Wednesday, August 25, 2010

CCRMC Improvement Academy: Deming's System Of Profound Knowledge Session One

"We have learned to live in a world of mistakes and defective products as if they were necessary to life. It is time to adopt a new philosophy...." -W. Edwards Deming
CCRMC's Improvement Academy meets Thursday August 26th at 9:00 AM in Building One, Conference Room One. I will present an overview of W. Edwards Deming's System of Profound Knowledge.

This will be the first of a series of dedicated learning sessions on Deming's System of Profound Knowledge and transformation.

Please join us.

Tuesday, August 24, 2010

More on Forgiveness

Posted by Jon Stanger, MD

[Five years ago, in the wake of a troubling case involving delayed diagnosis, a subgroup of our Ethics Committee was convened to consider and make recommendations for appropriate management of adverse patient outcomes and medical error within our system. The Subcommittee’s findings and recommendations led directly to the formation of our current Medical Error and Adverse Outcome (MEAO) Committee. I invite you read the final “Report of the Subcommittee on Disclosure of Medical Error.” It can be found in the “Ethics” folder on the desktop of any computer in our system, within the subfolder “3.0 – Policies and Reports,” and under the heading “Medical Error Disclosure Subcommittee Report.”]

Kudos to our CEO for having the courage, once again, to engage a very complex and critically important topic – without presuming to have all the answers. This time Anna has invited us to consider the painful reality of error within our professional practice and the prospect for forgiveness. Anna’s comments and references urge us to look beyond formal responses and institutional structures, to consider the personal, spiritual meaning of harmful error brought about by good people while trying to help others - and the potential for healing afforded by forgiveness.

Forgiveness is a tricky business and, I believe, it is important to resist facile formulations. Two possible conceptual traps in considering forgiveness I would call “cheap forgiveness” and “forgiveness denied.”

“Cheap forgiveness” comes into play when we see forgiveness as something we are entitled to. The reasoning goes something like this:

Medicine is a risky business from the outset. The patient comes to us for help and we do our best, but there can be no guarantees. Even in the best of circumstances, complications and mistakes are liable to occur. It is unreasonable for the patient and family to hold us morally or legally accountable for these unintended consequences... They owe us forgiveness.

It’s not that there isn’t some validity to this line of reasoning. Indeed, I think this is a powerful rebuttal to the current system of medical malpractice liability in our country. The error here is that this depiction, just like the legalistic remedy it seeks to counter, reduces a complex human reality – the specter of a vulnerable patient coming to harm at the hands of those trusted with his/her care – to a simplistic calculus of rights and obligations. This is a demand for “cheap forgiveness.“

Forgiveness – at least the kind of forgiveness that has a potential to heal – cannot be demanded or won as matter of rights or entitlement. Forgiveness is never an obligation of the aggrieved. It must be freely given, if it is to be authentic. And it must take account of the human dimensions and relational realities of the situation – realities like suffering, guilt, and perceived betrayal of trust. It must be earned.

What are the elements of “earning” this kind of forgiveness? Anna refers us to the wise counsel of the Reverend Victor Carpenter on the occasion of honoring Nelson Mandela at Harvard University. In this speech, Rev. Carpenter alludes to the work of Archbishop Desmond Tutu and the Truth and Reconciliation Commission in South Africa. During my years in seminary at the Graduate Theological Union, I had the opportunity to study Tutu’s Ubuntu theology and the history of the T & R Commission in some depth. Principles pertaining to forgiveness and reconciliation that have emerged from international experiences like that of South Africa include:

· Never ignore or trivialize the victim’s suffering.

· Causes must be uncovered and confronted.

· Repentance comes from the perpetrator, but reconciliation and forgiveness must come from the victim.

· Reconciliation involves construction of a new narrative of meaning that acknowledges the trauma while recognizing the humanity of the offending party and daring to trust and commit to relationship again.

· Forgiveness and reconciliation are processes that often take time.

I don’t think that it’s a stretch to see the relevance of these principles to our consideration of forgiveness and reconciliation in the setting of medical error. Here as well, forgiveness of the patient or family cannot be presumed, and reconciliation has certain prerequisites to re-establish the trust required for a therapeutic relationship. “Earning” reconciliation in the medical setting requires:

· Prompt discovery and honest disclosure of causes, to the extent possible.

