Saturday, February 28, 2009

Health Now

Providing us with a mirror, the Post offers a bleak glimpse into reality and shining example to us all.

A great piece. This is not somewhere or someone else.

Wouldn't it be great if we never needed such service?

Wednesday, February 25, 2009

The Future of Health Care

No one can really forecast the future of health care in the United States.

There is much talk about health care reform. There are a multitude of ideas. Indeed, there are some programs in place that may lay the groundwork for a new system of care.

Many constituencies have their favorite plans--single payer, managed care expansion, mandatory insurance, open access, regulatory control, pay for performance, etc. etc.

Yet, the future is uncertain, to say the least. And many of us wonder how the ultimate "decisions" about reform will be made. Who will have influence? How will it happen? Will it actually be a "rational" choice, or will the result merely be a "tumble down the road?"

Who can say? Yet, there are some "solid" realities that appear to me--and to others also.

In the US, we spend about $7,000 per year on health care for each and every resident in the country. Systems of care in other countries, that are considered models, spend less than half that amount. Meanwhile, our population health care outcome measures fall below many of those in model countries. In essence, we don't receive a very high quality product for our expenditure--raising the question of whether or not health care is really the "product" of our health care system.

With our economy in free fall, the sources of our health care dollars are quickly shrinking--government revenue, business revenue, investment revenue are all direct "hits" during the "recession/depression." In a world where many already feel that we are paying too much for health care, there is now considerably less to even think about spending.

As we divide up the $7,000 per person, we all wonder who truly benefits the most from these expenditures--drug companies, Wall Street, insurance companies, hospitals, technology companies, doctors, nurses, other employees of health care systems, or the patients? In the face of declining outcome measures and high rates of harm, it is hard to make the case that the patient is the primary beneficiary.

Human nature teaches us that the strongest opposition to change will be the ones who benefit most from the current system. If they are the most powerful of the constituents also, the road to change will be difficult without a revolutionary pressure to change. Kuhn raised a similar concept in his seminal explanation of change, "The Structure of Scientific Revolutions."

What we call the "health care system" actually is what mathematicians call a "complex adaptive system." Such a system changes always and changes like an amoeba--based upon rules, but slowly, incoherently, unpredictably, but adaptively. Some call this type of system a "chaotic" system. "Chaotic" in the sense that, in accord with Heisenberg's uncertainty law of physics, it is impossible to be certain of "where" the system is now, and "where" it is going at the same time.

Although the last century has seen a dramatic increase in the life expectancy of Americans (from 47 years in 1900 to about 77 years now), what we call "modern medicine" has accounted for very little of that improvement. Public health, sanitation, and improved socio-economics are responsible for most of the change. Medicine only contributed relatively small amounts with antibiotics and improved perinatal care. Although medicine "does" a lot, the contribution to population health is relatively small. And, for that matter, we have as a society nearly reached the limit of human life expectancy expansion.

So, I wonder if those six "solid" realities mean;

We are in the midst of a revolutionary change in the US health system, pressured by economic collapse and a general failure to produce increased quality of life. Individuals and groups who made a profit off of the old system of "care" will resist change and press for new profits, new enrichment. Those others who want more quality from the system will push for their version of quality. More and more people will become dissatisfied with the "disease treatment" paradigm of modern medicine and abandon it in favor of a "wellness" model of some sort. The client will generally want more focus upon increased quality of life rather than the mere avoidance of death.

Although we know that US health care will change, we will not be able to really see, predict, or understand any of the change except that which is "local" to us. The place where we can make a difference is that "local" part of the system--the individual contact with a client, the attention of the needs of family, the ongoing effort to improve, redefine goals based upon client desires, and the willingness to be a part of the solution.

Akin to any revolution (the American Revolution, the Industrial Revolution, etc.) the change happens locally, moment by moment, person by person, small action by small action. And that is our part in the process.

It is hard and frustrating work sometimes, yet it has a point and a purpose--maybe a goal that is not seen because it appears over the horizon, but still a purpose to improve and meet a need. And although "hope is not a plan," and we need plans to make progress. Hope is a sustaining resource that helps us all to maintain in the revolution.

I would not say, "hang in there, just keep your head down and move." That is NOT what we need. We need thoughtfulness, heads up and strong. But, strength comes from a center inside us all and hope nourishes that center.

Vaclav Havel, when talking about the Czech Revolution, said it much more eloquently than I can, "Hope is definitely not the same thing as optimism. It is not the conviction that something will turn out well, but the certainty that something makes sense, regardless of how it turns out."

In the end, our local actions will make it make sense.

Thursday, February 12, 2009

Check out Dr. James Mountford's latest work

When clinicians lead, published in The McKinsey Quarterly. A brilliant piece, well worth reading by Mountford and Webb.

