The SOAP Cycle: Collaborative Quality

Over the past two posts we looked at the care provider’s approach to quality at the level of the patient using the SOAP method, and the hospital approach to systems improvement using the PDSA Cycle. We noted that both methods are very effective when used conscientiously and how easy it can be to deviate from their intended use. It is interesting to observe that each method by itself, even when followed to the letter, understates key elements about their effective use.

The effectiveness of the SOAP format requires that the care provider and patient cycle through the process continuously, and the assumption is made that this will occur on a regular basis. As we have seen, there is a tendency for care providers to come up with a care plan and to make modifications to the plan only when a significant unanticipated outcome occurs. Adjustment is more reactive than proactive, and the adjustments that do occur frequently skip elements of the preceding “SOA” steps: we jump to solution and perpetuate suboptimal results.

The effectiveness of the PDSA Cycle, while emphasizing the continuous nature of an improvement process, makes the assumption that the initial plan is on target and meaningful. However, we have seen how frequently an improvement plan begins without thorough preparation. If we cycle a poorly conceived improvement initiative we get an “improved” poorly conceived improvement, which is not the same as a good result. Again we get a misguided, data-driven result that is suboptimal.

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What happens if we were to combine both cycles? Suddenly we have a way of making visible these key assumptions for each individual method, creating a complementary formula for complete quality. The common element to both methods is “P” or plan. When SOAP is inserted into the “P” of the PDSA cycle a unifying message is made clear. To the care provider, the message is that a care plan must continuously be evaluated and adjusted, even when things may appear on the surface to be going well. It is also a reminder that a care plan may be a subset of other issues that may be going on with the patient. Cycling through a care plan does not mean that the patient as a whole becomes secondary – we are reminded that on top of the treatment there is a patient whose other “systems” are being affected by our intervention. We need to maintain oversight of the big picture as well.

From the hospital systems improvement perspective, SOAP inserted into the “P” emphasizes that a successful PDSA Cycle outcome depends on a well thought out plan based on the input from patients and staff experiencing the challenge, the collection of meaningful data to validate and to narrow down the possible causes of the challenge, and a joint assessment to define the critical intervention points, from which a collaborative plan is developed. The message is to look at the challenge from big picture to small, to be inclusive, data driven and collaborative.

Not only does the SOAP Cycle serve care providers and hospitals in their respective areas of focus in quality care, but it can also serve to unify the language of quality in a way that enables care providers to become part of care process and system improvement at the hospital level. Although SOAP is used at the level of the individual patient, it is in essence a method of continuous improvement when properly used. In the context of SOAP, care providers can understand the PDSA Cycle with ease, and vice versa for hospital QI teams. Care providers bring invaluable expertise to hospital quality improvement, and in many ways the SOAP Cycle can align incentives and eliminate the barriers to entry into process improvement that result when outside methodologies such as Lean and Six Sigma are introduced. Indeed, if you look at any successful quality program you are likely to find that all of the SOAP Cycle elements have been incorporated into the process, regardless of quality program label. In that regard the SOAP Cycle can serve as a diagnostic tool to identify the weaknesses in any quality initiative that is not achieving the desired results. Very cool!

Food for thought:
Think about quality improvement initiatives that you are participating in or are a recipient to the results. What made them successful? What was missing from those that didn’t work out as intended?

Next post will incorporate universal systems principles into the model, completing the core elements for any QI process: The Universal SOAP Cycle.

The PDSA Cycle: Spinning in the right direction

Last week we looked at the SOAP format as an effective but under utilized care improvement tool at the level of the individual patient. Let’s now look at the PDSA cycle, a systems improvement tool that underlies most of the complex and designer quality improvement (QI) methodologies that circulate in healthcare (e.g. Six Sigma, Lean, Kaizen, TQM). Like SOAP, the PDSA cycle addresses many of the same “new” concepts that surface in QI, including evidence-based care, continuous and collaborative improvement. When used as it is intended, the results are measurable, significant and sustained. As with SOAP, however, the challenge is to stay on course with the PDSA process and we often overlook key elements, which lead to suboptimal results.

“P” is for plan – the objective of using the PDSA cycle is to identify the critical variable(s) in a system needing improvement and to develop a corrective plan. Rather than implement the plan on a large scale, the corrective plan is executed in a pilot area, a controlled environment where data collection, action and oversight is manageable. Identification of the system in need of improvement and its critical variable(s) are the key to a successful plan. This requires that the PDSA team completely understand and visualize the system being addressed, which is only possible if those using this system, namely frontline staff, are part of the team. Further, since it is the frontline staff that will be directly affected by the proposed systems changes, it is vital for them to be part of the crafting of the plan if the improvement is to be sustained. Finally, including only voluntary frontline staff to participate on a PDSA team is critical; by including only those who are interested in active participation, collaborative effort and a willingness to engage in the next step of the cycle are optimized.

“D” is for do, or action – This is where the team implements the plan in the pilot area. The key element for successful action is team member accountability: NO ACCOUNTABILITY = NO ACTION = NO CHANGE! It is the responsibility of the PDSA team leader(s) and senior leadership to hold team members accountable to the action plan. This is facilitated by making well-defined action items: WHO, WHAT, and BY WHEN? Action is also facilitated by a plan that has been created and agreed upon by the voluntary frontline staff comprising the PDSA team. Action items must be manageable: SMALL ACTIONS TAKEN ALL THE TIME are what create great results. Team members in action must be proactively visible in their efforts so that other staff members in the pilot area are aware of the improvement initiative underway. Not only does this generate overall interest but it also can generate a willingness of staff to assist team members with their action items.

“S” is for study – the results of the prior action taken are analyzed for success and for opportunities to make further improvements. WHAT is measured and HOW it is measured are key (sound familiar?). This data drives the continuous improvement process. Wrong data = wrong direction. The team makes an assessment of the collected information relative to the initial plan; any revisions that might further improve the existing plan are discussed and incorporated before proceeding to the next implementation step.

“A” is for act, or do, or action. In this step the PDSA returns to the pilot area with a revised action plan. Accountability, well-defined action items and proactive visibility again take center stage to bring successful action forward. Data is collected and results are measured so that critical revisions can again be incorporated into the plan in the next step, the “P” at the beginning of the cycle.

The PDSA cycle continues to circle in this fashion until an optimized improvement process has been created in the pilot area. If the PDSA cycle has been successful, not only is there an effective improvement plan but there is also the necessary visibility and interest among other staff members and leadership for broader implementation. This may require the creation of additional teams comprised of voluntary staff and always the continued strong support of leadership.

Food for thought:

- Think about the planning step: We often don’t spend the necessary time and effort in the planning process, nor do we include the right team members. How often do we bring in the expert consultants into our organizations to implement their one-size-fits all improvement plan? How often do our own quality departments assume complete responsibility for improvement initiatives? How often are frontline staff actively included in the process of making the system to be improved visible and understandable? If there is staff participation, is it active, sustained and voluntary? What’s the buy-in of the staff that participate?
- Think about the action step: Absence of accountability plagues healthcare in general. Most improvement initiatives are not voluntary and in an already stressed work environment, participants understandably try to avoid additional tasks. Again, how often are teams voluntary in nature? How many times do teams become gripe committees, all talk and little action? How frequently to we create well-defined action items that are small and manageable? Do staff in improvement areas really understand what is going on, what the goals are?
- Think about the study step: Many times our data collection and results measurement are poor and misdirected. Many times we take short cuts in our reassessment or skip over it completely. How many times do we “jump” to solution? How many times to we let an improvement team disassemble? How many times do the “experts” assume control of the process once the initial plan is underway?

