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.

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.

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.

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.“

Overcoming Organizational Resistance

When  inspiration, then success, then recognition and reward for the improvements we have made have come and gone, who will still love you—and whom do you love?

Only two things will remain with us when we cross to the other side: the creative genius (yes, genius) with which our Creator endowed us, and the hearts of those we love.

In other words, what we do with the abilities we have been given and those for whom we do it.

Each of us is unique -  equipped for this moment and our role in health care reform with a set of work skills, life experiences, and passions. Are we doing the most we can for this mission with what we have?

When resistance comes, and it surely will, remember why you are doing what you are doing, and for whom you are doing it.

Don’t let yourself be stopped.

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.

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I just got off the phone with the Associate Dean of Clinical Effectiveness at a large hospital in the south. His institution, like everyone else it seems, has spent a lot of time and attention on the HCAHPS results that now show up on the HHS Hospital Compare web site. Read more »