Comments

Tom – pleeeeeease do keep on ranting about healthcare. The problem is definitely not health policy and EVEN MORE DEFINITELY NOT about front line workers (excuse appalling grammar)

We get rightly excited about advances in medical technology and we marvel, wide eyed, at what can be done now at the ‘high tech end.’ Paradoxically (but typically) in two of Tom’s examples a nurse noticing a ‘change of colour’ in the patient was the life saving intervention. Two of the other examples were about infections (washing hands will save hundreds – probably thousands of lives per year) We can clearly see through these 4 random examples that survival is certainly not mainly about high tech medicine – the basics are still the cutting edge.

It must be sickening for skilled surgeons to see all their brilliant work undone by avoidable and simple errors. We can all probably provide (without thinking too hard or for tool long) 5 examples to match Tom’s 5 examples. A script writer in a soap opera couldn’t make this stuff up.

It is so sad because, at least in my experience, most managers (yes managers) and every front line worker in healthcare are trying his/her damn best to do a fantastic job …. So I agree with TP that poor leadership must be the key issue.

My immediate vision in attempting to find a solution is two fold;

1 Don Berwick and Tom Peters get together to tackle this crisis.
2 All healthcare providers worldwide adopt the Planetree caring philosophy that Tom has shared with us on this Blog and in presentations on many occasions – it is about putting the patient at the centre and doing that brilliantly.

Posted by Trevor Gay at August 25, 2008 8:21 AM

Tom:

What you wrote is spot on, but let me add two brief addenda.

First, in one of my favorite polls, a NEJM study asked doctors and patients whether or not they had had a personal experience with a medical error or knew someone who had. (This was not that long after the IOM’s 1999 and 2001 quality reports.) Big percentages said yes. THEN they asked the two groups what was the most important issue to them. Both groups went straight to economics:

35% of doctors and 42% of the public report experiencing a medical error in their own care or that of a family member, BUT...
-- Only 5% of doctors and 6% of the public say reducing medical errors is a top health care concern.
-- Physicians listed liability insurance costs
-- Public picked health care costs
(Blendon, et al., NEJM, Dec. 12, 2002)

Meanwhile, the consumer patient safety groups struggle for financing, since the affluent big givers who SURVIVE their hospital stay quickly forget the non-fatal errors and make big donations for new buildings, new equipment, etc. -- the prestige stuff that gets your name on a plaque at the hospital. I’d like to start with one simple project — consolidate the consumer patient safety sites to provide an easy-to-find resource portal for those who have suffered harm. Modest start up, even more modest maintenance fees, but it’s not going to get money from the drug companies or big status-quo foundations. Would the folks at your dinner table like to help?

I spoke earlier this week at a conference where new research on patient safety shows that the current estimates of harm are low (research to appear soon). The presentation traced the old research and showed methodologically why the new research was better and more accurate — and it came from someone who’d been on the IOM committees. Second, I heard from a heart surgeon for adults who had spoken up about an incompetent pediatric heart surgeon and lost his livelihood and a mom who had lost a baby and then been ignored by the hospital. Both of their experiences were in major metropolitan areas and relatively recent; post-IOM reports.

Every time I think I’m too cynical and militant, I get lessons in real-world experiences that leave me open-mouthed and indignant.

Which is why your outrage, to come full circle, is totally justified.

Posted by Michael Millenson at August 25, 2008 8:21 AM

Tom, as a fellow ex-military man (I was a Navy submariner), I found a recent New Yorker article fascinating.

Simply: military-style checklists have shown to dramatically decrease medical mistakes. The problem: doctors don't like the idea of their knowledge and skills being questioned.

A great quote from the article: "The typical I.C.U. [...] cut its quarterly infection rate to zero. Michigan’s infection rates fell so low that its average I.C.U. outperformed ninety per cent of I.C.U.s nationwide. In the Keystone Initiative’s first eighteen months, the hospitals saved an estimated hundred and seventy-five million dollars in costs and more than fifteen hundred lives. The successes have been sustained for almost four years—all because of a stupid little checklist."

It's a REALLY great read:

http://www.newyorker.com/reporting/2007/12/10/071210fa_fact_gawande?printable=true

Posted by Jed Christiansen at August 25, 2008 8:46 AM

Tom, every post I see where you rant about healtcare... I want to cry and shout from the rooftops - YES YES!!!