We have seen that both SOAP and the PDSA cycle have inherent weak spots when used individually. What happens when we combine them under an umbrella of universal systems principles? It turns out that we can create a robust model that incorporates all the critical elements and that can serve as a template for any care improvement process. Next week we will look at this combination: The Universal Soap Cycle.

SOAP: The Forgotten Systems Improvement Tool

David Dibble, my systems-thinking mentor at New Agreements Healthcare, and I were discussing the challenges of making systems improvement accessible to care providers a few weeks ago. Most times underlying system challenges manifest in the form of symptoms, and it takes some digging to uncover what is actually malfunctioning. I was struck by the similar challenges that care providers face when they are taking care of patients, and it occurred to me that we utilize a tool that organizes our care approach in a consistent manner: the SOAP note. Inherent in that four letter acronym is a very powerful, time tested template for ensuring that all the necessary bases are covered to correctly diagnose and treat a patient, irrespective of their condition. In a lot of ways, however, we have forgotten this system improvement power and SOAP has instead simply become a way of formatting a patient note. Many of the concepts that are now surfacing as new ideas in care improvement, such as patient centeredness, being data driven, and taking a team approach to an evidence-based care plan have all been long embedded in this SOAP acronym. Let’s remind ourselves about this by taking the acronym apart.

“S” is for subjective, or symptoms. The entire care process for the patient begins by the care provider listening to the patient describe their complaint. It’s a frontline driven approach (sound familiar?) – the patient guides the care provider to the health problem. An effective care provider listens with respect, without judgment and asks questions to elicit the complete picture from the patient’s point of view. If additional information is required, a family member may be asked to contribute to the history. Not only is the patient heard and able to describe what it’s like to be experiencing the problem, but he/she is integral to identifying the next step: differential diagnosis and data collection.

“O” is for objective, or data collection. As we know, the most important element to data collection is WHAT is measured and HOW it’s measured. The patient’s subjective input and the care provider’s skilled assessment of the described symptoms direct data collection. This includes physical exam, review of SYSTEMS (interesting how that word shows up!), old records, labs, and studies. We all know what happens when the patient data collected is not focused on the critical elements (remember the Critical 20?) – think about the medical student or intern who orders everything “just to cover the bases.” Not only is it expensive and inefficient, but it frequently sends us all off on wild goose chases with unrelated incidental findings – as Deming would say, “off into the Milky Way we go!” Tight data collection based on the Critical 20 makes it much more likely for us to proceed effectively to the next step: assessment and diagnosis.

“A” is for assessment, or likely diagnosis. When the patient and care provider combine the focused symptoms, signs and data further narrowing of the differential diagnosis is usually possible. We arrive at a working diagnosis, which usually results in a treatment plan. Again, the working diagnosis and treatment plan is only as good as the information collected in the preceding two steps. Think about how many times we go down the less optimal path because we overlooked or were too rushed to recognize a critical input.

“P” is for plan, which leads to action. An effective plan incorporates all of the prior steps, resulting in clear action and improvement to the patient’s condition. An effective plan requires excellent communication, interdisciplinary team work and patient input (if the patient isn’t part of this, implementing a sustainable improvement is not likely to occur! Remember, change is easy until we’re directly affected by it – nobody is closer to the change than the patient).

Once the plan is activated, effective care providers will ideally begin a SOAP "loop" to evaluate and to modify the care process as appropriate. Thus, on a regular basis we check in with the patient to see how they’re doing with the treatment (“S”), we do a physical exam, check labs and studies (“O”), we re-assess our care path (“A”) and continue or modify our plan as necessary (“P”). As the major issues are resolved, we evaluate the patient for any other treatment interventions that might present as important. If we’ve done our job, the patient improves and the patient continues with the care plan or makes lifestyle adjustments such that he/she remains well (sustained improvement).

Food for thought:
- Think about how easy it is for us to cut patients off when they describe their symptoms. Not only are they frequently frustrated with their care providers and disenfranchised from the care process, but we frequently head down the suboptimal care path by jumping to solution. Rather than taking the necessary time to be thorough, we end up course correcting repeatedly in our data collection and treatments, which is an incredible waste of time and resources. Patient and staff satisfaction plummet.
- Think about how we deliver care in silos – every specialist to themselves. Data isn’t shared, frequently it conflicts and the result is a patient who has no idea what’s going on and a care process that’s suboptimal. We can be almost certain that our care interventions will not be sustained when patients are on their own. Instead they continue to cycle through healthcare with the same issues.
- Think about how disjointed we cycle through the SOAP process to make the necessary adjustments to our care intervention. Frequently the patient is excluded from further significant input once we’ve made the initial “diagnosis” and we often transition from proactive to reactive additional data collection, many times at the expense of patient discomfort or harm.
- Think about how the SOAP process relates to improving the systems within which we all work. Who is affected by the broken processes? Who needs to be heard so that the symptoms and relevant data can be collected? Who needs to be part of the solution so that an effective plan resulting in sustainable change is made possible?

Next week we will look at a process improvement tool used in systems improvement at the hospital level and explore its connection to patient care. SOAP is applicable to process improvement and care providers have a lot more to contribute to this than we think.

Rubber Side Down!

I am on a mountainbiking trip in Southern Utah this week (Brian Head) - no new post until the week of 8-11. Happy Trails!

Provider Training Provider: Variability Guaranteed

The goal in developing efficient, high quality and user-friendly systems is to eliminate as much variability as possible. Creating such systems depends on the collection of meaningful data and on the identification of the best practices that will serve as the backbones of the processes. What is frequently overlooked in the implementation of care processes is how we train care providers effectively in their use, particularly at the physician level. We usually fail to recognize that training is itself a system and that the outcome of the training is greater than 90% dependent on how the training is set up. Contrary to our popular belief in medicine, there are best practices in virtually all care processes and what we should be doing to provide the best care is to train directly to these practices. What we usually use instead is the model of care provider training care provider, and it guarantees the following:

1. Deviation from every best practice
2. Variability of care delivery between virtually every care provider
3. Inefficiency
4. Increased cost
5. Staff dissatisfaction
6. Compromised quality and safety

Care provider training care provider is suboptimal because of the following: When a care provider relies on his or her understanding and experience to pass on a best practice, it is inevitable that the transfer of the practice will be incomplete and that it will be modified; disagreement with the parts of the best practice or a particular anecdotal patient experience are frequent causes. The recipient of this training then applies his or her own interpretation and experience to the passed-on practice, which in turn gets passed on to the next recipient. And on and on… Before you know it, everybody is doing things their own way and the best practice becomes a distant memory. It’s not a big stretch to see how efficiency, quality and safety plummet while costs skyrocket.

Our suboptimal training model becomes invisible because it fits right into our culture of autonomous care – in fact it reinforces the culture! The dysfunctional training model, however, becomes visible to the user when it is taken to extremes (catch phrases to explain processes such as, “do as I say, not as I do” or “this is the way we’ve always done it” are good markers). Occasionally a dangerous practice points to the risk of the provider training provider model, as I experienced recently.

