Monday, August 31, 2009
In the aftermath of the US Airways flight that safely landed a planeload of people in the Hudson River earlier this year, a pilot's words about the investment the flight deck has in safety stuck with me. "We're first up and last down on every flight." His words resonate because they so clearly align with a jet's nose-up take-off and wheels-down landing, an image indelibly etched in my mind after flying hundreds of thousands of miles.
We don't have reinforcers like that built into healthcare. But there are signs that the stakes are going up for leadership engagement in patient safety. Last week, The Joint Commission issued a sentinel event alert describing safety-sensitive beliefs and actions required of leaders--many that challenge healthcare's historic "Just Do It" approach to safety.
The Joint Commission's bulletin stresses the importance of matching what leaders say is valued with what's visible to front line professionals during routine and high-stakes junctures of care, particularly in the aftermath of high-profile error. Once again, we'll be borrowing from aviation.
So here's a nod to modeling transparency, an essential element of a culture of safety. I'm @SafetyNurse. Fly me!
Saturday, August 29, 2009
I may have been aware of some peripheral commotion but didn't really pay attention until a flight attendant, who had apparently noticed the title of the large textbook on my tray table, tapped me and asked, "Are you a medical professional? There's a gentleman on the plane who thinks he may be having a stroke. Are you willing to help him?"
I'm a perinatal nurse. Placentas. Labor. Birth. High-stakes vascular events in my clinical world are nearly always preceded by the diagnosis "pre-eclampsia," something a male simply cannot get. "Sure," I said, struggling to put on my shoes. "Stroke, stroke," I thought as I lumbered toward the designated seat. I think I should say something like, "What makes you think you are having a stroke, sir? Does something feel numb? Are you having trouble moving?"
When I reached the gentleman, however, talking was out of the question. He was cold, clammy, unresponsive, with a thready, bradycardic pulse. Where I live, people call this condition, "fixin' to die."
The flight attendants, working from a checklist, had notified the captain and sought help from medical personnel amongst the passengers. Communication with medical experts on the ground were being facilitated (loudly, with assessments and observations called from one flight attendant, stationed near our passenger-turned-patient, to another flight attendant, stationed at the now-open cock-pit door).
We apply oxygen by tight face mask. The first responders are three: me, an ex-Army corpsman, and someone who declines to be identified, although he is able to get oxygen flowing. (Something that's useful to know if you're a first responder while in flight: they don't drop the oxygen from the over-seat compartments. That's for emergencies that impact the oxygenation of everyone on the plane. Your team will be given a portable oxygen tank, and it may be helpful to remember "lefty-loosey, right-tighty" once you locate the on-off valve.)
"I have an AED, ma'am, I have an AED," the flight attendant repeated, rather persistently, pushing the box in my direction. Still feeling a pulse, but he's grayer, and the pulse rate is lowering. "Think, think," I thought. (The image of defibrillating a large man, mid-cabin just couldn't take hold in my mind. All I could picture was the impossibility of saying, "I'm clear, you're clear, we're all clear," when 5 rows of passengers are sitting in the metal chairs this man is going to touch if we lay him out here.)
Meanwhile, there's more flight attendant-to-cockpit communication (okay, yelling) as preparations for flight diversion are considered in light of the passenger's grave condition. "Does he have any medical conditions? Heart disease, diabetes,....." came the question as the flight attendant moved down the checklist. His traveling companion looks up, gasps, and says, "He has diabetes." Sweeter words had never been heard. This was something a perinatal nurse could do something with.
"Sugar," I said to the flight attendant. "Bring me sugar from your cart." The gentleman was unresponsive but the table sugar, which I applied (er, jammed) rather unceremoniously under his tongue and moistened with a few drops of water made him come around right quick. (Something else that's helpful to know if you're a mid-flight first responder is that flight attendants have a checklist and their efforts work in tandem with any assistance you can offer. The checklist helped to get useful facts, like this gentleman's diabetes, uncovered rapidly. This information would have been used by the medical professionals on the ground if I hadn't been able to put the pieces together and initiate corrective action. The take-away lesson? Help may not be as far away as it initially feels at 35,000 feet.)