My dad, 6/2007... Major surgery for a tumor in one of the TOP NYC teaching hospitals. In the OR: anesthesia team, cardic team, kidney team, pancreas doc, oncology team, circulatory team. 5-hour surgery went FANTASTIC!

When did it go wrong? When he contracted a life-threatening bacterial infection in ICU. Klebsiella: a bacteria that is so preventable with good procedures.

(A great resource: FDA's Bug Book http://www.foodsafety.gov/~mow/intro.html).

My dad specializes in quality control in major commercial kitches. He was appalled - his kitchens are cleaner than that ICU and the procedures they had there. Wear gowns and masks? Sometimes. Change gowns and gloves between patients? Maybe. Visitors entering in groups of 4 or 5, no protective gear and with their small children: contstantly (what parent brings a toddler to ICU?)

He spent 14 days in ICU isolation (with the infectious disease team) before being released home with a nurse. He just wanted to get the hell outta there.

Why? Why does this happen? It was so frustrating! Thanks be that my dad is a tough cookie, and is 100% back to normal (sans one kidney).

So, GO GO GO!!! Rant and shout. Bloggers, link away!!! This is such an important issue, yet so hidden and hushed up.

Posted by Gayle at August 25, 2008 9:16 AM

Yet another place where the human (in every meaning of the word) aspect cannot be replaced by technology.

I feel, more and more (as I sit behind my computer where I spend waaaay too much time) that we're tech-ing ourselves out of caring enough.

Posted by Joel D Canfield at August 25, 2008 10:49 AM

Tom, when you say that bad management and sloppy leadership are to blame, you’ve really hit the nail on the head. I’m sure you’ve read the research by Amy Emdondson (quoted in Stanford prof Bob Sutton’s book, the No Asshole Rule). Edmdonson studied how leadership and co-worker relationships influenced drug treatment errors in nursing units.

Incredibly, she found that units with the best leaders reported making as many as ten times more errors than the units with the worst leaders. Emdondson figured out what was really going on: the nurses in the best-led units felt safe enough to admit mistakes. In contrast, fear was rampant in units with the worst leaders. Sutton makes Deming's point that when fear is present, people focus on protecting themselves rather than helping their organizations - and Edmondson's research shows that's true even when lives are at stake.

The question is, what is it about the workplace that allows bad leadership and fear to come about? I’ve written a book titled, “Why Your Boss is Programmed to be a Dictator” in which I’ve shown, using Systems Thinking, that all workplaces are dictatorship systems – and how fear is the automatic result. (I understand from Cathy that the book is already with you. I realize you aren’t exactly a Systems Thinking enthusiast, but I am sure the book will challenge your beliefs on Systems Thinking).

Posted by Chetan Dhruve at August 25, 2008 1:54 PM

I just came across an op ed column from yesterday's Boston Globe, "Adding Insult to Surgical Injury" by Stephen Soumerai, a Harvard Medical School professor. He highlights problems of "pain management" in hospitals: "Poor continuity of care and infrequent assessment of patient comfort and pain." He has lots of suggestions including: "There should be more continuous nursing care. More full-time nurses are needed who can work regular shifts...The pace of communication about clinical problems among nurses, residents, and doctors is glacial and needs to speed up." (http://www.boston.com/bostonglobe/editorial_opinion/oped/articles/2008/08/24/adding_insult_to_surgical_injury/)

Posted by John O'Leary at August 25, 2008 3:34 PM

I agree absolutely with Mr. Gay. In my many years in U.S. healthcare administration I found that nearly all people in the field are passionate about the level of care they give. They are in it first and foremost to save lives. But that’s the problem isn’t it. An industry that thrives on “saving” people with high technical know how. The perspective is further reinforced with perverse financial incentives that reward the most specialized health providers who affect the least amount of people. In all the examples TP gave the real question was how to stop the chronic disease from happening before they got to the hospital. The hospital focus is low impact. Yes, mistakes are made, but I can guarantee the real mistakes happened long before any of them where sent to surgery. A report showed that 80% of heart disease is preventable. 70% of health status is a result of lifestyle choices. Real leadership is needed to redefine what it means to be a healthcare institution.

