“We’re writing about mistakes again, Curmudge? I thought that our discussions on April 1 and April 8 wrapped up this topic for good.”
“It’s got to stay on our radar screen, Jaded Julie. Those of us in health care require periodic reinforcement that the proper response to an error is not name, blame, and shame. So here’s a reminder, coming at you.”
“I seems so natural to blame someone who commits an error, and then we compound their embarrassment by calling them stupid. It’s as if that attitude is hardwired in everyone at birth. And then the blamed person feels so badly that they will do everything possible to hide any error that they make in the future. But none of this is new information. My guess is that your wanderings on the Web yielded some new insights about errors that you’d like to share with our readers.”
“You’re right, Julie. They are in a book by Kathryn Schulz called, Being Wrong: Adventures in the Margin of Error. She feels that we make errors because, as humans, we are capable of using a guessing strategy known as inductive reasoning. We make decisions based on what we think will happen in the future, i.e., by inductive reasoning, and some of our guesses regarding the future are wrong.”
“I think I understand, Curmudge. Humans have always used inductive reasoning to guide their trial-and-error development of tools, and in the modern age, their professional talents. If we couldn’t do that, we’d still be living in caves, or maybe in trees. So now, people like concert musicians—after extensive training and hours of practice—can play thousands of notes with few if any errors. But mistakes can and do occur because the performer is human. Hey, this sounds a lot like necessary fallibility that we talked about way back on February 19, 2009.”
“Although several kinds of mistakes can occur in health care, such as shortcuts that have gone awry, let’s focus on those that are purely unintentional. To quote Kathryn Schulz, ‘Embracing our fallibility is the only way to build effective backup systems to prevent or mitigate mistakes.’ ‘Understanding the origins of our mistakes is the only way we can learn to deal with them.’ And so we must ferret out and defuse the booby traps in our systems. Our search for the systemic root cause begins when a mistake or a near miss has been reported. We treasure near misses because they reveal potential problems without anyone’s having been harmed.”
“I suspect that near misses are more like buried treasure because they are so often hidden and not reported. So what’s the bottom line, Curmudge, as if I can’t already guess?”
“You know it as well as your own name, Jaded Julie. Get rid of the old name, blame, and shame culture and replace it with a just culture. That will allow us to find and replace those potentially error-causing aspects of our systems with checklists, standardized work, or decision-support software.”
Affinity’s Kaizen Curmudgeon
Another excellent article on patient safety: The Wrong Stuff: What it Means to Make Mistakes. http://www.slate.com/blogs/blogs/thewrongstuff/archive/2010/06/28/risky-business-james-bagian-nasa-astronaut-turned-patient-safety-expert-on-being-wrong.aspx
Thursday, July 22, 2010
Thursday, July 15, 2010
Docs on a Treadmill
“Jaded Julie, there’s something wrong with our title. What is it?”
“It’s not the physicians who are on the treadmill, Curmudge. It’s hamsters or gerbils serving as a metaphor (how do you like that word, Old Guy?) for physicians who are caught up in the excessive demands of their practice.”
“You are correct as usual, Julie. But the thing that really bothers me about the title is that it depicts physicians in an inescapable situation. These people are resourceful and highly intelligent. When I was teaching them as undergrad premeds, they got the A’s in the class.”
“As I see it, anyone—not just a physician—in a difficult job situation has three options: stay and endure it, change the system to relieve their discomfort, or leave. Back on September 3, 2009 in The Evolution of Personalized Care we talked about several things individual physicians and groups have done to reduce the stress and increase the efficiency of their practice. In subsequent postings we described how these innovations were brought together to become the Patient Centered Medical Home.”
“Note, Julie, that most innovations came from physicians in a small group practice (Dr. Burger, the Sinskys, etc.). And in addition, there are many individual improvements in efficiency that are never published. A small group that includes a friend of mine has hired nurse practitioners and implemented an electronic health record. A recently retired pediatrician wrote a book and gave it to all of his patients; this resulted in his having fewer calls from distraught mothers in the middle of the night.”
“Sounds like he was a modern day Dr. Spock. But what about those solo-practice docs who don’t have time to read the literature or the resources to try anything new?”
“They are indeed out there, Julie. The Kane Scrutiny blog recently summarized the findings of a survey of small practices regarding the Patient Centered Medical Home. The respondents’ reservations about operating as a medical home were (in order): lack of money, lack of time, and lack of information about the process involved.”
“The small practices’ responses are a real concern, Curmudge. I’m grateful that the medical home concept is spreading through Affinity’s clinics. Physicians and staff that I have talked with in our pilot clinics are enthusiastic about it, and it will help us bring personalized care to more and more of our patients.”
