So When the F___ Is This Going to Stop Being News?
I'm listening to an interview with the outgoing ambassador to Afghanistan, who was also the former Commanding General there. He says his breakthrough (he argues, realistically I think, that there's been progress) was when he started, and I paraphrase, "going out to the countryside." Likewise, in Iraq, when he was CG, General Petraeus apparently had a big poster on the wall with his guiding philosophy. The last item, in far bigger print than the others was "WALK."
So when the hell, in industry or the army, is "walkin' around," getting out and about, going to stop being a "breakthrough" leadership idea?
In 1979, on a visit to then-president John Young, Bob Waterman and I first heard about Hewlett-Packard's MBWA. Managing By Wandering Around. It was love at first sight. And it still is for me. (And, doubtless, Bob.)
Of course, HP was late to the party. By about 125 years.
In my opinion, General Ulysses S. Grant has been by far America's most effective general. (Unconditional Surrender Grant, as he was sometimes called.) Back in the 1860s, Grant was talking about, de facto, CWVA. That is, as he labeled it ... Commanding While Visiting About. On horseback, of course. In fact, better still, Grant was famous for CBWA-ing pretty much by himself. When other generals would "visit," it was invariably with a retinue in tow—loaded with colonels and other officers. Grant traveled with just one enlisted man accompanying him whose task was to ride off and deliver new orders from Grant to other commands.
Why is ... getting out and about ... MBWA-CWVA ... in 2011 ... still news?
Tom Peters posted this on 07/11/2011.
It beats the hell out of me.
As one CEO put it, of my life's work, back in 1984 ... "a blinding flash of the obvious."
I Do NOT "Have It In" for Mass General Hospital! (Or at Least, Not Much)
Lunch at the Harvard Club in Boston. First time. Age 68. Friend in publishing. I idly mention I'm vaguely thinking about a book on "patient safety." Words barely out of my mouth when a story explodes from her about a relative who'd recently suffered a series of blunders, some agonizing, at a "leading med center" in Boston.
A week before I'd paid a visit to a company I work closely with in Washington D.C. Chatting with the president about this and that. Healthcare came up because I was in the area for a couple of medical appointments. Kaboom! From her mouth explodes a horror story regarding her 90+ mom at a "leading med center" in Northern Virginia, which, like Boston, is chock-a-block with "leading med centers."
And then there was the recent dinner with fellow-sorta-oldies when health arose. (As it usually does these days.) In a flash, pretty much unbidden by me in this instance, every one offered a story of rather recent major med center f___-ups. (This may have been the 10th time this ritual has occurred—so far, alas, I'm batting 1.000. EVERY ONE in my un-scientific sample has offered a RMHFS/Recent Major Hospital F___-up Story involving themselves or someone close to them.)
My own: At a "leading med center" in Boston, was seeing an internal medicine guy of significant repute. Go over everything in an hour-plus intake interview—including, obviously, my pacemaker.
He calls up my electronic records (hooray!) and finds a heart test with questionable results. He wants to follow up ASAP, and, at 5:30 p.m. orders an MRI for 7 a.m. the next morning. Some of you will sputter at that. I didn't (great responsiveness on his part, novel indeed!); or at least I didn't until midnight when I woke up with a start and did sputter, "Holy shit, pacemaker patients can't have MRIs." I quickly went on Google and confirmed what I was 99% sure of; we can have MRIs if a cardiologist is in attendance and if, as I recall, the pacemaker has been turned off‐otherwise a high chance of fry city!
Oh, and I forgot one other thing. As I said the test the EMR system spit out indicated a problem. Well, another doc who'd ordered that test a year before had immediately ordered a follow-up which had been clean. But, um, the EMR system which had coughed up the 1st test had inexplicably failed to spit out the results of the follow-up test which was clean—at the same hospital, of course. Hence, the doc who subsequently ordered the unsafe test for me was dealing with incorrect (incomplete) data provided by the electronic medical record system.
A twofer. Screwed-up EMRs. Dumb-ass "famous" doc at "leading med center" who'd ordered a test that could have caused significant harm. He is no longer my doc. One of my friends who is a leading cardiologist was appalled—he suggested that I "do something about it," but I declined.