Posted by Aaron Robinson at August 25, 2008 3:48 PM

The problem though lie more with the Insurance companies than with the actual hospitals, and with the extreme difficulty with which this job must be executed. I have some of my own horror stories (not myself personally but family members) mostly it comes down to the fact that the Insurance company will not pay a fair price for quality health care. Accidents will happen. That is simply the fact of life; if someone these incidents had happened in an industrial setting (such as parts not being made to specification, or some part being installed wrong it would not be a big deal). No one is perfect, what makes it worse is the fact that these doctors most of whom are good doctors (we have one of the best if not the best health care system in the world, not the cheapest or the most affordable but the best) get sued and their liability insurance skyrocketes. We won't even talk about how many diseases or disorders have similar symptoms and how easy it is to misdiagnose.

Posted by walters at August 25, 2008 3:58 PM

My father died during my graduate school years at Michigan when he was given penicillin and had an allergic reaction to it. He had gone back to the hospital immediately upon feeling really bad and was told that the penicillin would work its way through his system. He went back home. The next day in the wee hours of the morning my mother got a call from my father. He was weak, but he told my mother the whole story. He died shortly thereafter.

The painful thing was we were not there for my father, none of his 12 children. He did not have an advocate. We lived thousands of miles away. So, this 52 year-old Korean War Vet died in silence after being sent home when he should have been re-admitted. I so agree to the presence of a loved one during stays at the hospital, although he didn't expect to stay. He thought it he was in for a routine procedure. I guess no procedure at a hospital is routine. Everybody needs an advocate, especially in hospitals.

Posted by Judith Ellis at August 25, 2008 5:22 PM

Mr.Tom,

Its so true. Especially in India.

Regards,
R.Ramya Reddy

Posted by Ramya Reddy at August 26, 2008 1:55 AM

A recent piece of research on the health provider organisations in my city (Leeds, UK) recently showed that only 16% of staff had received any kind of appraisal or development planning in the last 12 months that they found useful.
The Healthcare Commission report, based on an annual survey of 155 000 NHS staff, makes for scary reading.

Only 26% thought their employer valued their work. This figure ranged between trusts from 58% to 11%.
Survey responses indicate poor levels of communication between staff and senior management, with only 22% thinking it is effective.
The survey shows that only 53% receive clear feedback on their work.
Results from previous NHS surveys have shown that staff who had received an appraisal in the previous 12 months were more satisfied with their jobs and less likely to consider leaving.
In spite of this fact only just over 60% of staff had been given an appraisal in the previous 12 months.
Only 39% of staff were satisfied or very satisfied with the recognition they get for good work. Not feeling valued was the reason most often given by staff who said they were thinking about leaving their jobs.
Communication between staff and senior managers is poor. Only 23% said senior managers involved staff in important decisions and only 22% considered communication between staff and senior management to be effective.
31% per cent said senior managers encouraged staff to suggest new ideas and 17% said different parts of the trust communicate effectively with each other.

Too much emphasis on 'scientific management' and not enough on engaging staff in the problems of providing ever improving healthcare.
http://progmanager.wordpress.com/2008/08/26/too-much-management-in-the-nhs/
and http://progmanager.wordpress.com/2008/04/09/nhs-trusts-poor-management-practice/ for more!

Posted by Mike Chitty at August 26, 2008 5:53 AM

Tom:

Long-time/first-time:

Don't have an email for you, but wanted to send this along...apropos of this post.

http://www.indystar.com/apps/pbcs.dll/article?AID=/20080826/BUSINESS03/808260363

Keep up the good fight, and love the blog!

Posted by Robert at August 26, 2008 6:37 AM

It's all very well and good saying that the frontliners all want to do a great job and that it's largely due to a colossal failure of management. However, it strikes me that this is an issue where every healthcare professional is going to claim to be concerned, ethical, professional and so on and then to assume that it's everyone else who needs to change. But the fact is, if there are hundreds of thousands of avoidable deaths, then the unavoidable suspicion is that there are many, many killers working in healthcare.

Don't these people accept responsibility for their own acts and ommissions? Do they think it's OK to be lax (and put lives at risk) because "everyone else" is lax? I'm afraid I find it hard to reconcile all these claims that the frontliners want to do a good job when there are still thousands and thousands of deaths because these same people don't do stuff as basic as handwashing and changing gowns. Fact is, if kit's provided and you don't use it, you are negligent.

