SaferPatients

The Dreamliner has been grounded for several months due to safety incidents with its batteries. The news media has provided in-depth coverage of the story. One filem clip that made the news was of female voice of the Boston-based air traffic controller telling the pilot of the Japan Airlines 787 that he must stop at the end of the runway; she is sending emergency vehicles out to deal with the fuel leak. She doesn’t have to argue, the conversation is calm, clear and concise, and the plane stops with no argument or discussion. Both the pilot and the ATC controller are personally accountable for what happens to the aircraft and its passengers.

Here’s what Richard Corder on the blog KevinMD has to say about that incident…

“In our hospitals, these “incidents”, these “near misses” rarely get reported internally; the associated press and the national evening news certainly don’t pick them up as front page stories.

If we are obsessed with safety, like the human factors focused airline industry, our near misses and our good catches would be enough for us to stop the line, stand back and work to develop safer systems.

I know that the analogy is not perfect, our clinicians and care givers are tending to the complex human system that we cannot treat like the machine that is a plane, that being said there are lessons to be learned.

So what can leaders do?

Lead a culture where you model that it is safe to speak up and encourage people to call out near misses, report good catches and model the mindset and actions of being personally accountable.

Make it known that while clear roles and clarity around authority are important, everyone is personally empowered to speak up or call an unsafe or potentially unsafe behavior to the attention of their colleagues.

Use all meetings, from the board to the bedside, to tell stories of how a mistake was avoided and how, when things go wrong, you recovered.

When things do go wrong because they will, we are human beings caring for human beings, don’t point fingers and blame people. Own the outcome, work to learn from the failure, apologize, atone and remain open to feedback.

Adopt some of the human error mitigation systems that the airlines have embraced.”

Richard is right on the money with his comments.

If you are like me, you steel yourself against the cutting remark, the bitter criticism,  and the person who just doesn’t like the work you are doing in patient safety.

“Too rote!” they cry.

“Doesn’t apply here,” they complain.

“Are you crazy? I don’t have time for that,” goes the refrain.

“What proof do you have?” they ask with a sneer.

“Just another ‘project of the month’” they say with a resigned sigh.

But all of this is the feedback we get when we touch a nerve and are doing work that matters enough to care about.

The worst sort of feedback is no feedback at all. That means we’ve created nothing worthwhile at all.

Almost all of us believe we are capable of editing, giving feedback or merely criticizing.

Initiating a safety project, a new process, a protocol, a new policy–these are things that don’t come naturally to many people. The challenge is in starting something even when you’re not officially in charge.

Not enough people believe they are capable of taking the initiative and seeing it to a successful conclusion. It’s so much easier to complain, but then say, “It’s not my job.”

The shortage of people who look around and say “Why not? I can fix that,” doesn’t have much to do with the innate ability to create or initiate.

It has everything to do with believing that it’s possible and acceptable for you to do it. Even if you are not the manager or administrator.

Most people have been brainwashed into believing that their job is to critique the world, not to design what happens in it. It might have been your job in the past just to do what you were told, and no more. But if you are going to survive in the new world of health care reimbursement, ACA, value-based purchasing, and web sites that publish your safety metrics, it’s not anymore.

Get off the sidelines, stop pointing out other people’s typos, and find out where and how you can contribute. Here are a few ways you could do that without getting anyone’s permission…

1. Standardize the way you do your own personal patient handoffs.
2. Determine the most complex thing you do every day. Make a personal checklist for the critical items in that process.
3. Organize your work space. Show your co-workers why you did it that way.
4. Determine the process you use the most during your work day. Figure out a way to standardize the way you do it so it is most efficient with the least variability. Share the result with your colleagues

Your patient’s deserve it.

Try this framework during patient interactions to improve the patient experience:

“Human-Business-Human”

This framework calls staff attention to the vital importance of first “entering the interaction on the human level” before attending to the “business” and concluding each interaction by “exiting on the human.” While efficiency, accuracy, and delivery speed are important “business” elements, encounters with patients are deprived their healing dimension without a genuine and sincere human, emotional connection.

The first “Human” can be as simple as acknowledging the patient by name and introducing yourself and explaining what you will be doing for the patient.

