Lessons Learned

Just finished a book by a number of clinicians, all US based. It is outstanding. Written to honor Paul Batalden, it is a treasure chest of advice, hints, tips, aphorisms, about the practicalities of changing healthcare. Unusually I am unable to pick out a highlight, as the quality (no surprise) is uniformly excellent. Get it here.

A vision of the future? Bilingual healthcare workers

From the inestimable Muir Gray, (thanks Tony), one possible approach to the problems facing us. Remember Einsteins definition of insanity, doing the same thing over and over and expecting different results. I think that summarizes healthcare. The model we have is designed, or rather evolved from the post war period to deal with a different set of problems. Acute self limited, or fatal illness. Coincident with the rise in healthcare technology, probably the early 50's with the development of ICUs following polio epidemics, the healthcare-industrial complex has in part generated problems and expectations that we are no longer equipped to handle. The paradigm of how care is delivered has to change radically. There is a very interesting book published in the 80's looking at how complex societies fail. The thesis and it applies equally well to complex systems is that a system evolves to deal with a complex problem, problems become more complex, hence the system becomes more complex and eventually a point of diminishing returns is reached where the inputs (think regulation, accreditation, legislation etc) consume more resources and the system collapses.
Gray provides one possible approach to this challenge. Basically the bilingualism to which he refers is that healthcare workers must be versed in not only the ability to provide clinical care to their patients,

"They need to know how to:

• Develop systems
• Build networks of clinicians and patients
• Design pathways
• Manage knowledge
• Harness the internet’s potential
• Engage patients
• Create and manage programme budgets
• Develop the right culture"

He describes this as population medicine. It is highly recommended. 

Much ado about bundles

Following yesterdays post about bundles, a couple of interesting papers from this weeks NEJM. Two studies here and here, and an editorial about reducing infection in hospitals. The two studies came to different conclusions; the first examined the efficacy of screening for MRSA in ICUs and implementing barrier precautions on all patients until their MRSA status was known. The interventions were not shown to be effective in reducing transmission of MRSA or VRE. However, and this is the really big take home message for me, in cases where hand hygeine or glovers were indicated, the compliance with these measures was as low as 62%!
In contrast, the VA study instituted a bundle approach; a MRSA bundle was instituted in 2007 and over 2 million hospital discharges were studied. The rate of health care associated MRSA infections fell by between 45% (outside ICU) and 62% (inside ICU) over a two year period.
For some expert comment, see this CDC post.

Is it better to be a dog or a medical student?

Lots doom and gloom out there, so something to put a smile on your face, unless you are a med student!
From A cartoon guide to becoming a doctor.

Health care spend, any room to reduce it?

While not strictly looking at quality and cost at a hospital level, a paper just published by OECD examines the potential for savings in health expenditure. It suggest that countries can achieve savings up to 5% of GNP by all countries becoming as efficient as the best performing countries. Note that there does not appear to be much if any correlation between healthcare spend and outcomes across countries. The authors suggest that countries by reaching the level of the best performers would increase life expectancy at birth by two years; in contrast a 10% rise in health expenditure would increase life expectancy by three to four months.

Harm

Great discussion by Bob Wachter on his blog about harm, preventable harm, errors and trigger tools amongst other things. He makes the point that we should focus on eliminating preventable harm, at least in the first instance. Beth Israel Deaconess publishes on its public website details on its progress towards eliminating preventable harm.

Giving doctors orders

If you are a doc, you know that very few people order you around, apart form your kids. Maureen Dowd discusses this and its implications in todays NYT. Yet another story of a family member dying. But she can be very amusing, and this is one of her funnier and more poignant pieces.

Bundles of joy or of sorrow?

The idea of bundles makes intuitive sense, gather together some evidence based interventions and ensure they are implemented reliably all the time, sit back and watch the magic. Pronovost showed the power of bundles in his NEJM paper some years ago. An observational study by Jarman and others in the BMJ last year suggested that using various bundles in a large London hospital was associated with a large reduction in hospital mortality.
So along come the surgeons to upset the consensus. A study in Archives of Surgery compared standard institutional practice with an extended bundle of interventions, all of which had been previously demonstrated in isolation to be effective. These interventions included:

1. No pre-operative bowel preparation
2. Pre-operative and intra-operative patient warming
3. Supplemental oxygen intra and post operatively
4. Intra-operative fluid restriction
5. Use of a surgical wound protector 

Over 200 patients were studied; main outcome measure was surgical site infection rate at 30 days as assessed by blinded infection control experts. The rate of SSI in the control group was 24%, vs. 45% in the bundle arm. Most of these SSIs were superficial.

Any explanation? Its possible that the interventions are ineffective, or less likely that they are counter synergistic, i.e. although singly beneficial, when combined they counteract one another. Alternatively even positive studies may due to chance be negative. The main concern though apart from giving ammunition to those who wish to reject the benefits of standardisation is that there will be a call for more RCTs in this and every other areas. While we have traditionally believed that RCTs are the gold standard, Ioanniddis work is even questioning this dictum. The other big problem in conducting RCTs is that we assume that apart from the intervention being studied, all other factors are uniform. This is clearly  not the case, and this has proven to be a difficult obstacle to surmount in trials of equipment such as new ventilators.

Game changing move for patient safety in US

Bob Wachter on THCB has a piece on what he calls a game changing safety initiative. Berwick and Kathleen Sibelius announced yesterday the "Partnership for Patients". This is a very ambitious well funded widely supported program. Its stated goals are to reduce preventable harm in US hospitals by 40% and preventable readmissions by 20% by 2013! It's nice to see Berwick has not lost his taste for aiming high. To quote Wachter:

• "For the first time, it establishes safety goals and programs as a private/public partnership, with early buy in from large insurers and employers. A broad tableau of leaders from provider organizations, insurers, federal agencies, businesses, and patient groups shared the stage with Sebelius and Berwick at this morning’s announcement to highlight the partnership theme.
• It provides large amounts of funding and technical assistance – nearly one billion dollars – both through the new CMS Innovation Center and elsewhere, to promote new knowledge and skill building.
• Like the 100K Lives Campaign, it seeks commitments from hospital executives and boards to tackle key safety goals.
• It provides support for collaborative networks designed to promote shared learning.
• It rewards hospitals for achieving certain milestones with both recognition and additional resources; those that do very well will be eligible to receive funding to help other hospitals improve."

The financial stick is that by 2015, 9% of medicare reimbursement will be tied to reaching these goals.
Interestingly, the means of audit to confirm compliance with these aims will be a detailed chart which appears to me to be using the IHI global trigger tool. Exciting times.

It would appear in some ways to be modeled on the 100,000 Lives campaign in that it sets lofty goals, appeals to sentiment, has a short time frame and uses social pressure to ensure others want to join.

Innovation

A quote that came through in an IHI email today about innovation:
"Innovation distinguishes between a leader and a follower"
Steve Jobs

Not sure I totally agree. Many innovators failed to benefit from their innovations, and often the mindset of an innovator is antithetical to being a leader. Nevertheless, a great quote from the man who invented Peters iPad 2, (x2)

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%.