I can predict some of the reactions this post will get. I don't deny that standards all round need to improve. I just don't buy into the idea that everyone working in frontline healthcare is an angel and it's those evil administrators who are causing all the problems; nor do I believe that such a simplistic attitude will solve the problem. There are rotten apples at all levels and they all need to be thrown out.

Posted by Mark JF at August 26, 2008 7:29 AM

#6 cannot be emphasized enough, so I will do it again. A veteran at this after spending the past 7 years of my life advocating for family and friends after the sudden hospital death of my father. A 24/7 advocate is a must have. Someone who cares, pays attention and has some common sense. Lives are literally at stake here.

Posted by Kate at August 26, 2008 7:59 AM

My wife's mother passed in February of this year. For a thousand reasons an advocate is necessary, although ours is a financial dilemma.

My father in law is still getting bills on the 12 (say what, 12??????) different accounts that are in his deceased wife's name. He pays $2320 here and then get's a refund for $4110 there. Then he gets a late bill sent to collection for $1060, unpaid. All of it comes from the same hospital. None of it makes any sense. In a time of grieving the hospital essentially is an organizational, monetary disaster that surviving family members have to deal with. I'm sure many people care....just not the ones working in the organization of the billing cycle.

Posted by Greg at August 26, 2008 9:11 AM

Again, I'm going to sound a note of dissent. Why on earth do we need a 24/7 advocate? Shouldn't we be treating causes and not symptoms? A 24/7 advocate is putting a bandage on the problem. What we need is a system that works properly and therefore doesn't need 24/7 advocates.

Posted by Mark JF at August 26, 2008 10:02 AM

WOW! Those were some painful and personal examples! I just started reading "Better" by Dr. Atul Gawande. He devotes an entire section to the difficulties of getting healthcare workers to wash their hands. If you want to get upset but also hear about some interesting solutions, I recommend the book.

Posted by David Rendall at August 26, 2008 10:15 AM

I pray MarkJF that you are in good health and you will not need to ever visit the hospital. You then would be the patient and under duress. You may not be able to properly respond to doctors and nurses. Yes, without doubt, hospital administrators, doctors and nurses should be responsible and held accountabable for negligence, but they too are human and make mistakes. (Appreciation for their work is also important.) Under the circumstance, wouldn't you rather have an advocate than not?

Plus, advocates, namely loved ones, just make you feel better when you're hospitalized. My mother could always count on a steady stream of vistors who asked questions politely and respectfully, yet insistently. The doctors and nurses talked about the lady with the 12 polite children and loads of grandchildren. And, they seemed happy to see us coming. We had a family meeting about the proper responses and behavior in the hospital, especially for the grandchildren and the more agressive adults of which I may be one. As the youngest, however, I was not the point person. But I dutifully got in line. This is important.

We not only made my mother feel good, but by the time she left the hospital the doctors, nurses, and dieticians actually thanked us for our concern for our mother and our honor of their position. (Because there are so many of us, we appointed one person who would call the doctor directly, but if we were there and things were not right, of course, we would speak directly to the staff.) It's important for advocates to be insisitent but kind. Kindness goes a long way. I have never been in the hospital myself. Thank God! But I would certainly like an advocate, namely any of my sisters who are all kind, but fierce.

Posted by Judith Ellis at August 26, 2008 10:51 AM

And, TP, I've been meaning to say this but keep forgetting: 65 AND 70 IS NOT OLD! "With long life I will satisfy you and show you My salvation." Continued good health for you and yours.

Posted by Judith Ellis at August 26, 2008 11:06 AM

Judith - I'm sure there is a time when a 24/7 advocate is needed. But my point is: wouldn't it be so much better if everyone was treated with such respect, compassion and care that they were unnecessary?

Posted by Mark JF at August 26, 2008 2:55 PM

Yes Mark, wouldn’t it be just great to think we didn’t need to have advocates because the service is perfect? …. But you and I know very well the reality is that hospitals have never been perfect and never will be.

Unless I misunderstood (in which case I apologise) I think Judith was suggesting ‘family advocates’ and I would support her ideas totally in that.