“Have you thought about the physicians in other large organizations, Julie? If they feel that they are stuck on a treadmill, there’s not a lot they can do to change the process. It’s pretty hard to initiate changes from the middle of any organization, and it’s especially difficult if the organization is very large and extremely hierarchical. The options there would seem to be either stay or leave.”
“The military is about the largest and most hierarchical outfit that I can think of, Curmudge. All too often physicians leave when they have fulfilled the active duty obligation they incurred when they accepted a scholarship to medical school. One career Army doc that I know transferred from a hospital to an infantry battalion. So, Rambling Writer, what’s the bottom line of this discussion?”
“In most situations, primary care is not binary, Jaded Julie. It’s not simply good in a medical home and bad if it is delivered by a doc on a treadmill. There are lots of variations in between provided by physicians who have devised ways to make their practice more efficient. Of course, in my opinion the medical home concept is the best. Here it is, summarized in the Kane Scrutiny:
‘The PCMH concept calls for physician practices to develop a team approach for caring for patients; use evidence-based practices; coordinate patient care; utilize performance measurement and quality improvement; adopt health information technology, and track patients and results.’
As the automobile salesman used to say, ‘You can’t do better than that, now can you?’”
Affinity’s Kaizen Curmudgeon
“It’s not the physicians who are on the treadmill, Curmudge. It’s hamsters or gerbils serving as a metaphor (how do you like that word, Old Guy?) for physicians who are caught up in the excessive demands of their practice.”
“You are correct as usual, Julie. But the thing that really bothers me about the title is that it depicts physicians in an inescapable situation. These people are resourceful and highly intelligent. When I was teaching them as undergrad premeds, they got the A’s in the class.”
“As I see it, anyone—not just a physician—in a difficult job situation has three options: stay and endure it, change the system to relieve their discomfort, or leave. Back on September 3, 2009 in The Evolution of Personalized Care we talked about several things individual physicians and groups have done to reduce the stress and increase the efficiency of their practice. In subsequent postings we described how these innovations were brought together to become the Patient Centered Medical Home.”
“Note, Julie, that most innovations came from physicians in a small group practice (Dr. Burger, the Sinskys, etc.). And in addition, there are many individual improvements in efficiency that are never published. A small group that includes a friend of mine has hired nurse practitioners and implemented an electronic health record. A recently retired pediatrician wrote a book and gave it to all of his patients; this resulted in his having fewer calls from distraught mothers in the middle of the night.”
“Sounds like he was a modern day Dr. Spock. But what about those solo-practice docs who don’t have time to read the literature or the resources to try anything new?”
“They are indeed out there, Julie. The Kane Scrutiny blog recently summarized the findings of a survey of small practices regarding the Patient Centered Medical Home. The respondents’ reservations about operating as a medical home were (in order): lack of money, lack of time, and lack of information about the process involved.”
“The small practices’ responses are a real concern, Curmudge. I’m grateful that the medical home concept is spreading through Affinity’s clinics. Physicians and staff that I have talked with in our pilot clinics are enthusiastic about it, and it will help us bring personalized care to more and more of our patients.”
“Have you thought about the physicians in other large organizations, Julie? If they feel that they are stuck on a treadmill, there’s not a lot they can do to change the process. It’s pretty hard to initiate changes from the middle of any organization, and it’s especially difficult if the organization is very large and extremely hierarchical. The options there would seem to be either stay or leave.”
“The military is about the largest and most hierarchical outfit that I can think of, Curmudge. All too often physicians leave when they have fulfilled the active duty obligation they incurred when they accepted a scholarship to medical school. One career Army doc that I know transferred from a hospital to an infantry battalion. So, Rambling Writer, what’s the bottom line of this discussion?”
“In most situations, primary care is not binary, Jaded Julie. It’s not simply good in a medical home and bad if it is delivered by a doc on a treadmill. There are lots of variations in between provided by physicians who have devised ways to make their practice more efficient. Of course, in my opinion the medical home concept is the best. Here it is, summarized in the Kane Scrutiny:
‘The PCMH concept calls for physician practices to develop a team approach for caring for patients; use evidence-based practices; coordinate patient care; utilize performance measurement and quality improvement; adopt health information technology, and track patients and results.’
As the automobile salesman used to say, ‘You can’t do better than that, now can you?’”
Affinity’s Kaizen Curmudgeon
Thursday, July 1, 2010
AIDET Redux
“I guess what you are talking about, Curmudge, is AIDET all over again. Back on October 1, 2009 we discussed AIDET for Physicians. Of course everyone at Affinity should know about using AIDET (Acknowledge-Introduce-Duration-Explanation-Thank you) in communications with patients.”