· Sincere expression of regret or apology.

· Time taken to answer questions and to listen to the patient’s story.

· Demonstrable commitment to learn from the error and to prevent future recurrences.

Any expectation of forgiveness or reconciliation that side steps these elements of the process would be evidence of “cheap forgiveness.”

The second trap of forgiveness I call “forgiveness denied.” “Forgiveness denied” applies when the clinician, having taken the steps to facilitate reconciliation, remains unable to learn from the mishap and move ahead without the patient’s explicit forgiveness – which may not be forthcoming.

This concept raises the question, “Whose forgiveness am I seeking?” I would argue that there is not a single answer to this query. Certainly, our first reaction must be to say that we are seeking (or hoping to earn) the forgiveness of the patient and/or family. I have seen the transformative, healing power of this experience – when the care-giver’s honesty, sincere expression of regret, and demonstrated commitment to prevent future recurrences are met by acceptance, understanding, and forgiveness on the part of the patient and family. No one who has been involved in such a case will ever question the healing power of the experience.

However, I have also seen any number of instances in which the most earnest efforts of the professional are not followed by any expression of forgiveness by the patient. Here again, I think we are wise to avoid falling back into the trap of “cheap forgiveness” that assumes we are entitled to such a response. So, is the dedicated professional in such a circumstance left to merely hope for some future softening of the patient’s disposition? To a certain extent, yes – while maintaining compassionate contact and openness to being with the patient through the process.

But there is more to the dynamic of forgiveness than seeking absolution from the patient or family. Indeed, I believe that the primary moral valence of any expression of forgiveness by the patient is as an indication of healing of the patient himself. This is not to say that the effect on the caregiver is not profound – it certainly is. When the family says, “We forgive you,” the physician is granted permission … to what? To forgive herself.

This gets us back to the question I raised earlier, “Whose forgiveness am I seeking?” and my suggestion that “the patient’s or family’s” may not be the only answer. It is critically important to recognize that clinicians also suffer in these cases. The emotional toll upon clinicians involved in cases of medical error can be devastating. And the all-too-common “shame and blame” response has the potential for personal and professional destruction, even as it obstructs constructive efforts to help this, and future, patients.

When we compassionately consider the position of the care-provider, as well as the individualized reality of the patient’s response, it becomes unreasonable to require the patient’s forgiveness before the clinician can find some peace in the wake of a mistake. Provided careful attention has been paid to the elements of earning reconciliation as discussed above, we must guard against dependence upon “forgiveness denied” just as we have rejected the facile expectations of “cheap forgiveness.” In a very important sense, then, another legitimate answer to the question, “Whose forgiveness am I seeking?” may be “my own”, or for those with a religious faith orientation, “God’s.”

Let me close this overly long commentary by strongly recommending two films. The first is “Long Night’s Journey Into Day,” a moving documentary of the Truth and Reconciliation process in South Africa.

My second recommendation is Ingmar Bergman’s masterpiece “Wild Strawberries.” This film is a harsh, but ultimately warm and very human story of an elderly physician who has been chosen to receive an honorary degree in recognition of his 50 years of service. During his lengthy road trip to the site where he will receive his award, Dr. Borg reflects on his life course, both personal and professional, and strives to come to terms with the realization of his own shortcomings. His sleep is disrupted by a dramatic nightmare in which he is called into a medical lecture hall to take a clinical examination in front of a large audience. Filled with self-doubt, he is grilled by the examining professor in the same “callous, selfish, and ruthless” manner that he has adopted toward his own students over the years. Now in the role of student himself, he is unable even to focus the microscope for identification of a bacterium on a slide. His diagnosis of a patient’s clinical condition is egregiously wrong. And, in the final question of the exam, he is asked to complete the sentence, “The first duty of the physician is … …” His mind is a blank. He can think of nothing.

Final grade – “Incompetent.”

We think we know the answer, don’t we? I thought I did. You… we… are wrong. The answer in the film? “The first duty of the physician is … … to ask forgiveness.”

