Risky Business

A report has just been published by the Royal College of Surgeons of England entitled “The Higher Risk General Surgical Patient: towards improved care for a forgotten group”. It is a very sobering examination of the outcome in non cardiac emergency surgery.

Higher risk non-cardiac general surgery is undertaken in every acute hospital. By way of comparison, the mortality for this group, which includes most major gastro-intestinal and vascular procedures, exceeds that for cardiac surgery by two to three fold and complication rates of 50% are not uncommon. There may be a lack of awareness of the level of risk. Among these patients, emergency surgery and unscheduled management of complications is common and this group of patients are one of the largest consumers of critical care resources. The health and financial costs are considerable. 

The most amazing statistic in this paper is the fact that “Complications occur in as many as 50% of patients undergoing some common procedures.”
My pet interest of variation in care and outcomes is addressed.

Review of 2008/9 hospital episode statistics (HES) data from Dr Foster reveal a greater than two-fold variation in relative risk of 30-day mortality (risk-adjusted) after non-elective lower GI procedures between trusts in the North West SHA (strategic health authority). It is known that the chance of a patient dying in a UK hospital is 10% higher if he or she is admitted at a weekend rather than during the week.

Anyone involved in ensuring good outcomes for surgical patients, or ensuring that hospital resources are used efficiently, (by reducing unnecessary complications) needs to read this.
 
 

Normalisation of Deviance

One of my favourite terms is the “Normalisation of Deviance”. I think it captures perfectly what happens every day in healthcare. We work around problems, pat ourselves on the back for finding a (temporary) solution, and ignore the very profound message that the system is sending us; this message essentially is “you dont understand your system and your processes and if you dont work out a way to fix this problem, there will be serious consequences”. In Reasons Swiss Cheese model, all those little holes are problems that usually were recognised well before a serious event occured, but were most often ignored and certainly never consciously addressed and removed.

As Scott Snook, a lecturer from Harvard puts it:

Each uneventful day that passes reinforces a steadily growing false sense of confidence that everything is all right – that I, we, my group must be OK because the way we did things today resulted in no adverse consequences.

A paper that describes the consequences of this thinking, really a form of magical thinking is available on the NASA website; it is a section of the report into the Columbia Space Shuttle disaster. Available here.

Deming, why now?

A piece worth reading, published by the Deming Collaboration, and authored by Rafael Agauyo, who studied with Deming and subsequently published a book about Deming and his methods, (which is an excellent overview). Although there is a danger of assuming that one persons hero is the answer to all the worlds problems, Deming has outlined a systematic approach; contrast this with the toolbox approach, i.e. lets introduce lean or TQM or some other method de jour,  stand back and watch our performance improve.  Although Deming is probably best known for his PDSA, or PDCA cycle, his more profound contribution was the System of Profound Knowledge.

Coaching

A great and as ever thought provoking piece from Gawande. He discussed the value of coaching and describes his experience and initial results of using a surgical coach. Well worth a read.

Hard Jobs

A quote attributed to Peter Drucker, one of the great management gurus:

1. “The four hardest jobs in America (not necessarily in order) are: President of the United States, a university president, a hospital CEO, and a pastor.”
   
2. “Health care is the most difficult, chaotic, and complex industry to manage today.”
   
3. “The hospital is altogether the most complex human organization ever devised.” 

I find that hard to believe, but on mature reflection, maybe not.

Physician Burnout

Physician burnout is a well recognised problem, and may be associated with other undesirable factors including substance abuse, depression, physician suicide and poor patient outcomes. I am seeing the phenomenon of burnout more frequently, but my impression is that the response of the system is not just to ignore this but to continue to pile on more pressure.
A paper just published here reports some very disturbing findings.

Quality of life was rated “as bad as it can be” or “somewhat bad” by 2402 of 16 187 responding residents (14.8%). Overall burnout and high levels of emotional exhaustion and depersonalization were reported by 8343 of 16 192 (51.5%), 7394 of 16 154 (45.8%), and 4541 of 15 737 (28.9%) responding residents, respectively.

Interestingly, international medical graduates showed lower levels of distress. The fundamental problem in my view is that physicians refuse to recognize these problems in their colleagues and indeed see such problems as “weakness and failure”

One factor in the difficulty in ensuring change happens in healthcare is that healthcare workers, especially doctors, find it easy to work around the system. If we had to wait as long as our patients, perhaps we might be more enthusiastic about changing and leading the change that must happen in our systems. A recent report suggests that our ability to circumvent the system, at least in the US is associated with a higher prevalence of disease than would be expected in the population; in other words does the ease of access imply an ease of diagnosis. Having had a recent experience of healthcare, it does appear to me that at least for doctors, other doctors may be more likely to test and treat.

Mirror, Mirror on the wall, who is the best of us all?

Conventional wisdom suggest that bigger and more sophisticated hospitals offer the best care. However, my anecdotal experience suggest that this may not always be the case. There are some emerging data which also put the lie to this hypothesis. Just published is The Joint Commissions annual survey of hospital quality in the US.
The measures used to assess quality might be criticized as “process“ measures, i.e. Are we delivering the care that we are supposed to deliver? but these are basic widely agreed measures. The most stunning finding was that many of the big name hospitals, even those that have tried to make their name as institutions that prioritize quality and safe care do not feature. Or maybe not so surprising; in a culture in which individuals prize their autonomy, it will be easier for smaller hospitals to ensure they are consistent in applying processes.

Variation

Those who have become followers of Deming realise the significance of variation, and the need to reduce  unnecessary or harmful variation. I came across a great quote today,

" the only variation we see should be that due to the patient- there is no other reasons for care to vary"

Competition?

Competition is touted as a solution for all the ills that afflict healthcare, not withstanding the evidence from a market that is not deficient in competition, the US, that more competition does not equate to better healthcare. One of the great thinkers, Muir Gray, has written two recent blog posts, here and here, which outline a pragmatic framework which could be used to foster improved healthcare. Strongly recommended reading.

Systems Thinking in the Public Sector

I have previously written about Vanguard, John Seddon and his approach to systems thinking. His writing has been a revelation to me, plainly explaining how we can do things better with fewer resources, less waste, more customer satisfaction and more job satisfaction. Not quite a free lunch, but the next best thing. See the Amazon link on the side panel. I strongly recommend his books.

How to measure harm

Amongst the many challenges we face in trying to improve safety of care is the paucity of knowledge we possess about the rate and types of harm occurring to our patients. The traditional approach has been to identify sentinel cases, either because they are obvious or they are reported via traditional risk reporting structures. This approach has many limitations. A more recent approach has been to systematically review charts looking for evidence of adverse events, which allows one to both measure the rate of harm, identify areas of greatest risk and then one can determine whether changes made are having any meaningful effect in reducing rates of harm.
A paper just published (free here) describes an alternative approach in which a trained observer directly measures rates and type of harm occurring. The authors found almost 14% of patients suffered at least one adverse event, and 6% of all patients suffered a preventable adverse event. Overall 33% of adverse events were judged to be preventable. The rate of harm varied widely by specialty with <2% of obstetric patients being harmed to 11% of medical and ICU patients being harmed. The severity of harm also varied, with almost 5% of cardiac ICU patients dying or being permanently disabled due to an AE.

Autumn and patient safety

After a long summer break, back to posting. I would strongly recommend this blog, authored by an Emergency Medicine physician, with a greta deal of expertise in the area of healthcare informatics. Well worth a read. http://frectal.com/