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!)

Thanks for speaking up

When I give talks about patient safety, I usually include a slide called, "Why Pilots Won't Nurse." It's an attention getter, one that draws smiles and sometimes fosters an "a-ha" moment for students, seasoned clinicians, and administrators.

I think that pilots won't nurse because, as a group, pilots are knowledgeble enough to reject systems that lack sufficient barriers, redundancies, and opportunities to uncover and rectify potentially lethal errors that have been set in motion. Commericial aviation isn't fool-proof, but the industry's 1 in 6 million crash rate shows what can be accomplished in high stakes domains when adequate barriers, redundancies, and recovery ops are in place.

I could add another slide: why pilots don't practice pharmacy. And there's no better place to read why than Bob Wachter's thanksgiving day post about the tragic case in Ohio, one in which a little girl lost her life, a family dissolved, and a pharmacist went to jail. 

Late last summer, Mike Cohen, the president of the Institute for Safe Medication Practices, published An Injustice Has Been Done about what happened to pharmacist Eric Cropp in the aftermath of little Emily Jerry's death. Bob and Mike talked about what Eric's case means, for professionals and for patient safety in a CareFusion webinar (the recording is available here). Thanks for speaking up.

I am thankful!

People who check in at Florence dot com come from all over the world, united by a desire to see better, safer healthcare systems emerge. I'm happy my efforts are contributing to hard work being done by so many others and thought it would be interesting to share where visits to Florence dot com came from last month.  (The darker the green, the more visits from that region.)

In this season of thanksgiving, I want to say how grateful I am for the opportunity to share reflections and pass along resources I value with so many of you.

This week, I heard a physician leader in a large multi-system healthcare organization talk about progress her organization has made in patient safety. The gains were substantial, and hard won, coming not from gorging on cheap Happy Meals, but from putting safety and quality at the center of the table where bright, powerful, and connected people in the organization regularly convene. These people not only plan the meal, they're accountable for what's served.

Patient safety, a component of quality healthcare, isn't the same as quality. People struggle to understand their relationship, especially in complex and evolving arenas like healthcare. Safety doesn't prove which chemotherapy regime is the most efficacious. It's what allows the one selected to be delivered as intended.

Safety may not reveal God's perfect truth. But, done well, safety is what allows humans to facilitate the activities--some miraculous, some mundane--needed to heal. If therapy fails because the chemotherapy regime selected isn't the best match for a person's genotype or stage of cancer, more work on the quality side of performance improvement is needed. But if a person dies from an accidental chemotherapy overdose or doesn't receive the curative benefits because of less obvious dosing errors, there's work to be done on the safety side.

I learn the most when people who are well into the safety journey talk about where they're stumbling. The physician who shared inspirational data about the reduction of serious, preventable safety events in her organization shook her head when asked about the barriers that prevent further gains. "It's hard," she said, "to make humans perform as flawlessly as the healthcare system needs them to."

This means that even in healthcare organizations where demonstrable gains in patient safety have been made, there's still plenty of work to be done. Improving system design and actively shaping the choices made by people who use the system is how David Marx, a systems engineer, attorney, and the author of the Just CultureTM algorithm, describes the work leaders undertake when they gather to create and sustain a culture of safety.

This year, one of my best reads was Marx' book, Whack-a-Mole: The Price We Pay for Expecting Perfection. It's a resource I'm thankful to have and one I hope you'll find helpful in your journey toward safest care, no matter where you are (in the world or on your journey).

Oh, and thanks for checking in today and on so many other days this year. Come back soon!