Sunday, August 22, 2010

A Culture of Safety: Forgiving

“The day is committed to error and floundering; success and achievement are matters of long range” ~ Johann Wolfgang von Goethe

I've been thinking about the "Safety Incident Detection and Response System Optimization" efforts and our culture. In reading about cultures in ultra-safe industry (airlines, nuclear power, European railways), as opposed to health care which is not considered to be, I have found that a relentless focus on learning and moving beyond the need to blame and the need for redemption seems to be a system attribute in each these industries. I should add that many others are thinking about this as well.

Thankfully, courageous leaders such as Lucian Leape, Don Berwick, Jim Conway, Maureen Bisognano and many more have advanced the discussions about how we respond to medical error and system failures into mainstream discussions and media publications. Here is a recent article the NY Times on disclosing medical error and apology. The Executive Director of Chugachmiut, Inc., an Alaska Native Tribal consortium recently posted in his blog "Lean in Alaska" Pointing Fingers, where he discusses a "no blame, no shame" culture. He points to W Edwards Deming's System of Profound Knowledge and Deming's focus on pride and joy in work. A simple Google query will yield thousands of related links on error, just culture, culture of safety, apology, blame, bad apple versus system response etc. There is no dearth of reading if you're interested.

A request for help. How do we move from blaming to forgiving?

I am not trying to minimize how complicated this is. To the contrary, I believe that too often this complex socio/cultural concept is oversimplified. The term "transparency" is tossed about as if it comes easy and as if it will save us. Please don't misunderstand, I am in favor of transparency. Yet I do believe there is a tension between transparency and for lack of a better term, a "need to know." There is a tension between an inclusive and democratic process and an autocratic process. Leading the system and providing service within it is a complex and humbling undertaking. I look to the words of one of the greatest change agents who ever lived, W. Edwards Deming who said, "All transformation begins with the individual." If we are to create safe, fair and just culture; if we are to create a culture of continuous improvement, we must begin with ourselves. With each new day and each new challenge we will continue to discover that those who came before us carried heavy burdens for us all. It's our turn now. We are here to make a new world.

I am not asking anyone to be perfect. I ask that we help each other and provide service to our community in the most respectful way possible. I don't pretend to have all the answers. I ask that we work together to lead our system forward and to recognize that sometimes, like those people we are here to support in carrying out our shared mission, we will make mistakes.

It's important that we all work together. It's important that we all learn together. That means all of us. Those we are here to serve are depending on us getting this right. We must learn to work through system failures and to work through mistakes.

I am not suggesting we forget harm or look away from difficult situations. I am suggesting we learn to forgive and not let it divide us as looking for blame will. I am not suggesting we be complacent in any way. I am asking that we draw on courage. Drawing on the same humility we require as leaders of our great health system, we must not allow mistakes to create permanent barriers between us. There will be times we must look beyond the mistakes of others and remember to be grateful they are participating. To better understand what I am saying I offer the speech Victor H. Carpenter presented at Harvard when Nelson Mandela was honored there. Please take a moment to read his very brief but powerful remarks on "Forgiveness: The Mandela Principle" and I believe you will understand what I am trying to say to you.

Change is here. With that, all that is possible lies before us.

Now, we move forward.

Saturday, August 21, 2010

Thanks to everyone who posted in my absence. The posts and comments are fantastic.

I'm delighted to tell you that some of the guests have agreed to come back from time to time.

Something wonderful to look forward to!


Friday, August 20, 2010

Upcoming changes in our system

Posted by Tess O'Riva, CCRMC Communications Director

In last Monday's message to staff , Dr. William Walker, Health Services Director, described some of the ways he is preparing Health Services to best meet the challenges and opportunities within Health Care Reform.

His message is below.
"In recent Director’s Report messages, I described what health reform under the Patient Protection and Affordable Care Act and the California Medi-Cal waiver means to Health Services and the patients we serve. As provisions of the Act and new requirements of the waiver – a bridge to health reform’s complete roll-out – are unveiling, I continue to realize that in order to prepare ourselves to meet the challenges that are before us now and into 2014, significant changes in our system, particularly the service delivery side of our organization and our leadership structure, must begin.

The new legislation offers many opportunities for demonstration projects and pilot programs, which would be well suited to our system. There are also new requirements and incentives for integration across our various Divisions. With this in mind, I have asked Dianne Dunn-Bowie to move to a new role as Executive Director, Health Services Integration and Governmental Relations. Dianne, with her many years of experience in all aspects of health care, will help us to strengthen key political relationships, build new community partnerships and develop new models of service integration.

