Staying on Course

England’s National Health Service (NHS) published the NHS Constitution this week, designed to protect and forward the rights of patients. I looked at the pamphlet that was sent out to the community for feedback during the development of the Constitution. It starts with the sentence "The NHS belongs to the people." That is a powerful statement. Imagine a health system that belongs to the people. Here is a short interview with health secretary, Alan Johnson.

While reading other comments in The Guardian about the NHS Constitution, it struck me how different these conversations are from ours here in America and here in Contra Costa County. I’ve been told that our public system in Contra Costa County was in part modeled on the British system (NHS). So I ask, what about our system? To whom does it belong? Who has a right to use it? How are we presenting it and what are peoples' perceptions of it? Speaking about his convictions regarding health care, Don Berwick in a letter to his daughter Jessica said, "we aren’t asking if it's a human right, we’re saying it is." He described an unyielding conviction to build a better world. That better world will require a great deal of change. To read more thoughts about what that change might look like and how other systems around the world have evolved you can read Atul Gawande’s article published today in the New Yorker, Getting there from here.

I posted some thoughts about Reverend Martin Luther King Jr. last Monday. The following reflection can be found on our on our medical center website:

In the immortal words of the late Reverend Martin Luther King, Jr., we are reminded that life's most urgent question is: What are you doing for others? Public hospitals like Contra Costa Regional play a critical role in providing health care, and we are proud of our role as the health care safety-net for vulnerable populations. We care about the community we serve.

As we look forward, storm clouds seem to be forming on every front. It’s tempting to head for the shelter of what is safe and familiar when the path we should take isn't well marked. While we may not be able to see the path, we must remember that we do have a compass: it is our mission, to care for and improve the health of all people in Contra Costa County with special attention to those who are most vulnerable to health problems.

Can you see it? Our mission points the way we must go. We belong to the people of Contra Costa County; we are here to serve them. With what looks to be dark skies ahead, now more than ever we must constantly refer to our compass, our mission. It tells us what to do. It tells us where our attention should lie. It tells us who we are.

Possibility

This is my son 10 years ago standing at the edge of the reflecting pool, near the base of the steps of the Lincoln Memorial. We had spent the week talking about the monuments and what they stood for. This was the moment that stands out in my memory of that trip.

To see the possibility in my child's eyes, the possibility that he could achieve anything he could imagine, was a moment I will never forget. The truth is that our children are the face of tomorrow.

Today we honor Martin Luther King, Jr. His message still every bit as relevant today. He spoke of the "fierce urgency of now" and the temptation of the "tranquilizing drug of gradualism."



Dr. King refused to settle for anything less than the the opportunity to realize the American dream for all people. It is because of his courage and the courage of many other Americans that my son could stand years later at the edge of the same pool and imagine that anything is possible.

I am eternally grateful to Martin Luther King, Jr. and the many who fought to bring freedom to all Americans.

Anna

Off and Running: Following up on the Sprint

It seems so often we never feel ready to begin action. I know in my case, I like to plan in ways that I can avoid all possibility of failure. In doing so, I often delay getting started on things that are really important to me. In fact, in some cases, the more important the outcome of something is to me the more I seem to delay getting started.

A couple of weeks ago, I shared news from the Institute for Healthcare Improvement (IHI) National Forum. The IHI introduced three new areas of work to us this year, as well as, the Improvement Map (if you're interested in reading a recent article about the Map and the new interventions from Healthleaders Media click here) .

Do you remember I asked for you to join me in a sprint to the summit? Well the department of surgery is off and running.

Here is a message I received from Dr Ramon Berguer, Head of the Department of Surgery

"Trial completed with both WHO and SCOAP checklists (total 4 cases). Overall quite positive, some redundancy we can modify. When I had to do a case without them this am I actually felt uncomfortable. In every case something was shared that one of the members either didn't know or forgot. I'll give you more details some other time. We'll continue to trial them and modify as needed. We'll be discussing this at PCC and will move forward with gradual implementation after we refine it a bit more."

