“Back before 9/11 when I would fly to Chicago on Air Wisconsin’s small aircraft, the door to the cockpit was often wide open. We passengers could see the pilot and copilot consult their checklists prior to takeoff and landing. I’ve even watched the pilot’s radar as he flew around a thunderstorm.”
“I presume you had no reservations about their using checklists, did you Curmudge?”
“None whatsoever, Jaded Julie. That’s the way things were done on commercial flights; they are still done that way except we can’t see it through closed and locked cockpit doors. Everyone understands that checklists enhance flight safety by ensuring that no critical steps are overlooked.”
“By now everyone working in health care should be aware of the evidence showing that checklists used in medicine achieve the same goals as those used in aviation. Our checklists enhance patient safety.”
“The articles that I have seen appear to be directed at physicians, and their most common objective is to increase checklist use. Gawande’s The Checklist Manifesto (1) is written for a general audience, but I suspect that most copies are purchased by people within health care. Patients in general may not be used to checklists in medicine.”
“After he is induced, a patient in the OR won’t know if a checklist is used, and a patient in intensive care is probably too sick to care. However in other areas patients might have reservations about a physician consulting a checklist. In fact, other physicians might feel the same way. This could lead to reluctance by physicians to use them. Curmudge, I’m concerned.”
“The same could be said about clinical decision support systems, Julie. It’s hard to envision a physician leaving the patient in the exam room to go back to his office to consult Isabel on his computer. He should be able to do it right there.”
“And the solution is…”
“Improved physician-patient communication and perhaps even a changed culture among physicians and patients. The physician will need to help the patient to understand that better outcomes result when the physician uses evidence-based protocols, checklists, and decision support systems. Patients already accept the physician’s consulting his PDR to ascertain the correct dosage of a medication. These other tools are simply the next step in providing better patient care.”
“That ought to fly, Curmudge, especially as patients become more knowledgeable and more involved participants in their own care.”
Affinity’s Kaizen Curmudgeon
(1) Gawande, Atul The Checklist Manifesto: How to Get Things Right (2010, Available through Amazon.com.)
Thursday, April 29, 2010
Thursday, April 22, 2010
Assisting Clinical Excellence (ACE) Awards
“Curmudge, you are myopic.”
“Of course I’m myopic. You don’t think I wear these trifocals for fun, do you? Many months ago you said that I couldn’t track an elephant in four feet of snow. That’s about as myopic as one can become.”
“Well, this time you’ve really done it. Back when we talked about Operas and Hospitals and the fact that nonclinical staff might be considered invisible, you didn’t mention Affinity Health System’s recognition programs.”
“You’re right, Jaded Julie. Perhaps you should have reminded me, but ‘better late than never.’ Here, take my arm and lead this old codger through Service Excellence and Recognition on the intranet.”
“Start on the Affinity intranet home page, click on Affinity Learning Center, and then on Service Excellence. Then jump to the bottom of the column and click on Recognition. At the left margin are three programs, External Customer Service Award, Assisting Clinical Excellence, and C.A.R.E. Enough to Share. We’ll focus on Assisting Clinical Excellence (ACE) because it includes awards for individuals in nonclinical positions. Some of these individuals have been from potentially ‘invisible’ support areas.”
“To me, this whole awards program has been invisible. You never know what you are going to find hidden in the deep recesses of the Affinity intranet.”
“That, Curmudge, is because you didn’t look through the proper lens of your trifocals. Here’s the ACE award in a nutshell: ‘This award recognizes individuals from ancillary departments who have assisted a clinical department in achieving Top 10% for Patient Satisfaction—Likelihood to Recommend.’ If you look carefully at the February 2010 awardees, you’ll see the broad spectrum of occupations represented, including Steve Shink from Facilities.”
“You’ve convinced me, Julie. I just looked at the April 2010 list and there’s our own Karen Schaefer, recognized by the staff of the Children’s Health Center. But recall our discussion on Operas and Hospitals? We were concerned about recognition of staff who might be regarded as invisible. Karen will never be invisible; in my book, she’ll always be a star.”
“Curmudge, I couldn‘t agree more.”
Affinity’s Kaizen Curmudgeon
“Of course I’m myopic. You don’t think I wear these trifocals for fun, do you? Many months ago you said that I couldn’t track an elephant in four feet of snow. That’s about as myopic as one can become.”