We must move quickly to seamless and safe handoffs of patient care between our inpatient and outpatient systems. We must improve access to primary care and specialty services and develop more effective interactions between inpatient and outpatient staff. We must develop improved case management and care coordination functions. I have concluded that this will not happen within the current structure of separate Divisions. I am therefore combining Ambulatory Care and the Medical Center into a single Division under CEO Anna Roth effective September 1, 2010.

This past year has been an unprecedented year of change at CCRMC. In the last twelve months all but one executive leadership position has turned over as leaders retired after a long and rewarding career at CCHS. Several months ago, CCRMC CEO Anna Roth began redesigning a number of her departments, including safety and performance improvement, professional development, detention health and emergency services, behavioral health, perioperative services, and inpatient medicine. In addition to the ongoing operational redesign efforts, Anna has introduced initiatives to build internal capacity to grow and continually improve.

Also on September 1, 2010, Dr. Chris Farnitano, Chair of our Family Medicine Department, will move into a management Medical Director position with primary responsibility for leading the development of new models of team-based care, patient-centered medical homes, improved patient flow and timely access to outpatient care. Our goal is to be a national model for improved chronic disease benchmarks. Dr. Farnitano will also be intimately involved in the system changes necessary for the installation of our Electronic Medical Record over the next couple of years. We are also currently recruiting to hire a Chief Operations Officer for the Hospital and Health Centers. Reporting relationships for this new structure are now being developed.

In the weeks, months and years ahead we have much work to do. As we continue to learn more about the specifics of health reform, I anticipate that there will be additional restructuring. Some of our efforts will be successful and others will need to be tweaked or rethought. This will be an exciting time for all of us.

The dedication we have to serving the community and to supporting each other makes us a model for the new American system of health care. We have made great strides over the past decades to develop a system that puts the patient/consumer/client first and provides the kind of services that care for the whole patient. I believe that with the dedication and commitment of all of you, we will successfully make the system changes necessary and meet the challenges that are before us."

Putting Contra Costa Health Services at the forefront of Health Care Reform is both exciting and inspiring. I share Dr. Walker's belief that our system is poised to change the way health care is delivered and be a model for the nation, not only because of our unique structure, but because of the people we work with. I can't wait!

Tess O'Riva

CCRMC Communications Director

Tuesday, August 17, 2010

UCB Interns Rock!

Posted by Julie Kelley, Mental Health Program Chief
Don't forget to come to the Improvement Academy on Thursday at 9:00. The UCB Public Health Interns are presenting their Gap Analysis of the IHI Improvement Map. Having had a preview, I can assure you're in for a treat

Also, we look forward to hearing about your plans to include patients/family members on your Improvement Teams.

See you there.

Julie Kelley
Mental Health Program Chief

Monday, August 9, 2010

Embracing the Uncomfortable

Posted by Katherine Lao, CCRMC Graduate Student Intern / MPH Candidate / UC Berkeley School of Public Health

Prior to working for CCRMC, I spent some working in programs referred to as “health-pipeline” programs that worked towards addressing health disparities by developing healthcare professionals from underserved and underrepresented backgrounds. I was a 20-year old intern at that time, and I immensely grateful for these programs to opening the world of healthcare, diversity, and social justice to me. In many ways, the students that I have met and their passions, motivations and inspirations for going into the field of healthcare have also become mine.

While I personally did not live in disparity, I spent a good amount of life growing up around it. I was born and raised in a middle class/upper middle class family in Manila, Philippines, and I remember daily pictures of families living underneath bridges, street children selling cigarettes or knocking on car windows to make a living, and next door neighbors without the resources to take care of their sick children. Poverty surrounded me every single day and while I constantly wondered why it was that way, I had also learned to accept it as the norm and had somehow became numb to the suffering around me.

I went back to the Philippines for the first time three years later (back in 2003), and I clearly remember the culture shock and the pervasive feeling of discomfort I felt in the three months that I was there. Poverty seemed hidden and invisible in the Silicon Valley suburb I had grown accustomed to, and here I was once again confronted by daily reminders of suffering and poverty. Amidst all this, I was among the company of affluent friends and family who entertained me at beautiful resorts, posh restaurants, and daily luxuries. Manila has been consistently described as a “city of contrasts” with the economic gap between the rich and poor blatantly obvious to many of its citizens. Latest reports show that even amidst economic growth between 2000 and 2006, poverty incidence in the country in fact grew worse.

