Happy Holidays and A Happy New Year!

To all our readers:

Thank you for sharing in our passion for education and a safer healthcare system for all–

See you in 2013!

The Value of Inviting Patients to Participate In Their Care–Rosemary Gibson at MedStar Health

As a holiday gift to our readers, we would like to share a talk given by Rosemary Gibson, noted author and patient advocate, who was just named in a recent Forbes article as one of 13 to Watch in 2013: The Unsung Heroes of Healthcare.  Rosemary was kind enough to share her expertise with the Patient Safety and Quality leadership at MedStar Health this past October. In an earlier post, Dave Mayer provided highlights from her keynote address, found here. The following video is a copy of her talk, as she outlines the value of ensuring patients are included in all aspects of their care.

Please share Rosemary’s wisdom with your own institutions, as we take a break from blogging this week to reflect and recharge for 2013!

More “Skin in the Game” – Is This Where We Are Going?

The name of this blog, Educate the Young–and on occasion Regulate the Old, originated from the somewhat disheartening realization that education alone wasn’t going to create the complete adoption of cultural change–the collective mindfulness of high reliability organizations, and the personal commitment of every caregiver to do all the extra little things it takes to ensure our patients are as safe as possible. To be fully patient-centered, not self-centered. Unfortunately, regulations, carrots and sticks, and negative reinforcements may also appear to be necessary to create the behavior change needed to get us to zero preventable harm events. These rules can sometimes be painful and appear to oppose a just culture approach, but they have also been shown to work when other behavior change methods do not. While the debate over the value of extrinsic versus intrinsic motivators to change continues, so does the harm to our patients.

In Bob Wachter’s post this summer, The New and Improved “Understanding Patient Safety” and Evolution of the Safety Field, he states that the greatest change in his thinking over the past 5 years is the need to balance:

…a “no blame” approach (for the innocent slips and mistakes for which it is appropriate) with an accountability approach (including blame and penalties as needed) for caregivers who are habitually careless, disruptive, unmotivated, or fail to heed reasonable quality and safety rules. Fine-tuning this balance may well be the most challenging and important issue facing our field over the next 5-10 years.

And in November of this year, Peter Pronovost commented in his blog (here) on the leadership it will take, not only to turn Parkland Hospital around, but others as well:

…doctors, nurses and administrators care deeply about patients; they do not want to harm them. They work with broken, underresourced systems. The next CEO must recognize this and seek to understand rather than judge, to learn and improve rather than blame and shame…This won’t be easy. The public wants accountability. Parkland is under scrutiny from federal and state regulators. Yet real improvements will come from internal rather than external motivation…The CEO will need to help the staff see shortcomings in safety as their problem and believe they are capable of solving it. The CEO will need to inspire with lofty oratory, and then drop down, roll up her sleeves, and get things done.

Financial penalties based on safety and quality measures are now prevalent in healthcare. Value-based purchasing, quality care indicators, and readmissions are now tied to revenue deductions, and more measures tied to reimbursement are on the way. Will continuing to increase these type of quality-base incentives be what it finally takes to get us to where quality and safety should be? Or are there more severe penalties on the horizon for not following evidenced-based safe practices?

People are now speculating on what would happen if physicians had more “skin in the game” — a Warren Buffet-ism suggesting that people who feel the hurt financially when something goes wrong will take a more vested interest in the outcome of their efforts. This risk-taking behavior change is seen in business and other areas, including healthcare. In a recent post on his blog, A proposed exception to malpractice coverage, Paul Levy posed a “what if”:

…Any surgeon who has carried out a wrong-site surgery who did not follow the universal protocol for a time-out would not be covered for malpractice claims on that procedure.  Any anesthesiologist who was attending such a surgery likewise would not be covered for malpractice claims on that procedure…

There is possible history behind this proposal. Obtaining informed consent to do a procedure on one part of the body and then (after knowingly violating safe policies and procedures like universal protocol) “harming” another part of the body without gaining informed consent could be classified as battery and a criminal offense. Some in the legal community believe this approach could be used to negate malpractice coverage as wrong-sided surgeries and procedures continue to occur.

The response Paul received provided a good look into just how complex this behavior change is, and in a follow-up post, Let’s go for autonomy, mastery and purpose, he responded by sharing that in his experience, it takes a balance of attention to the needs of the systems in tandem with personal accountability, referring to Dan Pink, a motivation expert, author and TED Talk alumni that carrots and sticks detract from, rather than build up, a workforce.

So would more skin in the game, and a hit to one’s financial well-being (e.g. home, automobile and other personal assets), be what is necessary to help create the culture change we now need to put our patients first and show the last safety “hold-outs” that people are fed up with non-compliance to policies and procedures that have been shown to reduce risk?  I for one would like to believe this is not true–that the vast majority of us still embody our oath to do no harm first and foremost, and that financial or personal gain is not the driving force behind our efforts in healthcare. But I have also watched improvements in care occur at a much slower pace than hoped, and sometimes only after CMS required it–despite all educational energy and effort put into those improvements prior to the mandates. The conversation continues…

How the Stories of Our Lives Can Change Healthcare

If you’re interested in how to use stories to change your healthcare work, please watch this two-minute video before reading.

