Kaizen Curmudgeon

Flow

2012-01-13T10:01:00.000-06:00

“Curmudge, you should be distraught, but of course you never are. You arrived at work at 9:15 today, and I know that you intended to be here by 9:00. Fortunately, work hours are not a big deal with volunteers.”

“I had an appointment with a physician across town at 8:15 this morning, and I felt certain that it would be over and I’d be here by 9:00. I’m usually with the doc for five minutes at the most, and that was the case today.”

“Oh-oh. Something must have been messed up at the office. Would you tell me about your experience? Perhaps we can learn something from it. But please, no profanity or histrionics.”

“To begin with, Julie, I think the doc is great, and the receptionist has always been very accommodating. The first sign of a problem was when I arrived at the multi-specialist office building at 7:55; the line of people waiting to register stretched out the door. Ultimately, I got inside and registered by 8:10 after having confirmed all the personal information that was already in their records.”

“Since you didn’t get here until 9:15, that must not have been the end of your delays. Obviously you spent some time in the waiting room.”

“Finally the nurse (name unknown—she didn’t introduce herself) took me back to an exam room. Per our well-practiced drill, I removed my shirt and froze until the doc arrived. As expected, she was there and gone in five minutes. I stopped at the desk on the way out, made my return-in-six-months appointment, and headed for work at 8:55.”

“So, professor, what is today’s lesson, other than ‘don’t take off your shirt in a cold exam room’?"

“There was a very pertinent posting on daily kaizen last November. The title was Getting In-Flow, and it details what the author did to improve her office. To a patient, flow means moving through the appointment smoothly without needless periods of waiting. To the office staff, flow is a day without surprises, disruptions, or highs and lows in work load.”

“As we have learned, Curmudge, the office needs to practice heijunka, or level loading. If they can’t have more patient registrars at 8:00 a.m., maybe they can eliminate the operation and use registration kiosks. And in addition, they should plan ahead and not schedule potentially long appointments at the beginning of a day. I remain puzzled at how a physician’s office can be one-half hour behind by 8:15. They seemed to accept the fact that delays and lack of flow were normal.”

“Good observations, Julie. Would now be an appropriate time for me to share my observations about patient waiting?”

“It would. True flow means no waiting. Isn’t it incongruous to realize that health care facilities are still being designed to accommodate a waste—waiting—by having ‘waiting rooms’?”

“Back to reality, Ms. Perfectionist. Except for OB and Peds, a major fraction of our patients are senior citizens. We often assume that because they don’t have employment obligations or a crowded social calendar, they shouldn’t mind waiting. That may be true in the short term but quite inaccurate in the long term. By definition, a senior citizen’s days are numbered—with the number often quite unknown. If there’s something he/she wants to accomplish while still on this earth, he’d better get busy on the task. There’s no time to wait.”

“So what do you conclude, Curmudge?”

“Health care providers should implement flow and try to make their waiting rooms obsolete. Of course, my specific conclusion from my most recent office visit is that the practice of Lean in health care is not yet universal.”

Affinity’s Kaizen Curmudgeon

Motivation

2012-01-04T11:00:00.000-06:00

“Hey Jaded Julie, would you like to hear some anecdotal evidence that supports an obvious conclusion?”

“If the conclusion is obvious, it doesn’t need evidence; but I’m always willing to listen to your strange stories.”

“In a stateside Army unit with no immediate plans for deployment, more soldiers show up for sick call than in a deployment-ready light infantry unit or in a Special Forces unit that deploys regularly. Soldiers in the stateside unit apparently want to be relieved from heavy duty or outside work.”

“Well, I know where you got that factoid. Obviously, the stateside soldiers aren’t motivated. It’s also obvious that you have some more examples.”

“In early 19th century warfare, when battles were won by conquering fortified cities, a unit of volunteers called the Forlorn Hope would be the first to charge through the first breach in the city’s defenses. Although the soldiers faced almost certain death (thus the name Forlorn Hope), they would be promoted if they survived.”

“That sounds like insanity, Curmudge. But it’s not limited to long ago. Think of the suicide bombers in Afghanistan. That is certain death, but their motivation has something to do with virgins in the afterlife. Apparently they never heard Professor Harold Hill (in ‘Music Man’) sing, ‘a sadder but wiser girl for me.’ But enough of this banter. What does this have to do with Lean?”

“For Lean’s ongoing existence, motivation has to be continuously refreshed. If we lag in our motivation to continuously improve, it will be reflected by a lag in our Lean transformation. Maybe that’s what happened in those organizations that suffered Lean burn-out.”

“I’ve got it, Curmudge. Fresh ideas are needed to help us maintain our patient focus. Acronyms like C.A.R.E. and AIDET. Personalized Care is more than just a marketing theme; it’s what we do. The newest motivators are the ‘Always’ teams. This term comes from the choices about recommending Affinity found on patient surveys: Always, Usually, Sometimes, Never.”

“Some of our motivational reminders are more enduring than acronyms or slogans. Consider Affinity’s Values: service, integrity, teamwork, justice, creativity, stewardship. They are lettered on the wall of our team room. One should take a moment and consider whether they are guiding our actions.”

“It’s time for the bottom line, old guy. What is it?”

“Motivation is more than slogans, acronyms, or programs developed by committees. It must happen every day in gemba, and it’s the responsibility of leaders at every level. Workers will be motivated when they see that their daily improvements are paying off in efficiency, less waste, and better patient safety and outcomes.”

“Hey Curmudge, what keeps you motivated?”

“As I said long ago, I am an inveterate learner and teacher. But most of all, it’s the people.”