Nationally, the US does not fare any better:
  • The top 1% of the U.S. population holds more wealth than the bottom 90% combined. During the past 25 years, while the rich became richer, the net worth of the least affluent 40% of American families fell by half.

  • People in the highest income group can expect to live, on average, at least 6.5 years longer than those in the lowest. Even those in the middle (families of four making $41,300 to $82,600 a year in 2007) will die, on average, two years sooner than those at the top.

  • More African American, Native American, Latino and Pacific Islanders are in poor or fair health than whites at practically every income level (although recent Latino immigrants report better health).

  • In 2002, Former U.S. Surgeon General Dr. David Satcher and colleagues calculated that if Black and white mortality rates were equal, 83,570 African Americans would not have died. That’s 229 “excess deaths” per day: the equivalent of an airplane loaded with Black passengers being shot out of the sky and killing everyone on board every single day of the year.

    Source: Unnatural Causes Amazing Facts

Here in Contra Costa,

  • While Whites make up more than half (52.9%) of the population, and represent the greatest number of deaths; African Americans are at the greatest risk for poor health outcomes and suffer significantly higher death rates from all causes combined than county residents overall and than Whites, Latino, and Asians.

  • Contra Costa communities with the highest percentage of low-income and non-white residents – San Pablo, Richmond and Pittsburg - experience higher death and disease rates than the county overall for many chronic and communicable disease, injury and maternal and child health issues.
Source: 2007 Community Health Indicators for Contra Costa Report

We, too in fact, are a nation of contrast.

After several years of liberal Berkeley education, I remain, if not more even more, uncomfortable with these disparities. Even after several trips back home in the recent years, the pervasive feeling of discomfort remains in the back of mind and I still struggle with simultaneously juggling the two worlds of poverty and privilege all within the same place.

I shared these feelings of frustration with a mentor a couple of years back after my trip to rural South America. I shared with him my frustrations, and the guilt I felt in being in a position of privilege with an education and the ability to venture off and volunteer abroad for two months. His advice has stuck with me since then, “channel all that frustration and anger into something productive – something useful that could contribute something to the world,” he said. “Instead of complaining and wondering why things are the way they are, ACT and work towards making it better.”

In light of remembering his advice, I have also come to recognize that perhaps I need to EMBRACE my discomfort with the concept of disparities. Perhaps because it is this discomfort with inequality that continues to push me to change things and make them better. That discomfort has been the one true source of motivation in my career. In some ways, I do not ever want to be comfortable knowing that gaps in quality care, income, health, education and social justice exist…because being comfortable means being complacent and being complacent means doing nothing…and doing nothing means status quo…and that in turn, means that people continue to suffer.

Friday, August 6, 2010

Seize The Moment

Posted by Teresa Pasquini, Danny's Mom

Following the Report Out for last week’s two Improvement Events, I was introduced to a gentlemen interviewing for a position at CCRMC, and I paraphrase, “This is Teresa Pasquini, she is the Mom of a consumer (psychiatric patient) who our system has harmed and she also has been harmed.” This is not a typical introduction from the CEO of a hospital. There is nothing more powerful than an acknowledgement of pain even if it is unintended and based on systemic barriers or defects. I so appreciated that transparent, humane introduction.

As I reflect over the past year that I have spent volunteering as a family member and advisor on the CHF Kaizen 3, the Healthcare Partnership, the Executive Operational Planning Team, the Behavioral Health Value Stream Mapping, the Behavioral Health Kaizen 1 and 2, and the Safety Event VSM, I have been very aware that this is a moment in time that must be seized. There are opportunities for learning, empowerment, transformation and healing that I never imagined.

Anna is right; the system has harmed my son and my family. Prior to my first Kaizen experience, last July, I would have justified blaming anybody that works in the system for that harm. Not anymore. I know better now. I now know that nobody comes to work to harm my son or my family. I have also learned that you can’t change what you can’t see and how blind one can be to the obvious. These lessons are teaching me to be less angry at the system that has harmed my family. That first Kaizen created our “Vision of Hope.”

