interesting to think about from the doc’s point of view (and the chicken farmer), as well. The temptation is for those in charge to defend the status quo by fighting transparency. This ignores a simple truth:

When book reviews are posted, book sales go up.

Yes, the argument of fairness matters.

(Yet) it turns out that transparency increases profitability.

Here’s the thing: when consumers get used to transparency, they’re also more interested in the quality of what you sell, and are more likely to willingly pay extra. They’ll certainly cross the street to buy from an ethical provider. And once people start moving in that direction, the cost of being an unethical provider gets so high that you either change your ways or fade away.

Inundate us with images of cleanliness and quality instead of blacking us out. Don’t race to the bottom (you might win). Instead, force your competition to race you to the top instead.

[Aside: the same objection happened when we started regulating hygeine in restaurant kitchens. Yes, it got more expensive to clean the pots and kill the rodents, but it was okay, because post-Duncan Hines, demand for quality went up enough to more than pay for it.]

The same argument holds true for doctors. Once information about good doctors becomes widespread, patients will be more willing to seek out those doctors, rewarding the ones who consistently take better care of their patients. The entire profession doesn’t suffer (we’ll still go to a doctor) merely the careless doctors will.

One more: A leading politician in India is arguing that bribery (in certain transactions) ought to be legalized. Why? Because if the briber feels free to rat out the bureaucrat, bribery goes down.

In all three cases, sunlight is an antiseptic and the marketplace rewards those that behave–and the entire market grows when the standards increase.

Consumers and those that want their admiration ought to reward those in favor of transparency.“