Affinity’s Kaizen Curmudgeon

In case you missed it earlier, this year’s holiday story from Curmudge and Julie may be accessed elsewhere.

Choices

2011-12-15T11:19:00.000-06:00

“It used to be said, Julie, that the only things certain in life are death and taxes, but that’s wrong. Some people don’t pay taxes. The correct statement is, ‘the only things certain are death and choices.’ " (1)

“At the time many choices are made, people tend not to appreciate their significance. For example, one’s choice of a job and its location affect the environment in which one’s children will grow up. For that matter, one’s choice of a mate impacts the very existence of one’s children.”

“Fortunately, a lot of these are two-party choices. In the distant past Mrs. Curmudgeon vetoed some of my job location choices with two words, ‘too rural.’ In many cases, if one fully comprehended the future impacts of a choice he had to make today, he would be paralyzed with indecision.”

“Curmudge, we have been reading a book about choices; it is James C. Hunter’s The Servant (2). It’s not about the kinds of choices described above. It’s about moral choices and the fact that it is up to us to make them.”

“You’re right, Julie. If I were to list the five best books that I have read in the past ten years, it would be on the list.”

“I’m not sure that you have read five books in the past ten years. But no matter how you count, it’s a great book. Without its intent being obvious, it introduces the principles of servant leadership in the form of an allegory involving six people meeting for a week with a teacher at a retreat center.”

“Perhaps we should explain why our title is Choices and not Servant Leadership. In his epilogue, Hunter includes this quote, ‘it is of no profit to have learned well if you neglect to do well.’ It is our thesis that to gain value, one must choose to put to use what he has learned. If one puts down this book and says, ‘Ho hum, that was interesting,’ he is both insensitive and foolish.”

“But Curmudge, we’ve addressed servant leadership in several Kaizen Curmudgeon postings. There were three in May 2008 and two last November, on 11/11/11 and 11/03/11. Do we need more?”

“We certainly do, for two reasons. Hunter’s 2004 book (3) was sort of a textbook, but The Servant grabs your heart and mind. The second reason is that we need to hardwire Hunter’s eight essentials of good character: patience, kindness, humility, respect, selflessness, forgiveness, honesty, and commitment.”

“Well, at least the words aren’t in Japanese. My guess is that today we’ll pick off the high points that haven’t already been addressed, and as before, quoted material will be from Hunter’s book.”

“Fortunately, Julie, all of Hunter’s words are in English, and the first one we’ll mention is paradigm. Paradigms are the psychological maps we use to navigate our way through life. ‘The outside world enters our life through the filters of our paradigm.’ You can bet that the paradigm of the traditional command-and-control manager is different from that of the servant leader.”

“I’ve got it, Curmudge. In order to improve, the traditional boss who wants to become a leader has to change his paradigm; and Hunter’s teachings describe how he can do it. For starters, the leader has to identify and meet the legitimate needs of his people, and that is what serving is all about. In case you wondered, legitimate needs are those listed, in order, in Maslow’s hierarchy: food, water, shelter; safety and security; belonging and love; self-esteem; self-actualization. Self-actualization is being all you can be. Sound familiar?”

“Let’s pick love off Maslow’s list and use it in a leadership sense. This is the agapé-type love as used in the Bible. It is the ‘love of deliberate choice rooted in behavior toward others without regard to their due.’ Agapé love and leadership are synonymous, and the properties of agapé love are that same list of Hunter’s eight essentials of good character. Are you surprised, Julie?”

“I am not; please remember that I read the book. Note also how well that list correlates with the list of characteristics that people look for in a good manager: ‘honest & trustworthy, good role model, caring, committed, good listener, held people accountable, treated people with respect, gave people encouragement, positive & enthusiastic attitude, and appreciated people.’ When we think more about that list, we realize that ‘love is not how you feel toward others but how you behave toward others.’ “

“One item on the list represents an almost universal weakness—being a good listener. ‘Active listening requires a disciplined effort to silence all our internal conversations while we are attempting to listen to another human being.’ We should attempt to see and feel things as the speaker sees and feels them, and to empathize—be fully present—with the speaker.”

“I guess, Curmudge, that requires you to do more than just turn up your hearing aid.”

“Another common oversight is neglecting to give praise to people. People need to be appreciated. Your praise should be specific and sincere. Catch people doing something right. I think I’m better at it now than I was 40 years ago, but it doesn’t mean much coming from a volunteer.”

“In the past we have managed to bring several postings on servant leadership to a logical conclusion, Curmudge, but what is the real bottom line? What should we shout from the top of the parking ramp?”

“Becoming a true leader is a choice. Servant leadership is not inborn; it must be learned and then practiced. As we have said before with different wording, ‘we are more likely to act ourselves into a feeling than to feel ourselves into action.’ (4) So here’s what to shout: ‘Servant leadership. Just do it.’ “

Affinity's Kaizen Curmudgeon

(1) Soren Kierkegaard
(2) Hunter, James C., The Servant (Crown Business, 1998)
(3) Hunter, James C. The World’s Most Powerful Leadership Principle (Crown Business, 2004)
(4) Jerome Brunner

Note: This year’s holiday story from Curmudge and Julie may be accessed elsewhere.

The Most Recent Kaizen Curmudgeon Postings

2011-11-22T10:58:00.000-06:00

On December 22, 2010 the Kaizen Curmudgeon blog celebrated its 150th posting by listing the titles and posting dates and supplying links to the 50 most recent postings. Provided below is the same information for each posting since December 29, 2010. This is in celebration of the “almost 200th” posting.

