Lucian Leape via @theNPSF on Culture Change for Safer Healthcare: A Daily Commitment

Please enjoy this message from the National Patient Safety Foundation and Dr. Lucian Leape.

Have a safe and happy holiday weekend!


High Reliability Boot Camp: Preparing for Zero Preventable Harm

MedStar Health is partnering with HPI (Healthcare Performance Improvement) to take this innovative health system to zero preventable harm utilizing the principles of high reliability organizations we have discussed previously on ETY (see Travel Buddies…, Reporting on Near Misses…, Mindlessness vs Mindfulness, and more!)

With the depth of data now available to patients, providers and administrators, it’s much easier for all to see how well we are doing and where our challenges exist in healthcare. And while data allows for benchmarking, reimbursement, transparency and more, Judy Ewald, Senior Consultant from HPI reminded all in the room that what patients want while in our care remains very simple:

  1. Don’t Harm Me
  2. Heal Me
  3. Be Nice to Me

Since the number one goal of all healthcare providers is to do no harm it would seem everyone is aligned. Not to mention, medical harm is costly — per HPI’s data, 16% of patients sampled who experienced an adverse event had increased hospital costs associated with that event, which amounted to $387M in a 2008 sample of Medicare patients. And that’s just the dollars and senselessness of it. Too many patients and families pay for medical harm with both mind and body. But this isn’t new information — we know this. So how do we change it?

HPI provides some tangible tools and a road map that health systems can turn to in order to embed a transparent culture of safety–a reliability culture, designed for safety that integrates human factors engineering making it intuitive for healthcare providers to do the ‘right’ thing, and harder to do the ‘wrong’ thing. MedStar Health, with its own National Center for Human Factors Engineering led by Terry Fairbanks MD, is poised to embed this crowning skill set into their high reliability journey.

Nationwide Children’s Hospital in Columbus, OH is part of the HPI family and provides an excellent example of the transparency high reliability seeking organizations also embrace along the way. The link above takes you directly to their external website, and an open discussion on their serious safety event rate. The video below models an excellent example of leadership around the type of transparency needed to be successful.

And finally, here are some key takeaways from Monday’s high reliability boot camp:

  1. The role of a leader in a safe and reliable culture includes: 1) Defining values & expectations; 2) Finding and fixing problems, and; 3) Reinforcing and building accountability
  2. Safety has to be the Number One organizational focus. No other agenda takes higher priority.
  3. A summary from the work of Edgar Schein, Society of Sloan Fellows Professor of Management Emeritus and a Professor Emeritus at the MIT Sloan School of Management — If you want to change culture, remember it will be a result of what your employees see you doing as a leader — the behavior you reward, the stories you share openly, how transparent you are as a leader and how you respond in the critical moments.
  4. Practice 5:1 Feedback with all associates — 5 positive reinforcements to every one negative.
  5. Communication is key. Find a tool that works and make it standard work. I liked SBAR.
  • Situation (What’s the situation, patient or project?)
  • Background (What’s the important information/problems/precautions?)
  • Assessment (What’s your read of situation, problems/precautions?)
  • Recommendation (What’s your recommendation, request or plan?)

If you too are on the journey to high reliability, we would love to hear about it! Please share the solutions and tools that have helped, and the challenges along the way.


Healthcare Delivery of the Future Driven by Patient Centered Research

Always intrigued by what the future of healthcare might look like, I’m sharing a video that was shown at a research retreat hosted by the MedStar Health Research Institute, led by Neil Weissman and Kelly Smith.

With a call from AHRQ, NIH, PCORI and more, to include patients and families in research that can be quickly implemented at the point of care, how far away do you think the healthcare environment envisioned by Microsoft above really is? What is your vision of healthcare delivery for the future? The research paradigm, like the educational paradigm, is shifting and all are being invited to contribute their ideas. Jump in!