“Well, this time you’ve really done it. Back when we talked about Operas and Hospitals and the fact that nonclinical staff might be considered invisible, you didn’t mention Affinity Health System’s recognition programs.”
“You’re right, Jaded Julie. Perhaps you should have reminded me, but ‘better late than never.’ Here, take my arm and lead this old codger through Service Excellence and Recognition on the intranet.”
“Start on the Affinity intranet home page, click on Affinity Learning Center, and then on Service Excellence. Then jump to the bottom of the column and click on Recognition. At the left margin are three programs, External Customer Service Award, Assisting Clinical Excellence, and C.A.R.E. Enough to Share. We’ll focus on Assisting Clinical Excellence (ACE) because it includes awards for individuals in nonclinical positions. Some of these individuals have been from potentially ‘invisible’ support areas.”
“To me, this whole awards program has been invisible. You never know what you are going to find hidden in the deep recesses of the Affinity intranet.”
“That, Curmudge, is because you didn’t look through the proper lens of your trifocals. Here’s the ACE award in a nutshell: ‘This award recognizes individuals from ancillary departments who have assisted a clinical department in achieving Top 10% for Patient Satisfaction—Likelihood to Recommend.’ If you look carefully at the February 2010 awardees, you’ll see the broad spectrum of occupations represented, including Steve Shink from Facilities.”
“You’ve convinced me, Julie. I just looked at the April 2010 list and there’s our own Karen Schaefer, recognized by the staff of the Children’s Health Center. But recall our discussion on Operas and Hospitals? We were concerned about recognition of staff who might be regarded as invisible. Karen will never be invisible; in my book, she’ll always be a star.”
“Curmudge, I couldn‘t agree more.”
Affinity’s Kaizen Curmudgeon
Thursday, April 15, 2010
Operas and Hospitals
“Curmudge, you once told me that a hospital had many things in common with an opera. I would appreciate it if you could refresh my memory; I don’t hear much singing around here, just hammers and saws from our remodeling.”
“Of course, Jaded Julie. Consider the vast array of people who make up an opera’s cast—both seen and unseen. The stars who sing the solo arias, the singers in the secondary roles, the chorus and orchestra, the supernumeraries, and the technical crew. Supernumeraries are the on-stage non-singers (‘spear carriers’) who are seen but not heard, and the tech and production crew are neither seen nor heard.”
“You’ve told me, Curmudge, that each one of these people is absolutely essential for a good performance. I know I’d be especially grateful for the guy who projects the supertitles (translations of the dialogue) on the screen above the stage.”
“The audience acknowledges the stars with solo bows and the secondary singers and chorus after the final curtain; the orchestra stands and receives applause before the final act. But at the end of the performance the ‘supers’ and tech crew are on their way home while the audience is still clapping. Their ‘applause’ must be their feeling of satisfaction from having done a good job.”
“I still don’t hear any music, Maestro. So what’s the connection between an opera and a hospital?”
“Pretty simple, Julie. The physicians, nurses, and technologists who bring personalized care to our patients are known and acknowledged, just like those who fill the performing roles in an opera. Patients are grateful—and they often say so—after their heart has been repaired, or their baby has been delivered, or even after they have experienced a colonoscopy or bone marrow biopsy with minimal discomfort.”
“And I guess you are about to say that those folks in a hospital who do not deal directly with patients are like the supernumeraries and techs in an opera.”
“That’s it. In a hospital they are the folks who keep the building and instruments functioning, who cook and serve in the cafeteria, who keep every inch of every room clean, who deliver mail and packages, and who push carts around piled high with plastic bags filled with who-knows-what. Like the supers in an opera, their ‘applause’ is their satisfaction from doing an essential job well.”
“I’ve got it, Curmudge. It’s like The Perfection of Our Ordinary Actions that we discussed on March 25. They are ‘performing extraordinarily well the ordinary exercises of every day.’ And in addition, I strongly suspect that they have good leadership. But shouldn’t there be a way to reinforce, on a regular basis, our appreciation for their good work?”
“There certainly is. To many people walking through the hospital, our nonclinical staff are invisible; they are there but not acknowledged. We must make sure that they don’t feel invisible. Learn the names of those you see often and greet them by name. They will reflect your smile. Thank them for their good work. When a housekeeper empties your wastebasket, don’t let her leave without being thanked.”