Kaizen Curmudgeon Blog Title—Date Posted

Stan’s Story Redux—12/29/10

Autonomy—1/06/11

Autonomy 2—1/27/11

What shall we do with you?—2/02/11

The Middle Years—2/09/11

Way to go!—2/17/11

Way to go! 2—2/24/11

Complacency—3/03/11

Complacency 2—3/10/11

Kaikaku, a countermeasure for “We’ve always done it that way.”—3/18/11

I’ve always done it that way.—3/24/11

The Crystal Ball—Prologue—4/07/11

The Crystal Ball 1—4/15/11

The Old Men’s Table—4/18/11

The Crystal Ball 2—4/27/11

The Crystal Ball 3—5/05/11

The Crystal Ball 4—5/12/11

The Crystal Ball 5—5/19/11

Happy Fourth Birthday—5/20/11

The Crystal Ball 6—5/31/11

The Crystal Ball 7—6/03/11

The Crystal Ball 8—6/13/11

The Laboratory—6/30/11

The Laboratory 2—7/07/11

The Laboratory 3—7/14/11

The Laboratory 4—7/21/11

The Laboratory 5—7/28/11

Conventional Wisdom—8/08/11

Hardwiring—8/12/11

Hardwiring 2—8/18/11

Sepsis—8/26/11

Sepsis 2—9/07/11

Sepsis 3—9/15/11

The Bad, Good Medication—9/23/11

Series Contents—9/29/11 This contains subtitles or keywords for individual postings in series posted between April 1, 2010 and September 15, 2011.

How Things Happen—10/06/11

The Need for Lean Leadership—Entropy—10/13/11

Lean Leadership 2—10/20/11

Lean Leadership 3—10/28/11

Lean Leadership 4—Servant Leadership—11/03/11

Lean Leadership 5—Links Between Lean Leadership and Servant Leadership—11/11/11

Affinity’s Kaizen Curmudgeon

Lean Leadership 5

2011-11-11T10:20:00.000-06:00

Links Between Lean Leadership and Servant Leadership

“I trust, Jaded Julie, that you are still willing to play the role of a front-line leader in a generic hospital?”

“No sweat, Curmudge. That’s as easy for me as it is for you to play the role of a cantankerous old codger. I believe last time we promised to describe how servant leadership can be tied with Lean leadership. To me, the most obvious connection would be through the Lean principle of respect for people.”

“Good observation. In manufacturing the Lean manager respects the knowledge and ability of the workers to solve—with coaching—the problems that arise in their process. This should be easier in a hospital, where most of the people in gemba are professionals. In your role, Julie, achieving mutual respect might be the most important element of respect for people. In your unit the ‘people will not care what you know until they know that you care, and they won’t believe the message until they believe the messenger (1).’ “

“I agree, Curmudge. As Hunter has said, ‘Management is what we do; leadership is who we are. Simply knowing how to do the job well has little to do with developing the skills necessary to inspire others to do the job well.’ “

“In our lesson on becoming a servant leader back on May 22, 2008, we mentioned the need to get feedback from one’s direct reports. In doing so, you might tell your people about servant leadership and your efforts to become one. Hopefully they will acquire a stake in your success.”

“Accountability is essential in Lean management, and it’s an important part of servant leadership. Of course, it should not be a problem if people are motivated. ‘Motivation is people moved to action because they want to act. We cannot change anyone; the best we can do is influence their future choices.’ “

“It’s clear to me, that while a servant leader will help his/her people be the best they can be, he will strongly influence them to do so. Here is what Hunter’s book says about accountability: ‘It is immoral not to fire those who can’t do the job. Think about the bad messages we send about our lack of commitment to excellence and our failure to do the right thing.’ ‘The biggest gap in leadership skills is failing to confront people with problems and situations as they arise and to hold them accountable.’ I’ve seen that at all levels, Julie, and I confess to not having acted promptly in at least one case. But that was before Hunter wrote his books.”

“I think I’ve got it, Curmudge. A servant leader is a person of high character who is willing to use ‘tough love’ to help his/her direct reports to be the best they can be. Now here’s a tough problem for you. What about the employee with family responsibilities who simply wants to work her shift and go home as soon as possible? She has little interest in ‘being all she can be.’ ”

“Let’s not overlook the possibility that she might already ‘be all she can be.’ If she really wants to leave promptly, she might be your strongest ally in improving the unit’s efficiently. People in health care usually believe on the day they are hired that what they are doing is important, that it serves a purpose, and adds value to the world. Perhaps between then and now something has caused her to become de-motivated. Your training as a servant leader should help you differentiate between a person with legitimate needs and one who is truly a detriment to the organization. Thus servant leadership doesn’t provide silver bullets; it develops the character to make difficult decisions.”

“Lean is based on continuous improvement, and Lean leadership—supported by servant leadership—is the way we make the improvements happen. Leaders are made, not born, and they don’t leap from the cradle as servant leaders. Becoming a servant leader, like Lean, requires continuous improvement.”

“That’s it, Julie. While one can read books on Lean and servant leadership, one can only accomplish the desired goals of each by continuous efforts in the workplace.”

“Well senescent senior, that’s a lot to learn. But if you can, anybody can.”

Affinity’s Kaizen Curmudgeon

(1) Hunter, James C. The World’s Most Powerful Leadership Principle (Crown Business, 2004)

P.S.—Back on May 22, 2008 we talked about how one might become a servant leader. Anyone who wasn’t reading our blog back then can click on the link and learn about Hardwiring What We Have Learned.

Lean Leadership 4--Servant Leadership

2011-11-03T10:46:00.000-05:00

“Jaded Julie, even though you couldn’t stay for the whole orchestra concert, did you enjoy what you heard?”

"It was great, and as you advised, I listened intently. The first violins all played the same melody, but sometimes the woodwinds or the brass played something different. But it fit together beautifully.”