And finally, one more example of future care delivery provided by Kaiser Permanente’s Center for Total Health:


Using Play and Games to Achieve Educational Objectives

The @Edutopia Big Thinker Series presents Katie Salen, Executive Director of the Institute of Play, and Professor in the School of Computing and Digital Media at DePaul University. From the Institute of Play website, Katie: 

The overarching theme from her short video below is that games provide excellent learning environments by allowing for collaboration, team building, exploration of identities, and also a forgiving space where students have the ability to take risks and fail. There is a growing movement toward using these playful environments to uncover the needs of a future yet to be defined in many industries.

Much of medical education has traditionally been the antithesis of this new order for education — where collaboration, continuous exploration and discovery are just as valuable as having what is believed to be the “right” answers for today. Will health sciences schools be willing to adopt a new culture of learning? Are some already doing so? Please share!


Benchmarking and Safety: Should We Be Concerned?

bench·marking

  1. A standard of excellence, achievement, etc., against which similar things must be measured or judged.
  2. Any standard or reference by which others can be measured or judged.

When I was young, my friends used to say I was too competitive for my own good–though they described my competitive tendencies with a little more color. They even accused me of “bending the rules” at times just to gain a competitive advantage. Whether it was the testosterone of my teens, or just something inbred in my character, I hated losing.  As I grew older and entered healthcare, the competitive fire mellowed and my vocabulary changed to phrases like “win-win” situations, collaboration, shared learning…and benchmarking.

Benchmarking is a very important tool used in most industries including healthcare. I have always been a big believer in benchmarking one’s outcomes against others. From an improvement standpoint, how else can we assess where we stand against a norm, and then use those benchmarks to focus on quality and safety improvements? Made total sense to me. Besides, from a safety and quality standpoint, hospitals are constantly being benchmarked against one another by numerous organizations that publish grades, scorecards, self-developed rankings, and more.

Paul Levy & Dave Mayer at MedStar Health Quality & Safety Retreat April 2013

Paul Levy & Dave Mayer at MedStar Health Quality & Safety Retreat April 2013

A few things have now made me re-think some of my beliefs related to benchmarking, and the possible unintended consequences that may be occurring in the quality and safety domain. One challenge to my thinking occurred when Paul Levy (Not Running A Hospital) recently spoke to over 100 quality, safety and risk management leaders from across our health system. Paul spoke on transparency, and the ground-breaking work done at BI Deaconess while he was CEO there many years ago. During his talk, he also shared his thoughts on benchmarking and stated:

“There is no virtue in benchmarking to a substandard norm. Eliminate. Don’t benchmark!”

Wow – Don’t Benchmark?? His statement reminded me of a quote I have often heard throughout the years…”In the land of the blind, the one-eyed man is king”.

As I connect with safety colleagues and friends across the country, it seems we have all set the quality and safety benchmarking goal of being in the top 10% of hospitals across the country. Math was never my best subject, but even I can figure out we can’t all possibly be in the top 10%. It also means those that benchmark to the top 10% still have a long way to go to eliminate harm, as Paul points out.

Striving to achieve quality and safety greatness is vital for all us; using outcome measures to track our progress is a necessary component in achieving that highest level of care. However, my growing concern is that benchmarking might be used only to gain the “competitive advantage” for increasingly uncertain healthcare dollars. If this mindset takes hold, then why share safety and quality best practices with others for fear you might lose your ranking to a competitor? I don’t believe safety and quality people think this way…but am concerned many CFO’s have to. Competing on safety is something other high-risk industries, like aviation, have never done. Airlines may compete on things like on-time arrivals, lost baggage, or customer service, but they always share safety learnings and best-practices.

Paul is right. As far as safety goes, if we strive to eliminate (versus benchmark against a substandard norm), we only compete against ourselves. We know what the ultimate measure of success is – zero harm. More thoughts on competitive concern to come…


@edutopia Big Thinkers on Education: Where is #Meded?

From legendary film director, Martin Scorsese to Sir Kenneth Robinson (ETY post, The Changing Educational Paradigm) to John Seely Brown (ETY post, A New Culture of Learning) and Constance Steinkuehler, Asst. Professor in the Digital Media program in the Curriculum & Instruction department at UW-Madison, and a founding fellow of the Games+Learning+Society Initiative whose video follows–all are contributing their expertise to the redesign of education via Edutopia, a product of The George Lucas Educational Foundation. Lucas’ Foundation has produced the Big Thinkers on Education video series, and is enlisting the impressive list above, along with others at the top of their fields to contribute their ideas to the changing educational paradigm.