I was working with a senior resident who was supervising a very junior resident. We induced general anesthesia and the junior resident intubated our patient without incident. While I was holding the endotracheal tube in place so that the junior could presumably secure the tube in place with tape, he instead proceeded to protect the eyes with eye guards. I suggested to him that the first order of business should be to secure the airway and that he please do so, to which he replied “I’m sorry, but I’ve been told by many others to tape the eyes first,” while continuing to take care of the eyes. The senior resident then informed me that several years prior she had missed a coffee break because her attending, while taking care of a patient in another room, had accidentally spilled benzoin (liquid adhesive) into his patient’s eye during tube taping – since then she had trained everyone to protect the eyes first.

Fortunately, there were plenty of us around so that I could continue to hold the tube until it was taped in place, but you can imagine what could happen if this becomes his standard and there is less help available or during an emergency. The junior resident will be exposed to multiple variations to airway management as he works with different staff members during his training – what will he teach his junior when the time comes?

Food for Thought:
Everything is connected. Think about the perpetual loop of dysfunction that results in a healthcare system that embraces autonomy, the provider training provider model and the underlying absence of basic care processes. Each component reinforces the next and around we go. Systems-thinking is the only way to break the cycle, and education is another area that needs a systems fix.

Bells and Whistles vs. Tape and Safety Pins

Our obsession with providing the latest clinical interventions and technologies for our patients is both a blessing and a curse. As we have seen in previous posts, our attraction to the shiny new, the technically sophisticated, the next best thing results in our losing sight of the basic care processes that provide the critical support to innovation. Aside from the fact that we have never really learned how to implement and integrate new technologies using systems-thinking, our disregard for the basics repeatedly sabotages the success of any new intervention or technology.

As I was rounding on the post-operative pain service this week, I hit upon a great example of the new being implemented upon the crumbling old. We manage a large percentage of our post-surgical patients’ pain with epidurals and with peripheral nerve catheters. Regional anesthesia is particularly useful for major thoracic, abdominal and orthopedic cases, and by the end of the week we are usually managing pain for thirty to forty patients. Patients with epidurals and peripheral nerve catheters are generally very appreciative of the pain control provided with this modality, which validates and reinforces our use of regional anesthesia.

Regional anesthesia has been around for a long time and traditionally blocks were placed without direct visualization. When I did my regional anesthesia fellowship eleven years ago, we relied on superficial anatomic landmarks, tactile and verbal feedback from patients to guide our block placement. To reduce the risk of injury and to improve the success of the peripheral nerve block, we started using electrical nerve stimulators, which served as a type of homing signal and provided visual feedback as the nerve to be blocked was approached. The sophistication of the nerve stimulator increased but this was not good enough, so along came the next technology: Ultra-sound guidance. Now the possibility exists for direct visualization of the nerves to be blocked, presumably with another jump in successful pain control and a reduction of complications.

On the post-surgical side, the technology focus was on the pumps used to deliver the local anesthetics. What started out as adaptations to pumps used for intravenous medications evolved into sophisticated, patient controlled pumps designed specifically for local anesthetics. They were safer and provided the opportunity patient-centered pain control. The technology development for these devices continues.

Enter the snafu. In the fifteen years that I have been doing regional anesthesia and acute post-operative pain management, I would be hard pressed to say that the quality of pain management with nerve blocks has improved significantly. How can this be? We have better techniques for placing nerve catheters, the pumps are better, the technology in these areas keeps advancing. There are numerous reasons, but the one that jumped out at me was in the picture above: the connector piece between the block catheter and the pump tubing. The technical challenge is to secure the small bore nerve catheter to the large bore pump tubing such that it will be resistant to disconnection; disconnection disrupts the continuous delivery of local anesthetic, resulting in pain, and disconnection contaminates the nerve catheter end, resulting in an increased risk of infection. Catheter disconnects occur on an almost daily basis and in spite of this, look at the technology applied to this problem: safety pins, three way stop-cocks, tongue depressors, tape, more tape. This method of connection has not changed in at least fifteen years, not because we can’t improve upon it but because it just isn’t sexy enough to grab our attention! The absurd juxtaposition of the high tech supported by the primitive is not lost on the patients, who frequently let out a nervous chuckle as we jerry rig their lifeline for pain control.

What struck me about this example is how analogous it is to the current condition of healthcare. Technology advances and the focus of most quality initiatives occur on top of an invisible infrastructure of basic care processes that are barely being held together by creative repair jobs. When they break, we add more tape. They get our reactive attention only when something catastrophic happens. Usually we add more tape…

Until we make these basic care processes visible and important (the critical 20%), quality improvement will remain marginal and expensive.

Wrong Site Surgery: What do we expect?

An article was published in the Boston Globe this week about a wrong site surgery that happened at the Beth Israel Deaconess Hospital (BIDMC) on Monday (see http://www.boston.com/news/health/blog/2008/07/surgeon_operate.html). Unfortunately, wrong site surgery continues in many hospitals in spite of all of the attention placed on prevention. Why does this continue? Here are two likely contributors.

1. Nobody is paying attentions to the broken care processes that support the high profile safety initiatives. Even though my blog post from last week did not depict BIDMC, the chaotic OR work environment that the nurse describes in her hospital has parallels in almost every US hospital. Nurses spend as much as 45% of their time looking for missing instruments and equipment every day – if everyone is hunting and gathering just to get a case going, is it any wonder that site verification and the safety pause gets overlooked? There’s another systems principle that states that an organization will only measure what it considers to be important – if it’s not measured, it’s not important. Reflect on the computer entries for OR efficiency in my preceding post and you will notice that the only thing that’s important is getting into the room on time; there’s no valuable measure of the underlying process for room preparation that would flag anything that the nurse describes. If it’s not measured, it’s not important.

2. We have misunderstood the use of inspection in a quality process. Here’s a fundamental rule on the use of inspectors: they are not to be used as part of the quality process; instead they are there to identify problems that have already occurred in the process so that they can be fixed! Further, the more inspectors you have the worse the quality oversight; nobody takes responsibility for overseeing the process. Think about how we do site verification. Every care provider involved is typically responsible to site verify before they do anything with the patient. Most of the time every care provider is already multi-tasking, hunting and gathering and doesn’t have the time to be thorough; “No problem,” they think, “somebody else will catch any issues I miss before we get to the OR.” The patient comes into the OR, and now we have the safety pause being performed by everyone who has already done their own verification process in preop: think they’re focused, especially now where they’re under pressure to get the case started? To them it’s a redundant formality and there are more important things to do.

Food for thought:
Care providers are set up for failure when they work within these care and quality processes. The 90/10 rule rears it's ugly head again to create catastrophic patient harm! Until we make these underlying care processes visible and fix them with frontline input, we don’t have a prayer in eliminating wrong site surgery. We also have to learn to use inspection (site verification and the safety pause) in a way that it can be effective – with undiluted accountability and to improve the care process.

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I will be on vacation next week, so no blog post until the week of 7/14/08.