The second “Human” in the framework can be as simple as saying “Thank you for choosing us for your health care.”

Indeed, humanity is the heart of patient experience success.

For more information go here.

(This post is an adaptation from Seth Godin)

There is the mistake of overdoing the defense of the status quo, the error of investing too much time and energy in keep things as they are. This harms patients and hurts your bottom line. It costs more.

And then there is the mistake made while inventing the future of patient safety, the error of small experiments that didn’t quite work as well as we hoped.

We are almost never hurt by the second kind of mistake. In fact, we innovate by “failing quickly.” Yet we persist in making the first kind of mistake, again and again. This is not helping our patients.

They depend on investment income, spending reserves or corporate subsidy to survive.

If you are not profitable, how can you invest in safety, quality and patient satisfaction?

The answer is actually simple. Organizations that have set high safety and quality standards and have developed a culture that enhances physician, staff and patient satisfaction have lower costs.

Study after study has demonstrated that high-quality with patient safety lowers cost. If there is a commitment to drive your patient and employee incident rates toward zero, costs will decrease. How would finances be affected if surgical complication rates, lost employee days due to workers compensation, and readmission rates were much lower in your hospital than they are now?

LifeWings recently completed a patient safety improvement program at a two hospital system in central Illinois. by focusing on creating a culture of safety the two hospitals reduced staff turnover, dramatically lowered their patient mortality, and improved their employee and patient satisfaction.

Net result? They produced a 16% profit margin. Quite remarkable when you realize that the average profit margin in the industry is 3%.

Not only is patient safety the right thing for your patients, it’s the right thing for your bottom line.

The first thing that you learn from reading all of the self-help books, all of the do-it-yourself books, and from listening to all the marketing hype in this world is that “fun and easy” are the two magic words.  You can learn anything by buying a book with “…for dummies” in the title.

Difficult and frightening never seem to be part of the equation.

Unfortunately, the patient safety and quality work you’re being asked to do now in this crazy world of a change-a-minute in health care, is frightening. It’s frightening to stand up for what you believe is necessary to do for patient safety, it’s frightening to do something that might not work, frightening to do something that you have to be responsible for.

Let’s face it, this is emotional labor you’re getting paid to do for your health care organization. Put your heart into your work for your patients and it might get crushed.

Two things might hold someone back from sharing the mission of patient safety they’ve got inside: One, the fear of telling the truth to the administration about what’s really risky in the way you care for patients, or two, the pitiful strategy of hiding the truth behind the pitch of “We’re doing as well as anyone.”

Your patients need you. Find your voice, stand up and tell administration and staff what you care about.

What you do in patient safety is vitally important, and what makes it your passion is that it is personal, important and fraught with the whiff of failure. This is precisely why what you do, when you do it well, is scarce and thus valuable—it’s difficult to stand up and own it and say to your peers, “Here, I made this. and it makes our patients safe.”

Right now, the urgency is real. We have to create more culture change, create better systems of care, and build more reliability in our everyday work.

Your patients are waiting for you to get over being frightened. Find your voice. Make it heard.

The value of a debriefing after a surgical procedure cannot be underestimated. It has been linked to improved performance in various medical and surgical fields, including improvements in specific procedures, teamwork communication, error identification, improved communication, and professionalism.

A recent study of the effectiveness of a debriefing process was published in 2012. The study details how a briefing/debriefing tool was implemented in the ORs of a hospital. In 44 months of use, the tool identified 6202 defects (issues with instrumentation, radiology, laboratory, supply, and communication/safety, etc.). (Wouldn’t it be awesome if you had a system in your hospital to identify and fix this number of defects in process of care?)

The list of errors identified during briefing or debriefing was sent to administrative personnel so they could begin to address them at ther surgical service weekly meeting, and was provided on a monthly basis to administration. Staff members and physicians were informed of the steps being taken to resolve issues on a daily basis by the clinical outcomes nurse (for staff members) or the administrative nurse manger (physicians).

This study, among several others, showed that briefings and debriefings were a practical and successful means of identifying and fixing both clinical and operational errors in surgical care.