Many patients in hospitals are not only literally ‘undressed’ but emotionally ‘undressed’ to the point of vulnerability - even those people considered the ‘strongest.’ Let’s not overlook the fact that hospitals are frightening places for many people.

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I think we should welcome and celebrate advocacy for all patients. The best hospitals welcome advocacy – particularly from close family members because it improves communication and the partnership approach to patient care – advocates are part of the team as the example of Judith’s family proves.

Posted by Trevor Gay at August 26, 2008 5:20 PM

Yes, MarkJF, the thought of there being a perfect world is quite delightful. But this is not the case currently. I am encouraged, however, with the thought of what advocacy brings, a communciation that Trevor points out that was indeed very much a part of the kind of dialogue our family had with the hospital staff.

Our response to my understanding encouraged the staff and seems to have made the difference in service. The human element must never be underestimated no matter the profession or the professional from doctors to plumbers. We all do better with encouragement and appreciation, an obligation to do the right thing not withstanding.

Posted by Judith Ellis at August 26, 2008 6:08 PM

Trevor - You have understood my point indeed.

Posted by Judith Ellis at August 26, 2008 6:11 PM

Several years ago I was in a brand new wing of a hospital (just over a year old) and left with a cast on one foot. I needed to use the ladies room after a typically lengthy time in the waiting room. I went into several of the nearest ladies room because I was motoring around with some difficulty - they were all beyond filthy and one was even overflowing with wastewater. I went to the lobby and asked for the location of the most remote and underutilized bathroom in the joint. This was a truly disgusting experience and served to remind me that I would be wise to guard my health, so that I never need to set that foot in a hospital for the rest of my life. Yes,as others have mentioned, simple cleanliness would be a good start - but seems to elude the health care establishment. Fast food restaurants,discount stores and warehouse stores all keep clean restrooms - why can't hospitals, where cleanliness is critical, do the same?

Posted by Christy Stadelmaier at August 26, 2008 11:06 PM

So what about access to health care? 45million + Americans do not have access; that's a problem with policy. As a developed nation we have dismal health indicators when compared to others; e.g., life expectancy and infant mortality. It's all three, including policy.

Posted by Don at August 27, 2008 6:12 AM

Following up to my story with regard to patient advocates:

At first, my father felt no need to have my mom sleeping in the waiting room, being an advocate for him. All was well, she should go home and we'd all take our turns bringing mom daily.

After the infection, they realized that they could not trust the staff to tell them truthfully and clearly what was going on.

My mom slept in that waiting room for 2 weeks, got to know every single doc and nurse working the ICU, learned the ICU and doc's schedules, had every machine, tube, wire and maddening beep explained. My mom became a bulldog.

You MUST have someone there with you, because when you're the patient you are too busy (and exhausted) trying to heal to keep up with it all. It is 24/7, and you need eyes and ears that can see and hear clearly - focused on what is going on (and evesdropping when need be!).

Posted by Gayle at August 27, 2008 8:21 AM

While there are all kinds of research and stories and anecdotes showing how simple, inexpensive things such as checklists, bar code systems, frequent hand washing, etc. etc. etc. can significantly reduce errors in medical care and reduce hospital acquired infections, there is little incentive for doctors and hospitals to implement them, especially when lengthening the hospital stay can put more money in the hospital's pockets.

It will take a few sharp malpractice lawyers to put all the research together with comparisons of how their client's care differed from the care offered in the few hospitals that do 'do it right', and how their clients suffered as a result. The resulting big lawsuits and hefty settlements might finally give the doctors, hospitals and HMO's a hard enough kick in the ass (or the wallet) to change.

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It is a bit of a mystery why the larger HMO's have not led the way, since these changes would ultimately save them some serious money. They seem to think that denying large claims will save them more money that will improvements to the system.

If the medical profession over the last 50 years had followed the same basic techniques of quality improvement and learning from mistakes that the manufacturing sector or commercial aviation have followed over the same time period, medical care would be awesome and serious mistakes would be a rarity, not the norm.

It should be noted that several years ago that in a comparison of a software program v.s. real doctors, the software was much more accurate at diagnosing what was wrong with the patient than the doctors given the same information. Go figure.