I Believe

This was forwarded to me by a colleague. The following article appeared in the Washington Post this week. There is something about reading stories of transformation that are so inspiring to me.

Recently the President and CEO of Beth Israel Deaconess Medical Center, Paul Levy wrote on his blog that he had been worried lately that he had "adopted radical views suggesting that we learn together." He said he was worried that his "insistence on the importance of transparency with regard to eliminating certain types of infection...was just too outlandish for people to absorb and accept." He cited an article in USA Today about hospital acquired infections.

I found comfort in his introspection. I often feel like a radical and even outlandish at times. I look back just a few years ago. I remember when there were no red lines on the wall behind the beds. How did we know what 30 degrees looked like? What was a bundle? I remember when we didn't believe it possible to go months (even years in some cases) without a Ventilator-Associated Pneumonia. I remember when I believed the only rapid response was known as a "code blue." Why would I think otherwise? It's how I was trained.

Thankfully, things are changing here and everywhere. I enjoyed reading this article in The Washington Post. I find strength in the stories from the bedside of others who are committed to improving health care one test at a time.

I'm not sure I would have ever identified myself as a skeptic, but I can say without reservation that when it comes to improving health care through the use of the science of improvement and reliable design, I do believe.

A Skeptic Becomes A True Believer
By Manoj Jain
Special to The Washington Post
Tuesday, February 10, 2009; HE01

I was skeptical when my hospital embarked several years ago on an initiative to reduce the number of hospital-acquired infections in our intensive care unit.
These are infections that originate from the tubes and catheters inserted into the body -- for example, ventilator-associated pneumonia, related to a tube lodged in the windpipe to assist in breathing; urinary tract infection, related to a catheter inserted into the bladder to drain the urine; and bloodstream infection, related to a catheter threaded in the veins reaching the upper chamber of the heart.

Mind you, the tubes are critical for life-sustaining functions (breathing, nourishing, medicating and eliminating waste) during a serious illness when the body's organs are failing. The problem is that during the recovery period, some of the trillions of bacteria that live on a normal person's skin and in the alimentary, urinary and respiratory tracts begin to tunnel alongside the tubes into places they don't belong. Here they can cause life-threatening infections.

Before our initiative, for every 1,000 "device days" (for example, 100 ICU patients using one of those devices for 10 days), seven patients would get pneumonia, six would get blood infections and four would get a urine infection. That was the norm. In fact, for years I thought that hospital-acquired infections were the price we had to pay for intensive care. "You stay two weeks in the ICU and you get an infection -- that's not unusual," we would tell families.
And, honestly, it seemed to be a fair price. Patients with severe congestive heart failure and fluid in the lung are kept breathing by a ventilator until the heart recovers, the lung fluid clears and they are breathing on their own. Within a week they're back at home. So what if 10 percent of patients develop infections? We have powerful antibiotics to combat them. And so what if the treatment is expensive? (A ventilator-associated pneumonia or a bloodstream infection typically adds nearly $25,000 to the patient's hospital bill.) Medicare or an insurance company is paying.
Most important, without the devices, many of these patients would surely have died.
So as I said, I was skeptical when my hospital joined the quality improvement initiative led by the Institute for Healthcare Improvement, a nonprofit founded by Harvard pediatrician Donald Berwick.

Berwick is in the vanguard of nationwide efforts to reduce medical errors, standardize treatments, cut waste and bring patient-centered medical care to the bedside. Some 4,000 hospitals, including ours, participate in his institute's programs. In the case of our staff, Berwick insisted that we could reduce and even eliminate hospital-acquired infections.
Within a week after our first collaborative meeting (this was in the fall of 2002), the IHI team suggested that the ICU doctors and nurses at our hospital begin to use a checklist for every patient. For a patient on a ventilator, for example, it would include raising the head of the patient's bed to 30 degrees to prevent gastric secretions from going into the lung; seeing if ventilated patients could handle reduced sedation, so they could be extubated earlier; giving peptic ulcer prevention medicine to prevent gastric bleeding; and giving blood thinners to prevent clots in the leg that could potentially travel to the lung and cause a fatal pulmonary embolus.

Those sets of orders became known as an IHI "ventilator bundle." Similarly we had a "UTI bundle" for people with urinary catheters and a "central line bundle" for those getting catheters into the deep vessels close to the heart.

That last bundle required doctors to wear a sterile gown, mask and gloves before placing a central line -- a fairly obvious idea. I questioned how repeating such routine injunctions could have much effect on our infection rates.

But the truth is, at most hospitals in America, we have been far from 100 percent consistent on routine procedures. Berwick and the IHI realized that following those orders every time without a written guide was unrealistic. Airline pilots are not expected to do pre-flight checklists based on memory.

The quality improvement initiative forced us to look at the process, measure the results, provide feedback to key people and develop strategies to improve the care of our patients. Yet it all started with those checklists.