“That was a countermelody. If the whole orchestra had played exactly the same notes, it might have sounded like a grade-school band. You have observed that when something extra is added to a simple theme, the combined effect is enhanced.”

“I’ve got it, Curmudge. But what does this have to do with Lean? If there’s no connection, this posting will end up in the wastebasket.”

“I used countermelody, Julie, as a metaphor for servant leadership. If you can combine servant leadership with Lean leadership, your performance as a Lean leader will be greatly improved.”

“We talked about servant leadership over three years ago, on May 8, 2008 and also on May 15 and 22. I agree that it’s time for a refresher.”

“Let’s skip the history of servant leadership and get right to today’s lesson. Most of what we will share with readers is found in books by James C. Hunter (1, 2). In fact, much of this posting will simply be quotations from Hunter’s second book. We’ll also reference the statements of authorities that Hunter quoted.”

“Curmudge, I understand that Lean and servant leadership are complementary, but how do they differ?”

“Pretty simple. Lean is organizational; servant leadership is personal. Lean is the organizational culture that we are trying to develop. Servant leadership describes the character that should be a part of a truly successful leader. If all of the managers in an organization were servant leaders, pulling off a Lean transformation should be a slam-dunk.”

“We know intuitively what character means, but how does Hunter define it in the servant leadership context?”

“ ‘Character is our moral maturity and commitment to doing the right thing regardless of personal costs. Character involves the will to respond to stimuli according to values and principles rather than to appetites, urges, whims, or impulses.’ Here are some of the essentials of good character: patience, kindness, humility, respect, selflessness, forgiveness, honesty, and commitment.“

“Presumably, these are also essentials of leadership. Here are some things that others have said about character and leadership: ‘Ninety-nine percent of leadership failures are failures of character (3).’ ‘Leadership is character in action (4).’ ‘There are no weak platoons—only weak leaders (5).’ “

“Julie, we must have said this back in 2008, but it’s worth repeating: Leadership is ‘the skills of influencing people to enthusiastically work toward goals identified as being for the common good, with character that inspires confidence.’ “

“Okay, we’ve tied leadership to character, but how does ‘servant’ enter the picture?”

“Here it is at the most basic level: ‘If you choose to lead, you must serve (6).’ It’s simpler if you consider The Law of the Harvest; you reap what you sow. ‘You sow service and sacrifice; you extend yourself for others and seek their greatest good; you will build influence with them.’ “

“But in the world of commerce and even health care, the word ‘servant’ sounds a bit wimpish.”

“Don’t confuse a servant leader with being a total ‘Mr. Nice Guy,’ Julie. Here’s what Hunter says: ‘The servant leader does not abdicate responsibility to define the mission, set rules governing behavior, set standards, or define accountability. Then the leader helps people meet their legitimate needs so they can become the best they are capable of becoming and effectively accomplish the mission.’ Note that Hunter said ‘needs’ and not ‘wants.’ He illustrates that in this way: ‘If you get your people what they need, they will get you everything that you need. Our leadership will be defined not by what we accomplish but by what we get accomplished through others.’ “

“Old Guy, it looks as if we’ve presented some of the most important elements of servant leadership. I trust that next time we’ll relate servant leadership more closely with Lean leadership.”

Affinity’s Kaizen Curmudgeon

(1) Hunter, James C. The Servant (Crown Business, 1998)
(2) Hunter, James C. The World’s Most Powerful Leadership Principle (Crown Business, 2004)
(3) Schwarzkopf, Norman
(4) Bennis, Warren
(5) Creech, William
(6) Book of Matthew (paraphrased)

Lean Leadership 3

2011-10-28T09:35:00.000-05:00

“Continuing with our music analogy, Jaded Julie, what is the first thing that happens after you have arrived at a concert venue?”

“I go to the ladies’ room and ‘powder my nose,’ as my mother would say.”

“But right after that you would receive a program for tonight’s orchestra concert.”

“Right, Curmudge. I’ll need that to learn what’s going to be played and who will play it. Say, that reminds me of the visual controls—the dashboard or process status board—that we are developing for the unit back at the hospital. That makes our organization, efforts, and accomplishments transparent to our team as well as to passers-by.”

“I’m delighted that you are thinking about work, Julie, but you must not be enjoying the concert. So what goes on the board? I presume that it is updated at the beginning of each shift.”

“These are my thoughts, Curmudge. I will need to collect input from above and below me in the organization. Presumably this would include hospital-wide and unit measures of performance. Unit data would include census, patients (room numbers) of concern or likely to need special care, and anticipated discharges. Safety issues and the status of process improvement efforts should be included. Of course, it shouldn’t become so crowded that one can’t see the forest for the trees.”

“Good, Julie. Now that the dashboard is designed, let’s think about standard work for you, a front-line leader in a nursing unit. You might not have thought about it, but you closely resemble front-line leaders at Toyota. They have developed hands-on proficiency at all of the operations performed by their team. With all of your experience, you have developed comparable proficiency in nursing. Congratulations, you are a supernurse.”

“I won’t be a supernurse in this position very long if I don’t develop some leadership standard work. Each day (or shift) will start with a report from my predecessor and a tour of the unit to collect data to update the dashboard. This will be followed by a brief stand-up huddle in front of the dashboard with the nurses in the unit; of course, this can’t occur until they have taken report from their counterparts on the preceding shift. We’ll welcome any ‘float’ nurses and assure that they will be brought up to speed on our standard work. The focus of this short meeting will be the current data on the dashboard, especially that pertaining to current improvement projects.”

