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/

Systems Thinking in healthcare

This blog just launched is well worth checking out. Based on work by Vanguard, a UK systems thinking consultancy and its CEO, John Seddon. Seddons stuff, books, papers, podcasts etc are worth checking out. There is a simplicity which hides a very deep and profound complexity in his methods. I don't think they have done much in healthcare, but read Systems Thinking in the Public Sector , and you will immediately see analogies. Value Demand and Failure Demand have become part of my vernacular. Bottom line message, our healthcare system is broken, and we need to rethink it. Positive spin, there is a huge amount of waste. Read it and decide.

Cowboys and Pit Crews

A great piece, as usual, from Gawande, with the aforementioned title. Bottom line, we have to change the way we think and work.

Valentia

Knightstown, Valentia, Co. Kerry, Ireland

If you ever have a chance, come here, just to rest your soul. 

Derrynane Beach, Easter Sunday

One of the most beautiful places in Ireland.

Weed Card by Garfunkel and Oates (Official Video)

Paradise

Recession and Physical Child Abuse

A paper was presneted last week at the American Association of Neurological Surgeons' annual meeting in Denver by a fourth year medical student. Mary Huang presented her study which sought to determine whether there was an association between economic downturn and abusive head trauma in children. She found that the risk of abusive head trauma doubled during a economic recession, and the severity of the injuries appeared to increase also.

Patient Driven Care

A greta post on Paul Levys blog, in which he proclaims following a meeting in IHI that he is no longer an advocate for patient centered care, but henceforth will be proclaiming the benefits of patient driven care. In his own words,

"What I am suggesting is that clinicians should do their best to collaborate with patients to understand their needs and desires and to jointly design plans of care that are as consistent as possible with those needs and desires."

Such a move would require a sea change in the way we practice and deliver care. It reminds me of a good friend who when i told him the difficulty I was having in getting a computer in my clinic room asked me why I needed a computer. To access UpToDate and other resources, I replied. "You mean you would look up information in front of patients?", was the stunned response.

Pauls point aligns nicely with what Maureen Bisognano said at the International Forum, that patients are our greatest unused resource. 

Disclosure and Litigation

We are all aware of the reputation of the US legal system as litigation central for mistakes in healthcare. Surely the worst thing to do is to publicize ones mistakes in this environment? Paul Levy on his blog points out a fascinating cultural dichotomy. He explains how during his tenure as CEO of BIDMC, medical errors were publicized. He contrasts this openness with the reluctance of various European hospitals to disclose their errors. Perhaps we should be learning from our American cousins?

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.