It turned out that the passenger was a relatively new diabetic, and the day of traveling had put him off of his normal eating routine (although he had remembered to take his medications that morning). We continued on to Philly, with the gentleman refusing the EMS care that met him at the gate. I waved to him at the baggage claim area, and told his companions that he really should seek follow-up care immediately, something I very much doubt he did.
At my interview at ISMP the next day, I was asked if I had had a good flight. Of course, I told the story about the book and the in-flight interventions, at which point one of the staff members said to Mike Cohen, ISMP's president, now my mentor and friend, "See Mike, the book saved another life." Probably true. (I learned a great deal of life-saving information when I actually read the book, and I highly endorse it, both for its intended purpose and any adjunct benefit it affords the traveling public.)
May you always have a good book and fly the friendly skies!
Materials in this post first appeared on my Medscape blog, "On Your Meds: Straight Talk about Medication Safety" in April 2009.
Wednesday, August 26, 2009
So I screen a bit harder on the second date, looking for ideas and experiences that I find authentic and those that push me to reflect on these issues in a deeper way. Blog carnivals provide the "Readers Digest" version of what bloggers have written over the past week or so. Sometimes carnival hosts ask for posts on a particular topic, others just ask authors submit their favorites. I've found blog carnivals are a good place to go on a second date.
Here are two that published this week: Grand Rounds and Patients for a Moment. If you go, you'll find front line clinicians and patients telling stories about how the rubber meets the road in healthcare. They're authentic and, if you're like me, you'll probably find some that push you to think more about what, and why, you believe what you do about healthcare reform.
Tuesday, August 25, 2009
In 1988, the Cesarean Section rate in metro Atlanta hovered around 35%. I was an intrapartum nurse, who had dutifully pushed more than my fair share of laboring patients to the OR due to presumed fetal jeopardy, only to watch--delighted and perplexed--when the vast majority of infants came out screaming: pink, flexed, and oxygenated. I was certain there were better ways to have a baby.
When I gave birth, I was a healthy, young woman at 41 weeks gestation, the far end of a planned and uneventful pregnancy. Back then, nurse-midwives offered a better approach to caring for women like me, and I believe they still do.
I wasn't morally opposed to surgical birth: I just didn't want to give birth that way unless it was necessary. So I shopped for care, using indicators I understood, like C-Section rates, episiotomy rates, and the number of infants still breastfeeding at 3 months. (If you have a C-Section in a facility where only 15% of the infants are welcomed that way, you probably need one.)
Although my daughter seemingly could not wait to arrive, labor slowed as we reached the hospital, a lull that's pretty typical when laboring mammals are disrupted. And it took a long time, quite a long time to finish transition and birth my 8lb 3oz baby, who had chosen to position her hand alongside of her face for the journey.
In the late '80's laboring women were allotted about 2 hours to get their first baby pushed into the world. And I can remember feeling worried as I approached that mark. It was around that time, however, that my nurse-midwife--who had delivered 3 other babies early that morning--settled herself in, assessed the situation, and began providing very specific directions: "Pull back this way, now push." "Try this." "Push again: harder!"
Eventually, I was but a push away from having a baby. Or so it seemed to everyone in attendance. (While I was in labor, I was nicer than I usually am and, after 3 hours of pushing, I had become something of a sympathetic patient to the nurses on the unit. So, in addition to my nurse-midwife, primary nurse, and husband, I had a gaggle of interested L&D staff members offering support.) But still, I could not push that baby out. "Push harder, one more push, and the baby will be here!"
