High standards in evidence at Duke

Here's the counter-example to the folks at Parkland Memorial Hospital, in terms of transparency and taking ownership for failure.  After bouncing around the scientific world, the story regarding a Duke University School of Medicine researcher padding his resume went worldwide last year, but there were also questions raised about the methodology behind the three clinical trials.  This kind of thing is an embarrassment to any institution, and the manner in which it is handled is indicative of the kind of leadership in place.

Hunt Willard, the Director of the Institute for Genome Sciences & Policy, has issued a letter to the community that makes clear he is the exemplar of what you would hope for.  Here are the key excerpts:

These events represent a teachable moment for all of us, and I want you to hear directly from me about what I think it means for us.

It is very clear now that we were too slow to recognize and acknowledge flaws in the underlying data, insufficiently attentive to the need to carefully track versions of both data and software, and inadequately responsive to external publications and communications that pointed out errors in the underlying data. All of these indicate a need for a tighter process, and I recognize all of this as a failure of leadership and a failure of oversight, failures for which, as director of the IGSP, I feel a level of responsibility.

In accepting responsibility for these failures, I underscore my deep commitment to the responsible conduct of research and to setting standards for accountability at all levels of our organization. I welcome your thoughts in this area, as well as any concerns you may have throughout the coming year.

Really, what more could you ever want from a leader?  But there is more, a lesson in the nature and values of the profession:

Bravo to Dr. Willard and his colleagues.

Good catches are catching on

For every adverse event that is reported in a hospital, there are likely 100 or maybe 1000 near misses that often go unreported.  Those close calls contain a wealth of information regarding systemic problems within a hospital.  Some hospitals have expanded their computerized reporting system to catch these problems.  For example, Children's Hospital in Denver did this.  After an electronic, web-based, secure, anonymous reporting system for anesthesiologists was put in place, a total of 150 incidents were reported in the first 3 months of operation, compared to four entered in the same time period a year previous.  "This . . . provided data to target and drive quality and process improvement."

Johns Hopkins uses another approach, a Good Catch Award. As noted in this paper presented to the Maryland Patient Safety Center last year:

The Good Catch Award creates positive incentives for providers and staff to report patient safety events. At the institutional level, the Good Catch Award encourages individuals to identify and report adverse events, near-misses, or other medical errors. The program rewards individuals who contribute and has been received positively by many providers and staff. The pilot phase of this program focused on identifying defects in the perioperative environment and devising a partial solution. The current phase of the Good Catch Award program shifts its focus to sustainability and strategies to maintain the implemented systems changes that resulted from the 13 Good Catch Awards given in the past two and a half years. This includes an educational component for providers, one of the original steps in the Good Catch Award process, to ensure better dissemination of information and implementation of systems improvements throughout the ACCM department. The program is ongoing in its effort to identify defects, formulate solutions, and recognize those who actively work to create a safer environment.

Here's a summary chart of the results:

This kind of program also exists at the University of Connecticut Health Center.  As noted:

John Dempsey Hospital's goal is to change any negative perceptions healthcare providers and others may have about reporting errors. Staff is encouraged to report near misses. It helps to identify areas where patients’ quality of care and safety might be improved. Reporting a near miss is considered a “good catch” and comes with rewards:

• Good Catch award certificate.
• Good Catch lapel pin.
• Special recognition within the Health Center community.
• A copy of the award certificate in Human Resources personnel file.
• Sincere thanks for dedication to patient safety and personal satisfaction.
• Reviews of all good catches to determine if additional safety measures should be implemented.

At our hospital, we had a Caller-Outer of the Month Award, similar in concept.  Instead of honoring someone who had solved a problem, our Board decided they would honor someone who had called out a problem. The idea was to provide further encouragement through the organization to those who notice and mention problems. 

These are all variations on the theme. All approaches lead to much good and are worth a look to be considered for emulation elsewhere.

Becker's shows how Lean fights the Nut Island Effect

I wrote an article in the Harvard Business Review a while back called "The Nut Island Effect: When Good Teams Go Wrong."  It was about a group of folks at a sewage treatment plant in Quincy, MA: A team of skilled and dedicated employees became isolated from distracted top managers, resulting in a catastrophic loss of the ability of the team to perform an important mission. The irony was that most people viewing the team would say that it had all the attributes of an ideal working group -- dedication, collaboration, a strong sense of integrity and values, and indefatigable energy with regard to doing the job. It is probably no coincidence that many of the staff members had served in the military, where those virtues were highly valued.

Over the years, many people have noticed the same phenomenon in other industries.  Bob Herman, with Becker's Hospital Review, has picked up on that fact, with an article focusing on the presence of this syndrome in hospitals.  He cites my experience after entering this field:

[H]e found that the "us versus them" behavior was rampant in healthcare. "We have a team of people that's motivated by the best possible values — physicians, nurses, operating room staff, people in the pathology lab — and they get isolated the same way the guys at Nut Island did," he says. "You can go into any hospital in the world, and I bet if you described this syndrome to five or 10 people, they'd look at each other and say, 'That happens all the time.'"

 

Bob relates how the use of Lean process improvement in the hospital setting can help reduce the likelihood of this pattern occurring.

Once frontline staff members are trained to report setbacks and managers act on those calls, hospital leadership can map out the processes in question, diagnose the problems and reduce the waste that is bogging down production.... [T]here is a bevy of benefits from this type of systematic hospital improvement based on Lean principles: Employees are not as tired; employees are less likely to make a medication error because they are not as rushed; staff morale improves as more people get to know each other; there is less staff turnover; there is an improvement in overall quality of care; and money is saved as the waste in all processes gets weeded out.

Thanks to Bob for such a clear exposition of these points.