Sully inspires and presses for action

Captain Chesley "Sully" Sullenberger was the guest of honor at a "Patient Safety Leadership Roundtable" hosted at MIT by a great group of people* from the Boston area.

Many people know of Sully from the dramatic Hudson River emergency landing in January of 2009, but he also is an expert on quality and safety improvement in the air transport industry. He was here to discuss possible applications of lessons learned from that industry to the health care field.

A key one, of course, is the use of crew resource management techniques. He defined CRM as "a compact, with defined goals and responsibilities" among team members. He noted, "These are not soft skills. They are human skills. They have the more potential to save lives than new medical technologies."

Referring to the current interest in checklists, he reminded the group: "A checklist alone is not sufficient. What makes it effective are the attitude, behavior and teamwork that go along with the use of it."

When I suggested that, in health care, the implementation of CRM management also suggests inclusion of patients and families in the "crew," he concurred, saying, "We have to listen to expertise, wherever it comes from."

He called on the group to apply a sense of urgency to this problem. Citing several publications, including this article on the temporal pattern of harm by Landrigan, et al, in the November 25, 2010, issue of the New England Journal of Medicine, he noted that there had been a flat rate of improvement in this field (charts excerpted below).


"I wish we were less patient. We are choosing every day we go to work how many lives should be lost in this country."

He remarked on the scattered application of systemic approaches to safety in the health care industry: "We have islands of excellence in a sea of systemic failures. We need to teach all practitioners the science of safety."

--
* Jody Hoffer Gittell (Relational Coordination Research Collaborative, Brandeis University, MIT Leadership Center); John Carroll (MIT Sloan School, Lean Advancement Initiative); Jon Chilingerian (Brandeis University); Amy Edmondson (Harvard Business School, MIT Leadership Center); Ed Schein (MIT Sloan School, MIT Leadership Center).

Who's on first?

This story about the Joint Commission in the Boston Globe is disheartening.

The lede:

The national organization that accredits hospitals will tackle the failure of medical staff to respond to patient alarms, making it a top priority this year.

But the real story is the failure of the Joint Commission to address this issue in a comprehensive and thorough manner. Indeed, it seems to have dropped the ball:

In 2004, the commission decided to make improving alarm safety part of its national patient safety goals, which signaled it was a high priority. However, the agency soon dropped the goal, thinking that hospitals had solved the problem.

The Joint Commission seems to need to spend some time getting a focus on things. It makes animated cartoons about avoiding the spread of germs. It refuses to make its library of hospital best practices widely available. Even in this story, it seems to fear transparency: "He wouldn’t release numbers, but Schyve said the Joint Commission is getting more reports of hospital staff not responding to crucial alarms, or alarms being shut off."

This is the group that accredits hospitals for participation in Medicare. How can Congress let an accreditation agency that works for the public be so opaque with regard to clinical information and with regard to its progress in working on systemic change in hospitals?

Second thoughts on transparency in Ontario and Denmark

Barb Farlow, a patient advocate in Ontario, mentions a debate going on in that province. Here is an excerpt from a legal blog called Legal Feeds:

Governments often slip little-noticed and seemingly unrelated items into their spending plans, but just a single line in the recent provincial budget measures bill is causing a split within Ontario’s medical community.

Section 15 of the “better tomorrow for Ontario act,” which is currently in second reading before the legislature, would amend the Freedom of Information and Protection of Privacy Act to provide an exemption for the release of “information provided to, or records prepared by, a hospital committee for the purpose of assessing or evaluating the quality of health care and directly related programs and services provided by the hospital.”

The provisions take effect Jan. 1, 2012. The new amendments come just a few months after the government passed Bill 122, the Broader Public Sector Accountability Act, that provided broad public access to hospitals’ administrative and policy-related information for the first time by subjecting them to the freedom of information act. The latest proposed changes would partially reverse those reforms.

Health Minister Deb Matthews has defended the move to exempt information related to quality of care from public release. According to the Free Press, Matthews believes subjecting hospitals and doctors to greater scrutiny would prevent open dialogue about problems and how to fix them. “They must have a very open and frank discussion,” she said.

I noticed a similar attitude among colleagues attending the recent conference in Copenhagen, summarized in an article by Anders Heissel in Dagens Medicin. After I gave my talk about our hospital's decision to disclose infection rates and medical errors broadly to help stimulate process improvement, some had these reactions:

Apparently most of the Danish hospital managers who were present felt that one should be cautious in opening the door to more information that exposes the hospital's deficiencies.

The Director of the country's largest hospital, Odense University Hospital, Jane Kraglund, believes that the hospitals already publish enough data about quality.

"Our quality is transparent, but we do not learn much by putting a malpractice on the website. When we make mistakes, we have a strict system where the error is systematically reviewed, but it will not necessarily come out to the public. Moreover, more information about risk would be more confusing for the patient, "says Jane Kraglund.

Steen Mikkelsen, Director of Hospital North (hospitals in Roskilde, Køge, Holbæk, Kalundborg and Fakse), said,

"We are constantly in a competitive situation, and our standing could be damaged if there are too many bad stories about a place where you expect to get the best treatment. Clearly we will inform patients about possible errors, but the question is whether we should only do it to the patient or to the whole public. I am in doubt as to whether he mistakes we make always give rise to learning."

Proving I guess, that the survey I did that day in Denmark may not have been quite honest or accurate!

