Think outside the box

An interesting blog post from Moss Kanter about innovation. Basically very few organization can shift their way of thinking from business as usual. This is a cause of great frustration for the visionaries and innovators within that organization. Great relevance to healthcare.

Culture eats strategy for lunch

The title of this post refers to an oft quoted piece in business and change literature; to paraphrase, you can have a great plan but if it doesn't take into account the culture of the organization, you will fail. This I think is the crux around which healthcare reform and quality improvement specifically will succeed or fail. This is the great intangible that must be isolated and measured, so that we can truly begin to determine how healthcare providers differ from one another in terms of the quality of the service they deliver. As doctors we believe that the keys to a great service are world class doctors, state of the art facilities, the latest in IT; basically the best that money can buy.

However a study just published in the Annals of Internal Medicine, link here, (subscription required), suggests that this credo is incorrect. Curry et al interviewed 158 staff members from 11 hospitals, which were either in the top or bottom 5% nationally in the US for mortality post heart attack. The factor most highly correlated with outcomes was a cohesive organizational vision that focused on communication and support of all efforts to improve care. In other words, it was the culture, the communication ethos, mutual respect, leadership and desire to improve that should determine where you want to be treated, not all the high tech stuff and big names. This is consistent with my own observations nationally and internationally. All hospitals have problems, the high performers are the ones that seek out the problems and respectfully engage all their staff and leadership to solve them. It is my strongly held belief that one can distinguish between the high and low performers within an hour of visiting them.

Previous studies have suggested that the traditional factors that underpin success include being an academic medical centre, having more beds, and being located in a large city. Curry found that these factors accounted for only 20% of the difference. This is a very significant study, and provides ammunition for those of us who believe the system can be dramatically improved without massive expenditure; the down side is that changing culture can be extremely difficult.

Optimizing Patient Flow to enhance productivity and safety

 What if the healthcare system could introduce a method of improving productivity by 15-20% within months, at no extra cost, but by doing so improve safety dramatically, reduce stress, burnout, absenteeism, patient experience, and all the other good things? There is such a system, with very good evidence behind it. See link here.

1.    Safety:

a.    Arguments around safety in healthcare worldwide usually centre around the need for extra resources, rather than in the first instance optimizing the system in place. By reducing variability in the system, cases can be more closely matched to the available infrastructure and staffing resources, thereby reducing the dramatic peaks and troughs that are seen in every hospital, especially with respect to elective activity. These artificial peaks (due almost entirely to elective activity) may then give rise to the impression that the facility is under-resourced and under-staffed; by reducing this artificial variability the current infrastructure and staffing levels can be utilized to deliver a service that is safer (right patient in the right bed at the right time), and avoid a mismatch between staffing (esp. medical and nursing) and patient numbers.

2.    Efficiency/ productivity:

a.    By utilizing resources as outlined in the previous section, expensive plant such as diagnostics, operating rooms, and intensive care beds can be utilized more effectively and productively. The traditional upper estimate of hospital occupancy has been estimated at 80%; the only rationale for this figure is to provide a surge capacity, a buffer for times of increased demand on the system because no control was placed on how the elective component of demand was managed. By properly managing this demand, it is likely that overall occupancy can reach 90-95% on average safely. One hospital has reported a continuous occupancy rate of 91% since implementing this system. Rather than reducing the number of cases performed, this efficient allocation of a scarce resource allows each individual surgeon to perform more procedures.

3.    Financial benefits:

a.    Obviously, under the current Irish hospital reimbursement scheme, financial benefits are harder to estimate and realize. However, it is clear from point 2 that the return on investment is greater by optimizing hospital flow. Whether this equates to greater revenue as in the US system, or more patients treated for a given budget as in the Irish setting, the end result is greater productivity.

4.    Patient satisfaction:

a.    Hospitals that have (in the US) implemented this system have eliminated wait lists, ER waits, cancellation of elective procedures etc.

Evidence base.