Data Collection: WHAT you measure and HOW you measure it

Data collection is one of the fundamental principles of systems-thinking and quality improvement. Being evidence-based is the buzz phrase in most quality and safety initiatives, and reams of data are collected on many things. There is often the notion that the more data we have, the better the improvement will be. This mindset frequently results in less than optimal results since quality is much more important than quantity. In data collection, the most important consideration is the identify What needs to be measured and How this will be measured. The “what” and the “how” can only be identified if a system or process is first made fully visible and understood. Then we need to identify the critical process elements (the critical 20% creating 80% of the results) and go to the source, with frontline care providers who actually do the work, to capture the information. Distinguishing between the formal from the informal process at work rears its head again.

What follows is an example of data collection that tracks the formal process rather than the informal process. In this hospital OR, efficiency and improvement focuses on time intervals manually entered into a computer, ideally in real time. Multiple time intervals are measured and the only one that is focused on at the quality improvement level is the time that the patient is in the room; for the first case of the day, 7:30 is the goal. As you read this, ask yourself whether the collected computer data reflects the “what” and the “how” to improve the OR environment.

Formal System: Computer Recorded Case Times

Set-up Begin: 7:18
Room Ready: 7:20
Patient In: 7:23*
Induction Complete: 8:22
Incision Made: 8:51
Ready to Close: 12:49
Surgery End: 13:40
Ready to Transfer: 13:40
Time Out: 13:42

*This is the only time deemed important: Patient In after 7:30 is documented as a late start

Informal System: Nursing Account of Same Case

This is not a litany of complaints. This is not one OR person “blaming” others, this is merely a commentary on one case, that unfortunately is very representative of what we are doing every single case.

Room 9, a relatively simple Dr. “X” spine procedure. 0730 on Tuesday.

We did not have a 6AM person setting up our rooms. The room did have a Jackson table with a Wilson frame on it. There were no dressings for the Wilson frame, and no face pillow. There was no “crank” for the Wilson, and the only one in the drawer in Room 10 was the wrong one.

Our float person was covering another room until 8AM.

The regular computer was not working. I had phoned the help desk two weeks earlier about the problem, it was never fixed. Today it was a problem because our films were from an outside hospital, and they were on a disc. Three phone calls to the help desk eventually brought a technician to the room. NIC notified.

Case was not booked with a C-arm. Dr. “Y” notified Dr. “X”’s office about the importance of doing this. Two phone calls to X-ray. The radiology tech was very gracious and did manage to secure a C-arm for an hour or so.

No microscope in Room 9. We claimed one that “J” and “B” were with (labeled Room 11) and eventually were able to locate the matching monitor, not in our area.

Two individual lights in the OR lights were out…call Bio Med.

Dr. “X”’s spine set contained two rongeurs that were caked with old bone. I bagged and tagged them, notified the NIC, she notified “K” from Quality Control and I ordered a Laminectomy I and II from Central Processing. I visited clean holding twice to collect them. The needed instruments in that kit were also dirty.

“K” came asking for the “slips” from the offending kits.

My room had one step stool. I borrowed another from Room 10, which was very soiled with blood and bone. I borrowed another. The care assistants did clean up the first one.

The arm board attached to the Jackson table broke as anesthesia attending slid it higher on the table. The patient’s arm did not fall. Located a care assistant who was dispatched to find another arm board.

My room (cabinets) were poorly stocked and in disarray. There were three incomplete Neuro prep kits, no body part for the hair clipper, no 1” paper tape, no gelfoam, 15 boxes of random sutures on the shelves, the Neuro sutures were depleted.
I had one ring stand only, and a broken lid on one of the trash containers. At 12 noon there were no towels on the exchange cart, nor were there any 60cc syringes, or 1000 drapes. Those were just the items I went looking for.

When my case finished, I took the patient to the recovery room, went to preop to see the next patient, and returned to the OR to start setting up…I was not able to clear the old sutures out of the cabinet, or gather supplies to re-stock the rooms. I did ask the supply room to come and make a list, but I never saw that happen. My apologies to the person who relieved me at three o’clock… and I guess that’s where we’re at… it’s a mess… I’m sorry… but it just isn’t getting done… run in and out of the adjoining rooms… scramble for what you need… borrow one of these… and lend something in return.

I know you can read between the lines… everyone of these simple “items” represents one more phone call… more waiting… time out of the OR… time away from the surgery… distractions and a hurriedness.

Help.

Questions: (What you measure and how you measure it)
1. Does the formal system reporting that quality improvement is based on reflect the informal system at work?
2. By computer, the patient was in the room before 7:30 and will be recorded as an on-time start – is this measure indicative of a quality process where no improvements are necessary?
3. With all of the running around that has to occur to get the patient in the room, do you think that the room was actually ready at 7:23?
4. Do any of the other recorded times suggest possible areas for improvement?

This example has a lot of lessons in it. Next time we’ll look at the implications of this work environment on staff satisfaction and patient safety.

Everything is Connected: Authentic Communication with Patients, Families and Staff

I was inspired to address this topic after receiving this blog comment:

I was struck by your statement, "The simple reality is that it takes a compassionate and supportive work environment to create a foundation for teamwork, a methodology for applying systems improvement that is simple and accessible, and quality improvement has to be returned to the frontline people with the support of leadership." Your initiative with the Peer Support program seems to be a step in the right direction toward this "compassionate and supportive work environment," but by your own description the members of that environment were not initially receptive, suggesting that at baseline there appears to be a general lack of supportiveness and dearth of compassion in place. Have you learned from your training and experience other PRACTICAL means (besides formalized Peer Support) of fostering a "compassionate and supportive work environment" that might be helpful to people in other environments who are also interested in creating better foundations for optimally functioning systems?

As I develop further as a systems-thinker I marvel at how everything is connected. This blog comment gave me an AHA! about the link between efforts to implement authentic communication around adverse events (i.e. disclosure, apology and support) and the challenge to create a compassionate and supportive work environment.

As we all know, the culture of healthcare remains very fearful and defensive around the management of adverse medical events. While many hospitals advertise robust policies for disclosure and apology in order to be in regulatory compliance, most organizations do a very poor job of implementation. In the process of communication with patients and families around these events, there is an inherent compulsion to have every contingency covered before any conversation is initiated with a patient or family (it took me five months of active engagement to organize a meeting between my patient and the hospital administration following my adverse event (see May 2 posting); it happened then only with great reluctance and trepidation).

Patients and families will tell you that they don’t expect all the answers when communication is initiated, but that they do expect updates in real time as the information becomes available. The cultural mindset to overcome on the provider side is that we want the communication to be pragmatic, comprehensive and finite (a project) while patients and families want an ongoing process of authentic communication. We want to use empathy (we don’t want to express how we feel) and patients look for sympathy (they want to know that we feel). When we communicate with such misalignment, anger and eroded trust on part of patients and families is the norm.

This same cultural mindset impedes our attempts to create a compassionate and supportive work environment. We exercise the identical pattern of poor communication with each other every day without realizing it. I had such an experience when I was doing some quality improvement consulting at a hospital. As is the case in most hospitals, there had been many previous improvement projects at this institution where leadership had failed to follow through with the recommended changes. There was a tremendous amount of anger and skepticism on part of the staff with yet another initiative when we began. However, our engagement managed to re-instill excitement into the improvement process, largely because we had empowered and supported the teams comprised primarily of frontline staff to identify and to solve the problems themselves. Respect and authentic communication set the standard. The teams worked hard and came up with some very significant system-based improvement ideas. At the end of our engagement, we submitted the teams’ recommendations to the hospital leadership for review and approval, while the teams anxiously awaited their response. While most of the suggested improvements were relatively small investments, there were some larger investments that had to be taken into deeper consideration before leadership could make a decision.

