A Blue Christmas

The message inside the card reads, "Wishing you Christmas peace."

Some things just don't make sense. 

Elvis-as-messiah is one of them. And why a pharmacist will spend Christmas behind bars this year for an on-the-job error is another.

You can read more about Eric Cropp and the circumstances behind the tragic death of a toddler here.

Eric's address in the Cuyahoga County, Ohio jail appears at the bottom of the linked article. I'll be sending him one of the Elvis Christmas cards. There are 17 others in the box. I'll be happy to send one on your behalf, too.

These are a few of my favorite things.....

That's what Julie Andrews sang in the Sound of Music.

But I found them set to a different tune in a patient safety video created by nurse leaders who are DNP candidates. Thanks to Marie Duffy, Nancy Ramos, Cynthia Robotti, Rosita Rodriguez, and Sheryl Slonim for producing this excellent resource!

Grand Rounds at Charlotte's Web

Welcome to this holiday edition of Grand Rounds! It's the time of year when friends and family gather, when stories are told and memories are made. But the winter weather and short days here in the northern hemisphere seem to prompt brevity in our everyday comings and goings. It seems like the right time to combine storytelling and brevity and channel Charlotte, one of the most masterful storytellers I met during a childhood spent with my nose in a book.

In keeping with Charlotte's knack for saying what she meant and meaning what she said succinctly, I've categorized this week's submissions using six words that describe quality healthcare. (They're borrowed--in ways I suspect would make Templeton the Rat proud--from the Institute of Medicine's report Crossing the Quality Chasm.) This week participants were asked to submit one word describing the inspiration or take-away lesson for their post, and you'll find their words woven into today's Grand Rounds.

I hope you enjoy the tale. And do take the opportunity this holiday season to revisit Charlotte's Web. Better yet, share it with the next generation. As we seek solutions to the vexing issues healthcare bloggers wrote about for this edition, we'll be needing new words, spun by young people whose imaginations are ignited.

The word used by the authors of Crossing the Quality Chasm to say that patients should not be injured from care intended to help them.

Last week The Blog of the Interdisciplinary Nursing Quality Research Initiative completed an ambitious commemorative series marking the 10th anniversary of To Err is Human. Since Florence dot com is, first and foremost, a real-time patient safety primer, I'm going to carefully letter my chosen word here: LEARN. And tell you to click on this link to access INQRI's lovely collection of stories, recollections, and sage advice.

Care does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic means.

Dr. Rich gets to the meat of the matter in  Let Us Shun The Obese this Holiday Season. Dr. Rich's heart of darkness post (key word: demonization) could have fit nicely in many dimensions of care, patient-centered and effective sprung to mind. But his astute observation that obesity is often rooted in genetics makes it fit best here.

In The Users' Guide to the Health Reform Galaxy, Bruce Siegel stays on message with his word: equity. But read this post to learn why an insider believes minority groups could lose ground if health reform is not "done right." Louise from the Colorado Health Insurance Insider says the word is flaws and writes Why Health Care Reform is Important.

Care based on scientific knowledge should be provided to all who could benefit and not provided to those not likely to benefit (avoiding underuse and overuse, respectively).

Amy Romano, CNM gets a blue ribbon in this category for maximin, a word I didn't know and one that would surely delight Charlotte. Amy wisely included a vintage PubMed link explaining her word, and she articulates her position in What SUVs Can Teach Us About Maternity Care. Paul Auerbach discusses The Canadian C-Spine Rule, with a take-away word of algorithm.  Allergy Notes offers up "allergy" as an index word for the post describing the difference between food sensitization and food allergy.

Rounding out this dimension of quality healthcare are those who prompt us to pay attention to the quality and accessibility of  high end data. Eve Harris offers transparency as the take-away lesson in Asking Dr. Science. Walter Jessen at Medpedia, an innovative 2.0 health information community, uses "reliable" to describe Medpedia Now Includes News & Analysis, Alerts, Q&A. And over at Clinical Cases and Images - Blog, we're reminded that it's also helpful to think. And rewarded with a thoughtful post, Medical Textbooks and Atlases Searchable on Google Books.