This is a great example of leadership on the part of the surgery department. I am impressed with their nimble response and look forward to hearing about the future learning and discovery as they continue to test the use of the checklist under a variety of conditions.

Believe it or not, I was a runner as a young person. My strength was distance running, although I did run the 800-meter, which is considered a dash/sprint. What I learned when running relays was that the race was divided into different segments or 'legs,' and the team strengths were spread out throughout the course of the race. As I reflect on the work going on in the surgery department, it looks like the runner has left the blocks and leg one is underway!

I applaud the perioperative team and would like to thank them for getting us started on our 'Sprint to the Summit'.

More thoughts on this very soon…
Anna

Flying the Plane

I wanted to share an email with you that I found very compelling. It was written by our Residency Director, Dr. Jeremy Fish. I asked him if I may share it with you as I think you will find it both interesting and heartwarming.

Dear Residents,

The days have grown shorter, many of you now arrive at work in the dark, and leave work in the dark. That's not always the most fun thing to do as we prepare for the Holidays.
It's not unusual in this season of Joy for some of us to feel the pull of sadness. Family get-togethers, travel, missing travel because you have to work, buying gifts or not having time to buy gifts because your on a tough rotation---these are the dynamics of the Holiday season. Medicine is an everyday, 24 x 7 career---illness knows no holiday. I am always amazed, however, at how some patients can hold out and enjoy a holiday before crumbling into the Emergency department the day after the holiday. So, sometimes right when others are recovering from the frenzy of the holidays, our workload rises in a paradoxical way.
There is much sacrifice in becoming a family physician---few boundaries protect us from the reality of our patients. Yet I have great gratitude every year for the sacrifice and dedication our residents bring to work every day. Despite being the lowest paid, often hardest worked physicians in our system---residents bring a great deal of hope and healthy energy into this system. In fact, the residents are the core to our mission here in my view.
Sometimes I hear someone express that they think having residents makes healthcare riskier---maybe less safe for patients. They want attendings to be everywhere and do everything. Yet when I read carefully about what makes things safe I am reassured again and again that our residents make the care here better AND safer than it would be without them. Here's are some little known facts from intensive aviation research on the role of expertise and communication in flight safety .
One would guess that the safest way to fly is to have the most experienced, most expert person flying the commercial jet. That was a standard view in aviation until someone got the crazy idea of studying that assumption. In doing so, guess what they discovered-- -the safest flight records came when the LEAST EXPERIENCED person in the cockpit was actually FLYING THE PLANE . That perplexed a lot of people for a while until they looked into communication patterns. Guess what, very few people have the willingness to question the MOST EXPERIENCED person in the cockpit---out of deference and fear of offending him or her co-pilots have allowed planes to run out of gas, pilots fly into mountains, fly into the ocean---when subordinates clearly knew it was happening and very meekly attempted to HINT that the experienced pilot was making mistakes.
Guess what, most experienced and weathered experts DON'T HEAR HINTS !! They have learned to trust their own judgement above all others .
Well, when the lesser experienced person is in the pilot seat---the experienced person tends to pay more attention to more than just the direction they are going. Think of it like when running a code---if you are intubating the patient while trying to lead the code---you are NOT leading the code....in fact no one is leading the code. In emergency and risky situations that run outside the norm it is best to have a lesser experienced person in the driver's seat and the experienced veteran navigating, guiding, and planning. It turns out that the leadership role is the most critical element of safety---and that the leader is observing, guiding, directing but not always actually flying---especially when unexpected events occur.
The other major finding of these studies was that HORIZONTAL hierarchies in the cockpit are SAFER---meaning the pilot and co-pilot speak to each other as peers, using first names. This environment encourages the subordinate to speak more frankly when an emergency happens.
So two essential elements of our training program are that our RESIDENTS are often FLYING THE PLANE while our attendings (especially our most experienced) are guiding them, are comfortable being called by their first name, and setting a tone of calm no matter how crazy things appear in the moment. It is very reassuring and encouraging to me to find that key human behavior safety research confirms that our Residency training structure is exactly what safety experts would put together to assure healthy and safe communication for our patients.
Thank you all for assuring the health and safety of our patients and for working so hard and complaining so little as you complete three of the most vital years of your careers !!
Happy Holidays,
Jeremy