“At that point, I’d be ready for a coffee break, but I know that you don’t have time. It’s time to get out in gemba and see that the agreed-upon standard work is being followed. If the work had not been standardized, you wouldn’t be able to detect deviations. When you see a deviation, ask ‘why?’; it might represent a new idea to improve the process. Be alert for ‘workarounds’ and ‘treasure hunts;’ they are clear signals of problems to be addressed and corrected. As a supernurse, you will be the unit’s fount of knowledge and master of techniques. If a patient is a ‘hard stick,’ you’ll be able to insert an IV catheter on the first try. And even when special talents are not required, you can provide an extra pair of hands to fill in where needed.”

“Thus far, except for the dashboard much of my job doesn’t sound too different from what it was before Lean.”

“But now your front-line leader’s job has become standard work. Your tasks are very similar (standardized) to those of other leaders in other comparable units. Through your joint efforts, you have learned what works best and adopted it as standard work. All of you are coaching your teams in standard work, continuous improvement, problem solving, and respect for one another. This requires that you possess personal discipline and can impart—through coaching—discipline to each of your direct reports.”

“Before we leave Lean at my level of leadership, we must not forget my daily or weekly meetings with my supervisor or manager. Her standard work is to assess my accountability for providing the Lean leadership that we have been discussing. She fully understands the value of gemba walks and agrees that ‘the currency of leadership is presence.’ If I appear unenthusiastic about Lean, she will remind me that, ‘it is easier to act your way into a new way of thinking than to think your way into a new way of acting.’ That translates into, ‘just do it,’ or ‘try it and you’ll like it.’ “

“Our readings (1,2) have suggested that regular daily or weekly meetings of leaders and their staffs going at least three levels up the chain of leadership are essential in maintaining the momentum of a Lean transition. Remember Masaaki Imai’s admonition, ‘Kaizen is everyday improvement, everybody improvement, everywhere improvement.’ Remember also that Lean, like the flywheel we discussed back on March 26, 2008, resembles a bearing with lots of friction; it requires constant pushing. That puts a lot of responsibility for Lean’s success on the shoulders of middle managers who must adopt Lean leadership.”

“There’s a bundle of stuff that we front-line and middle managers have to know and do on a daily basis, Curmudge. Can you summarize from our reading?”

“From Kenney (1):
• ‘Know the status of daily work.
• Know if planned work is completed on time.
• Understand both upstream and downstream impact.
• Know that standard work is being followed.
• Know when to take action and what action to take.’

From Mann (2):
• ‘Assessment based on data captured on visual controls.
• Assignment for corrective action and/or improvement.
• Accountability for having completed the previous day’s assignments.’ "

“All of that sounds pretty intuitive, Curmudge. As I’ve said before, ‘Lean is just organized common sense.’ Lean leadership is powerful because it enforces daily accountability. And if people do this every day for months or years, they will forget what they would slide back into if they had any inclination to back-slide.”

“By the way, Julie, whatever happened to that concert that you were attending?”

“I got so wrapped up in thinking and talking about Lean that I was asked to leave.”

Affinity’s Kaizen Curmudgeon

(1) Kenney, Charles Transforming Health Care (CRC Press, 2011)
(2) Mann, David Creating a Lean Culture (CRC Press, 2010)

Lean Leadership 2

2011-10-20T10:26:00.000-05:00

“I suspect that all of us start each workday with standard work. I turn off the alarm clock and jump out of bed. Shave, do stretching exercises, and bring in the Wall Street Journal from the driveway. Eat breakfast, get dressed, and drive to work. Except for weekends, every day is essentially the same.”

“That was when you were working, Curmudge. Now that you are retired, you get out of bed more slowly and take time to read the front and editorial pages of the Journal. Everything else is pretty much the same as before.”

“My point, Jaded Julie, is that everyone knows about standard work, but each person has his/her own routine. That’s okay at home but not at work. Correcting this problem—facilitating the development of a unit’s standard work—is one of the most important tasks of a front-line supervisor. That’s the role I’d like you to play, Julie—a charge nurse or coordinator in a nursing unit of a generic hospital.”

“At least it’s better than my last role—a terminal patient in an ICU. If the nurses and techs haven’t taken a Lean Overview course, there’s a lot that I’ll have to teach. Kaizen events, value-stream mapping, A3 problem solving, 5S, PDCA, and more.”

“What the team members learn should stick with them, because they’ll be putting it to use right away. Remember that the standard processes will be developed by and owned by the team. A standard won’t fly if it is imposed from above.”

“Can you give me some ideas of things the team might achieve, Curmudge?”

“For inspiration, read about what other Lean hospitals have accomplished (1). Note that in every case their focus has been on enhancing the patient experience. Here are some of the things done at Virginia Mason Medical Center: made ‘taking report’ at shift change more efficient, reduced nurses’ time required for paperwork, instituted medical emergency teams, changed hourly rounding so that nurses would anticipate patient needs, and involved other departments in studies of systems to reduce the hospital’s ‘silo’ culture.”

“Those all sound good to me. They are excellent examples of Lean as it should be practiced in gemba. If I, as a front-line supervisor, could lead my team to accomplishments like those, you’d deem me an unqualified success.”

“You’ve made good progress, Julie, but there’s more. At this point in your fictional Lean leadership journey you are not doing what is needed to make those process changes endure. The problem is that some people in management—I hope not you—tend to leave standard work at the breakfast table. They arrive at work, check the day’s schedule for meetings, sometimes say a brief ‘good morning’ to the team members, and begin to fight the day’s most serious fire. They are attempting to manage a Lean team, but they aren’t practicing Lean themselves.”