1.    The American Hospital Association has identified six priority areas in its efforts to accelerate hospital performance improvement; these include health care acquired infections, health information technology, medication management, patient safety, and of relevance to this document, optimizing patient flow and throughput. The AHA state that “patient safety is negatively impacted when patients do not move through hospitals in a timely and efficient way. The AHA endorses the methodology of the Institute for Healthcare Optimization as a means of improving patient flow.

2.    The Leapfrog Group for Patient Safety is an umbrella group representing some of the largest employers in the US, (IBM, Intel, Toyota, Boeing, Motorola, FedEx). Collectively they represent employers and agencies that purchase care for more than 35 million people in the US. Leapfrog ranks hospitals in the US publicly on a number of patient safety measures. A study by the Commonwealth Fund (June 2008) reported that hospitals publicly reporting their Leapfrog Quality data had a lower mortality rate for Acute Myocardial Infarction and Pneumonia. Participating hospitals are asked if they adhere to the following quality and safety practices:

                                               i.     Computerized Physician Order Entry

                                             ii.     ICU Staffing with intensivists

                                            iii.     Compliance with performance standards for certain high risk treatments

                                            iv.     Leapfrog Safe Practices Score

3.    From 2011, the Leapfrog Group will measure a hospitals policy around flow optimization and safer scheduling, (personal communication). The group states that patient safety can be negatively impacted by a hospitals scheduling policy. The Leapfrog group supports the methodology of the Institute for Healthcare Optimization as a means of improving patient flow and reducing patient risk.

4.    In 2006 the Institute of Medicine (IOM) released “The Future of Emergency Care in the United States Health System”, a series of reports assessing the severe problems facing the nation’s emergency care system and offering recommendations to improve it. The report states "hospitals should reduce crowding by improving hospital efficiency and patient flow and using operations management methods and information technologies."

5.    The Joint Commission, the body responsible for accreditation of US hospitals, endorses a strategy of providing scientifically grounded methods to optimally manage patient flow and reduce variability as part of a policy to improve patient safety. It endorses the methodology of the Institute for Healthcare Optimization.

6.    Don Berwick, the head the Center for Medicare and Medicaid Services (CMS), one of the most powerful positions in American Medicine, has stated that there are two sleeping giants in trying to achieve quality healthcare, patient safety and patient flow.

7.    A number of the largest and most renowned US academic health centers have recently begun work on redesigning their patient flow and throughput, (personal communication). One 212 bed hospital has seen a revenue boost of $50 million annually within one year of implementing this system. Cincinnati Children’s has seen its productivity increase by the equivalent of a 100 million dollar capital rebuild, (100 beds) and its annual revenue increase by $137 million.

8.    A number of Childrens Hospitals including Cincinnati, Lucille Packard, and Great Ormond Street have adopted this approach.

9.    There is emerging evidence in the medical literature that failure to incorporate these principles is associated with serious adverse outcomes. In one study by Pronovost (2009), the odds of being readmitted to an ICU were five times greater when the number of patients admitted to the ICU were above a certain volume. 

Reporting Poor Performance by Doctors

A very concerning piece, but not that surprising to those in practice. A study of >1000 UK doctors found that almost 30% would not report concerns about a colleagues poor performance. The main reason for this was concerns about retribution. It brings to mind a conference I attended 2 years ago in which a keynote speech was by three well known, (non-nmedical) whistleblowers. They made the point that whistleblowers are often motivated by anger or revenge, and that if they were faced with the situation again, they would not reveal their misgivings. This was very sobering; one assumes that whistleblowers (an awful term) are motivated by altruism.

Progress of the Safety Movement

Some (relatively) disappointing news recently. An analysis of the Safer Patients Initiative was published in the BMJ (here and here). This was a large scale intervention comprising a large number of components of care. Unfortunately, there was no evidence of any difference in outcomes between control and intervention hospitals. What could the possible reasons be? There are a number of hypotheses,

1. hospitals will get safer regardless of interventions, and do not need this type of large scale change, (unlikely)
2. These interventions were too complex, encompassing 43 different interventions, (probable)
3. Management and clinician buy in, expertise, knowledge and support were insufficient to show a difference, (highly likely)
4. The interventions sought has insufficient evidence to underpin their use, (highly likely in some cases)
5. Many hospitals, (both intervention and control) already had high levels of quality in some domains, hence the big effects were less likely to be seen, (likely)

So what lessons can be drawn? I think there are a number.