In fact, checklists may be one of the great medical innovations of recent years. Take the work of Peter Pronovost, an anesthesiologist at Johns Hopkins Hospital, rated one of the top 100 most influential people in the world last year by Time magazine. By implementing a checklist on the insertion and management of central venous lines with the help of Pronovost and his team, ICUs in Michigan hospitals reduced bloodstream infections to nearly zero.

Last month the New England Journal of Medicine published an international study led by Atul Gawande, a surgeon at Harvard, on implementing a checklist for surgical patients. It included common-sense things such as confirming the correct surgical site (left leg, not the right, for amputation) as well as technical checks, such as making sure antibiotic prophylaxis is given zero to 60 minutes before surgery, when it is most effective.

One item on the list is "Confirm all team members have introduced themselves by name and role." Studies have shown that a member of a health-care team is more likely to speak up when something is wrong if the members know each other by name.
That team concept has been key to the initiative at our hospital. Each morning, the ICU physician leads multidisciplinary rounds with the patients' nurses, ICU charge nurse, pharmacist, dietician, respiratory therapist and many others. That was a major change in our behavior, and its benefits were quickly apparent. With everybody on the team feeling responsible for reducing the number of infections, nurses became more vigilant, criticisms were welcomed rather than resented, and administrators began tracking infection rates like they tracked the budget and hospital census.

What was the result of all that effort?
After two years, we saw a 50 percent decline in our ICU infection rate, with a 21 percent (or $702) reduction in cost per ICU discharge. I was no longer skeptical; in fact, I often joked, "If this trend continues, I'll be out of a job as an infectious-disease consultant." Our hospital team, along with Berwick, went on to publish the results in the journal Quality and Safety in Health Care.
An interesting footnote: There were some resisters at our hospital -- often, unsurprisingly, the traditionally autonomous physicians. One afternoon in our infection-control meeting, an ICU nurse complained about a surgeon who refused to fully drape and wear a mask when placing a central line. He argued there was "no need." The nurse asked me what she should do.
With the firmness of a convert, I told the nurse: "Be a Rosa Parks. If it is not an emergency, and the surgeon refuses to follow the protocol, do not assist the surgeon in placing the line. I will back you up."

Thereafter, the surgeon complied. The hospital's culture of patient safety and quality had changed. And our efforts continue.

Manoj Jain is the medical director at Medicare's quality improvement organization in Tennessee and an adjunct assistant professor at the Rollins School of Public Health at Emory University in Atlanta. Comments:

Sunday, February 8, 2009

Operations Team Huddles

The demand for our service has grown at an unprecedented rate. Every operational area in our system is feeling the increase in volume.

The Operations Team began on-site huddles this week. Our intention is not to bring answers or solutions but to help discover solutions with you through the use of systematic testing. We spent three mornings in the Emergency Department to learn more about some of the space and flow challenges that they face from the people who work in that area.

Several small tests were conducted on Friday aimed at bringing care providers closer to the patients. You will see two new satellite lab draw areas in the Emergency Department. The feedback on Friday about these satellite areas was positive and minor modifications are already being tested. We will keep you posted. In addition, we plan to test the use of a navigator in the third floor lobby. We will post the results of the tests but have not determined where and how to best do that so that everyone can easily follow along. Any suggestions?

I want to thank everyone for such a gracious response to our presence and willingness to share and learn together.


Wednesday, February 4, 2009

“Pain is inevitable, suffering is optional…”

Might it be that the comments of an ancient Buddhist monk could offer some direction to those of us working at CCRMC in these difficult times? The quote above is from an unknown monk, but it has been repeated often in the modern era by Thich Nhat Hanh, a modern teacher who has authored a book about pain and suffering (The Heart of the Buddha's Teachings: Transforming Suffering into Peace, Joy, and Liberation, 1999).

So, you ask, “What does any of that have to do with CCRMC or my job?” Well…maybe upon further reflection….

In the last 6 months, I have felt great pain and I have seen much pain reflected in the faces of many (most) of my coworkers. Not the physical pain that often troubles our patients. Rather, the deep spiritual and psychological pain that one feels when the world is unsettled, risky, threatening, and uncertain.

Sometimes, the pain presents itself as a question:
“How will the economic downturn affect me?”
“Will I lose my job?”
“Can I pay the mortgage?”
“Will I have health insurance?”
“Will all of the work of my career be for naught as the County health system collapses?”

Sometimes, the pain comes forth as a feeling: anger, frustration, panic, anxiety, sadness, emptiness…

Sometimes, the pain is a behavior: arguments, mean statements, brusque actions, lackadaisical work, increased sick leave, problems sleeping, over-eating…

Sometimes, it merely festers. “Will it ever end?”