“I’ve got it, Curmudge. Without Lean leadership, members of the team start drifting away from standard work and return to doing things ‘the way I’ve always done it.’ As we learned last week at Granddad’s farm, entropy is at work.”

“It’s also like a choir, where everyone might be singing a solo if it weren’t for each member reading from the same score…”

“…and an orchestra where we hear a bunch of toots and bleeps until the conductor taps his music stand with his baton.”

“Please note, Julie, that in both organizations the conductor can’t stop directing, walk away, and expect that the good music will continue. So next week we’ll return and play the next movement of the Lean Leadership Symphony.”

“I hope it won’t turn out to be a dirge. Bravo, Curmudge!”

“Brava, Julie.”

Affinity’s Kaizen Curmudgeon

(1) Kenney, Charles Transforming Health Care. (CRC Press, 2011)

The Need for Lean Leadership--Entropy

2011-10-13T10:14:00.000-05:00

“Curmudge, did I understand you to say that many organizations are stymied in their Lean journey because they haven’t developed a Lean management system to go along with Lean implemented in their workplace?”

“That’s what the literature says, Jaded Julie. People in gemba have learned to use Lean tools, like standard work; but without ongoing reinforcement by Lean leadership, they tend to slip back into their old, nonstandard ways of doing things. Then the Lean journey sputters to a halt.”

“That’s a sad commentary on human nature. But you have said that this tendency toward disorganization is quite natural, applies to everything—not just people—and that it is described by a thermodynamic term called entropy. Without an external input of energy, disorganization—entropy—tends to increase.”

“You’ve got it, Julie, and I can assure you that the objects in my example never studied thermodynamics. When I was a child back in the early 1940’s I used to visit my grandfather’s farm in the hills of southwestern Virginia. Granddad’s sons, my uncles, were away in the war, so he was running the farm with the help of my step-grandmother and their dog, Shep. When it was time to milk the cows, Granddad would send Shep up the ‘holler’ (hollow, a narrow valley) to collect the widely scattered cows and herd them back to the barn. Because Shep was part Border Collie, this was a very natural task.”

“I’m listening, Curmudge. This will undoubtedly turn out to be one of your homespun tales ending with a lesson.”

“So we’ll continue, Jaded Julie. The cows went into the barn and into their familiar stalls (in those days we didn’t have stanchions). Grandfather milked each cow by hand. I tried to help but got little milk; I did get a solid whack on the head by the cow’s tail. Upon finishing, we opened the barn door and the gate to the pasture, and the cows filed out and up into the hills.”

“I suspect that we are just about to learn something about entropy, the topic of today’s conversation.”

“The cows might have stood shoulder-to-shoulder and marched in rank up the holler like a cavalry charge consuming the grass in a wide swath. They didn’t, of course. Each cow went its own way—some on one hill and some on another—so they were scattered all over the place for Shep to find them when milking time came around again.”

“I’ve got it, Curmudge. The cows’ random distribution demonstrated entropy, the natural tendency toward increased randomness. That’s similar to the story you told once before about your grandson. Although his toys were put away neatly in the toy box each evening, they were scattered all over the house by the end of the next day.”

“When winter came to Granddad’s farm, he kept the cows in the barn. It was a lot of work carrying in feed and hauling out manure, but he didn’t want a cow breaking a leg slipping on an icy rock on a steep hill. However, if the barn door and the pasture gate had been left open and if Shep had been busy trying futilely to herd the chickens, the cows would have wandered out of the barn, up the holler, and again become scattered randomly up in the hills.”

“I’ve got it again, Curmudge. When the cows were not being carefully managed, they backslid into their old habit of wandering randomly. Their actions again demonstrate the tendency of entropy—randomness—to increase.”

“Here’s another example of increasing randomness. If one puts a cube of ice—a well-ordered structure—into a glass of Scotch, the ice will spontaneously melt into less-ordered liquid water. Of course, the full explanation is rather complicated.”

“Good example, Curmudge, but not if you like to drink your Scotch neat. So are we going to carry this lesson over to Lean, where we’ll discuss workers and managers instead of cows and Border Collies?”

“Nurse Julie, you can bet your white cap (if you have one) on that.”

Affinity’s Kaizen Curmudgeon

How Things Happen

2011-10-06T10:03:00.000-05:00

The Medicare Summary Notice and Provider Reimbursement

“Curmudge, don’t you think a better title would be How Things Work?”

“Not really, Jaded Julie. Saying that something works implies a favorable judgment regarding the performance of the subject, and I don’t think that we are qualified to do that.”

“But doesn‘t a ‘happening’ suggest a natural occurrence, like a tornado or a snowstorm? Isn’t provider reimbursement completely anthropogenic?”

“It is indeed man-made, Julie, but instead of semantics, let’s tackle our subject.”

“How did you get onto this topic, anyway?”

“A friend asked me to explain some of the numbers on her Medicare Summary Notice, which is sort of like an insurance company’s Explanation of Benefits. If you wonder why we are limiting this discussion to Medicare, it’s because most of my friends are my contemporaries and all of my contemporaries are either on Medicare or deceased.”

“Let’s get with it, Curmudge. I believe we must start by learning some abbreviations.”

“RVUs (Relative Value Units) are used to determine how much medical providers should be paid. Components of RVUs include physician work (time, skill, training), practice expense, and malpractice insurance expense. They are adjusted by a factor that reflects the different costs of practicing medicine across the country and are then multiplied by a dollars-per-RVU conversion factor.”

“I know the next one; that’s the CPT (Current Procedure Terminology) code. There is a CPT code for each medical, surgical, and diagnostic service, and each CPT has an associated RVU. That’s the origin of the ‘Medicare-Approved’ values next to each CPT code on your Medicare Summary Notice. The RVUs have a lot of bearing on provider compensation, Curmudge. Are they handed down on stone tablets?”