1. Large scale change is difficult, messy, a long term commitment and often fails
2. Leadership, at management and clinical level is critical
3. Improvement and quality must be seen to be the only way to do business, not an optional extra
4. There must be a better system of measurement; even today measuring mortality is contentious. The ideal measurement system should be one that measures patient outcomes from the perspective of the patient, and reimburses the system, not a provider for optimal outcomes. See Micheal Porters work from Harvard for more on this

Torture and Solitary Confinement

Not strictly medical improvement and certainly not seasonal, but a very powerful piece from Gawande just published in the New Yorker. Well worth a read.

Safety and over the counter medications for children

A paper just published in JAMA provides some fascinating information about a lack of consistency in dosing instructions and measuring devices in over the counter (OTC) medications for children. the results are to say the least disturbing.


Results Measuring devices were packaged with 148 of 200 products (74.0%). Within this subset of 148 products, inconsistencies between the medication's dosing directions and markings on the device were found in 146 cases (98.6%). These included missing markings (n = 36, 24.3%) and superfluous markings (n = 120, 81.1%). Across all products, 11 (5.5%) used atypical units of measurement (eg, drams, cc) for doses listed. Milliliter, teaspoon, and tablespoon units were used for doses in 143 (71.5%), 155 (77.5%), and 37 (18.5%) products, respectively. A nonstandard abbreviation for milliliter (not mL) was used by 97 products. Of the products that included an abbreviation, 163 did not define at least 1 abbreviation.


Given that a major contributor to adverse medication events in children relate to dosing/ weight errors, obviously these discrepancies pose a potential risk. Of more importance, though it is not the subject of the paper is the efficacy and side effect profile of many of these therapies.

High Reliability Organizations

There has been a great deal of discussion recently about healthcare adopting the same approaches that have facilitated high reliability organisations to achieve exceptional levels of safety despite operating in high risk high consequence environments. Examples include aircraft carriers, nuclear submarines, the nuclear power industry and aviation.
What are the features of a high reliability organisation? Are these concepts translatable to healthcare? Are there any examples of HROs in healthcare?

There are according to one expert in the field five characteristics of HROs.

•Preoccupation with failure rather than success; this is self explanatory. The HRO almost celebrates failure and actively seeks it out recognising that only by recognising the defects within it's systems can it seek to rectify those defects.
•Reluctance to simplify interpretations; always seeking the explanation especially the explanation that defines the cause of a possible future mistake.
•Sensitivity to operations; To be sensitive to operations, we must monitor a messy reality and respond to the unexpected.
•Commitment to resilience; HROs recognize that not every risk can be mitigated, but anticipate failure and ensure that redundancy is built into the system.
•Deference to expertise; instead of hierarchy structures determining responses, the decision making in a HRO migrates to the persons with most expertise in that area.

The key difference between HROs and other organisations is that they respond differently to what others would consider signals of no significance. Mindfulness is what some have described this aspect, the capability to respond strongly to weak signals and respond strongly to mitigate the potential adverse consequences of such a failure. An example in healthcare might be the test result that is delayed, a routine test of no significance but this is a warning that the system is prone to error, that a time critical result may also be delayed. The HRO responds immediately to address this failure, the Low Reliability Organisation (LRO), effectively all of healthcare, is unlikely to take any action. HROs are constantly looking for evidence of failure or potential failure. Clearly these concepts can be applied to healthcare, though the details are likely to differ. However, it is likely that the only organisation which will successfully make this transition will be those in which the culture is receptive, indeed greedy, to make this change, and in which the leadership see becoming a HRO as the number one priority of the organization. This is such a fundamental shift that it likely that very few organizations will be successful in their attempts to become HROs.