In my new favorite magazine, Fast Company, a Co.Create section article, The Heart of Storytelling… recently highlighted how the American Red Cross is using stories of those who have received their services to help share their message and provide information about the work they do. To the credit of both the Red Cross and their ad agency, BBDO New York, the two groups recognized that their original ad campaign using storytelling lacked authenticity and felt forced. So instead, they mailed video cameras to those who could tell the story first hand, and then edited the content to share the words of those who had lived these life-changing events, such as:

Maybe putting a camera, or tools like social media, blogs, email, or good old-fashioned pen and paper in the hands of more patients, allowing them to tell the world about authentic experiences of care will leave a greater impact on those providing care, as well as their peers and consumers of healthcare. We’ve been told by many expert storytellers to share stories that touch the heart to create the change we need. But how long do emotions need to stay charged in order to equal action? And what is it that finally flips the switch to act? Is it unwavering social support or is it that the “character” within the story moves us to action? The suspension of disbelief created in a movie theater is fleeting, and the change needed in healthcare is lasting and challenging. Do we need to be reminded of these patient stories over and over, or will we become desensitized over time?

In an April 2012 Social Science & Medicine article, Aspirin Use and Cardiovascular Events, Strully & Fowler et al showed again how social networks influence health behavior–specifically cardiovascular health in this study. Their research showed that the cardiovascular event of a same sex friend or family member–i.e. a woman’s female friend or a man’s brother–was shown to increase the likelihood that each would adopt aspirin therapy to prevent cardiovascular disease. Their research also considered the confounding factor that those who actually took aspirin might be influenced by the same well-meaning physician–however this turned out not to be the case. The story this data could be telling us is that health behavior is influenced more so by the story lines of the lives of friends and family than the prescriptions given by healthcare professionals for non-acute care. At least for me, this research implies my health behavior will change when one of my girlfriends has a stroke. This research also implies that maybe we don’t have to wait for someone “like us” to have a cardiovascular event before we change the story. Rather, perhaps health prevention of the future is creating a new story altogether and targeting influential people within a social network to make treatment, or positive health behavior, spread like good gossip or a bad virus.

Using Healthcare Human Factors to Keep Patients Safe

We can’t change the human condition but we can change the conditions under which humans work.
James Reason

I had the chance to attend a mini-course on the Science of Safety at IHI’s 24th Annual Forum last week, led by Don Berwick and others. I have heard him give this talk before but it is a good message…plus Don can speak on hand soap and totally engage his audience while making the talk educational. His focus was on how and what we can learn by adapting human factors engineering principles in our healthcare work. Don referred to James Reason’s quote above, and focused his presentation on 5 Human Factors Engineering lessons healthcare has to adopt within our culture:

  1. Avoid reliance on memory
  2. Simplify
  3. Standardize
  4. Use constraints and forcing functions
  5. Use protocols and checklists

Human factors engineering expertise is being invited into the safety and quality conversation more and more today.  Similar to that of patients and families, this set of eyes and knowledge has also been lacking from discussions that lead to meaningful change in our care systems. Large integrated health systems, like MedStar Health, are taking that next step and are making major investments in human factors engineering in their quest to make care safer for their patients at any cost. Terry Fairbanks and his team at the National Center for Human Factors Engineering in Healthcare represents this new model. The only large center of it kind in human factors engineering in the United States, Terry’s team is available to help redesign our systems (and others) in the best interest of patient safety, as well as design safer and more efficient systems altogether.

What is human factors engineering? A simple explanation from Terry’s website describe it as:

…an interdisciplinary approach to evaluating and improving the safety, efficiency, and robustness of work systems, such as healthcare delivery. Human Factors scientists and engineers study the intersection of people, technology, policy, and work across multiple domains, using an interdisciplinary approach that draws from cognitive psychology, organizational psychology, human performance, industrial engineering, systems engineering, and economic theory.

As Don Berwick emphasized in his talk, a human factors approach puts science into the safety conversation–providing us new ways to look at old problems. Albert Einstein warned us ‘we can’t solve problems by using the same kind of thinking we used when we created them’ and Terry’s team introduces new and different ways of thinking about the problems in our healthcare systems that continue to put patients at risk.

On March 11-12, 2013, Terry’s team will be the official host of the Human Factors and Ergonomics Society (HFES) conference in Baltimore.  This will not only help the HFES draw healthcare providers and administrators into their work, but also allow attendees to better understand how human factors applied to healthcare creates a safer healthcare environment for both patients and providers. It is a “must attend” conference for those looking at taking quality and safety learning to the next level.

Why Is Change So Hard In Healthcare?