What the hospital administration decided to do was to hold off on any communication to the team participants until all the issues were resolved. Weeks passed without any communication and as would be expected, the increasingly frustrated frontline staff began to validate in their minds the usual pattern of “no follow through” by hospital leadership. Meanwhile on the administrative side, action was being taken to implement the recommendations! In spite of our repeated encouragement to leadership that they at least acknowledge the tremendous work that the teams had done and that they simply communicate some kind of a real time status report, they refused and finally requested that we leave them alone. The trust and enthusiasm that had been painstakingly developed with staff was replaced with anger and cynicism towards administration; as one of the nurses put it, “another blown opportunity for leadership to shine.” Even with the subsequent implementation of some of the recommendations the damage caused by poor communication was largely irreparable.

The parallels between the communication challenges around adverse medical events and improvement initiatives are striking. It is a vivid example of our cultural aversion to authentic communication, and the unnecessary harm that this causes to patients, families and staff. It is also a great example of the interconnectedness of systems: a poor communication process in one domain manifests everywhere else. Finally it is reflective of the principle that the only way to create sustainable change is to see a system or process in its entirety before problem solving: we have no chance of exercising authentic communication around adverse events with unless we understand and exercise authentic communication in the work environment. If we don’t treat ourselves with respect and authenticity, we don’t treat our patients with respect and authenticity.

Food for thought:
1. Authentic communication is a process, not a project
2. Authentic communication is compassionate communication (even when tough love is required)
3. Authentic communication is effective communication
4. Authentic communication has no boundaries
5. Authentic communication is a platform for change

Basic Care Made Visible: The Angry Patient

One of the frequently overlooked issues in the quality and safety movement is the importance of the fundamentals of care. We have a tendency to look at high profile issues like ventilator associated pneumonia or medication reconciliation (both of which are important) while forgetting that basics of patient care must be in place first. If we don’t see the connection of basic care processes to the high profile issues, we are effectively treating symptoms rather than root causes. As insiders, we forget how much workaround we do to get the basics done. Patients as outsiders are able to see what for us has become invisible as the following story reflects:

I enter Mr. Smith’s room for a post-operative pain evaluation. My introduction and query into his level of pain are met with a cold, silent stare. I ask him again how his epidural and PCA are working for him. Initial silence, followed by a reluctant response: “I’m very angry, not at you but at the hospital for the way I am being treated here.” I sit down on the window ledge and ask him to share what’s going on. He informs me that up until last night he thought the hospital was the “best thing since sliced bread” but that after this morning that’s no longer the case. He has no complaints about the nurses and physicians providing the care and what he shares is his frustration and anger about the lack of attentiveness that has resulted from staff being stretched way beyond their capabilities. He notes that his nurse is taking care of so many patients, many sicker than he, that she has no time to clean him up, to change the sheets, to assist him with walking. He notes how earlier in the morning his IV pump was reading “low battery.” Since he hadn’t gotten any responses to his nurse call button before, he asked his sicker neighbor to push his button. (“The poor guy,” he says, “he’s been waiting to get an MRI for two days”). The nurse showed up just as the pump started to alarm due to power failure. Fortunately the pump needed to be simply plugged in so that the batteries could recharge, and as the nurse started to leave the room, the patient noted that all of the infusions were blinking “reset.” “I don’t think I missed out on getting anything, but what if I hadn’t noticed or been able to call the nurse back and tell her?” His nurse walks into the room carrying a chair as the patient and I chat. “Look at that,” he says, “nurses should not be spending their time moving furniture!” She smiles and as she hurries off to do something else says, “I do it willingly.” “Willingly or not,” says the patient, “she shouldn’t be doing it.”
This reminds the patient of another earlier experience. He recounts how he was sitting in a chair and that his oxygenation was too low on room air. His nasal cannula tubing would not reach the wall oxygen source from the chair and the nurse went off to find extension tubing. She was gone for 20 minutes, looking for the tubing. She finally came back, and having been unable to find the extension proceeded instead to rearrange the furniture so that he could sit closer to the wall with the regular tubing. She then started to change the bed sheets without turning the oxygen on, again having to be reminded by the patient. He’s incredulous. “She’s probably one of the best nurses here, and she’s great, but she just has too many things to do at once to keep priorities straight.” Finally he says, “I have to do something about this, I don’t know what, but I might have just found something new to do with my life.”

Food for thought: Notice how the experience encompasses multiple basic care processes in the areas of:
1. Quality of Care
2. Patient Safety
3. Patient Satisfaction
4. Staff Satisfaction

The only way these connections become visible is with a system-based approach to problem solving.

Sub-optimizing the Patient Medication List

Hospitals frequently end up implementing suboptimal systems that actually result in a more dangerous patient safety environment. Healthcare is so inundated with poorly stratified safety guidelines and regulations that hospitals rush to initiate endless improvements in order to remain in compliance, without understanding the implementation challenges and without follow through. The results are initiatives that look great on paper at the executive level but that are completely dysfunctional at the level of patient care. Let’s look at an example.

LGR was under pressure to implement an electronic pre-admission Patient Medication List (PML) to reduce the incidence of medication error. A task force was put together to develop an IT-based process that would enable care providers seeing patients in the surgical pre-admission test center to enter the patient’s home medications into the computer; this record would then be printed as a separate sheet and placed into the patient’s paper chart behind the new PML tab for straightforward, easy access. Here’s the formal system:

1. Patient comes to the surgical pre-admission test center with their list of home medications.
2. The care provider evaluating the patient enters the medications into the new computerized PML template.
3. The PML is printed out and placed into the paper chart behind the new PML tab
4. The PML serves as an easy cross-reference during admission for any new medications added.
5. On discharge, the PML is referenced to ensure that the patient continues with their usual medications as appropriate.

Here’s what actually happened when the PML was launched (informal system). Computer entry of patient medications into the PML worked well enough in the pre-admit test center, provided that patients actually knew their detailed medication histories. Because the medications were now listed in the PML, the medication section of the history and physical form (H&P) was now simply noted with “see PML.” By the time the charts were assembled and the patients were on the floor recovering post-operatively, only 70% of patients seen in pre-admitting had copies of the PML in their chart. Further, only 25% of charts had the PML tab, resulting in the need for caregivers to search through the entire chart to find the PML, when it was present. With time, it became so frustrating to look through the chart for the PML that many caregivers stopped looking at all. They’re almost back to square one except that now there is no medication list in the 30% of the charts at all because the H&P says, “see PML.” You would think that caregivers could at least go online to look at the electronic version of the PML; however, access to the PML was restricted to a subset of users. So, while LGR is now in compliance with the PML guideline, appearing to be a leader in patient safety, here’s the suboptimal result that replaced the existing process:

1. In-chart documentation of pre-admission medications has dropped from 100% to 70%.
2. The PML process as developed works only 25% of the time! (PML in the chart & behind the PML tab).
3. There is now a double standard for documenting pre-admit medications since none of the surgical patients admitted directly or through the emergency department have a PML (not part of the roll-out).
4. Caregivers are so frustrated by the inconsistency that they largely forego looking for the PLM at all - it’s easier to ask the patients directly about their meds.