The voices became louder with each contraction, and I remember thinking, "How in the world did I wind up with precisely the kind of mad, directive, cheering crowd we had driven past all of those other hospitals to avoid?" But, as my grandmother had opined, giving birth was a lot like shitting a ham. There was, literally, no room to worry about anything else.
That's when my midwife, Margaret, did the most amazing thing: She told everyone in the room to be quiet. Then she tapped my leg, kind of brusquely and said, "Look at me." So I stopped doing whatever I had been doing that hadn't resulted in birth. The contractions abated. I looked at her.
"Why won't you push your baby out?"
There was a very long pause. "Oh, Margaret," I said, "I'm really afraid to be a mother." And I cried.
The quiet in the room turned to silence. I could sense the staff shifting and felt their gazes move toward the ceiling. By the time I delivered my firstborn, I had probably witnessed upwards of 500 births myself. And I knew that this was not an everyday announcement. A stuck baby and "being stuck" were infrequently differentiated in the world of traditional obstetrics I had come from. And I had never witnessed an intervention like the one I had just received.
But Margaret knew what she was doing.
She took her time responding. And when she did, I remember her saying something like this: "You are young and healthy. You've worked hard to get this baby here, and it's ready to come out. And your life is going to change when it does. There are no guarantees in this world, but I think you'll be able to handle whatever changes come along. And I think it's time to let this baby go."
With the next contraction, there was no holding back. Moments later, my husband and I were welcoming our own baby: pink, flexed, and screaming. We named her Margaret Claire.
I've thought of Margaret's words many times over the years. And they're with me again tonight as I once again prepare to leave my daughter in a college town 800 miles from my home. You'll be able to handle whatever changes come along. It's time to let the baby go.
See you at Thanksgiving, Mags!
Monday, August 24, 2009
Packages like The Joint Commission's "Core Measures" target a small number of high-frequency, reasonably well understood disease processes, then measure how well people treated in hospitals receive standard, evidenced-based interventions. At their best, core measures mean people with conditions like congestive heart failure and community acquired pneumonia receive the care most likely needed to treat their condition and reduce the risk of complications whether they're in Denver, CO or Dahlonega, GA. Kind of like a #2 Value Meal is the same burger, fries, and Coke everywhere you go.
The Joint Commission's National Patient Safety Goals (NPSG) are another set of menu items. These measures identify error-prone places in systems used to deliver care, then specify practices individuals, teams, and organizations should take to minimize the risk of harm-causing errors. Many emerging norms, like "read back and verify" (used when high-stakes information is transmitted verbally) and fall prevention programs, are driven by NPSGs.
Accreditation bodies use performance on these standards when evaluating an organization's quality. So do payors (including Medicare, Medicaid, and a host of private insurers) with reimbursement schedules increasingly tied to performance. Consumers are seeing evidence of them, too. As I travel around the country, I notice remarkably similar billboards announcing awards received by local hospitals for their performance in highly visible measures of care.
This is a huge step forward in defining expected outcomes and making the processes used to achieve them more transparent. (It's worth remembering that until the IOM report To Err is Human was published 10 years ago, the possibility that patients were harmed as a result of seeking care was not discussed, let alone quantified or seen as the threat to public health that it is.)
I've been a registered nurse for nearly 25 years. And before that, a waitress. So I can tell you from experience that a boxed lunch is not the worst thing that can come of a kitchen.
Current measures and methods for measuring quality are imperfect. They're stymied by a host of confounding variables, but the science of measuring what's good, bad, and ugly in healthcare will mature. Being able to see what's on the menu is a good first step, but Happy Meals aren't satisfying and they're not enough to sustain us over time.
Thursday, August 20, 2009
I just can't picture a 22 year old--who, thanks to Guitar Hero, can play the riffs in "Dream On" better than Joe Perry--entering multiple passwords, then clicking on 8 screens to release a box of Depends from a med-surg supply room.
And you should definitely check out the student's post if you're worried that the next generation doesn't bring full hearts and the ability to see the big picture. Rock on!