When I uttered those words in my first Kaizen Report Out, I really didn’t know the weight it would carry or even what I meant. I was just high on the Kaizen spirit and knew that something big had happened. What did I mean by Vision? Was it the personal ability to see something or the organizational vision that would show us the direction we needed to go? But, we didn’t know where we were going, we couldn’t see the vision.

What about Hope? According to Wickipidia, “Hope can be passive in the sense of a wish, or active as a plan or idea, often against popular belief, with persistent, personal action to execute the plan or prove the idea." Well that is certainly true. When the Healthcare Partnership formed and created our “Vision of Hope” we were certainly wishing for a better way for our consumers, families and staff and we set out on a path of change that was certainly against popular belief. Bringing patients and families front and center, as partners of transformation, has not made everyone comfortable, but with persistence, we have made others see the vision, the plan. Our wish is coming true.

The Healthcare Partnership has created a forum for weekly brainstorming and support for system change. We didn’t know where we were going, but we kept feeling our way. We stepped on each other’s feelings and apologized and moved on. We kept coming together every week to build a logo, a mission statement, plan an event, support one another, and share our humanity. We have now splattered our vision of hope all over CCRMC and into the community, while we are learning, empowering, transforming, and healing.

I had my first guest entry on this blog a little over a year ago, upon the completion of my first Kaizen event at Contra Costa Regional Medical Center. I was invited to participate as the first family member on an improvement team at CCRMC. For me it was a life changing experience. It has opened doors, literally, that I never thought would open. The vision now has clarity and the hope is contagious.

My name is Teresa Pasquini, Danny’s mom. The mental health system has harmed my son and my family, but with the help of CCRMC staff and community partners, the wounds are healing and the vision is hopeful.

Thursday, August 5, 2010

11% of County Waste is Recycled

Posted by Juliette Kelley , Mental Health Program Chief

I got a county email today in the subject line it read, “Only 11% of county waste is recycled – it needs to be higher.” It set off a little tiny chain reaction inside me.

I managed to avoid math and statistics throughout most of college. Algebra is a foreign country for which I did not have a passport. I was successful at my avoidance strategy until I got to graduate school. In graduate school I had to take biostatistics which I entered not unlike how a cat takes to water – all four limbs rigid and claws extended. I was thrown in and managed to emerge with an honorable grade but determined to forget what I could. After all, I was going to work with people, not statistics. I did reasonably well avoiding statistics in my career. I could keep up with studies and understand lectures but I still didn’t need to keep up with my numbers unless pressed.

Then I met Anna. In the same way that the late Steve Irwin (the Crocodile Hunter) used to hold up an Australian Brown Snake and utter “Danger! Danger! Danger!”; our Chief Executive Officer, Anna Roth looks at health care programs and utters, “Data! Data! Data!” In other words, how do we know what we need to change if we aren’t really measuring what we are doing right now? It’s a good question.

I am used to operating in the dark, many of us are. Not just at the hospital or in the County, but in general. We are a nation of anecdotes and personal feelings which carries more weight that it should. In a hospital, the higher up on the professional food chain we go, the more heft there is to your opinion. If you are a nurse, you have an ordinary array of professional currency but if you are an MD, even one fresh out of medical school, your opinion trumps the nurse. If you are a custodian or an aide, your opinion barely moves the opinion-meter. Finally, if you happen to be a family member or a patient – well, you are there to be convinced your opinion is pointless. Data shifts the weight of personal opinions and cultural hierarchy. It provides a starting place so improvement can be measured -- simply and without judgment.

The ambiguity isn’t the fault of the person emailing the letter. In fact, I applaud the effort to make us all aware of the recycling opportunities we have in the county. But it showed me that something had shifted inside of me, I – a mathematic-phobic social worker was asking questions that would lead to data that could change the way I practice, the way I make decisions even if it was only about trash.

This is how culture change happens in any organization – one thing at a time, no matter how small which leads to a personal change which eventually leads to a system change.

Now, you have to excuse me while I go shred the contents of my in-box and recycle.

Wednesday, August 4, 2010

Best Laid Plans

Posted by Jon Stanger

I’ve always thought that there is great wisdom in the expression, “If you want to hear God (or the gods, or Fate, or your therapist) laugh, tell Him/Her your plans.”