Food for thought:
1. As currently implemented at LGR, the PML has increased the potential for medication error by as much as 30% and it is now systematized with an IT interface. We frequently forget that while computer automation can improve safety, it is not the magic bullet. Computers are tools and not solutions: if the underlying process is not understood in its entirety, we will only automate what we already have, or make it worse.
2. The process is only understood if the people doing the work are involved! In addition to the IT folks we need to include caregivers doing the pre-operative assessment, the people involved in chart assembly and the caregivers taking care of patients during their admission.
3. Closing the implementation loop is critical. Too frequently, we launch an initiative and assume that the execution will follow to completion on its own as we run off to address the next guideline.

Sub-optimizing the Paging System

There are so many challenges in healthcare needing immediate attention that it can be overwhelming to know where even to start. What frequently happens is that a particular department or division will take it upon themselves to make an improvement that benefits their area, without recognizing the impact that this change has on a broader scale. When an improvement occurs that benefits one area to the detriment of “outside” process participants, this is called sub-optimization. Sub-optimization looks great as a formal process but in the informal process (i.e. the way it plays out in the front line of care) it quickly becomes unmasked. Not only does sub-optimization make the overall process worse but it also creates an immediate work-around. Here’s an example:

A large healthcare network reached a point in its growth where the computer-enabled paging system could no longer accommodate abbreviated callback numbers with only five digits. The decision was made to make a change in the system that would require users to enter the full ten-digit number into the callback field. Advanced warning of the change was made by email and on e-bulletins several weeks in advance to launch so that care providers wouldn’t be caught by surprise. So here’s the formal improvement:

1. Care provider goes onto the computer to page someone
2. On the paging screen, they enter the ten digit callback number
3. The person paged calls back using the ten-digit callback number
4. Communication as before!

Easy, straightforward and user-friendly, right?

Here’s how the launch went: When the new system was activated, frontline care providers quickly realized that they could no longer enter callback numbers to a significant number of phones because they didn’t have ten digit numbers! It turned out that in at least one of the network hospitals about one third of the phones are on internal phone lines with only five digits. Further, many of these phones are the ones that are next to the computers from which pages are sent and many are located in patient care areas where emergency contact may be critical.

Fortunately, frontline care providers are accustomed to “improvements” made without their input and quickly devised a work-around (informal process). The paging system is alpha-text capable, so almost immediately people started to write the five digit number in the text box, leaving the “improved” number entry blank. Of course, now everyone is largely ignoring the “improved” number entry site for all of the numbers, and they continue to abbreviate all numbers into five digits as before.

Sub-optimization occurred, at least in part, because the changes to the paging process were made without vital input from frontline caregivers who use the system every day. Without their input, the paging process was not visible in its entirety and the correction made was only from the vantage point of the IS/Communications department. The new and “improved” system is now worse than it was before. Not only has inconvenience been systematized, but it has also introduced an element of risk into the paging process for patients and staff when critical calls need to be made. Frontline care providers recognized this immediately and made the necessary work-around. Of course this work-around is also sub-optimal because it reinforces the likelihood that the wrong number will be called at another hospital (remember the initial reason for doing this change?)

So in the end, a lot of effort and resources went into what is now a suboptimal change because the right people weren’t at the table. It always takes far more effort to fix sub-optimization - it doesn't take long at all for the work-around to become very comfortable! I wonder if IS/Communications is even aware that a work-around is in place.

Formal vs. Informal Care Process: MRI

We touched on systems that we deal with in our daily lives outside of work. Now let’s look at an example of a formal vs. informal system in the hospital setting. (Reminder: the challenges that we face in healthcare are universal, and the purpose of this forum is not to separate out one institution from the next nor is it to finger point at individuals or departments. There will only be two references to hospitals, the larger hospital (>500 beds) as LGR, and the smaller hospital (<500>)).

Formal System: LGR provides anesthesia coverage for challenging MRI cases. This includes patients with severe anxiety and claustrophobia as well as patients with severe pain or co-morbidities that require extra attention. The formal system is set up as follows:

1. Anesthesia provides MRI coverage one morning per week on Thursdays.
2. The requesting service books the MRI case in advance with Radiology and with Surgical Scheduling so that the patient is officially on the anesthesia schedule
3. The outpatients are seen in the pre-admission test center on a day preceding their scheduled MRI; inpatients are evaluated the night before by the on-call anesthesia team.
4. The patients arrives at MRI about 30 minutes before the scan with complete paperwork
5. The anesthesiologist assigned to MRI reviews the chart, checks the anesthesia equipment set up by the anesthesia tech, and off they go.
6. The MRI cases are completed by 11:30AM and the anesthesiologist then proceeds to interventional radiology to provide similar afternoon anesthesia services.

Here is a description from the vantage point of the anesthesiologist of the system as it actually plays out at LGR. It’ not quite the same!