“They might as well be. They are determined in meetings of a committee representing all medical specialties. I have read of these meetings described as the proverbial ‘smoke-filled room’ but without smoke.”

“And finally we have ICD (International Classification of Diseases), a system of diagnosis codes. This is a medical classification list for the coding of diseases, signs and symptoms, abnormal findings, complaints, social circumstances and external causes of injury or diseases, as maintained by the World Health Organization (WHO). We are now using Revision 9 (ICD-9), but Revision 10 (ICD-10) must be employed by October 1, 2013. The new code set contains more codes than ICD-9, including many for very specific occurrences.”

“Do you suppose that they have one for getting crushed in a buffalo stampede in Buffalo, New York?”

“It’s interesting, Curmudge, that Medicare will reject a provider’s claim if the procedure code is not appropriate for the diagnosis code. For example, an x-ray of the wrist will be rejected if the patient is diagnosed with glaucoma. It is certainly critical for a provider to have proficient back-office support.”

“So back to the Medicare Summary Notice, the most common one (Part B) showing claims from individual providers. You may note that the ‘Medicare-Approved’ amount may be a lot less than the ‘Amount Charged’ (by the provider). Don’t worry; you’re usually not responsible for the difference. The next column is ‘Medicare Paid Provider’. It is typically 80% of the ‘Medicare-Approved’ amount. The remaining 20%, in the ‘You May Be Billed’ column, is the total that you plus your secondary (medi-gap) insurance are expected to pay. On occasion, my final out-of-pocket cost has been around 1% of the amount charged. Mrs. Curmudgeon’s hospital bill was $4,000, but I ended up paying only $40. Actually, I thought she was worth more than that.”

“Curmudge, despite all of the RVUs, codes, and correction factors, it just sounds as if providers are paid on a piecework basis. Did you ever have a job in which you were paid for piecework?”

“I did that back in the 1940’s when I was a child. It was called berry pickin’. We kids would stand on a designated corner, and a farmer would come by to pick us up and take us to his berry field. I would select a row that appeared to have lots of berries (I think they were strawberries), grab a basket, and fill it as fast as I could. Then another basket and then another. It was hard stoop-labor, and we were paid only a few pennies per basket. To this day, whenever I buy berries my back hurts.”

“Do you see any parallels between your experience and provider compensation?”

“Well, I suppose choosing a medical specialty might relate to selecting a row with lots of berries. (Some day we’ll cogitate a bit on why docs select specialties.) And my filling lots of boxes of berries might correlate with a provider’s racking up a lot of RVUs.”

“Pretty interesting, Curmudge. I hope your friend who inspired this topic wasn’t looking for a short answer.”

Affinity’s Kaizen Curmudgeon

Series Contents

2011-09-29T11:56:00.000-05:00

“Curmudge, you messed up.”

“Jaded Julie, what do you mean, I messed up? Everything we do is a joint effort. You must mean that we messed up, but what did we do or not do?”

“Back in 2009 we had 12 postings on Patient Safety. Each posting had an extended title so the reader would know in which posting to look for information on medications or infections or falls or whatever. Later we posted series (three or more postings) on Mistakes, Amazing Devices, Evidence-Based Medicine, The Crystal Ball, The Laboratory, and Sepsis without extended titles. Unless he/she had an excellent memory (which you don’t have), the reader would have to search for a particular topic within a series by trial-and-error.”

“You’re right as usual, Julie. Let’s create extended titles or keywords for the postings within those series. That will help me when I want to insert a link back to an earlier posting. As you know, I forget what’s in an article the day after it is posted.”

“You conjure up the subtitles, Curmudge, and I’ll type.”

April 1, 2010: Mistakes—mnemonics, sleep deprivation
April 8, 2010: Mistakes 2—standard work, checklists, ‘Isabel’
July 22, 2010: Mistakes 3—necessary fallibility, see February 19, 2009

Aug. 5, 2010: Amazing Devices—AutoAnalyzer, pulse oximeter
Aug. 12, 2010: Amazing Devices 2—Library resources, PDA Road Map; Information at Your Fingertips;, August 6, 2009
Sept. 2, 2010: Amazing Devices 3—The Wireless Future of Medicine
Sept. 9, 2010: Amazing Devices 4—ultrasound, electronic stethoscope

Sept. 23, 2010: Evidence-Based Medicine—URLs for reviews
Sept. 30, 2010: Evidence-Based Medicine 2—review articles, clinical trials
Oct. 14, 2010: Evidence-Based Medicine 3—evaluating the literature
Oct. 14, 2010: Evidence-Based Medicine 4—“Will it help my patient?”
Oct. 21, 2010: Evidence-Based Medicine 5—getting a second opinion

April 7, 2011: The Crystal Ball—prologue
April 15, 2011: The Crystal Ball 1—need for Lean
April 27, 2011: The Crystal Ball 2—specialized consultancies, IHI
May 5, 2011: The Crystal Ball 3—Sg2
May 12, 2011: The Crystal Ball 4—The Innovator’s Prescription by Clayton Christensen, disruptive innovation
May 19, 2011: The Crystal Ball 5—intuitive & precision medicine, NPs displacing docs displacing other docs, pharmacogenomics
May 31, 2011: The Crystal Ball 6—‘solution shops’ & value-added processes; straightforward and difficult diagnoses
June 3, 2011: The Crystal Ball 7—chronic diseases, integrated fixed-fee providers
June 13, 2011: The Crystal Ball 8—two health care philosophies; HSAs plus high-deductible insurance

June 30, 2011: The Laboratory—phlebotomist, specimen processing, blood bank
July 7, 2011: The Laboratory 2—CBCs, chemistry, troponins (heart attack), hemoglobin A1C (diabetes), microbiology
July 14, 2011: The Laboratory 3—identification of bacteria
July 21, 2011: The Laboratory 4—pathology, histology, cytology
July 28, 2011: The Laboratory 5—quality control, workload, turnaround, education requirements

Aug. 26, 2011: Sepsis—introduction, pathogenesis
Sept. 7, 2011: Sepsis 2—diagnosis, management
Sept. 15, 2011: Sepsis 3—resuscitation bundles, MMC data

“Julie, these should be helpful for our readers and also for me. Let’s do this the next time we write three or more postings on the same general topic.”

