Cowboys and Pit Crews

Originally posted 6-3-2011:
I am a huge fan of Atul Gawande, the author of "The Checklist Manifesto" and numerous New Yorker articles regarding the healthcare system. He recently gave the commencement speech at Harvard Medical School, which he titled "Cowboys and Pit Crews".

The speech is a great 10 minute read on the current state of healthcare. He discusses how the increased complexities of medicine have made it impossible for any one doctor to have all of the knowledge needed to effectively treat a patient. As he puts it, "Everyone has just a piece of patient care. We’re all specialists now—even primary-care doctors."  He goes on to say a better team approach by all caregivers is needed to promote better patient care. "We train, hire, and pay doctors to be cowboys. But it’s pit crews people need."

Pit crews...it's a great analogy for the kind of team work needed to improve the outcome of patient care. Maybe I should start watching NASCAR races for inspiration.

Growing role of Pharamcy in patient care

Originally posted 5-27-2011:
It turns out Pharmacists are having a greater influence on patient care.  According to the results of a recent ASHP survey, "there is significant evidence that Pharmacists' unique expertise is sought after and valued by other health care providers." Some of the statistics show that physicians are accepting pharmacists' recommendations at a much higher rate compared to a decade ago.  They are also providing more prescribing advice through clinical consultations, and are more involved with high-risk drug therapies.  The most telling statistic is that "60 percent of pharamcy directors view [Pharmacy & Therapeutics] committees as being highly effective at increasing safety."

This is great news. The drug experts are being asked to be the drug experts more than ever in the clinical environment. It tells me more teamwork is occurring to treat a patient effectively and safely.  With the increasing complexities of healthcare creating more specialties, it is nearly impossible to ask one care giver to have all of the answers needed to treat a patient. Let the experts and specialists cover their areas and work as a team to cover the broad spectrum of a patient's care.

This is the sort of culture change that is necessary to improve the quality and safety of healthcare. Culture is the hardest piece of the healthcare system to change, but it is encouraging to see that some things are trending in the right direction. 

Radio broadcast on Healthcare Associated Infections

Originally posted 5-26-2011:
I came across a fantastic radio broadcast from WHYY Radio on Healthcare Associated Infections (HAIs).  Dr. Neil Fishman gives a great overview of the HAI problem, how to help control infections, and antibiotic resistance. I recommend listening to it if you have an hour to spare and want to learn more about why HAIs are such an important issue in healthcare at this time.

If nothing else, listen to the first 20 minutes. The broadcast starts off with an interview with Kerry O'Connell, a patient safety advocate who has been suffering for years from the effects of an HAI.  It is stories like Kerry's that remind us why preventing infections are so important. It is a reminder that every HAI effects someone, and those effects can be devastating sometime. It is a shame that one infection can lead to multiple surgeries and cause someone to fear getting the necessary treatment needed at a hospital.

A thought on a technology trend

Originally posted 5-19-2011:
I have been hearing about some technology trends recently that has caught my attention. I came across this article that suggested the E-readers like the Nook or Kindle are going to become obsolete due to the rise of the tablet PCs. The article also referenced a small slideshow highlighting 9 gadgets that are going obsolete due to increased Smartphone popularity.  I was surprised to see Flip video cameras and point and shoot cameras listed in there.  But the explanation for this trend makes sense - "consumers are increasingly trading single-purpose devices for multifunction gadgets. "

It is very clear the everyday electronics consumer values the convenience of having a device that has multiple functions over having many devices that can one thing very well.  As a Smartphone user myself, I totally understand and enjoy the convenience. However, I don't really use my phone for pictures, because my point and shoot camera takes much better pictures. I would prefer to take higher quality videos on a separate digital recorder than use my phone. And I'll be honest - I still use an old fashioned radio alarm clock instead of my phone to wake up in the morning. Maybe it's just a matter of preference, but there are times I am willing to give up convenience for quality with technology.

So why am I sharing these thoughts here?  I have talked to a lot of clinicians over the last few years that had many issues with the ease of use with specific healthcare software. Many of these issues seemed to be focused on EMR systems, which has surprised me because I have never done usability work for EMR's.  One time I was on vacation and heard someone mutter, "I hate using this <product>."  These uninitiated discussions with pharmacists, nurses, doctors focused how difficult it is to navigate certain applications that "do a lot of everything, but not any one thing well".

As technology continues on toward this multi-functional trend, I wonder if it is appropriate for healthcare. Sure, in one application you can do everything necessary to complete your job of providing effective and safe patient care. There aren't multiple logins and passwords to remember to make things convenient. But is it a disservice to the patients that having convenient software that does a lot of everything adequately (or inadequately), as opposed to having multiple applications where each one allows the completion of tasks in a more efficient fashion? If the complexity gets too large and the ease of use starts to deteriorate, are we then reducing the safety and quality of using the software as a tool for patient care?