Tuesday, August 18, 2009
Not that there's anything inherently wrong with standardizing, simplifying, and packaging so that it's easy to get a hold of stuff. "Happy Meals" happen when efficiencies used to deliver predictable results in a reliable fashion are applied to food. And it's certainly nice to give toys to children.
But, as I used to tell my children, the prize associated with a meal is supposed to be food. It makes the gnawing feeling in your stomach called "hunger" go away. That is your present.
As childhood obesity takes stage as a significant public health concern, Happy Meals are being called out. We're beginning to question whether reliable access to high-fat, low nutritional value food is a good thing.
People like me, who fed Happy Meals to our kids once in awhile, probably recognized that these meals weren't served from the table of bountiful harvest. But the short term benefit of a quick meal and minimal clean-up exceeded any longer-term consequences we were reasonably able to anticipate. Who among us knew that so many kids were eating so much junk so frequently? Who would have guessed that Type 2 diabetes would become a childhood illness? Who could have known that the burgeoning weight of American kids would render pediatric drug dosing reference guides, based on growth tables from a previous generation, obsolete?
This is why strategy must be separated from the processes used to make it through the day: we plan meals better when we're not hungry. Strategic planning is about coming to the table, not to eat, but to think about what should be served up and how the pantry should be stocked.
Coming next: Part 2, Happy Meals in healthcare.
Thursday, August 13, 2009
The actual bill is 1,000 pages long, tough reading even for wonky wonks. So I'm passing along some information I received this morning from David Axelrod, a senior adviser to President Obama.
Mr. Axelrod is the father of a 25 year old daughter who suffers from severe epilepsy. Prior to the advent of the newest epilepsy drugs, his daughter experienced daily seizures so severe that she suffered brain damage. She's only now beginning to have stable, quiet brain, and the Axelrods are discovering what her true abilities and potential may be. (This wasn't in Mr. Axelrod's e-mail- it's information I read a few months ago when Newsweek did a special report on epilepsy.) I think it's important information to know because unlike members of Congress and other long-term governmental employees, Mr Axelrod knows first-hand what it means to battle for coverage and live in fear that a family member might not get needed care.
I'm a parent who has faced concerns like these. And while I can't know or understand every single nuanced thing in the healthcare insurance reform bill, I'm very sure that Mr. Axelrods's concerns align very closely with mine. The concerns I worry about, now and in the future, look a lot like the Axelrod's, not because I have a severly handicapped adult child. But because I could. Any one of us could face a catastrophic illness or event that forever changes our ability to secure healthcare in the system we currently have.
You should base your decisions about whether reform measures are good things or bad things for you, your family, and your country based on the changes that are proposed. It's helpful to remember that making healthcare affordable for everyone makes you safer, too. Without vaccines, some members of your Bible Study group will die. Some children in your kid's Girl Scout troops will too. Having basic, affordable healthcare for all citizens is not the same as subsidizing everyone's luxury vacation. Nor does it mean pulling the plug on Grandma.
Be wary of rumors and ideas that are circulating but are NOT part of the bill before the Congress. The only things that can become law--and affect you and your healthcare--are the items that are addressed in the bill itself.
Snopes.com is a good site for learning what is true, partially true, and not true at all. You should check on the things that don't seem right to you. Be sure any information that concerns you is in context. Beware of short, scary soundbites. Look to see who said it, when, and if it makes sense to you when you have all the facts.
These points explain what will change if the Congress passes the reform measures that are before them. I've used them to evaluate the proposed changes and form my decision to support the bill before Congress.
From Mr. Axelrod's e-mail:
8 ways reform provides security and stability to those with or without coverage
1. Ends Discrimination for Pre-Existing Conditions: Insurance companies will be prohibited from refusing you coverage because of your medical history.
2. Ends Exorbitant Out-of-Pocket Expenses, Deductibles or Co-Pays: Insurance companies will have to abide by yearly caps on how much they can charge for out-of-pocket expenses.