Care is provided in ways that are respectful of and responsive to individual patient preferences, needs, and values. It ensures that patient values guide all clinical decisions.

The ACP Internist offers Doctors, Ditch the Tie and Coat, an interesting piece about appearance (how patients' perceptions of providers are shaped by both culture and the providers' choice of attire). I found another new Charlotte-worthy word reading this post: zoris. (Check out the post to learn what it means if it's new to you, too.)

Laurie Edwards says the relativity factor is confounding when people with chronic diseases go about Learning to be a Primary Care Patient. Amy Tenderich winds up in the middle here, too, a welcome place according to her Wayback Wednesday post Oh, Glorious Middle. And Rachel's simply titled post is For Now. But the word she sent along, patience, may say even more about what patient-centered care really entails.

Jacqueline at Laika's MedLibLog captures the arachnoid spirit, giving her post a one word title: empathy. The post shows how much we long for care that considers more about who we are than our "chief complaint" often reveals. If Jacqueline had been in the mood to spin longer, she could have called this post, "What comes around, goes around!"

Developmentally appropriate care may mean calling on the healing power of friendship, something Nancy Brown points out in Helping Friends Who are Stressed and Depressed. In another part of the village, Barbara Kivowitz cautions that assumptions are not always helpful in Seven Myths about Couples and Illness. And Will Meek says the word is forgiveness and writes about it in How to Forgive.

One of the things I like best about the IOM's six dimensions of care is this: stakeholders don't always wind up tangled in their own little bitty egg sacs. Lock Up Doc offers the word transparency to explain her position on Should Patients With Borderline Personality Disorder Be Told Their Diagnosis? (It's a stance that also earns her a place in the coveted "patient-centered" category.) Curiosity earns The Happy Hospitalist a place here, too. (And his post Gynecological Exams: Best Done By Male or Female Gynecologists earns another label: funny.)

Dr Charles gives a nod to resilience in his post Hypochondriachal Heroism. And child psychiatrist An Ang Zhang explains something that makes healthcare delivery a challenge: Lying people. She says more in The Smartest Lie: Lord Winston; Super Doctors & The Dark Side. But At How to Cope with Pain, the word is contest! Visit for a holiday-inspired change of pace and see what's cooking! (Spoiler alert: It's not pork.)

The need to reduce waits and sometimes harmful delays for both those who receive and those who give care.

Kim, a future nursing student, writes revisiting my hospital stay. Although she sent patience along as her take-away, I've chosen to place her post here because omissions count in quality measures. Rats!

Harry Stern at InsureBlog is worrying about supply and demand, too. His post, More (Un?)Intended Consequence, projects doctor shortages and backs up rather glum predictions with data from the Association of American Medical Colleges. ACP Hospitalist echoes the concern, with a call-to-action word: need. The post is New York survey shows dire need for hospitalists, internists.  I'll take this opportunity to weave in a bit of Cavatican-style cheer: mid-levels.

  Avoiding waste (of equipment, supplies, ideas, and energy).

At Shoot Up or Put Up, Tim's NHS pharmacist guest blogs with Diabetics - Blight of GPs; Milk Cows of Pharmacists, explaining why people with diabetes should engage their pharmacists. (He gets a blue ribbon for including a farm animal in the post title.) And a wry, trans-continental laugh for his take-away word: Pharma-conomics. Dr. Wes offers a one-word take-away to describe a mixed blessing: patient-provider e-mail. And he articulates both "added value" and "be careful" features of this mode in The Inefficiency of Medical E-Mail.
 
Jessica Otte explains how hard it is sleep while completing an obstetrical rotation in No electric sheep for me: Sleep is fragmented. Medical residents and how much sleep they get impacts the efficiency of individual physicians and the system that depends upon them. Her word is delusion. (I think it's meant to describe her current sleep-impaired state. But the word may also describe conventional wisdom that allowed residents' hours to remain relatively unchecked in the latter part of the 20th century.)
 