(But back to the Harvard Club. I'd come to Boston from Vermont for a med visit. A 350-mile round trip. Office I'd been to before. A small procedure to be done. Except, though it was in my records, they'd forgotten to write me an order for the monster antibiotic I needed to take before I came. Must do it to prevent problems that might occur, thanks, again, to that pacemaker. Whoops, 350-mile round trip pissed away!)
I've been studying patient safety for going on 10 years. The story is appalling. Hundreds of thousands of unnecessary deaths each year in the USA alone. And the story overseas, as far as I can tell, is much the same. And then there are the millions of blunders that are not fatal. And the millions of mis-recorded or mis-interpreted prescriptions. And the recent article that says we under-count med errors by a factor of ... 10. And the un-recorded more jillions of blunders in doctors' offices.
(I've also studied the failure of docs to follow standard protocols, which comes more or less under the heading of "evidence-based medicine"—lack thereof.) (And I've studied unexplained bizarrely high differences in procedure rates from one town to the next with similar demographics.) (And I've studied over-testing and over-treatment that in the USA causes huge harm, not to mention over a half-TRILLION dollars in annual healthcare costs/waste.) (And studied the charming practice of "inventing diseases" followed upon occasions by pharmaceutical companies.) (And, speaking of pharmaceutical companies, one of my wife's best friends, at Johns Hopkins, is a/the leader in the effort to get pharmaceutical companies to report all their trials data, not just the data from the trials that support their pre-ordained conclusions.) (Etc.) (Etc.)
Often I have to pinch myself, the stories are so horrendous. Sometimes I tear up. And I am, I admit, pissed off 100% of the time. Yup, I was long one of the dumb-assed bastards who was nutty enough to think that the folks in the white coats had their collective heads screwed on right—or at least screwed on.
(Oh, meant to tell you I had leukemia one weekend about a year ago. Yup, the lab had blown the blood work. Re-test fine. Phew. And did I tell you that my doc hasn't suggested to me—age 68—in two years that I might want to have a physical? Well, stupidly, I haven't had one, though on my own I have a doc pal prescribe blood work about every nine months which he then reviews.)
Back to "leading med centers"—the evidence shows that they rank high on the lists of sinners on these issues. They often are chock-a-block with genius specialists who indeed perform near miracles (good on them!!!), but I always wonder if, on net, these famous places do more harm than good. It may not be true, but it's not a wholly lame hypothesis.
(NB: Don't get me wrong, I'm sure most healthcare workers "care." But so did the UAW guys who were making defective cars in the 70s. Caring is nice. Caring is not enough.) (Well, sadly, I'm not all that sure on the "most care" dimension. My wife's mom was just at a "leading med center." Her assessment: "They got the work done, but there was nary a sign that they cared about what they were doing"—but that's just one datum.)
At any rate, the night after the wasted 350-mile trip and the productive and enjoyable lunch at the Harvard Club, I stayed at Boston's Liberty Hotel, which happens to be about 50 yards from Massachusetts General Hospital. The next morning I went out for papers, and as I came back to the hotel I found myself amidst a shift change at Mass General. The folks looked lively and intelligent. Nonetheless, I got to wondering—maybe triggered by the lunchtime tale of woe and/or the futile 350-mile trip. And I turned my "got to wondering" into a series of rather harsh, though from the heart and not unwarranted, tweets.
See employees pouring into Mass General: Wonder how many will be party to NON-patient-centric, UN-safe acts?
Employees pouring into Mass General: Will help-to-harm ratio be > 1.0?
Employees pouring into Mass General: What % docs will treat nurses, techs as the equals they are?
Employees pouring into Mass General: Wonder how many will be party to UN-necessary tests per statistical likelihood of usefulness?
Employees pouring into Mass General: Wonder how many will be party to UN-necessary surgeries per statistical likelihood of usefulness?
Employees pouring into Mass General: Wonder if ER will be as ILL-managed as usual?
Employees pouring into Mass General: Wonder how many specialists will give two thoughts to the rest of the patient's body?
Employees pouring into Mass General: Wonder how many WRONG-med-doses or WRONG-meds-per se will be administered?