For the monk, observing the world in a very conscious way, life and pain live together at times. To live is to have pain at those times. The mother in labor, the child becoming a teenager, the adult losing a parent, anyone having surgery—pain comes with the territory and cannot be avoided. It is hardwired into life, just as the perception of pain is hardwired into our nervous system. It is inevitable…

However, the monk noticed that different approaches to the pain of life lead to much different responses to the pain. Some approaches can help us learn, others can trap us in suffering—the process of “holding” the pain in our lives on an ongoing basis. Sometimes, we all suffer with pain.

Holding the pain (suffering), means integrating it into our personality. In a very real sense, holding onto pain means becoming the pain that we feel. We become that pain as we tell ourselves stories about the pain that we feel. Suffering, or the absence of suffering, is all about the stories that we tell ourselves about the pain that we feel. Those stories can either hold the pain close, or send it away.

Stories in our lives attach meaning to our thoughts. We all hold a conglomeration of stories in our minds—and those stories provide us with our identity. The stories are the keys to meaning.
The young adult who blames a parent for all that is wrong—needing to have someone to blame in order to stand the pain brings the pain inside and prevents it from leaving. A patient who holds anger at a nurse, an employee who blames a supervisor for the frustration of the job—these examples and more hold the pain inside and cause what we call suffering. The suffering becomes an integral part of the meaning of that person’s life. It cannot go away as long as the story stays the same.

Suffering is a choice, a choice attached to a story about pain. It is a choice made either intentionally or subconsciously, that embeds our pain into our souls. A choice that gives us some identity, but it is a choice that costs us immensely. The choice to tell the story of pain to ourselves means that we cannot let it go.

However, we can “unmake” our choice if we desire. We can reframe our pain in a new story—a story that connects the episodic pain to learning and lets it pass like the pain of an immunization—helping us to heal ourselves.

The monk says that the option is ours.

So, I wonder if the thoughts of the Buddhist monk might help us all at this time......?

What do you think? What is your story about our times?

Monday, February 2, 2009

We need to talk

I’ve been thinking about how important it is that we talk and listen to each other. This blog was designed in an attempt to open an alternative line of communication. It was my hope that not only two way conversation may occur, but perhaps an open forum of dialogue from a diverse set of perspectives might follow.

The importance of communication cannot be underestimated. In the United States the root cause of sentinel events that has been most frequently identified since 1995 (66% of reported sentinel events), is communication*. Could that mean that the majority of serious preventable harm in US hospitals is caused by communication failures within the system?

In reviewing the Institute of Medicine’s six “Aims for Improvement” what could this framework be communicating to us on behalf of the patients we serve?

Safe: Please don’t hurt me. Provide care for me with a health system that is safe.
Effective: Give me what I need based on the best known science.
Patient-Centered: Please respect me and all the things that make me uniquely who I am. Let me choose to be involved in my health care decisions in a way that I am comfortable.
Timely: Please don’t make me wait unnecessarily. Provide care to me at the right time.
Efficient: Please don’t waste my time or my care provider's time.
Equitable: Please give me an equal chance to be healthy. Please don’t leave me behind.

The importance of communication probably isn't a new concept to you. Communication is at the root of so much of what goes right and wrong for us in all aspects of our lives. We communicate for reasons beyond mere information exchange. We communicate for survival and companionship.

Last week, while at a meeting for the Integrated Nurse Leadership Program I learned about tap code , a method of communication that is commonly used by prisoners. In this case it was used by prisoners of war (POW) to communicate with each other. Letters are placed on a grid and by assigning a number to each letter; prisoners could communicate with one another by tapping on things such as a wall or pipes. It is simple in design yet very effective.

Newcomers can easily and quickly catch on. Information such as what questions interrogators were asking, to who needed help or extra food or supplies could be shared among the prisoners. POW Vice Admiral James Stockdale describes the code ,"Our tapping ceased to be just an exchange of letters and words; it became conversation. Elation, sadness, humor, sarcasm, excitement, depression -- all came through." Here is a link to a video of Stockdale speaking about the importance of the ability to communicate. In listening to him it's clear to me that this tool not only allowed for the exchange of information, but also the exchange of human spirit. He recalls that the men would communicate at any cost, "if you get caught and tortured for a while, that's just the do it anyway."

Failed communication isolates us from each other and all too often leads to misunderstanding; misunderstanding to misinformation; misinformation to complete chaos.

In the coming weeks, operations leaders will begin to seek input from you about how we can better communicate, how we can better listen. Our aim is to build an enduring system that promotes open and transparent communication. It’s not to say that we haven't done many things to promote better communication, because we have, but we can improve and we need to do more. Your participation will be essential. We are seeking the input of others from within our system that specialize in communication. Please join us as we seek your help to explore strategies that will strengthen our ability to connect with each other and those we here to serve.

More very soon...