To achieve this level of effectiveness, debriefing MUST be done…

1. Consistently - after every procedure, even when things go well. Otherwise debriefings will become associated with poor outcomes or bad behavior. If you don’t debrief when things go well, you won’t debrief when things go poorly.
2. As soon after a procedure as possible and with all team members involved - including the surgeon.
3. For the express purpose of identifying and communicating systemic issues to the proper hospital administration, which MUST keep the OR staff updated on the progress of remedying the issue. If you are not going to bother fixing the issues identified in debriefings, don’t waste your time implementing a debrief system.

Debriefing can be a powerful tool in creating team unity and awareness, as well as reducing errors, which in turn lead to amore enjoyable working environment for medical personnel and a safer operative experience for the patient. In my 12 years of experience of helping hospitals improve patient safety, a debriefing system is THE MOST POWERFUL TOOL available to create a culture of safety - but it also the most difficult tool to implement well. Making the effort to implement it is worth the difficulty, but only if you are willing to adhere to the three rules above.

Value Based Purchasing (VBP) is here.

VBP is a control scheme introduced by CMS to reduce the cost of health care. Under VBP, providers will be reimbursed for care given to Medicare patients based on patient satisfaction and the ability to get good scores on CMS core measures.

Medicare has been very clear about the impact to hospital bottom lines. Average performers won’t break even. If you have average core measures, and average patient satisfaction your institution will lose money.

The way to maximize your reimbursement and protect your budget is to have high performance compared to national benchmarks with other hospitals across the country, and to make  dramatic improvement against your own baseline scores. Either way, you must improve.

If you add the reduced reimbursements to an additional 20.4 million Medicare patients over the next decade, and then add the effect of productivity adjustments, 15 percent more institutional providers will go bankrupt by 2019, according to the former administrator of CMS.

What is the solution to value-based purchasing?

• increased use and adherence to protocols,
• real-time monitoring and feedback,
• focused scorecards, and
• better training for doctors and nurses on patient communication techniques.

You must be better than average, or you will be worse off financially next year. But how to get better?

If you are depending on individual clinicians to spectacularly rise to the challenge on their own, you will fail. 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.

Watch a three-minute movie about LifeWings.

A Boston surgeon who performed the wrong procedure on the hand of an elderly woman has disclosed the excruciating details of his error in one of the nation’s most prominent medical journals.

As usual this case had all of the classic error-inducing factors: 1) The procedure was done at the end of a long day; 2) Stress was high because several other surgeons were behind schedule. When surgeons are stressed, the surgical team is stressed; 3) The patient was moved to a different operating room at the last minute, with different staff, including the nurse who had performed the pre-operative assessment; 4) The surgeon didn’t have a habit of leading or actively participating in the Time Out (seeing them as an unnecessary burden); 5) There were communication issues as the patient didn’t speak English.

The surgeon did speak Spanish and spoke to the patient in that language. This exchange in Spanish was mistakenly interpreted by the Circulator in the room as a “Time Out,” the safety pause for the medical staff aimed at double-checking surgical sites, but no formal check occurred.

While admittedly I wasn’t there for this event, I have personally observed many other OR situations like this one, and I have no doubt that the nurse did an internal debate with herself about whether she should speak up and question the surgeon about the Time Out and the need to do it in English for the benefit of the team. For whatever reasons, including the stress she felt from the surgeon and the fact that the surgeon didn’t typically lead, or get actively involved in the Time Out, she decided it was okay to let it slide.

If the surgeon had always made it a habit of leading the Time Out, and of making a safety statement at the end of it encouraging his team to speak up if they saw something not in the patient’’s best interest, it would have made it easier for the nurse to speak up.

A classic, effective, stop-the-line assertive statement by the circulating nurse at that moment would have changed everything.

He didn’t, and she didn’t. The result was the surgeon performed a carpal-tunnel-release operation, instead of a trigger-finger-release procedure.

What did the surgeon learn? “I no longer see these protocols (the Time Out) as a burden. That is the lesson,” he said.

It is unfortunate that so many see the proper execution of a Time Out as an unnecessary time waster until “it” happens to them.

Experience is a great teacher, but she sends in terrific bills.

Watch a three-minute movie about LifeWings.