Employees pouring into Mass General: Wonder how many arriving non-ambulatory patients will be accompanied by some sort of advocate?
Employees pouring into Mass General: Wonder how many patients will be given courses of treatment IN-consistent with generally agreed-upon evidence?
I have NEVER BEEN a patient at Mass General. Hence these queries (which all, in effect, start with "I wonder") are not aimed at Mass General per se. As I said in a follow-up tweet, if I'd been staying at a hotel near some other "leading med center," I would have said the exact same thing with its name substituted. (NB: One close observer of this scene suggests that if you want the best results on safety, go to "St. Elsewhere." Or, I'd add, if you qualify, a VA hospital—the VA is perennially tops in almost all patient safety categories.)
(Fact: I've only had ONE de facto direct Mass General encounter. I must say, in all fairness, it was ... HORRENDOUS. It was my wife's ER experience following her slipping and breaking her ankle. Five hour mid-day wait—she was told by a tech, and I do not jest, that she was lucky the wait was so short. All five hours on a gurney in a charmless/chaotic/very public corridor amidst very sick people and ceaseless hubbub. Virtually no staff contact other than less than two minutes with a harried staff doc who said, "We'll have to get an x-ray"—for that she went to med school? Extreme pain, five hours with no palliative—not even water for the 1st two or three hours. Subsequent X-ray guy on loan from another hospital's staff; he was (VERY) un-necessarily rough. And nobody who really seemed to give a shit—don't get me started on "patient-centered care," virtually total lack thereof. I am, of course, dead certain that July 2009 experience does not color in any way my view of Mass General. At an American Hospital Association meeting a few weeks after my wife's "experience," I said I thought the "leading med center"—I didn't ID them, though everybody figured it out—CEO "ought to be fired." ERs are a bitch and lose money, I acknowledged, but the dude signed up to be CEO of the whole hospital, so it's his problem 100%.)
Enough! I could write a book! Maybe I will. Title already picked, taking off from In Search of Excellence: Lessons from America's Best Run Companies. This one: In Search of Excellence: Lessons from America's Safest Hospitals"—yup, there are some who do this stuff incredibly well!!
(FYI: My favorite response to the tweets came from a friend I'd sent the set to. He is one of the USA's most renowned docs. Said he'd laughed and laughed and that he and his wife had picked their favorites, which he sent on to me. Nice!) (No, it wasn't Don Berwick, more or less father of the patient safety "movement," but it sure as heck might have been. Currently, Dr. Berwick is trying, as top dog, to introduce this stuff into Medicare-Medicaid. My favorite Berwick-ism on the topic of patient safety: "When I climb Mount Rainier I face less risk of death than I'll face on the operating table"—Berwick's safety crusade was largely triggered by mistreatment his wife received at a "leading med center" in, uh, Boston; he was a Harvard Med School guy.)
I am pretty ineffective in declaiming on this topic. To be an effective speaker one must follow the dictum of John Knox: "You cannot antagonize and influence at the same time." I ordinarily slavishly follow that rule—but on the topic of patient safety I have no sense of humor at all.
Idiosyncratic reading list:
Best Care Anywhere: Why VA Healthcare Is Better Than Yours, Phillip Longman
Josie's Story: A Mother's Inspiring Crusade to Make Medical Care Safe, Sorrel King
Safe Patients, Smart Hospitals: How One Doctor's Checklist Helped Us Change Healthcare From the Inside Out, Peter Pronovost & Eric Vohr
Putting Patients First: Best Practices in Patient-Centered Care, Susan Frampton & Patrick Charmel
Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer, Shannon Brownlee
Demanding Medical Excellence: Doctors and Accountability in the Information Age, Michael Millenson
Hardwiring Flow: Systems and Processes for Seamless Patient Care, Thom Mayer and Kirk Jensen
Inviting Everyone: Healing Healthcare Through Positive Deviance, Arvind Singhal, Prucia Buscell, and Curt Lindberg
Tom Peters posted this on 07/06/2011.
NB: Ho hum, and just off the wire, as I write this, from the Journal of Internal Medicine: "Medication errors are the second-leading cause of accidental death, and the only kind of accidental death that is increasing over time." As I said, ho hum.