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.