Over at the Healthcare Business Blog, David Williams says Atul Gawande is too optimistic about healthcare cost control when he advances the idea that the future of healthcare reform may lie in the county extension office. Williams is serious: his take-away word is pessimism. Marya Zilberberg calls out Gawande for another reason: shortsightedness. It's explained in her post Can US agriculture reform inform the healthcare debate? She offers thoughtfulness as her word.
 
Joseph Kim's one word is "leaving," a topic that inspired his post, Should You Leave Clinical Medicine? Finally, Jolie Bookspan offers appreciation at this time of year, with some special "academy" awards.
 
Correction to information for the next edition of Grand Rounds! It will be hosted next week, 12/22 by Nancy Brown of Teen Health 411. Nancy will accept submissions (to brownn at pamfri dot org) until Sunday, 12/20/09 at midnight. The theme is "coming together."


Note: The descriptors of the IOM's Six Dimensions of Care are reproduced from pages 5 & 6 of the Executive Summary, Crossing the Quality Chasm.

Take a Break from Hooking that Ugly Rug

My daughter hears with a cochlear implant. My 17 year old son, born with a digestive system problem that would have been lethal 50 years before his birth, now referees his dad's hockey games. Thanks to a heart-lung transplant, my first cousin lived to see her son grow from age 2 to age 12. Aggressive medical and surgical management of heart disease has enabled my dad to live beyond, by many years, the age when heart disease claimed the lives of his father and older brothers.

I think my family is probably a lot like yours. We're full of people who are the beneficiaries of medically-mediated miracles. When I visualize what modern medicine is capable of, the image is profound, mature, purposeful. It pulls from the best of what humans--energies harnessed and God-given talents extended on behalf of others--can do. Maybe it looks like this:

In the day to day business of healthcare, though, the challenge of engineering a system where safe, effective, and accessible care is realized can flummox mere mortals.

Don Berwick talked about the imperative of seeing the big picture earlier this week at IHI's National Forum. (I didn't attend this year, but benefitted from the summary Paul Levy shared on his blog.) If you didn't hear Berwick's words, Levy's post is worth a read.

The processes we use to make things come alive may work best when we break them into little bitty steps. But it's worth thinking about what it is you're trying to create and how you paint that picture for those whose efforts are integral to the success of the improvement efforts undertaken. Most professionals I know won't line up to see--let alone help craft--something that's supposed to come out like this:

When engineering quality measures, invest in front line clinicians. Engage them. Celebrate what they already do well. They're not all Michangelos. But few will be inspired to contribute by what's found in the craft aisle at Walmart.

It's also worth remembering that what's produced is going to be displayed in forums more like juried art shows than grandma's frig. So go on, take a break from hooking that ugly rug.

Grand Rounds in a Word

This week in Orlando, the Institute for Healthcare Improvement (IHI) is hosting their annual conference, one built upon a single well-chosen word: Simplify. I'll be hosting Grand Rounds here next Tuesday, 12/15 and thought we'd continue the tradition of saying what we mean and meaning what we say in a word.

You're invited to share what's on your mind about any healthcare-related topic important to you. Just send the name of your post and a link to blynnolson at gmail. The only thing you have to do to ensure your post will be included is this: Pull out ONE word that explains what motivated your post or describes the "take-away" lesson you want readers to remember and send it along with your submission. I'll do the rest!

Looking forward to receiving "the word." Please submit by 12/13/09 at midnight EST.

Who are these people? I don't always know but I'm lucky they're here.

Today is my birthday! And thanks to Facebook and other social media means, I'm able to be connected with people I know, once knew, and am getting to know! This is a blessing I am able to enjoy *virtually* every day! The diversity of people and experiences that make my life rich make me think--in very specific ways-- about precisely who is out there and what the challenges to making healthcare safe, effective, efficient, timely, equitable, and patient-centered really are.  

Here's something that made me smile last week, reprinted with permission from my cousin's Facebook page: 

Nick: "What's this?" 

