As someone who has run a number of marathons in my life, I have come to appreciate the term hitting the wall. No matter how well a runner trains, or how good we feel during the run, “the wall” can still stop us in our tracks around the 18-20 mile marker. Speaking from experience, when a marathoner hits the wall there is a choice to be made. There is an overpowering urge to walk off the course and go home–it is a miserable feeling. But we continue, walking at times if we need to because we are so close to the finish line and reaching the personal goal we set.
Many of us who spend our time in quality and safety can also hit a similar wall at times – I know I do. There are times when it seems like we take one step forward and two steps back. We get frustrated when change comes slowly, or certain physicians push back, wanting to keep the status quo even when the evidence shows they need to change the way they do things because it is harming patients. People tell us changing culture takes time and we need to be patient, but it is not always easy to accept–especially when we watch patient harm continue.
When I hit that quality and safety wall, I turn to our next generation of caregivers – residents and students. They are my 5 hour energy drink, my Red Bull, my Jolt Cola. This happened to me recently…but two next generation, resident-driven quality and safety successes pulled me out of my “we will never change healthcare” funk, and re-energized me as it always does:
First, seeing that the John Eisenberg Patient Safety and Quality Awards recognized the great work being done by a group of residents at the New York-Presbyterian Hospital/Weill Cornell Medical Center for their implementation of a Housestaff Quality Council (HQC). I first heard about this wonderful program when it was presented at an AAMC Integrating Quality meeting in Chicago a few years ago. Driven by a small group of committed residents who wanted to improve the quality of care being provided for their patients, they didn’t sit back waiting for their faculty to lead – they stepped up and led the work themselves. Because of their determined efforts even in the face of long duty hours, the HQC contributed to a number of hospital-wide sustainable care improvements for their patients. More information can be found in this Jt Comm J Qual Patient Saf article.
- Second, I was able to spend time with a number of friends from the Committee of Interns and Residents (CIR) a week ago in New York. Similar to the work being done by the HQC at New York Presbyterian Hospital, quality and safety leaders Hilary Corrigan, Justin Wood, Sandy Shea and Michael Kantrowitz shared some of the great quality and safety work CIR residents are doing across their system. CIR made a major commitment to resident quality and safety education a few years ago. Part of that commitment is the funding of ten resident leaders each year to attend the Telluride Patient Safety Resident Summer Camp. Many of you have read their reflections on the Telluride experience and about the work they are doing at their hospitals in this blog as well as Paul Levy’s blog–work that originated in Telluride. It is all resident driven work that is helping improve the quality of care being provided to their patients while saving lives.
Sometimes you don’t really need to “Educate the Young” – we just need to mentor them a little, provide support when they ask for it and then get out of their way. If the academic medical center culture is supportive (and not toxic), resident physicians can help us make significant improvements to patient care. They do this work because they know it is important and much needed. Without 20-30 years of growing accustomed to a certain way of doing things, and the lifestyle that comes with it, they don’t question what needs to change. They just roll up their sleeves and change it.
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…
The 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.
I was hoping it was only a matter of time before medical education made its way to Coursera. For those not yet in the know, Coursera enables the best universities to put courses online at no cost to students. As of September 2012, Coursera claims a student body of 1.5M from approximately 196 countries around the world, and offers 195 courses from science and technology to the humanities to health policy. Course enrollment ranges from 10K to 130K students per class, and the company’s goal is to deliver high quality content at the lowest possible cost to anyone, anywhere that desires to learn something new. Daphne Koller, co-founder of Coursera and a Stanford professor of computer science, doesn’t see their model replacing brick and mortar higher education–just forcing its hand in order to kick the quality up a notch or two.
Recently, Mount Sinai Medical School began offering three courses through Coursera’s MOOC (massive open online course) format:
- Dynamic Modeling Methods for Systems Biology
- Introduction to Systems Biology
- Network Analysis in Systems Biology
How will this format benefit, or detract from, a medical education? What format yet to be made mainstream would best fit medical training? Educational technology catch phrases like “blended learning” and “1:1 technology” seem like two elements that would easily enhance any learning environment without too much trouble, but how quickly are these new learning methodologies being accepted, implemented and adopted in medical schools? For more information on educational trends–see the Edtech Digest blog, and for the related new vocabulary, see this recent post, Trends–Infographic: Edtech Cheat Sheet.
In an earlier ETY post, The Changing Educational Paradigm, MOOCs had just recently been opened up to a mainstream audience and I promised to report back on my own exploration. I highly recommend without reservation trying it out firsthand, as there is a topic for everyone, and being able to access the site 24 hours a day allows for flexibility. I only wish I needed fewer hours of sleep than I do to function! My first course, Fantasy and Science Fiction: The Human Mind, Our Modern World, required students to read a classic work of literature each week, and as such, held more content than my current work-life could balance. The video lectures I viewed, however, were entertaining, insightful and provided in-depth analyses of some of the very best literary works, such as Dracula, Grimm’s Fairy Tales, Frankenstein and The Martian Chronicles.
The consummate student, I’ve since explored a second MOOC, Gamification, offered by Kevin Werbach Associate Professor, The Wharton School, Univ. of Pennsylvania. This course was much more manageable than my first exposure to this exciting new educational format, and as a result a record 8,280 students earned a certificate of completion. The Gamification class had 80,000 students from around the world, with one of the most active self-application rates of all Coursera courses, and a very active Twitter stream to accompany the discussions and meetups–see #gamification12 for more information. A short explanation of the course follows if interested:
On Tuesday, the Coursera servers were down according to their Twitter feed. Quite honestly, I’m surprised it doesn’t happen more often given the number of users accessing this site on a daily basis. The speed with which this educational model was adopted around the world is amazing. It speaks to the hunger we have for knowledge, and the need for high quality content. Regarding the collaboration and global networking opportunities? They are endless, and have only just begun to play out. In fact, if anyone knows how to get in contact with the decision-makers at Coursera, please contact me. I know a great Patient Safety & Quality elective that should be added to their offerings!