Posted by Bob at August 28, 2008 3:56 PM

Hi Bob – excellent comments on a subject close to my heart.

A couple of years ago I was heavily involved in some work around revalidation of doctors here in the UK. Sir Liam Donaldson, a doctor himself and the Chief Medical Officer in the Department of Health was the author of a report in 2006 called ‘Better Doctors, Safer Patients.’

One staggering statement in that report is;

‘Once doctors reach ‘independence’ status – i.e. consultant level in the UK – their knowledge, competence, clinical skills or performance are not formally assessed from that point until they retire. That could be 30 years. Contrast that with pilots who are formally assessed up to 100 times in that same time period.’

In my experience having worked with hundreds, maybe thousands of doctors in my career, is that almost without fail doctors in the UK (and I’m sure in the US too) are highly committed professional people. They always have the best interests of their patients uppermost in their minds and their actions. I can’t help feeling we need to put down the drawbridge in some aspects of healthcare to welcome in learning from such agencies as the airline industry.

Posted by Trevor Gay at August 28, 2008 6:08 PM

Trevor, you’re absolutely right of course, in saying the healthcare industry can learn a lot from the airline industry. I remember reading an article quoting Sir Donaldson, stating that the risk of dying from a medical error at a hospital is a staggering 33,000 times more than dying in an air crash. (article link - http://www.guardian.co.uk/society/2006/nov/07/health.lifeandhealth)

I think part of the problem is that flying looks inherently unnatural and dangerous, so the industry has to take great pains to ensure that flying is safe. In contrast, a hospital, far from looking unnatural, is somewhere we think we’re going to get taken care of. So there’s constant public “pressure” on the airline industry, whereas the same amount of scrutiny and pressure isn’t typically applied to hospitals.

It only takes one crash - like the recent one in Madrid - to make everyone talk of airline industry safety. But people routinely die of medical errors (195,000 dead in the US, according to the American healthcare ratings agency HealthgGrades), yet this never gets the same dramatic media coverage as an airplane crash.

Posted by Chetan Dhruve at August 28, 2008 11:21 PM

Astute observations Chetan.

I recall Tom talking about the equivalent of one jumbo jet crash EVERY WEEK as the stat for preventable hospital deaths – imagine the publicity if we had one jumbo jet crash per week. We really have to address the preventable death stats across the world – it is a scandal as the many poignant and tragic family stories on this Blog alone indicate – it is nothing less than a world crisis. How can we possibly pretend we are an ‘advanced society’ when we are murdering (sorry for my strong language ..... actually NO, I’m not sorry) so many innocent (and ill) people! Go figure.

Posted by Trevor Gay at August 29, 2008 12:08 PM

Thanks, Trevor. Your point is well received. Murder, however, includes the intent to kill. In this regard your word choice seems to be strong indeed.

Posted by Judith Ellis at August 29, 2008 5:15 PM

True Judith - you are right - maybe I was a wee bit strong with my use of words. Very frustrating though.

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Posted by Trevor Gay at August 29, 2008 5:19 PM

Understandable indeed...

Posted by Judith Ellis at August 29, 2008 5:54 PM

Yes, MarkJF, the thought of there being a perfect world is quite delightful. But this is not the case currently. I am encouraged, however, with the thought of what advocacy brings, a communciation that Trevor points out that was indeed very much a part of the kind of dialogue our family had with the hospital staff.

Posted by Stefan at September 5, 2008 6:01 AM

All Nurses and Doctors started their profession caring but I state something has anesthetized them to the needs around them. Caring is and emotion the system does not honor. JCAHO mandated locks on med rooms, locks on IV supplies, locks on doors within the locked medroom. I asked the so silly question, "Did we have a problem with medication or needle theft". This is a JCAHO mandate and we must comply. So lets hinder the workflow of the very people who are suppose to 'care' for your loved ones with no documented evidence of this being an issue. I have least ten examples of workflow hinderances all under the guise of National Safety Standards.Everyone within the hospital is struggling for higher ground (away from the bedside)hence the Nursing shortage. I have more policies that are nearly impossible to follow on a good day. God forbid someone should get sick, oh thats right, they are sick.
Kellyann Curnayn RN

Posted by Kellyann Curnayn at October 9, 2008 8:54 PM