3. Ends Cost-Sharing for Preventive Care: Insurance companies must fully cover, without charge, regular checkups and tests that help you prevent illness, such as mammograms or eye and foot exams for diabetics.
4. Ends Dropping of Coverage for Seriously Ill: Insurance companies will be prohibited from dropping or watering down insurance coverage for those who become seriously ill.
5. Ends Gender Discrimination: Insurance companies will be prohibited from charging you more because of your gender.
6. Ends Annual or Lifetime Caps on Coverage: Insurance companies will be prevented from placing annual or lifetime caps on the coverage you receive.
7. Extends Coverage for Young Adults: Children would continue to be eligible for family coverage through the age of 26.
8. Guarantees Insurance Renewal: Insurance companies will be required to renew any policy as long as the policyholder pays their premium in full. Insurance companies won't be allowed to refuse renewal because someone became sick.
Learn more and get details: http://www.WhiteHouse.gov/health-insurance-consumer-protections/
Wednesday, August 12, 2009
Here's the post the caused me to look up the correct use of ROTFLMAO: How'd she die? Duncan Cross gets Flo's over-achiever award this week because he managed to pack good, bad, and ugly all in one post!
Americans have been visible in town halls this week sharing, and in some cases shouting, their positions on healthcare insurance reform. I've been surprised that we haven't seen or heard much from business people, like folks in the US auto industry. This would be a good time for a reminder about what happens when an enterprise spends more to insure its workers and retirees than it spends on the raw materials needed to make a car (or a cupcake). And then has to compete in the global economy.
Tuesday, August 11, 2009
While you may not feel the need to find another source of information about healthcare reform, this one is worth checking out, if only to find out how "oleaginous armor" can be used in a sentence.
Get yourself a bag of Cheetos, mute the cable, put your feet up, and enjoy the read!
Monday, August 10, 2009
Too early school starts used to occur during the last week in August, a pattern I remember well since it meant my daughter often began school on her birthday. Melting cupcakes only added to what was hot, sticky, and wrong about that. But she's a sample of one, and I guess someone has to start school on their birthday no matter which day is selected.
In Georgia, earlier school year starts have mirrored the introduction of high-stakes student testing as a primary measure of academic quality. When competitive, heavily benchmarked testing occurs in April, school systems that pre-load instructional time are likely to deliver superior results relative to those on the same journey that got a later start. These "wins" are like getting excited when the train with a 9:05 departure beats the scheduled 10:15 run.
Here are my top three "teachable moments" arising from outcomes achieved through gaming:
- Lies, damn lies, and statistics. Discuss!
- Billy Crystal is famous for saying, "It is better to look good than to feel good." Explain how quality markers inform authenticity and shape performance.
- What can people interested in reforming healthcare learn from quality measures and improvement strategies selected by other industries? Compare and contrast measures and outcomes between "commercial aviation" and "public education."
Your time begins now.
Sunday, August 9, 2009
The same number--widely seen as an underestimate--that's been floated for the past 10 years when the first comprehensive national report on patient safety was published. Today's Hearst piece added an updated comparison (in the event that comparisons to deaths from AIDS; breast cancer; and auto accidents are insufficient for illustrating the magnitude of the problem). In one month, more people die as a result of medical errors and healthcare acquired infections than died on September 11th. For the record, these iatrogenic events continue to kill more people than AIDS, breast cancer, and auto accidents. Combined.
One article published the Albany Times Union provides an excellent recap of where key improvement measures, recommended nearly a decade ago, stand today. It's worth a read whether you're a seasoned observer of medical misadventures or are just beginning the journey.
I'm in the "seasoned" crowd, and there's something in the Hearst reporting that, while not progress in and of itself, may at last be signaling change, paving the path where progress will ultimately travel.