I do not have a clear answer, since I am not on the front line of patient care. I can only base these thoughts on my own experience with my Smartphone and other devices that help me do more than one thing.  Food for thought...but I would like to hear any feelings from care givers on this trend.

One year later

Originally posted 5-6-2011:
I made the realization that today is the 1 year anniversary of my starting this blog. I have to admit I was surprised at this realization, since I had no idea if this blog was going to go anywhere when I started it.  I have wondered if anyone was actually reading it; if there was anyone out there learning anything from this.  I was shocked to learn the blog has had nearly 10,000 views in the last year, and over 1000 in the last month alone.  Apparently, I have a bigger audience than I ever imagined.  I want to thank everyone who has been reading, and I hope you continue to come back and learn more about how we can improve the quality and safety of patient care.

There is still much work to be done to improve Patient Safety, but I can tell I am not the only one that has made the realization.  Over the last year, I have seen the issues getting talked about much more seriously. There is evidence that action is being taken to improve patient outcomes. And recently the Partnership for Patients: Better Care, Lower Costs initiative was launched by the government to reduce the amount of hospital associated injuries and reduce the amount of complications during patient recovery.   You can watch a nice summary of what the program is about here. It is a great sign to see that efforts to reduce patient harm in healthcare is being taken seriously at all levels.

The science of improving Patient Safety has a lot of momentum. I hope all of the readers of this blog continue to stay aware of the issues and take their own steps to making healthcare safer for patients.  I am very curious to see where we at another year from now.

Odd working schedules

Originally posted 4-17-2011:
I love it when current events make writing a blog entry easier. I am looking at the Aviation world again, and the new concerns about Air Traffic Controllers sleeping on their shifts.  If you have not been following the story - there have been 5 reported incidents to the FAA of an air traffic controller falling asleep on duty in the last month. Apparently, many of these controllers are doing a night shifts mixed with day shifts leading to fatigue issues. 

The AP wrote a brief article about what these odd work schedules can do to someone.  On top of fatigue, some other scary side effects these work schedules can cause include:

• "all kinds of problems related to memory and learning"
• "inability to concentrate"
• "affects...the ability to understand how one thing is related to another"

And finally the biggest kicker - "people working night shifts are more subject to chronic intestinal and heart diseases and have been shown to have a higher incidence of some forms of cancer." 

Not exactly the side effects you want from someone doing a job that requires critical thinking and could impact your safety.  It can be just plain dangerous in some situations. This is why fatigue for healthcare workers has been a concern for patient safety advocates for some time now. In fact, AHRQ has been looking closely at healthcare worker fatigue for about 10 years now.  I know nurses that have been subjected to similar work schedules in the last few years, and I always wonder if they really 100% at doing their job when they are not on a regular sleep cycle. 

The AP article does have a wonderful solution - naps. The suggestion is to allow on-shift naps, have someone else run the shift temporarily, to get someone running on their full cognitive abilities. I always thought the Spanish had it right with with their siestas. And even if naps are not practical, the FAA is going to look at changing the way shifts are scheduled for air traffic controllers. 

Maybe on-shift naps are an appropriate solution for healthcare workers fighting fatigue from odd work hours.  And even if not, administrators should be making sure they are not setting up healthcare providers to risk a potential error from harming a patient. Julie Thao had worked 16 hours, and slept in the hospital overnight before she accidentally switched an epidural and IV medication for a patient.

Think of it this way - "Studies have shown that a sleep-deprived driver is as impaired as someone with enough alcohol in his blood to be considered a drunken driver." I don't want someone that sleep deprived on the same road I am driving. Nor do I want someone that sleep deprived treating me or a member of my family in a healthcare setting.

More Hospital Errors than we thought?

Originally posted 4-13-2011:
Last week a new study came out claiming that one in three patient will be exposed to a medical error during a hospital stay. According to the article, the study explored a new method of measuring healthcare quality to detect events. The researchers looked at the same 795 patient records, and counted the number of events based on three methods of quality measurement: voluntary reporting, the current AHRQ quality indicator, and a new tool developed by the IHI. 

Voluntary reporting came out to a very low percentage, which I didn't find very surprising. However, I was shocked that the new IHI tool identified 10 times the events compared to the AHRQ quality indicators. I know that it is very possible for errors to go undetected, and I know there is a lot of room for improvement to improve the safety and quality of healthcare. But 10 times more errors?!?!?  Even I am a little skeptical at these numbers. 