Dad: "It's a pamphlet that tells you all about the flu shot you just got. You can read it if you want." 

Nick: *reads briefly, then BIG eyes* "I'M GONNA GET PREGNANT?????!!!!"

Thanks Ant and Nick! You left a great reminder that the toughest topics begin with basic steps to help people--all people--understand that when it comes to healthcare, patients are the ones with the biggest dog in the fight!

The Building Blocks of Better Care, 10 Years In the Making

This post is being cross-published today as part of The Blog of the Interdisciplinary Nursing Quality Research Initiative's commemoration of the 10th anniversary of To Err is Human.  You can find this contribution and other posts in two week series here.

Shortly after the second IOM report Crossing the Quality Chasm was published in 2001, Don Berwick authored a "users manual," a short document that clearly identified four broad stakeholder interests: the experience of patients; the functioning of the units where care is provided; the larger organizations in which direct care units reside; and the forces (policy, payment, regulatory, accreditation) that shape the performance of these organizations. Berwick described the model as necessarily hierarchical with the experience of the patient on top and other interests aligned to improve the health and functioning of the patients.

Berwick was probably wise to suggest that we begin crossing the quality chasm by holding on to the hierarchy. After all, no one understands hierarchies better than those who give and receive healthcare. By turning the hierarchy upside down, Berwick gave it a disruptive twist, one that helped re-establish the primacy of the care experience (and the outcomes attained) to the business of healthcare.

But I think Berwick was on to something better when he talked about the patient's experience being "true north." It's a construct that acknowledges the importance of the patient experience while seating all stakeholders around a common cause. 

The image of all stakeholders sharing space at the table works for me, especially since a decade's worth of study of system design and performance-shaping factors is dismantling the notion that strict hierarchies serve the interests of safety.

Ten years ago, the relationship between safety and strict deference to hierarchies—and other "soft" markers of dynamics that shape human performance—was not appreciated.  Cooperation, civility, and effective teamwork were seen as "nice to have's," the kind of behavior leaders might foster using sources like All I Really Need to Know I Learned in Kindergarten. Largely seen as social lubricants, behavior-based risk reduction strategies were given low priority in an increasingly technical healthcare domain.

A decade of studying what actually makes high-consequence industries reliable has sent healthcare stakeholders back to some foundational behavior-based learning. It turns out that things like speaking clearly, repeating words to be certain they have been understood; taking turns; using "inside" voices; and getting plenty of rest matter when individuals rely on complex processes to deliver intended outcomes. (Even "time-outs" have made a comeback!)

A series of recognizable standards and expectations are now visible on the frontlines of care. The Joint Commission’s National Patient Safety Goals is the most readily identifiable. But even more important to further progress are the larger studies and best practice recommendations linking elements of organizational culture to improvements in patient safety. Measures that support these relationships are plentiful, easy to locate, and increasingly integrated into forces that shape the performance of organizations.

The emergence of patient safety as a distinct discipline means the study of safety-sensitive processes and measures in healthcare now rests upon a conceptual framework, one that allows stakeholders to understand the science informing compliance measures in a way not possible before To Err is Human. We're poised to know, with increasing precision, not only who should be at the table but if what's being served is any good. 

Ten years spent building a table that so much rests upon is probably not too long. 

Glad you're here but there are other interesting places to visit, too!

The Tuesday redirect I normally reserve for Grand Rounds is being shared this week. This signifies a warm endorsement of the INQRI blog which today launched a 10 day series commemorating the 10th anniversary of the IOM report To Err is Human. But it doesn't mean that you shouldn't visit Health Technology News (where a good laugh is in store for those who remember Seinfeld & Co's patient adventures).

I've been surprised that the topic of patient safety--measures to prevent inadvertent harm to people who seek care--has received so little mainstream media attention in this very long season of talk about healthcare and reform. The INQRI To Err is Human series is a great place to hear how patient safety intention and outcome are converging, with some of the patient safety advocates who have led the charge taking time out to assess progress.

Check out INQRI in the coming days. There's something for everyone. (Florence herself is learning new things there!)