Informal System:
0730: There is construction going on in one of the MRI bays at LGR – it’s very noisy from the use of Jack Hammers; everyone is yelling to be heard.
0730: The patient arrives, upon chart review it is determined that there is no laboratory data. The MRI scan requires the use of contrast, which requires a baseline creatinine level to be drawn. There is no record of any recent laboratory work in the computer (looking in two IT systems: inpatient and outpatient); the patient had been seen in the pre-admission clinic 2 days earlier and blood had been drawn only for a coagulation profile (PT/PTT/INR). This lab is not necessary for this study.
0740: The patient is approached by the nurse and the radiology tech about the lab issue. The patient informs them that he presented a form with the necessary lab data when he presented to pre-admit clinic. No such sheet in the chart. The patient is now angry that LGR could lose this information. He now will have to have labs sent before we can do the study. He wants to talk with his referring neurosurgeon in person.
0750: The resident and attending anesthesiologist meet with the patient, acknowledge his frustration and suggest that to save him an additional needle stick that they can draw the blood sample through the iv. They also review his history and come up with an anesthetic plan to keep him comfortable during the study.
0810: The nurse contacts one of physician assistants to personally transport the blood sample from the MRI area to the lab after it is drawn. She arrives, apologizes to the patient and informs him that she will go to pre-admit clinic to find out what the problem was with the lab process. The patient says that he would love to go with her and give them a piece of his mind!
0820: The patient is taken out of the waiting area to the MRI patient prep area and placed on a stretcher. The resident starts the iv and draws a blood sample for the PA to take to the lab as arranged.
0830: PA goes to the lab – even though the sample is labeled “super stat” the result will take about an hour to obtain.
0908: The second MRI case is an inpatient scheduled for 0930. The tech asks the attending anesthesiologist (attending) whether she should delay the transport of this patient from the floor to MRI prep given the delay. She informs him that transport is usually arranged the night before for scheduled inpatients. He suggests that they hold off on sending for this patient until 10AM – given the unpredictable nature of transit time this will provide plenty of leeway so that this second patient has arrived by the time they’re ready; transport usually takes at least 30 minutes.
0910: The tech calls transport and is informed that the patient had never been scheduled with them (had they been on time with the first patient this second patient would not have arrived!). The tech asks that the patient be sent for at 10AM. She then calls the patient’s floor to inform the nurse that the patient will be coming down at 10AM.
0914: The attending receives a text page from Angiography to please call. He speaks with the nurse-in-charge, who inquires whether they will be able to start their scheduled case with anesthesia at 1130 as booked. The attending informs him of this unlikelihood given the delay. Fortunately, their schedule is flexible and he asks that they call him when they begin the second case so that he can send for the Angio patient.
0928: The nurse looks online for the necessary lab result for the first patient and it is still not entered. She calls the lab for the result and after a minute of waiting is informed of the lab value: It’s a go.
0930: The patient is taken into the MRI scanner, monitors are placed and sedation is given.
0942: The patient requires more sedation than expected, so while the resident remains with the patient the attending goes to the OR pharmacy to retrieve additional medications (OR pharmacy is at the other end of the building).
0943: The attending encounters an outpatient who is lost and requests assistance in finding the nuclear medicine clinic. He has a sense of where it is but given the poor signage, he offers to take the patient there himself. The clinic is halfway back to MRI. The patient is very thankful.
0945: The attending heads back to the pharmacy. Along the way three elderly family members stop to ask him who the third member of the Three Stooges is: Mo, Curley and? Without hesitation he answers “Larry” – he knows this data cold! They all have a good laugh.
1000: The MRI scan finally begins. The patient is well sedated, however, the pulse oximeter that they rely on to measure the patient’s oxygenation malfunctions repeatedly, resulting in continued scan interruptions, going into the scanner, pulling the patient out of the tube, readjusting the pulse oximeter, sliding the patient back in the scanner, leaving the room. Finally they get an intermittent signal by securing the pulse oximeter to the patient’s finger with a piece of tape.
1001: The second patient arrives to MRI – apparently they sent for the patient immediately disregarding the call requesting a 10AM pick up. This patient will now spend at least an hour on the stretcher waiting for her scan.
1013: The attending goes out to see the second MRI patient. Although the case had been scheduled the day before and should have been seen by the anesthesia call team, there is no pre-procedural assessment, no consent. The nurse informs him that she has the necessary paperwork for him to complete this but that she cannot stamp them up with the patient identification because the patient’s black ID card did not come down with the patient’s chart. She has called the floor and asked them to send it down.
1015: He reviews the chart in the meantime and begin to fill in the pertinent information
1028: The black ID card is hand delivered to him by one of the radiology patient care assistants
1104: The first case is complete, They’re 1.5 hours delayed. The patient will be recovered in Day Surgery and this recovery area requires discharge orders to be completed by the service performing the surgery or procedure. Radiology has never incorporated this requirement into their care process, so the attending asks the nurse to page the neuroradiology fellow to please go to day surgery to complete the paperwork. The patient informs them that he and his wife have traveled by train to get into the city and that they have to catch the outbound train at 12PM. Given that the scan was supposed to be completed at 0900, he thought that they’d have plenty of time. He tells us he’s leaving in 30 minutes whether we like it or not.
1109: I sign out the patient to the recovery room nurse and we realize that the patient’s chart has been left behind in MRI. I offer to go get it.
1141: Next patient in the room for MRI. Pulse oximeter continues to malfunction in the same way, adding approximately 25 minutes of additional time to the study.
1304: Patient taken out of the scanner. In the meantime the attending is down in Angio getting the patient ready for the procedure there. The resident pages him to inform him that the recovery room is full and that they will be on hold in MRI with this second patient if she has to recover there as originally planned. He inquires whether they might bypass the recovery room given that the patient has already met discharge criteria (alertness etc.). Fortunately they are out of the main OR and can exercise this work around option. The attending calls the resident back and inform him that this would be fine.

Think about the impact this informal system has on:
1. Levels of patient and care provider frustration
2. Efficiency and scheduling
3. Safety
4. Cost
5. Other?

This informal process has been in place for years and is so routine that it has become invisible!! Nobody thinks twice about this process – it’s just the way it is. Until we see it, dig into the core causes, and take a frontline system-based approach to correcting the issues, nothing changes; it’s the heroics of the people at the front who keep things running to the best of their abilities.

Systems Are Everywhere

Dear Friends,

What is a system?

Making systems visible: As I mentioned earlier, I had to completely re-learn my concept of what a system or a process is. I always thought of a system as something that was “out there” that I had to access in order to take care of my patients – the computer system, the blood bank, pharmacy, blood bank, the paging system. These are indeed all systems and what I slowly started to appreciate was that systems and processes vary in size and shape and that most importantly I was intimately involved in numerous systems myself. A system or process is a way that we do things in a repetitive manner to accomplish tasks at hand. Whether large or small, what’s amazing is how invisible they become once they are in place. Here’s an example: Every one of us has a specific way that we start our work day, every day, but how many of us recognize this and actually think about what we’re doing? How many times do you hit the snooze button before getting up? What’s the first thing you do when you get into the bathroom? You brush your teeth the same way every morning without thinking about it and if you want to challenge this idea, try brushing with your opposite hand or start the brushing at a different tooth location.

Formal vs. Informal systems: Another fundamental system concept that I had to acquaint myself with is the difference between formal and informal systems. The formal system is how the process is supposed to work; the informal system is how the process really works. The formal system is the one in the written manual, instructions and guidelines; the informal system is the one based on what actually works. It’s very rare that a formal and an informal system are the same. How many of us brush our teeth according to the instructions on the toothbrush box and on the tube of toothpaste, or the way the dentist tells us to? What’s important to note as well is that while the formal process is documented, the informal process usually isn’t – it gets passed on and modified by word of mouth. Two things happen to informal systems or processes as a result: each individual modifies them and they become invisible!

Why are these things important? What I realized is that just about everything I do has some sort of an informal process associated with it that has become invisible; in fact, I can run most of my daily routine on autopilot! This is all well and good if things are working well, but what if they aren’t? If I can no longer see the process because it’s become routine, how am I going to make an improvement that sticks? Chances are I’ll go back to the formal process and focus on making the changes there because it’s documented! But this isn’t going to do a great deal of good is it because the formal system isn’t the underlying process that’s driving the activity – it’s the informal process! The first order of business is to recognize that there is an informal process running the show and that is needs to be made visible in its entirety or nothing will change!

I can imagine what you’re thinking. “What does this have to do with improving healthcare?” We need to start seeing systems and processes in our non-work environment to appreciate the intimate pervasiveness that they have on our daily lives. When we recognize that we perform most of our daily routines on autopilot (invisibly) then we can start to look at what we do on a daily basis at work. So here’s your homework: look at a particular aspect of your daily home routine and write down how you do it – it’ll open your eyes!
Next time we will start looking at healthcare.