Following is the first in a series of short synopses from the Big Thinkers on Education series for ETY–

In the above video, Steinkuehler, who recently left her White House post as Senior Policy Analyst at the Office of Science and Technology Policy in the Executive Office of the President to return to UW-Madison, shares that she:

…studies thinking and learning in the form of online games…the intersection between videogames and online cultures and social networks like Facebook. [She performs] large empirical studies on what kids are doing [as well as studies] the intellectual side of online play in all forms, how games matter, what matters about them, and how do we save the world?

Where are medical educators flocking to join, learn and contribute to the conversations on innovation in education? There is much to learn from those working to engage the minds of students — young and old — in new, and meaningful ways. Please share what you have found in medical education innovation here on ETY!


Collateral Damage: Take Two

“Doctors love to patronize and dominate. Their arrogance and indifference to the philosophy of informed consent is widely known. Surprisingly, most residents and doctors in teaching public hospitals tacitly endorse such reservations against information sharing. To most of them getting informed consent is a needless nuisance, to be delegated to a raw resident whose sole responsibility is to get the patient’s signature on the dotted line.”
Issues in Medical Ethics Volume 8, Number 4, October-December 2000…and Chapter One, Page 1 of Dan Walter’s book titled Collateral Damage

Walt Kelly, 1970

Walt Kelly, 1970

It has only been a few weeks since reading Dan’s book – yet I felt compelled to go back this weekend and read sections of it again. Since medical school, I rarely read something–even the Sunday paper–without a yellow highlighter in my hand, a side effect of the competitive paranoia instilled in me during medical school. I went back this weekend to the sections I had highlighted in Dan’s book, and found the quote above, right up front – Chapter One, Page One. I understand and appreciate why Dan purposely chose that quote to open his book.  I also knew why I had highlighted it a few weeks ago…long before I had finished reading Pam’s story and all the research Dan so eloquently presents  on the “cardiac ablation business”.

I had highlighted this section because that opening paragraph took me back to last summer, and our Telluride Patient Safety Roundtable and Resident Physician Summer Camp. Resident physician leaders from across the country spend one week immersed in patient safety with a major focus on open and honest communication. Over a three-week period during the summer, almost 100 residents and health science students join us in Telluride, CO to learn about important concepts related to patient safety and transparency. Here is a short video clip about the student summer camp, which has organically grown from a roundtable discussion of patient safety diehards and patient advocates over the last nine years into what is now an Educate the Young patient safety summer school. Patients help teach all sessions at the summer camp.

A three-hour session on informed consent/shared decision-making is part of the week-long curriculum in Telluride. At the end of this session last year, Paul Levy (@PaulFLevy, Not Running a Hospital) asked the residents how much informed consent training they had received during medical school and residency. With a show of hands, every resident acknowledged the three-hour session on informed consent/shared decision-making at the Telluride Summer Camp was more training than they received during their entire medical school and residency combined. We all agreed this was a sad commentary on the current state of medical education as it relates to patient centered care. One of our Telluride residents went even further when he posted this reflection on the day’s educational session:

I don’t think that I’ve ever thought so much about informed consent as I did today. A discussion about informed consent to the level of detail that we had today needs to be part of all residency training in the first days of orientation and as refresher training later on in training. All physicians can, and should, do much better in providing informed consent.

Over the years, I have come to know many patients and families who have been harmed from care. It seems almost every story that was shared had a serious breakdown in informed consent, or more appropriately, shared decision-making.  The families of Lewis Blackman and Michael Skolnik, and many others, might have chosen much different treatment courses if all the risks and procedural outcomes were shared with them.

We need to get this right. It is fundamental to ever achieving high quality, safe care.  If we don’t, we will continue to see unnecessary harm, more books like Collateral Damage and more films like The Faces of Medical Error…From Tears to Transparency. As Pogo says “We have met the Enemy…and he is us.”


Follow

Get every new post delivered to your Inbox.

Join 903 other followers