“Now I understand, Curmudge, why you feel that the hospital is the friendliest place you ever worked. But I feel a bit sorry for the supers and stagehands at the opera who don’t even get a smile of appreciation.”
“Don’t feel bad, Julie. I pay big bucks to go to the opera, but those folks get to hear that great music for free. Good music is its own reward.”
Affinity’s Kaizen Curmudgeon
“Of course, Jaded Julie. Consider the vast array of people who make up an opera’s cast—both seen and unseen. The stars who sing the solo arias, the singers in the secondary roles, the chorus and orchestra, the supernumeraries, and the technical crew. Supernumeraries are the on-stage non-singers (‘spear carriers’) who are seen but not heard, and the tech and production crew are neither seen nor heard.”
“You’ve told me, Curmudge, that each one of these people is absolutely essential for a good performance. I know I’d be especially grateful for the guy who projects the supertitles (translations of the dialogue) on the screen above the stage.”
“The audience acknowledges the stars with solo bows and the secondary singers and chorus after the final curtain; the orchestra stands and receives applause before the final act. But at the end of the performance the ‘supers’ and tech crew are on their way home while the audience is still clapping. Their ‘applause’ must be their feeling of satisfaction from having done a good job.”
“I still don’t hear any music, Maestro. So what’s the connection between an opera and a hospital?”
“Pretty simple, Julie. The physicians, nurses, and technologists who bring personalized care to our patients are known and acknowledged, just like those who fill the performing roles in an opera. Patients are grateful—and they often say so—after their heart has been repaired, or their baby has been delivered, or even after they have experienced a colonoscopy or bone marrow biopsy with minimal discomfort.”
“And I guess you are about to say that those folks in a hospital who do not deal directly with patients are like the supernumeraries and techs in an opera.”
“That’s it. In a hospital they are the folks who keep the building and instruments functioning, who cook and serve in the cafeteria, who keep every inch of every room clean, who deliver mail and packages, and who push carts around piled high with plastic bags filled with who-knows-what. Like the supers in an opera, their ‘applause’ is their satisfaction from doing an essential job well.”
“I’ve got it, Curmudge. It’s like The Perfection of Our Ordinary Actions that we discussed on March 25. They are ‘performing extraordinarily well the ordinary exercises of every day.’ And in addition, I strongly suspect that they have good leadership. But shouldn’t there be a way to reinforce, on a regular basis, our appreciation for their good work?”
“There certainly is. To many people walking through the hospital, our nonclinical staff are invisible; they are there but not acknowledged. We must make sure that they don’t feel invisible. Learn the names of those you see often and greet them by name. They will reflect your smile. Thank them for their good work. When a housekeeper empties your wastebasket, don’t let her leave without being thanked.”
“Now I understand, Curmudge, why you feel that the hospital is the friendliest place you ever worked. But I feel a bit sorry for the supers and stagehands at the opera who don’t even get a smile of appreciation.”
“Don’t feel bad, Julie. I pay big bucks to go to the opera, but those folks get to hear that great music for free. Good music is its own reward.”
Affinity’s Kaizen Curmudgeon
Thursday, April 8, 2010
Mistakes 2
“Last time we talked, Curmudge, you promised to provide more countermeasures against making mistakes.”
“I’ll try, Jaded Julie, but sometimes the best defense is knowing the conditions under which mistakes can occur. Here’s an example from Hallinan’s book (1). It takes 10 years and a lot of practice to become a world-class expert, as in med school—internship—residency—fellowship, etc. Having a big library of the mind allows experts to quickly recognize patterns that others don’t; this allows people to develop shortcuts from their cognitive maps. However, overconfidence tends to be higher with tasks of great difficulty. In addition, information overload leads us to believe that we know more than we actually do.”
“And the countermeasures are…”
“Feedback is very helpful. The weather forecaster learns today whether the forecast he made yesterday was correct. Physicians get feedback during residency, but it’s rare when they are practicing independently (radiology and pathology are exceptions). M & M (morbidity and mortality) conferences are valuable but infrequent. Doctors need to be their own devil’s advocate and try to envision what might go wrong, especially when performing diagnoses. Graber and others (2, 3) call this ‘metacognition,’ the ability to monitor and understand one’s own thought processes.”
“C’mon, Curmudge, docs don’t have time to sit around second-guessing themselves.”