2009: Open Letter to Medical Staff Department Heads

Greetings,
As we enter this new year I resume my former role of Chief Medical Officer (CMO) which I had from 1987-2000.

(Trivia: What do I have in common with President Cleveland?)

In this role I will be the point person for staffing, contracting and union negotiations. I will work under the direction of Dr. Smith and collaboratively with him and with Dianne Dunn Bowie.

2009 is going to be a tough year for money. Nevertheless, I plan during the month of January to meet with each of you to better understand your current state staffing, vacancies and needs. I will then assemble this into one document. Jeff, Dianne and I will discuss it and will make decisions about how to prioritize and deploy the few vacant positions we have, and if, when and how to obtain additional ones.

Aina Wirthlin will be contacting each of you to set up an individual one hour meeting with me. Please bring written info to describe your current staffing and data to support any requests for additions. (Deming wrote: "In God I trust. Everyone else bring data.")

More that you can expect in 2009:

In addition, Jeff and I will be working to formalize the contracting structure and process to create more predictable and transparent outcomes. Any suggestions you have regarding this would be appreciated.

I expect all clinical department heads will be involved in issues regarding the continued need, contraction, or expansion of certain contract specialties. I do not plan to meet with any contractor without having the department head in the loop.

It is likely that I will desire standing meetings with each medical staff department head individually either monthly or quarterly to maintain open channels of communications and to create an established forum for constant engagement regarding physician services. We will talk more about this at our January meeting.

Given the severe budget shortfalls that will face the county (both state and local budget issues) we have no choice but to scrutinize exactly how we assign physicians. Our principle assignments as stewards of the public's money and health are to provide quality and access. In order to do so this year we may have to challenge long held paradigms.

And finally and most important: I expect each of you to be the "local experts" for your specialties. But I expect you to transcend that allegiance to be advocates for the system as a whole and the populations that we serve. I have utmost confidence that you will.

We can make lemonade.


Steven Tremain, M.D., A.B.F.P, F.A.C.P.E.
Chief Medical Officer & Chief Medical Information Officer

Where is System Redesign?

For my Dad on his birthday…

On June 9, 2005 the first annual Hospital Redesign Summit was held in San Diego. How much more perfect could this get, since I was charged with helping lead System Redesign? Like everyone else, I wasn't quite sure what that meant. I arrived late that night to San Diego after a very full week of long hours in the hospital dealing with what seemed to be an expanding list of issues. My week was not consumed by the halls of Contra Costa but spent in other hospitals sitting at the bedside of my father who had fallen quite ill. After what seemed to be weeks of sleepless nights, my father was transferred to a large tertiary medical center. It was a welcome reprieve as the drips and lines seemed to be increasing with each day. With him safely tucked in at one of the finest centers in the world, I could now get on a plane to learn more about “Redesign.” To be honest, I was tired and needed a break.

My day started off with a video from Sorrel King, mother of Josie. To this day I will never forget her words, the words of a mother who lost her child to a chain of errors and system failures.
~Josie King Story~
She challenged hospitals to think about having a team that was available to bring care quickly to people who were deteriorating before they went into a cardiac or respiratory arrest. She called it a medical emergency team or rapid response team.

I went from session to session and could not escape the realization that our system was broken. It wasn’t about the hospital, but rather the whole system of health. I also found others who were trying to learn ways to improve their systems through ‘redesign.’ I came home energized and full of ideas about improvement methods and reliability, and concepts like ‘spread.’ I also came home to find my father sicker than when I had left.