Two years ago, after thirty years in various roles as physician, educator, and ethicist at CCRMC, I was actively planning for my retirement. Sure, like so many of my compatriots, I hoped to continue a few hours per week at the hospital, but only a few. I had a definite plan. First, I would write the medical ethics textbook that had been percolating in my head for the last few years. Then I would move on to penning The Great American Novel, selling the movie rights to Hollywood and paying off my daughters’ sizable student loans. And, along the way, I’d finally find time to refinish the deck and master the fairway bunker shot. I had a plan. Two years, three years max, to accomplish those goals, and after that, well, we’d see. Really, I had a plan.

I can actually remember the precise moment, two years ago this month, that my carefully calculated orbit was knocked off course. I was returning to the hospital after a meeting with my retirement counselor, when I ran into Anna Roth in the parking lot outside the administration offices. Anna and I had worked together on the System Redesign Team and this was the first time we’d seen each other since her return from a year studying at Harvard and the IHI.

Jon: (Intending and expecting only the most superficial of social pleasantries.) “Great to see you, Anna. So, how was your year?”

Anna: (Characteristically restrained and demure.) “Incredible. Amazing. We’ve got a lot of work to do – and ethics has to be at the foundation of it all. Let’s talk. Let’s get started.”

That’s it. That was the beginning of the end of my plan for the next two years. I did, in fact, retire, at least in name. But from her position as COO, and then CEO, Anna recruited – or, more accurately, conscripted – me onto the Operations Team with a stubborn insistence that an “ethics perspective” was critical to the work we had to do at CCRMC.

If over the past year the nature of my role as ethicist on the Ops Team has seemed illusory at times, and if it feels like we are traveling uncharted territory in this venture, I forgive myself this, given that the whole field of organizational ethics for health care is in its infancy. There are even times when I think that our efforts, that the lessons we are learning right here at CCRMC – our innovations, successes, and set-backs – will be of benefit not only to our own system and patients, but have the potential to contribute to the emergence of organizational ethics as a national discipline. And that’s definitely a chapter worth including in my book.

I really do want to get on with my retirement plans – writing and such – but I have no regrets. Recent changes at CCRMC have not been without missteps and trauma. I don’t know where it will all lead or what major problems lie ahead – certainly there will be some. But I think that something very important is going on in our organization, and I’m glad to be a small part of it. In upcoming installments of my guest contributions to this blog I’ll try to get more specific about what that “something very important” might be and what an “ethics perspective” might have to offer for the tough world of running a health care organization.

That ethics textbook hasn’t progressed beyond the outline stage, and the world is going to have to wait a while longer for The Great American Novel. My deck remains unstained. But my 5-iron shot from the fairway bunker is a little better and, well, that will just have to do … for now.

Tuesday, August 3, 2010

Reminder: Improvement Academy Report Out on Testing Phase This Thursday 9:00am

Posted by Cheryl Toledo

A couple weeks ago, we were assigned to work in teams to think innovatively and create a proposal for a space/mechanism to make CCRMC's improvement efforts more visible to the community.

A week after that, each team presented their proposals and went above and beyond anyone's expectations! Each of the four teams reported on a different array of proposals and research ranging from interviewing staff and patients to building a website/kiosk to having holographic figures directing patients and families around the hospital. Signage, website and digital bulletin boards workgroups were then formed from everyone's proposals for the most exciting phase of the project: testing!

Each of the three new workgroups have worked diligently on testing out proposals to see if they work and to gain feedback and insight about next steps. We will find out about their progress this coming Thursday at the Improvement Academy.

Be there to hear all about it and support the teams' efforts this coming Thursday, August 5th at 9:00am!

Lastly, I just wanted to give a personal thank you for this wonderful experience! I'm learning so much from this process and loving the opportunity to interact with patients, families and staff! And if you haven't had a chance to check out our website prototype, we'll be sending out a link soon.

Thank you :)

Your friendly intern,


The Waiting Room

Posted by Katherine

The Waiting Room is PBS documentary film and social media initiative project being filmed at Highland Hospital on the critical role of safety net hospitals in the community - through the eyes of its patients and staff.

For more video clips, please visit