The piece is amply illustrated by the tragic stories of individuals whose lives have been lost or forever changed as a result of medical error. The profound feelings of grief and betrayal experienced by affected individuals hasn't changed, and won't change, until there are no more stories to tell. But what does seem to be changing is a shift in perception about where the opportunities for improvement rightly lie.
When the public demands and institutions support the notion that individuals can be made to perform flawlessly, progress--in any endeavor--is stymied. Individuals can never be flawless, and from a mathematical standpoint, the performance of individuals organized within a system can't be made flawless either. But the odds of disaster when individuals work within well-constructed systems can be reduced to a near-negligible point. This is a guiding principle in industries, such as commercial aviation and nuclear power, that reliably produce an intended, and expected, result.
The Hearst report is rife with criticisms, rightly centered on infrastructure and process defects. High-end individual performance by front line clinicians can only be predicted to occur, and reoccur, when seated within work processes designed to, well, work. The report is noteworthy in its mention of such things as:
- negative consequences arising from a decade-long failure to establish a comprehensive, nationwide error-reporting system
- how a lack of organizational transparency hamstrings patients, as pure consumers of care and in the aftermath of an adverse event
- the consequences when hospitals make full adoption of NQF's Safe Practices a low-priority item
If a journey of a million miles begins with a single step, we may have seen the first one taken this morning in the Albany Times Union. And we'll soon see if the baby really can walk when we see how patient safety is prioritized in the healthcare reform we're about enact.
Wednesday, August 5, 2009
I'm not a healthcare economist. And I really don't know what stories told by individual patients mean. I suspect that taken as a whole, individual stories help explain why Americans are spending 19% of our gross domestic product on healthcare. It seems sad that a young grad student would have such intimate knowledge of diagnostic coding--a key component of healthcare's error-prone, tit-for-tat bookkeeping system--when she faces so many other complex, inexplicable things.
I wish she didn't have to worry, as my college-age, cochlear-implant using daughter soon will, "Who will insure me when I get kicked off of my parents' health insurance plan?"
I don't like the way healthcare in the US is designed to treat "parts," not "people." I don't like that so many are denied access to basic care. And I don't like the fact that patchy, poorly coordinated care costs so much. So maybe there's something to be gained from sharing one more story.
It's a short story with a built-in fix, one that I first shared on Twitter. (Conveniently, it fit into one tweet, Twitter's 140 character micro-blogging constraint.)
Why I'm 4 e-docs: $40 copay 4 last real-time dx of "ovarian cyst." Never took my pants off.
Here's the rest of the story:
I saw my family doctor because I had right-sided pain that seemed an awful lot like the same pain I had on a previous occasion, when I was found to have endometriosis-induced ovarian cysts. (My OB/GYN had relocated, and I thought seeking care from, well, my family doctor might be a good idea.)
"I'm not the girl for this."
These statements are all valid points, reflecting sad realities of care that neither of us made but both of us face.
But they're points that could have been communicated without a face-to-face visit, saving my time and the doctor's. (Not only did I not take my pants off, I never even sat on the exam table. And the only touching that occurred was a handshake.)
I would have been happy to find out that the doctor had nothing to offer me via an e-mail exchange or a video chat, and I'd be happy to pay the going rate for e-consultation. Whether I had an ovarian cyst or a bad case of gas in December, 2008 will never be known. (The pain resolved before I could schedule a visit with a specialist.) And I don't mind not knowing.
But I do mind that the encounter was captured this way:
The diagnosis of "ovarian cyst" is certainly questionable. And where did 491.20, the CPT code for "obstructive chronic bronchitis without exacerbation" come from? Who had that?
Tuesday, August 4, 2009
But wait. Forget that Lou Dobbs has been acting like Lou Gossett, Jr.
Click on over to Grand Rounds where Kim and her Gumby-esque friends share a lot of interesting things, the healthcare reform posts being a real find. You may feel like you're in a Fellini movie.
But if you're looking for the best reads, you've got nowhere else to go!