The days following the Summit were filled with ideas scribbled on paper while sitting at my father’s bedside. I tried to keep up as the teams rounded on him. It seemed so odd that after all the time I had spent in a hospital, I hadn't a clue how it all worked. I couldn't figure out who was in charge of which part of his body. I couldn't keep up with his deteriorating health and growing amount of health care intervention. It was truly a mess but in just a few more days he was discharged to my home for what would surely be a very long but full recovery. It was four days later I had come back to work for a meeting about the digital diagnostic imaging system (PACS) when the call came in about my Dad. It wasn't good news…

As I drove home that night from the mortuary I wondered. Did he experience any harm due to error? He took high-risk medication, what if it was the insulin? Was it a postoperative complication or infection? Was it sepsis? I wondered what might have happened if there were some mechanism like the rapid response team that Sorrell King had described. I wondered about the people we serve.

When I returned to work, the System Redesign Team approached the most senior leadership and the Performance Improvement Committee with a request to endorse and actively participate in the IHI 100k Lives Campaign. In the months to follow, leaders all over the system stepped forward. Tools and how-to-guides were brought to life by teams that had already been working in many aspects of the 100k Lives Campaign interventions. We heard stories of steady improvements that began to take the form of breakthrough improvement. The energy was palpable.

As I read through the email responses to my ‘small test’ in communication and was stopped in the halls this last week, I realized that many people are wondering, "What ever happened to System Redesign?" It's a reasonable question, and it points to how redesign elements have been integrated into the current system. System Redesign was never occurring in a conference room but rather in improvement teams on your unit. 'System Redesign' wasn't a committee making sweeping changes and impersonal decisions that shaped the experience of the individuals we serve: you were, one decision at a time, one experience at a time, one patient at a time. The team located tools from experts to share with you. Tools that others across the nation had found, if used reliably, made it easier to do the right thing for your patients.

So where is System Redesign now? System Redesign has been diffused into structures such as Safety and Performance Improvement. Under the leadership of Dr. Tremain and many others, the County Board of Supervisors is learning more about safety and improvement and hearing stories from many of you about improvement efforts in your area. Redesign can also be found on every unit in the system. I have walked the units and found improvement emerging without exception in every site. I found a number of people who said you didn't need more resources but you needed to find different ways to do the right thing, a viewpoint supported by Steve Spear this last week in the New York Times (More for more? Spear, S.), where he notes that in health care, more is not necessarily better. Not necessarily more, but different, that is redesign.
Recently, I was on the fourth floor and a rapid response was called. I watched as the team delivered what appeared to be a seamless response that resulted in a rapid transition to critical care. I thought of his family. A few days later, I learned that the man had been discharged home. I thought of my Dad.

There is no wizard........

No, Dorothy, there is no wizard. We can't click our heels together and make patient care safer, and we can't click our heels together to balance the budget. Patient Safety, Quality Improvement, and all Financial Stewardship require hard work....every day.

I bundle these together for many reasons.

First, they are indeed intricately connected. We know that unsafe, ineffective, inefficient, or poorly timed care is not just bad care, it is wasteful care. Many of us grew up in the era where we were constantly told that more care = better care. We know better now. Better care = better care, and better care is often less care, especially if the "more care" comes from trying to get it right a second time.

Second, I recently was at IHI where Dr. Berwick eloquently talked about the two choices we all have...to fight to continue to make care safer over the next twenty years, or to give up because it is too hard and because the returns on our hard work and emotional committment are often too elusive. And then I returned to Contra Costa and California where we are faced with astronomical budget deficits. We will need to answer Dr. Berwick's question within this economic context.

So what's my answer? Giving up is not an option. We will work together to continue to improve the quality of the care we give. It will not be easy, and there will be tough choices, but giving up is not one of them.

And clicking our ruby slippers is not an option either.