Depression, the inside story

Anyone interested in how our system within our own lifetimes treated people should read this article. It is harrowing. Unfortunately I think mental illness is still seen as a weakness, "just snap out of it, for gods sake" is often the response. I am aware of employers who have failed in their statutory responsibility to ensure those with mental illness receive the same entitlements and protections afforded to every employee. We are not as civilized as we think.
A quote from the psychiatrist who treated the patient:

"Our patients are our best teachers. Jackie has taught me a huge amount about depression: what it feels like, the impact on sufferers’ and their family, and what does and doesn’t help.I have seen the toll taken by this ubiquitous disease, no less devastating in its impact than other chronic conditions. Jackie, an able and enthusiastic student, could barely finish her course at University, her employment prospects have been blighted, her social life restricted, and her capacity for pleasure and fulfilment curtailed. At their worst psychiatric services reinforce sufferers’ feelings of isolation and powerlessness." 

Increase comfort in the face of uncertainty

IDEO are a very interesting design and innovation firm based in California, and have done a lot of work in this area with Kaiser Permanante. They have provided assistance to the NHS Institute for Innovation and Improvement, Texas Children's Paediatric Associates, (the largest primary paediatric care network in the US) and many others. Their website is well worth checking out for anyone with an interest in healthcare innovation in its softer (i.e. not hardware, expensive drugs and hi tech equipment) guise. What caught my eye recently was a blog by an IDEO employee with the title that I have posted above. I liked their use of data from Twitter, and Google Analytics to measure the "buzz" in real time generated by their ideas.
This comes back to the point made by Maureen Bisognano recently, about using the power of patients to seek ideas. If we could measure what people believe is important judged by what they search or discuss on line, perhaps it might help us focus on what matters to patients as opposed to what matters to the "providers". Just a thought.
This I think is an area where some Irish design consultancies might find a niche.

Conservatives, tough on bacteria

Good to see politicians are getting the handwashing message.

Global Trigger Tools

Thanks to Annette and Levette. Two important pieces to check out if you are interested in trigger tools. First a paper in Health Affairs showing that the use of the Global Trigger Tool detects adverse events at a rate 10 times greater than voluntary reporting or using the AHRQ patient safety indicators.

Second, an upcoming WIHI:

The Power to Detect and Improve: Revisiting the IHI Global Trigger Tool and Adverse Events
Thursday, April 14, 2011, 7pm MT. See here for details. Both are free. The WIHI features great faculty. Check it out.

Mental illness and children

A great image showing the extent of psychoactive drug prescribing in the US. While there are many
interesting explanations for such rampant pharmaco-terrorism, this post has another purpose.

A recent story caught my eye, in fact it was so striking it kidnapped my brain. Headlined, "Is that Thorazine in the babies bottle?", it discussed the relentless rise in diagnosing and treating psychiatric illness in chilren and infants. According to the story, 500,000 children in the US are prescribed anti-psychotics! When I went looking for data about the incidence/ prevalence of psychiatric illness in children, the numbers are mind boggling. According to childstats.gov, in 2008 8% of children aged 12-17 experienced a major depressive episode. Of course, some may question this data, but it does appear that the incidence of major psychiatric illness, especially depression is rising across the Western world, and it has been suggested that the major contributor to this increase is rising economic and social inequality. If this is the case, medicating children from a very young age is not the solution, and is really only addressing the symptoms of a societal problem. For a more detailed discussion, read The Spirit Level . This is a magnificent book, likely to be seen in 50 years as the seminal public health work.

Beware Medical School

Here is an alternative look at medical school, from ZDogg.

Poetry and Reform

This summary is not available. Please click here to view the post.

International Forum and Social Movements

Helen Bevan and Maxine Power gave a wonderful hour long talk on the power of social movements, mobilising weak network connections, (in contrast to the network effects we usually think of being most powerful such as family, peers) in generating will to change. The focus was hospital based care, but I wonder how soon we will begin to see such strategies applied to the overwhelming need for society to concentrate on health and prevention.

Amsterdam in Spring.

A great city.

Forum; motivation and morale

Both Maureen Bisognano and Helen Bevan referenced the need to capture ant tap resources that we traditionally have failed to recognise. In Maureens case, the patient is a huge resource; Helen argues that we fail to capture the intrinsic motivation of many employees. The idea is that if an organisation can tap this, productivity can increase 30-40%.

international Forum and Maureen Bisognano and hospital flow

Maureen Bisognano in her keynote speech referenced specifically Eugene Litvaks work, and the benefits accrued to Cincinnati Childrens by implementing the methods he espouses. See my previous post about Litvaks work. http://saferhealthcareireland.blogspot.com/2011/03/optimizing-patient-flow-to-enhance.html

Emily Friedman at the International Forum

Magnificent keynote from Emily Friedman about challenges and possibilities for healthcare in Cambodia, harrowing stories. www.emilyfriedman.com

Effective Crisis Management, Free WIHI session

The next WIHI should be mandatory listening, WIHI click here

Includes Uma Kotagal and Jim Conway.