I asked two physicians recently, world experts in safety and who lead the safety/ quality efforts in their hospital, which is probably the most advanced hospital in the world in this field, where their institution was on a 1-10 scale in safety. About a 3-4 on a good day they replied. That is the characteristic of a hospital that is striving to be the best and safest in the world, but recognises that despite being the best, it has a long journey ahead.

This book is probably one of the seminal works describing HROs, and I recommend it highly. Weick & Sutcliffe

IHI Forum

I am attending the annual IHI forum, in Orlando far away from the arctic conditions at home. Amazing stuff,  spending the day at a course devoted to paediatric patient safety, with talks from the worlds experts in this area. Steve Muething, Cincinnati Children's talks about developing a high reliability organization in healthcare. Matt Scanlon, Milwaukee, talks about human factors and measurements in paediatric safety. Anne Matlow, Sick kids Toronto talks about the major problem of diagnostic error in children, pointing out that diagnostic mistakes account for 13-20% of adverse events, but are more likely to be preventable and are more likely to cause serious harm or death. Paul Sharek, Stanford discussed medication safety, raising the provocative point that although a great deal of money has been devoted to improving medication safety,  medication errors account for 20% of all errors and a much smaller proportion of serous harm.

Influenza; Is cure better than prevention?

At a time when healthcare systems around the world are facing severe financial strain, it is worth asking whether there are any quick and dirty solutions out there. Amazingly there are, chief amongst them the ability to reduce the morbidity and mortality attributable to seasonal flu by the simple expedient of administering flu vaccine. The evidence base is not just strong, but strongly impressive. To take one example, a Swedish study published in 2001 found that recipients (aged >65 years) were half as likely to die from any cause in the year of vaccination, compared to their unvaccinated peers.
One measure of the cost effectiveness of any intervention is the cost per Quality Adjusted Life Year (QALY) saved. One conventional measure suggests that a cost per QALY of up to $50,000 is economically worthwhile. The cost per QALY for flu vaccine is -$17, i.e. for every patient vaccinated, there is a saving to the funder of $17. A no brainer. So how are we doing in Ireland? Recent data suggest that only 50% of people > 65 receive the flu vaccine.
So in answer to the question above, prevention is better than cure.

Preventable Harm, Redux

A commentary by the authors of the NEJM paper I referred to recently has just been published. Well worth reading.

Diagnostic Error; The Elephant in the Closet?

Diagnostic error as a cause of avoidable harm has received relatively little attention in the quality safety literature until recently. Diagnostic error is a diagnosis that is missed, delayed, or incorrect. Various estimates suggest that errors of diagnosis account for 40-80,000 deaths annually in the US. Autopsy studies have shown that in 5% of cases, a diagnosis is found which if known prior to death and treated appropriately could have averted death. Physician errors are more likely to occur from diagnostic mistakes than medication error; are likely to result in serious harm and more likely to result in bigger lawsuit payouts.  The causes of diagnostic error are complex, and as yet poorly understood. One concerning finding however is that a lack of knowledge or expertise is rarely the rimary factor; indeed, some researchers suggest that experienced doctors who have "a gut feeling" may be led astray by their experience. For further reading, I would suggest this paper by Pronovost. A talk at the recent Risky Business conference which discussed the psychological basis of error is well worth viewing. (Free to view, but registration required)
There are few data in paediatrics; a recent study reported that 50% of paediatricians had made one to two diagnostic errors in the previous month. 45% reported diagnostic errors that harmed patients at least once in the previous year.
So we have identified a big problem, conceivably more serious than medication harm; what is the solution? In truth, no-one knows. Suggestions include computer aided diagnostic tools, realistic simulation in training, more training!, reform of tort law. We need to start with the basics, and begin to understand the causes of diagnostic error, and only then can we begin to introduce solutions. Medicine is messy, diagnosis in contrast to treatment remains an art; we have to make it more of a science.