“At Affinity, yes, but not everywhere. In Twice Blessed on May 13, I mentioned that many older patients use providers all over the area for various aspects of their health care. I’m one of them, and I had a rather simple procedure performed outside of Affinity a few weeks ago. Probably most Affinity employees and volunteers observe their health care encounters in other organizations with a critical eye, as I did.”
“And, Mr. Secret Shopper, what did you see?”
“First of all, I must congratulate the technician on her congeniality and professional performance. I’m confident that she did an excellent job. But with one exception, she didn’t use AIDET. She called me from the waiting room by my not-very-common first name, but she made no further effort (last name? date of birth?) to make certain of my identity. She never identified herself nor did she introduce the student who accompanied her. (‘This is Mary Smith, a student from the University of Wherever. Do you mind if she observes?’) I asked the young woman if she were a student, and her only word during the whole encounter was ‘Yes.’”
“Curmudge, you tend to ‘chat up’ nurses and techs; without that it would have been a very quiet encounter.”
“That’s right, Jaded Julie. The technician never explained the procedure, but I already knew how it was done and how long it would take. When it was finished, I’ll give her credit for telling me that I would learn the results in about a week. I thanked her for her good work, and her final words were, ‘Go through that door and turn left.’”
“I’m not impressed. Any other observations?”
“While a few other patients and I sat in the waiting room, a couple of the techs (or whoever) stood around the desk and talked about their weekend. That didn’t appear very professional.”
“So other than using AIDET, what would be your recommendations for that organization?”
“When I was in the same waiting room a few years ago, they had a phlebotomist whose welcoming smile would have melted the heart of the grouchiest curmudgeon. I had to restrain myself from running up to her, holding out my arm, and saying, ‘here, take my blood.’ And I wasn’t even there for a blood draw.”
“Your lesson must be that if one doesn’t practice AIDET, an engaging smile will go a long way.”
“It’s more than that, Julie. A pleasant voice has to accompany the smile. Here’s the complete lesson: Smile and speak with your most reassuring voice, acknowledge the patient by name and with eye contact, introduce yourself as completely as seems appropriate, explain the procedure and its duration, and thank the patient for coming in.”
“That sounds great, Curmudge. Why don’t you do that at the beginning of each of our discussions?”
“Because you already know that I’m just an old grouch.”
Affinity’s Kaizen Curmudgeon
“At Affinity, yes, but not everywhere. In Twice Blessed on May 13, I mentioned that many older patients use providers all over the area for various aspects of their health care. I’m one of them, and I had a rather simple procedure performed outside of Affinity a few weeks ago. Probably most Affinity employees and volunteers observe their health care encounters in other organizations with a critical eye, as I did.”
“And, Mr. Secret Shopper, what did you see?”
“First of all, I must congratulate the technician on her congeniality and professional performance. I’m confident that she did an excellent job. But with one exception, she didn’t use AIDET. She called me from the waiting room by my not-very-common first name, but she made no further effort (last name? date of birth?) to make certain of my identity. She never identified herself nor did she introduce the student who accompanied her. (‘This is Mary Smith, a student from the University of Wherever. Do you mind if she observes?’) I asked the young woman if she were a student, and her only word during the whole encounter was ‘Yes.’”
“Curmudge, you tend to ‘chat up’ nurses and techs; without that it would have been a very quiet encounter.”
“That’s right, Jaded Julie. The technician never explained the procedure, but I already knew how it was done and how long it would take. When it was finished, I’ll give her credit for telling me that I would learn the results in about a week. I thanked her for her good work, and her final words were, ‘Go through that door and turn left.’”
“I’m not impressed. Any other observations?”
“While a few other patients and I sat in the waiting room, a couple of the techs (or whoever) stood around the desk and talked about their weekend. That didn’t appear very professional.”
“So other than using AIDET, what would be your recommendations for that organization?”
“When I was in the same waiting room a few years ago, they had a phlebotomist whose welcoming smile would have melted the heart of the grouchiest curmudgeon. I had to restrain myself from running up to her, holding out my arm, and saying, ‘here, take my blood.’ And I wasn’t even there for a blood draw.”
“Your lesson must be that if one doesn’t practice AIDET, an engaging smile will go a long way.”
“It’s more than that, Julie. A pleasant voice has to accompany the smile. Here’s the complete lesson: Smile and speak with your most reassuring voice, acknowledge the patient by name and with eye contact, introduce yourself as completely as seems appropriate, explain the procedure and its duration, and thank the patient for coming in.”
“That sounds great, Curmudge. Why don’t you do that at the beginning of each of our discussions?”
“Because you already know that I’m just an old grouch.”
Affinity’s Kaizen Curmudgeon
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