I would like to learn more about the new IHI tool to better understand how they measure medical errors. What I hope is that the new measurements are a little more aggressive in what they determine is a medical error. It doesn't hurt to error on the side of caution and set a higher quality standard for healthcare. But if there were truly 354 events found within those 795 patient records - well then, the problems may indeed be greater than anyone imagined.

I would encourage anyone reading this to help provide me some insight into what they may know about these new quality measures. 

Dr. Pronovost on fighting infections

Originally posted 3-28-2011:
The Wall Street Journal published a short article today featuring Dr. Peter Pronovost.  Dr. Pronovost was one of the key leaders behind the use of checklists to reduce infections in the Michigan Keystone Project. The article is a great read as he talks about how the healthcare culture is impeding innovation, when hospitals should be able to come up with solutions to reducing healthcare associated infections (HAIs).

A couple things I wanted to highlight:

• I really liked the fact he believes public reporting is a good idea to make healthcare data more transparent, especially around infections. This gets back to my last post around the need for transparency to promote patient safety.
• Interesting quote on the lack of acceptance of the checklist in healthcare: "Could you imagine any other industry tolerating the violation of an evidence-based standard that kills 31,000 people a year?"

Japan, Nuclear Power, and Patient Safety

Originally posted 3-20-2011:
I am sure many of you have been following the tragic events that have occurred in Japan over the last couple weeks. The devastation and destruction from the earthquake and ensuing tsunami are beyond belief. And to top all of that off, the country and the rest of world have nervously been watching the nuclear crisis at the Fukushima Dai-ichi power plant. The coverage of this crisis has uncovered scandal involving shortcuts taken around nuclear safety in Japan.

What is interesting to me is for some years now I have learned that the nuclear industry is an extremely safe one. I have written a couple articles around using the airline industry as a model for patient safety and where that analogy can fall short. The second industry that has brought up in my Patient Safety courses as a model to look at is nuclear safety.  Like aviation, nuclear energy needs to be safe to prevent an accident that can effect many lives at once.

I realize a 9.0 earthquake is a pretty extreme circumstance. However, after reading about the safety shortcuts taken, I wonder if maybe some of the radiation leakage from last week could have been prevented. I also wonder if they power plant engineers had an adequate emergency plan for a major earthquake. It is hard to say for sure as the article says, "There's not enough transparency in the industry."

And that is the quote that concerns me the most from reading this. I have also touched on under reporting of errors in hospitals. Without transparency there is no way to learn from potentially dangerous errors. Hiding errors that can lead to safety allows the system to be exposed to future safety issues. I think this article can be seen as an example where Patient Safety should look at the nuclear industry...to show what should not be done. Reporting and learning from medical mistakes needs to happen to make sure those mistakes are not repeated. Let's keep promoting transparency to at all levels of healthcare to ensure the best outcomes for the patients.

Reducing Ventilator Associated Pneumonia rates

Originally posted 3-6-2011:
One of the more common forms of Healthcare Associated Infection (HAI) that a patient can acquire is pneumonia while being supported by a ventilator. Ventilator Associated Pneumonia's (VAP) are a significant portion of the many of thousands of deaths that occur each year due to HAI. There has been some great news in the battle to reduce the VAP rates.

Last month, the Agency for Healthcare Research and Quality (AHRQ) released a brief stating that some Michigan ICUs were able to recude VAP rates by 70%. Not only were these rates reduced, but these lower rates were sustained for a two and a half year period.  These hospitals were part of the Keystone Project that also significantly reduced the rate of Central Line Associated Blood Stream Infections.

According to the article, one of the main reasons for the success was a quality improvement initiative, known as the Comprehensive Unit-based Safety Program (CUSP).  CUSP is a strategic framework to improve safety that "integrates communication, teamwork, and leadership".  The five steps of the program are:
Step 1 – Staff are educated on the science of safety training.
Step 2 -- Staff use a written survey to help identify defects based on unit reports, liability claims, and sentinel events.
Step 3 – A senior hospital executive partners with the unit to improve communications and educate leadership.
Step 4 -- Staff learn from unit defects.
Step 5 – Staff use tools to improve teamwork, communication, and other systems of work.  

No wonder the CUSP framework is showing successful results. It takes a systemic look at healthcare and enables the ability to create solutions to fix the system. It provides education. It allows for open communication from the front end worker to the top levels of the hospital. It enables the workers to find solutions to their workflow. All of that promotes a healthy, open organization with the patient's safety taking center stage.

I think the results from the AHRQ brief are really exciting. But what is even better is that the CUSP framework is starting to spread to all 50 states.  This shows that the healthcare community is learning from each other to reduce HAIs and promote better patient outcomes.  I hope this is just the start of a positive trend in healthcare.