Storify on ChangeThe IHI 24th Annual Forum was held this week in Orlando, and while I personally wasn’t able to make this year’s meeting, I was able to follow the conference through Twitter streams #IHI24Forum and #smIHI. As I await the release of the keynote addresses to the IHI website, the beauty of social media has allowed me to glean some highlights through the tweets of attendees. Thanks to all who added substance to the ~1.3 million IHI impressions on Twitter over the course of the week.

Of particular interest, was Dan Heath’s keynote on change. Heath, who co-authored best-sellers such as  Switch: How to Change Things When Change Is Hard and Made to Stick, has studied and written on why change is challenging, but also provides suggestions on how to make it happen. The image, On Change, links to a Storify aggregation of tweets highlighting his talk, as well as others discussing change at IHI. IHI’s email summary of Heath’s talk also provided key takeways:

Comparing the emotional and rational systems of the human brain, Heath offered guidance on how to impact change and reinforced the point that data alone is not sufficient to initiate change —- emotion is much more powerful. He urged attendees to tap into the emotional side of change as they lead improvement efforts in health care, and reminded all that failure in the process of change should not stop us in our efforts to lead improvement.

And, finally–please share your thoughts on healthcare change in the poll at the end of this post!

The Future of Medical Education: Very Real Simulation of Procedures and Teamwork

A resident at MedStar Washington Hospital Center practices laproscopic technique

A resident from MedStar Washington Hospital Center practices her laparoscopic technique.

In a previous ETY post, Medical Education and Classrooms of the Future, I briefly touched on the value of simulation in training healthcare professionals. Academic medical centers across the country continue to funnel resources toward high-tech simulation centers that put providers–young and old–in learning environments that spare the patient as test subject and encourage skill mastery through practice. Others are complementing high-tech learning with team-based drills, allowing multidisciplinary teams to practice emergency procedures long before they are faced with a similar real-time event. One such center, SiTEL, is one of many entities within the MedStar Health system in the Washington DC and Maryland area that is helping redefine the science of safety through translational research, education and innovation.

Dr. Tamika Auguste, an OB/GYN physician, is one of several innovators within the health system. Auguste is training residents and fellows at the MedStar Washington Hospital Center and Georgetown University Medical Center, as well as OB/GYN providers throughout MedStar, using technological and team-based simulation of obstetric and gynecologic procedures and emergencies. Skill development is only part of the equation, as the ability to anticipate next steps and effectively communicate with patients, and as a team, is what elevates care to new levels.

What is truly amazing is not so much the current technology being utilized, as Auguste will tell you that low-tech solutions sometimes create a more realistic feel of being “inside the body”, but rather the results from her MOST (MedStar Obstetrical Simulation Training) program, and the related reduction in adverse events for Moms and babies. Tamika, amiable and happy to relate her efforts even post-call when we spoke, shared that the MOST program focuses on teams who need to complete a set of tasks in rapid order to save the life of a Mom or baby. Her energy and enthusiasm is infectious in and of itself, but the results showing a reduction in the number of shoulder dystocia events at her hospitals are worth smiling about–whether a provider or patient in a MedStar hospital for OB/GYN care.

Residents from MWHC and MGUH watch as a colleague practices hysteroscopy skills

Residents from MWHC and MGUH watch as a colleague practices hysteroscopy skills.

A simple definition of shoulder dystocia, a sometimes unavoidable complication during childbirth, is a delay in labor due to the baby’s shoulder becoming lodged behind Mom’s pelvis. According to Auguste, the way a team responds to this occurrence is what can change outcomes for all involved. MOST training at all MedStar hospitals completed in 2012, and both brachial plexus injuries and clavicle fractures have been reduced overall. The Infant Mortality Rate (IMR=infant deaths/1000 births) in Washington DC has also declined from 13.1 in 2007 to 8.0 according to 2010 data. And while Auguste won’t take credit for the drop, the fact remains that in 2010 over half of all babies born in Washington DC came into the world at two of her hospitals (Washington Hospital Center and Georgetown University Medical Center).

MedStar programs to create simulation and training of obstetric procedures and emergencies reach deeper than just the training of healthcare providers and the care of Moms and babies within their own health system. In addition to MOST, the following programs Auguste oversees also reach into the local community, as well as the OB/GYN community across the US:

  • Resident, Fellow and Midwife Simulation Labs
  • Society of Maternal and Fetal Medicine Postgraduate Course Development
  • ACOG Simulation Consortium Member
  • Community Outreach Partnership – Unity Healthcare
  • Special Moms/Special Babies (SMSB)
  • Teen Alliance for Prepared Parenting (TAPP)
  • MedStar Georgetown University Hospital – Girl Talk 2 Program

For more information on residency programs or OB/GYN simulation training, contact Dr. Tamika Auguste at MedStar Washington Hospital Center. Meanwhile, stayed tuned for future examples of medical education simulation and training–both high-tech and low-tech–and please share what you have found along the way.