Preventable Harm in Hospitalized Patients

Following on from my recent discussion about the use of trigger tools, a paper just published in the New England Journal reports the rate of preventable harm occurring in patients admitted to 10 North Carolina hospitals over a 6 year period. The authors used a validated trigger tool to analyze charts from 100 admissions per quarter.
The results are very alarming; despite a reputation as being a state that is very proactice in efforts to reduce harm, there was no reduction in harm over the study period. For every 100 admissions, there were 25 episodes of harm. It is important to point out that not every one of these episodes caused serious harm. 18% of patients were harmed as a result of medical care. 63% of these episodes were considered to be preventable. Of the harm episodes considered to be preventable, 26% caused permanent damage, were life threatening or caused or contributed to a patient death. overall 2.4% of harms caused or contributed to a patients death.
The most common errors arose from procedure complications, hospital acquired infections and medication errors.
This paper is a wake up call for the patient safety movement; despite much apparent and real progress over the past decade, it is a cause for concern that there has been no significant improvement in patient safety. There are likely many reasons for this; patient safety has not been a research priority, safety always involves a cultural shift within in heathcare which can be very difficult to achieve, and by not involving the younger generation of healthcare professionals, especially at their training stage, we are adding to the difficulty.

Toy Related Deaths in Children

There has been a reduction in the number of deaths of US children in 2009; 12 deaths vs. 24 deaths in '07 & '08. Riding toys are associated with approx. 50% of deaths, usually when the child rides into a ditch or pool and drowns. There were almost 200,000 injuries related to toys treated in US emergency rooms last year. A good excuse to cut down on toy expenditure this christmas or concentrate on jigsaws. Link

More on Checklists

Paul Levy writes in his oustanding blog about checklists, making the very relevant point that the checklist per se is not a panacea; it is one ingredient in a very complex system that contributes to safety.

Treatment of Otitis Media

A meta-analysis just published here reviews the diagnosis, microbiology and treatment of acute otitis media (AOM) in children. I have always been surprised by the low numbers of kids with AOM I see, compared with the reported prevalence. The results of this paper were quite interesting; the presence of a bulging tympanic membrane and redness of the membrane were associated with a positive diagnosis. nothing surprising there.

Following the introduction of heptavalent pneumococcal conjugate vaccine (PCV7), Streptococcus pneumoniae decreased, while that of Haemophilus influenzae increased.

The authors concluded, "otoscopic findings are critical to accurate AOM diagnosis. AOM microbiology has changed with use of PCV7. Antibiotics are modestly more effective than no treatment butcause adverse effects in 4% to 10% of children. Most antibiotics have comparable clinical success."

Trigger Tools

How should we measure the harm we cause in healthcare? One method, increasingly widely used, is a trigger tool. These are standardized and validated instruments with which one reviews a random selection of medical charts; when a "trigger" is identified that might signal a possible harmful occurrence, the chart is reviewed in more detail to determine whether harm did occur. There are two benefits; an organisation can measure the harm it is causing over time and take steps to reduce the harm, and second, measure its effectiveness in reducing harm over time. In contrast to conventional incident reporting, the rate of harm detected by these tools is 2-5 fold higher. For more reading, I would suggest the following; IHI and NHSIII

IHI Model for Improvement

Am attending and speaking at a forum hosted by HSE and Clinical Indemnity Scheme which is discussing the Heartbeat Scheme. Apart from the specific cardiovascular theme, Noeleen Devaney, a former IHI fellow is discussing the IHI Model for Improvement. She makes the critical point that this methodology can be applied to any problem in healthcare, clinical and non-clinical. Such an approach is critical to empowering front line staff, improving quality, and improving work satisfaction. For more information I would suggest checking out this section of the IHI website.

Medical Error in the White House

A recent article in the New York Times describes the experiences of a physician whose job was to be Physician in Chief to the sitting US president. It contains some fascinating nuggets; "White House doctors have erred. Air Force One carries antibiotics and other drugs, as well as several pints of blood reserved for the president and first lady. In 1994, when Mr. Clinton was planning a foreign trip, Dr. Mariano wrote, Dr. Bob Ramsey, an Army colonel and a blood specialist in the White House medical unit, gave doctors at the host hospitals the wrong blood type for the president, a potentially fatal medical error, and Dr. Ramsey was fired."

Change Concepts

An interesting look at "change" from a leading Harvard Business School Professor.