Poster of the Forum

International Forum Quality Amsterdam

Outstanding plenary from Maureen Bisognano. talks about need to redefine healthcare leadership, both at a personal and sttructural level. Some interesting facts, medication compliance or lack of estimated to be 4th leading cause of death worldwide, accounts for >$150 billion in US health spend. Lots of opportunity to save, reduce waste, Gives various successful exemplars. Talks about need to refocus and suggests IHI Triple Aim as a useful model.

Quality Education

excellent piece from BMJ Q&S concerning education and training in healthcare quality and safety. The authors make a number of valid points.

There is a lack of suitably qualified experts in the area of health Quality and Safety to provide education
The traditional approach o education imposes an artificial barrier between clinical and improvement work; the two must be seen to be two sides of the same coin.
A consequence of this barrier is that front line staff fail to understand the true significance of quality improvement
This last point is one that has not previously occurred to me; the traditional method of teaching, asking questions, implies to the learner that every question and every problem has a solution, which is patently not the case.

The authors provide a framework to transform the way such training is delivered.

QI becomes an integral part of clinical practice and training
Students and teachers become co-learners, along with patients, families, and non clinical staff
QI is seen to result not from "great individuals", but from a team approach to problem solving
The end result is not judged by answering questions correctly, but how effectively a problem is solved.

Hot off the press

Just published, a supplement to BMJ Quality and safety, all open access, looks like some great stuff.

Tonsillectomy

I am currently reading John Wennbergs "Tracking Medicine". There are some great insights, and I cannot recommend it enough. One of the most striking pieces I came across relates to the belief, now vanished, that tonsillectomy was critical for a healthy childhood:

"The American Child Health Association’s research design used a random sampling of 1,000 New York City school children. On examination by a school physician, 60% were found to have already had a tonsillectomy, and of the remaining 40%, nearly half were deemed in need of the operation. To make sure that no one in need of a tonsillectomy was left out, the association arranged for the children not selected for tonsillectomy to be reexamined by another group of physicians. The second wave of physicians recommended that 40% of these children have the operation. Still not content that unmet need had been adequately detected, the association arranged for a third examination of the twice-rejected children by another group of physicians. On the third try, the physicians produced recommendations that another 44% should have the operation. By the end of the three-examination process, only 65 children of the original 1,000 emerged from the screening examination without a recommendation for tonsillectomy. If the association had put those 65 children through additional rounds of examination, it seems likely that virtually every last one would have been recommended for surgery, a thought that gives new meaning to the phrase “no child left behind.”

While we may laugh at such a practice, are we really that different? Look at the variation you practice yourself, let alone the variation amongst your colleagues, and then remember that the variation within an institution is far less than variation between hospitals. As Wennberg says,

"Thus regions have characteristic “surgical signatures” and regions with high rates of a surgery in the early 1990s still tend to have high rates today, and the cumulative effect is to expose large numbers of patients to surgical interventions that they may or may not have wanted." 

To screen or not to screen? That is the question.

Screening arouses great passion, well greatish. Sticking to prostate cancer, there has been a back and forth argument for many years. There is no doubt that using prostate specific antigen testing detects many cancers; however the key question remains whether finding these cancers impacts survival. In other words, would many of these men die with rather than because of their prostate cancer. According to Wennberg, if 1000 men are screened for 10 years, 1 cancer will be found and treated successfully, 4 men will die of their cancer regardless and 50 men will be over-diagnosed and over-treated.
A study just published finds that over a 20 year period, there is no differnece in death rate form prostate cancer between those screened and unscreended.
Again, this points to the potential for reducing variation and reducing costs in healthcare.

Simulation

There is increasing interest in the benefits of simulation to ensure improved outcomes in healthcare. A piece in the Economist piqued my interest in this area. They describe a story I had never heard before, involving the role of former US President Jimmy Carter in dealing with a reactor meltdown in Canada in 1952. Carter led a 23 man team to disassemble a reactor near Ottawa that partially melted down. Such was the radiation exposure that each person was limited to 90 seconds at the core. To ensure that the process went as smoothly as possible in such adverse conditions,

"The team built an exact replica of the reactor on a nearby tennis court, and had cameras monitor the actual damage in the reactor's core. "When it was our time to work, a team of three of us practised several times on the mock-up, to be sure we had the correct tools and knew exactly how to use them. Finally, outfitted with white protective clothes, we descended into the reactor and worked frantically for our allotted time," he wrote. "Each time our men managed to remove a bolt or fitting from the core, the equivalent piece was removed on the mock-up."

The take home message is no surprise, simulation to be successful must be as realistic as possible, with real time feedback. A paper published in January in PCCM reports that with increasing use of simulation of cardiac arrest in a children's hospital, survival post cardiac arrest increased to 50%, substantially above the national average.