“Nevertheless, they should know that the odds of a wrong diagnosis are closer to 10% than 1%, and they should be aware of these countermeasures:
Learn (and be wary of) the inherent biases that can lead to errors.
‘Once you’ve come up with a working hypothesis, examine it carefully and consciously. Consider the opposite, rethink your key assumptions, and think about diagnoses that you can’t afford to miss.’”
“That sounds like good advice for a difficult diagnosis, but it’s probably more than is needed for a kid with a runny nose. But why should a physician go through all this ‘metacognition’ mental gymnastics when there is so much information available at one’s fingertips like we discussed back on August 6, 2009?”
“The more that I read about clinical decision support systems like ‘Isabel,’ the better they sound. But decisions on the use of these tools are in the realm of the clinician, not me. The same can be said about checklists; these are discussed at length in books (see Amazon.com) and other writings by Atul Gawande, Peter Pronovost, and others. Their use in reducing errors is well documented.”
“As I understand it, Curmudge, checklists pick up some of your brain’s memory load and free it up to concentrate on really tough problems.”
“I have a friend—older than I am—who says that his memory is perfect because he writes everything down. So you see that notes and checklists are valuable at all walks of life, especially for those of us subject to ‘senior moments.’”
“And you certainly have those, Curmudge. Are there other ways you’d recommend for minimizing mistakes?”
“Sure, Julie. Think ahead and prepare for bad things that might happen. Losing power in both airplane engines certainly qualifies as a ‘bad thing,’ and Captain Sullenberger attributed his survival to standardized work, crew resource management, and checklists.”
“So have you had any personal experiences like that, Curmudge?”
“Not nearly that serious. Many years ago my wife lost her cash and credit cards to a group of child pickpockets in Paris. Europe abounds in pickpockets, so one should be alert for any efforts to divert your attention. In addition to not having any valuables accessible, another defense is to scream, ‘Go away!’ in the native language. Then the pickpockets, especially children, know that you are not an ‘innocent abroad.’”
“You can do that?”
“In French, German, Italian, and when we were there, in Czech. That’s why I now always travel with Mrs. Curmudgeon; despite her bad experience she still chooses not to learn (or re-learn) any of those languages.”
Affinity’s Kaizen Curmudgeon
(1) Hallinan Joseph T. Why We Make Mistakes (Broadway Books, 2009)
(2) Croskerry, Pat http://journals.lww.com/academicmedicine/Fulltext/2003/08000/The_Importance_of_Cognitive_Errors_in_Diagnosis.3.aspx
(3) http://psnet.ahrq.gov/printviewPrimer.aspx?primerID=12
Check out the latest posting in Curmudge and Jaded Julie’s personal blog, Curmudgeon’s Wastebasket.Thursday, April 1, 2010
Mistakes
“Curmudge, I’m sure you have forgotten, but back on February 19, 2009 you mentioned that because of necessary fallibility people will always make errors. That sounds like a default alibi for screw-ups. Have we learned any more about why people make mistakes?”
“First of all, Jaded Julie, I do recall our discussion; it’s things like yesterday’s events that I tend to forget. I found a book, Why We Make Mistakes (1), that I hoped would provide all the answers, but we already know much of its contents. Fortunately, however, it contains a few gems of knowledge worth sharing, and the author backs up his assertions with 33 pages of bibliography.”
“Okay, armchair psychologist, why do people make mistakes?”
“People try to do too many things at the same time. Sure you can pat your head and rub your tummy, but you can’t make two conscious decisions simultaneously.”
“Gosh, Curmudge, I know people who can’t even make one decision ‘simultaneously.’”
“So if you think you are good at multitasking, think again. Tasks interfere in our brain. Within 15 seconds after starting a new problem, we have forgotten the old one.”
“Wow! Think how difficult it must be for the ED physician who sees several patients in rapid succession and then has to cycle back to an earlier one after receiving lab or x-ray results. I know they have to do that because it’s on Board exams.”
“It’s even more difficult for us older folks. We can’t shift the gears in our brain rapidly, our reaction time is slower, and our visual field is often narrower. This can be especially challenging while driving. Hopefully, senior citizens have enough wisdom not to drive while using a cell phone.”
“I have long suspected that your brain had a manual transmission, Curmudge. This must be what you call a ‘senior moment.’ A ‘senior 5 minutes’ might be more descriptive.”