With love and respect,
Rick

Learning from Adversity

Dear Friends,
I want to share with you an adverse event that I experienced almost nine years ago, which resulted in a major re-direct in my career and that served to define my approach to change.
On November 18, 1999 I was providing anesthetic care for a 37-year-old woman undergoing a total ankle replacement. I placed a popliteal fossa nerve block preoperatively with Bupivicaine and there was no deviation from the standard of care.
Within moments, the patient experienced a grand mal seizure and progressed to cardiac arrest. After approximately ten minutes of resuscitation the patient remained unresponsive. A fully prepped cardiac operating room was fortuitously available and our patient was rushed into the room, where she underwent a sternotomy for emergent cardiopulmonary bypass. The patient’s cardiac rhythm was restored and after being weaned off of the bypass machine she was taken intubated to the cardiac intensive care unit (ICU).
As is typical during medical emergencies, we were focused on the resuscitation with our emotions on hold. Only after the patient had been stabilized on bypass did the impact of what I had just done begin to sink in. I felt personally responsible for what had happened and compelled to communicate with the family. I thought I would be able to provide a factual account of the event to the husband but to my shock, the husband came at me with full emotional and physical force; fortunately the orthopedic surgeon intercepted him. I was now forced to confront my own emotional distress and I realized my complete lack of training in how to manage this situation. In an instant, the years of clinical training, my board certification and the respect of my colleagues as a competent anesthesiologist had become irrelevant and meaningless. I felt lost and alone.
The following day I was doing cases as though nothing had happened. No one mentioned the event as I performed my clinical duties with numb detachment.
In spite of multiple attempts to speak with the patient, there were three communication barriers: 1.) Risk management’s request that I leave communication with the patient to them; 2.) The ICU team’s desire not to be pulled into the aftermath; and 3.) The husband’s request that I keep my distance. When the patient was discharged home ten days after the event without any opportunity for me to communicate directly, a profound sense of responsibility broke through my fear and compelled me to write the patient a letter of apology with an invitation to open communication if and when she was ready.
Six months after the event, Linda Kenney called me in Seattle. This was Linda’s first opportunity to hear a factual account of the event and when Linda surprisingly offered me forgiveness, I felt an incredible emotional release. I had my life back and I could talk openly about what had happened. We met in person two years after the event, and as Linda described her frustration and anger at my institution’s refusal to communicate with her about the event, two things stood out for me: 1). That healthcare had strayed from compassionate care in a profound way; and 2). That the wall of silence that was there to protect against lawsuits was in fact a major contributor to them. I began to recognize that in addition to a gaping hole in the emotional support for patient’s and families that there was also very little support available for caregivers following adverse events. It was time to do something about this.
What followed was my commitment to be a voice for doing the right thing and to take courageous action in transforming healthcare, however remote the odds of success might appear. I supported Linda with the founding of Medically Induced Trauma Support Services (MITSS, see www.mitss.org), an organization whose mission is to support healing and to restore hope to patients, families and clinicians impacted by adverse medical events. At the same time, I took action within my hospital to create the Peer Support Service, a service that utilizes trains caregivers to provide emotional “first-aid” to colleagues involved in adverse medical events. Initially the climate was anything but receptive to these ideas, however, with commitment and perseverance what resulted was a gradual and steady recognition that the patient safety movement had to incorporate support into its improvement initiatives if it was to achieve sustainable change.

“They didn’t know it was impossible so they went ahead and did it” – Mark Twain

I have had the fortunate opportunity to do presentations on Peer Support at a national and international level over the past several years. These presentations have provided me with continued exposure to the latest developments in patient safety and quality. I have observed the increasing complexity with which the challenges are being addressed and the myriads of methodologies that now exist to solve our safety and quality woes. While there have been successes, what is now becoming apparent is a frustrating absence of sustained change and improvement. Things really aren’t getting a whole lot better and I started to become acutely aware that much of what hospitals are advertising as major improvements in presentations and publications is not visible at the level of patient care. Why?
I started to develop an interest in systems and process improvement and scrutinized improvement initiatives that were ongoing at my institution as well as others. I knew that there was some important connection between the work that I was doing with MITSS and in Peer Support and systems improvement but the link remained elusive for quite some time. Out of synchronous circumstances I happened to take a 10-day training offered by David Dibble titled “The New Agreements in the Workplace.” The core concepts for achieving sustainable change were simple and comprised of four things:
1. Find your purpose
2. Love, grow and serve your people
3. Be a systems-thinker, and
4. Practice a little every day.
I progressed through the initial few days of the training thinking that I already knew the curriculum, and I was happily validating my foundation of expertise. However, it started to dawn on me that I was anything but expert and that a lot of what I thought I knew was based on a wonderful set of incorrect assumptions. To my great surprise, I discovered that I was systems illiterate! What I was viewing as systems (IT systems, pharmacy, infection control, medical records etc.) were in fact macro systems far beyond the level at which change initiatives had to occur. I chose to participate in the remainder of the training with an open mind and as I continued to learn I suddenly saw the connection between peer support and systems thinking as critical elements to the transformation of healthcare.
We spend an enormous amount of time and effort in healthcare training our people in a fragmented manner about team building or process improvement. On the team training side, methodologies such as Good to Great or Crucial Conversations are sold as the magic bullets to safety or quality improvement. On the process side, we are introduced with great zeal and zest to complex methodologies such as Six Sigma, Lean Sigma, Kaizen and TQM. While all of these approaches are wonderful toolsets in the abstract, they produce very little sustained success, much to the frustration of their creators, to the consultants and to the client organizations. When we look at how they’re being implemented and by whom, it becomes very apparent why this is so.
There exists a universal systems principle that states that everything is connected. We have become so good at fragmenting healthcare into sub-subspecialties that we have in large part forgotten this key principle when we take care of patients. Everyone thinks that his or her focus is most important and the result is that nobody sees any connection in what they do to anything else, least of all the patient. This attitude transfers to the majority of improvement initiatives currently underway. It’s either team building and communication or process improvement. Then we take quality improvement away from the people doing the work at the frontline and relegate quality improvement to the “experts,” our quality departments and our patient safety offices. The simple reality is that it takes a compassionate and supportive work environment to create a foundation for teamwork, a methodology for applying systems improvement that is simple and accessible, and quality improvement has to be returned to the frontline people with the support of leadership. This is my purpose.
Chances are that most hospitals, consultants and process improvement gurus will posit that they incorporate all of these elements into their programs. What I believe will become uncomfortably clear as this blog develops is that the vast majority of quality improvement is top-down driven, largely disregarding the importance of frontline input, and that we are skimming the surface of the quality and safety challenge rather than going down into the infrastructure that is unglamorous and dysfunctional to the core. Healthcare is held together by the everyday heroic work arounds of the caregivers, who do everything in their creative power to see that patients get the care that they deserve. Everything is connected folks and until we start addressing the broken platform that supports the shiny, high tech side of care, we are going to continue on our stagnant path.
This blog is going to educate with stories from the frontline of care. This will not be a gripe site but rather one that shares the truth with compassion and with the intent of improving healthcare. This is not about finger pointing or about making any institution right or wrong – every hospital in America has the same challenges and what we need is the courage and the commitment to recognize this and to step up to do the right thing. Off we go!
With love and respect,
Rick

Greetings from the front!

Dear friends,
The hour is late so this is simply a quick note to say hello! I am an anesthesiologist at a major teaching hospital in Boston and a managing partner with New Agreements Healthcare. As I will share with you in coming posts, I have been on quite a personal and professional journey through patient safety and quality improvement in healthcare. While there are many good things happening, it is my feeling that many of the ongoing initiatives in safety and quality overlook fundamental principles in system-based thinking and human dynamics as well as the input of experienced frontline caregivers, which frequently result in short-lived, unsustained improvement. My hope is that we can talk about some of these principles and then support or challenge these ideas with real stories and examples from the front line of care. The transformation of healthcare is coming whether we like it or not, and the choice that we have is either to be reactive or proactive in the process. I choose the latter!