Proving also that a fundamental problem is that doctors do not believe the public will accurately or fairly judge hospitals that are honest about such matters. We never found that to be a problem at out hospital, and we were as transparent about such things as you can imagine. Our market share actually grew following our decision to be open about our clinical results, as clinical partners who agreed with our philosophy referred patients to us.

It is time for health care professionals to understand that patients can be trusted to be active partners in process improvement. Disclosure of clinical outcomes is a first and necessary step along that path.

Talking about transparency in Copenhagen

I am in Copenhagen to speak at a conference sponsored by Dagens Medicin, a newspaper for professionals and decisions makers in the medical and health care sector. According to my host, Kristian Lund, editor-in-chief, "The overall purpose of the conference is to inspire decision makers in Danish health care to improve leadership by using quality data. We are especially interested in hearing about your way of working with data and patient safety." As an outside guest, I am joined in a related topic by Johan Kips, Director of the UZ Leuven, the largest hospital in Belgium (2000 beds), who is here to address the attendees on the use of data to direct quality improvement. (Kristian -- another blogger! -- and Johan are in the accompanying photo.)

This is a fascinating topic to discuss in this venue, as the Danish health care system is quite good, but it does face interesting challenges. Here is a part of a summary from the WHO European Observatory on Health Systems and Policies.

Like the other Scandinavian countries, Denmark is characterized by a strong welfare state tradition, with universal coverage including diagnostic and treatment services, is free for all citizens except for certain services such as dental care, physiotherapy and medicine requiring patient co-payment. Equity and solidarity are important underlying values in the system, and surveys show a persistently high level of patient satisfaction. The system has a relatively good track record in terms of controlling expenditure and introducing organizational and management changes, such as transition to ambulatory care, and introduction of activity-based payment.

. . . More generally, the Danish system, like many other European health systems, faces challenges of guaranteeing access and quality while at the same time keeping costs under control. An ageing population and rising expectations regarding service are contributing factors in challenging the sustainability of the public health system.

This gives part of the context for a point Kristian wrote in my letter of invitation, "You will have a unique opportunity to influence Danish health care management in a rare situation since the government is ready to invest more than 5 billion Euro in new hospitals. Denmark is also about to reform the allocation of specialities and we are in the process of re-evaluating the education of specialists."

Here is a bit more background. Denmark currently spends about 8% of its GDP on health care (not counting the educational subsidy to those studying to be doctors and nurses.) There is an expectation that this will be quickly rising, to over 10%, within just a few years. There is pressure on the government to spend more to enhance and expand services. For example, while treatment of heart disease is excellent, cancer care is considered less than adequate by US standards, with less use of imaging and chemotherapy; and there is a desire to upgrade it. There is also a huge building program going on -- eight new hospitals are under construction. Too many hospitals are engaged in high-level procedures, and there is a need to consolidate those, but there is reluctance from those currently engaged in those arenas. I had heard previously that the primary care system was very good, with quick care and integrated electronic medical records. The former is true. It is easy to get an appointment quickly, and the care is excellent. The latter is not. Integrated EMRs are not present at the primary care level, although they are at the hospitals. Finally, there is budget pressure: When the end of the fiscal year arrives and a hospital is behind on its budget, it "manages by congestion," delaying procedures until the next year. A colleague here jokingly said, "I don't know why people from abroad come to visit, thinking our system is wonderful. We think it is awful."

I have talked on several occasions about the convergence of issues and health care design between the US and the nationalized systems of other developed countries. Denmark seems to provide another example of this. As my hosts indicated, we face the same demographic challenges and the same desire on the part of the public for the latest and best in health care technology. It is always helpful to share stories and ideas in pursuit of improved care for all.

They have heard. Are they ready?

Cheryl Clark at Health Leaders Media offered this summary from a recent conference of the American College of Healthcare Executives (ACHE).

They have heard, and hopefully understand, how important it now is. They are going to have to change their organizations in major, cataclysmic ways especially if they haven't started to do so already.

Tom Dolan, president and chief executive officer of ACHE, says leadership in general is now "much more knowledgeable" about the steps they have to take. "They know they need to reduce costs. They understand they have to adopt Toyota and Lean manufacturing strategies. They know they have to reduce errors, medication mistakes, reduce readmissions and improve quality measures for specific diseases. "They know they have to dramatically re-engineer the way we provide care and can't tinker the way they have in the past."

Here is what I am not sure of, and I mean this with affection and respect. I am not sure that the current generation of leadership in academic medical centers knows how to do what is summarized above. I actually think that leaders of some community hospitals might be better trained in such matters. Why?

Well, the career path of people chosen to be leaders of academic medical centers tends to be based on success in the things valued in the academic medical environment. As is often the case in universities, people work their way up through the ranks of the faculty based on prowess in research and specialized clinical areas. Sure, as they become division and department chairs, they take some courses in business and management, but their promotions tend to be based more on academic achievement than on managerial and leadership skills. And the continuing education courses often do not include strong training in the kind of process improvement techniques and philosophies mentioned by Mr. Dolan.

There are, of course exceptions. I can think of a handful of people who have made the transition and have demonstrated great leadership in instituting these kinds of approaches in an academic medical center. Gary Kaplan at Virginia Mason in Seattle is the prime example.

But maybe I am wrong. Let's give my readers an invitation to offer the names of others they know in this category. This is your chance to brag! Which people in academic medicine are in the vanguard of the kind of change mentioned by Mr. Dolan?