“Here’s an observation that I know from experience. Meaningless things are hard to remember. It’s harder to learn Arabic, with its own alphabet, than it is to learn French, Italian, or German, which have many cognates (words similar to English). Medical students learn parts of the body in the correct sequence by putting them into a mnemonic. Here’s an example for learning vertebrae subtypes: Certain Doctors Luv Sad Coeds. Cervical, Dorsal, Lumbar, Sacrum, Coccyx.”
“Thank goodness there are workarounds like that for some of our brain’s limitations.”
“There are some sources of mistakes that are difficult—if not impossible—to overcome. Sleep deprivation is a big one. Sleep-deprived people are prone to take risks; it’s almost as bad as driving while intoxicated. All too often health care workers work multiple and changing shifts that leave them sleep-deprived and with their circadian rhythm disturbed. Errors made under these conditions are not uncommon.”
“Recall your college days, Curmudge, when you never got enough sleep and you seemingly always had a cold?”
“The only way to survive that kind of life is to be young, and the only way to cure it is to graduate.”
“We’ve listed several sources of hard-to-avoid mistakes but not many reliable countermeasures. Should we discuss this further next time?”
“Good idea, Julie. If I don’t oversleep, I’ll be here.”
Affinity’s Kaizen Curmudgeon.
(1) Hallinan, Joseph T. Why We Make Mistakes (Broadway Books, 2009)
Check out the latest posting in Curmudge and Jaded Julie’s personal blog, Curmudgeon’s Wastebasket.
“First of all, Jaded Julie, I do recall our discussion; it’s things like yesterday’s events that I tend to forget. I found a book, Why We Make Mistakes (1), that I hoped would provide all the answers, but we already know much of its contents. Fortunately, however, it contains a few gems of knowledge worth sharing, and the author backs up his assertions with 33 pages of bibliography.”
“Okay, armchair psychologist, why do people make mistakes?”
“People try to do too many things at the same time. Sure you can pat your head and rub your tummy, but you can’t make two conscious decisions simultaneously.”
“Gosh, Curmudge, I know people who can’t even make one decision ‘simultaneously.’”
“So if you think you are good at multitasking, think again. Tasks interfere in our brain. Within 15 seconds after starting a new problem, we have forgotten the old one.”
“Wow! Think how difficult it must be for the ED physician who sees several patients in rapid succession and then has to cycle back to an earlier one after receiving lab or x-ray results. I know they have to do that because it’s on Board exams.”
“It’s even more difficult for us older folks. We can’t shift the gears in our brain rapidly, our reaction time is slower, and our visual field is often narrower. This can be especially challenging while driving. Hopefully, senior citizens have enough wisdom not to drive while using a cell phone.”
“I have long suspected that your brain had a manual transmission, Curmudge. This must be what you call a ‘senior moment.’ A ‘senior 5 minutes’ might be more descriptive.”
“Here’s an observation that I know from experience. Meaningless things are hard to remember. It’s harder to learn Arabic, with its own alphabet, than it is to learn French, Italian, or German, which have many cognates (words similar to English). Medical students learn parts of the body in the correct sequence by putting them into a mnemonic. Here’s an example for learning vertebrae subtypes: Certain Doctors Luv Sad Coeds. Cervical, Dorsal, Lumbar, Sacrum, Coccyx.”
“Thank goodness there are workarounds like that for some of our brain’s limitations.”
“There are some sources of mistakes that are difficult—if not impossible—to overcome. Sleep deprivation is a big one. Sleep-deprived people are prone to take risks; it’s almost as bad as driving while intoxicated. All too often health care workers work multiple and changing shifts that leave them sleep-deprived and with their circadian rhythm disturbed. Errors made under these conditions are not uncommon.”
“Recall your college days, Curmudge, when you never got enough sleep and you seemingly always had a cold?”
“The only way to survive that kind of life is to be young, and the only way to cure it is to graduate.”
“We’ve listed several sources of hard-to-avoid mistakes but not many reliable countermeasures. Should we discuss this further next time?”
“Good idea, Julie. If I don’t oversleep, I’ll be here.”
Affinity’s Kaizen Curmudgeon.
(1) Hallinan, Joseph T. Why We Make Mistakes (Broadway Books, 2009)
Check out the latest posting in Curmudge and Jaded Julie’s personal blog, Curmudgeon’s Wastebasket.
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