“I’ll remind you, Curmudge. If I don’t, you’ll forget.”

Affinity’s Kaizen Curmudgeon

The Bad, Good Medication

2011-09-23T10:02:00.000-05:00

“A long time ago, in my UW-Madison years, I used to share the ride home from campus with my neighbor, Bernie, a physician in the Division of Clinical Oncology. One day we were stopped at a traffic light and Bernie glanced at a passing pedestrian and said, ‘See that guy with the moon face. I’ll bet he’s on steroids.’ ‘If you say so, Bernie,’ and we continued on home.”

“That must have been your introduction to corticosteroid medications, Curmudge. Have you ever experienced them first hand?”

“Right hand as well as left hand, Jaded Julie. Tendonitis in several of my fingers was treated with cortisone injections. The pain was exquisite as the doc probed around with the needle inside each finger trying to locate the tendon. But I never had to take prednisone, the common oral corticosteroid that is the topic for today’s discussion.”

“Pray tell, O Unpredictable Oracle, why your brain decided to focus on prednisone, of all things.”

“Prednisone has been around since the 1950’s, and it is prescribed for a wide variety of conditions. Patients who are anywhere north of clueless probably have heard that there is something about prednisone that they won’t like, but they might not recall what it is. We are going to tell those patients what is in store for them by sharing what I have observed in the past year.”

“In my training I learned that cortisone is produced in the body’s adrenal glands, and its synthetic form is prednisone. It was originally hailed as a wonder drug for its effect on patients with rheumatoid arthritis, and it is used for other autoimmune diseases like multiple sclerosis and lupus. A valuable property of corticosteroids is their ability to prevent release of substances in the body that cause inflammation; that explains the injections into the tendons of your fingers. Other treated conditions include inflammatory bowel disease, some lung diseases, severe allergies, and asthma.”

“Because of its amazing versatility, prednisone is sometimes prescribed when nothing else seems to work…sort of a medication of last resort or a forlorn hope.”

“Forlorn hope? What is that?”

“It’s like a ‘Hail Mary’ pass, Julie, only an ‘incomplete’ has much greater significance for the patient.”

“Except for the ‘forlorn hope,’ everything we’ve said about prednisone sounds pretty good. What about side effects?”

“The package insert with most medications describes a lot of side effects that rarely occur. With prednisone, many of the side effects almost always occur, especially if the med is taken for many weeks or months. Most patients seem to gain weight around the middle and acquire the ‘moon face’ that my neighbor, Bernie, observed. You know how female patients feel about that. A patient with the beginnings of cataracts will find that they bloom dramatically and soon require surgery.”

“I’ve read, Curmudge, that mood changes are common and that prednisone tablets have been referred to as ‘nasty pills.’ Other threats are osteoporosis, increased susceptibility to infections, general malaise, and shaky handwriting. Prednisone even has side effects if one suddenly stops taking it. The body’s own corticosteroid factory goes on standby in the presence of an external source of the chemical, and it takes awhile for it to resume production.”

“I observed a patient entering a physician’s waiting room who had apparently been on prednisone long term for a lung condition. She was grotesquely obese, in a wheelchair, and clutching an oxygen cylinder with a plastic tube leading up to the cannula in her nostrils. I heard another patient whisper with fierce resolve, ‘I don’t want to ever be like that.’ Little did she realize that death was the only sure way to avoid that fate. Can’t you envision a patient’s final words before expiring, ‘At least I won’t have to take any more prednisone.’?”

"Yuk! What a morose ending. Can’t you think of a brighter way to conclude today’s discussion?”

“I can, Jaded Julie. It’s called ‘precision medicine.’ As we quoted Clayton Christensen in The Crystal Ball 5, it is ‘the provision of care for diseases that can be precisely diagnosed, whose causes are understood, and which consequently can be treated with rules-based therapies that are predictably effective.’ If society doesn’t stifle creativity, our grandchildren won’t have to be treated with medications that have as many side effects as benefits.”

“Halleluiah amen, Curmudge!”

Affinity’s Kaizen Curmudgeon

Sepsis 3

2011-09-15T10:25:00.000-05:00

“Jaded Julie, I’ve read so many articles on sepsis in the past few weeks that my head is spinning.”

“I know you are confused most of the time, Curmudge, but do you have chills, a fever, or are you hyperventilating? Here, let me check your blood pressure.”

“No, Julie. I don’t have sepsis. It’s just that the articles are generally similar, and as a layperson, I wouldn’t understand subtle differences if I saw them. So from now on, I’m not going to sweat the details. I’ll leave them to the physicians and nurses. Our focus today will be on Affinity’s experience with sepsis, including diagnosis and management.”

“But we’ve already discussed diagnosis. Is there anything special that we do?”

“There is, Julie, and it’s a mannequin called iStan. iStan is the smartest dummy in town because he can be programmed to portray a vast array of symptoms of a host of diseases. For example, iStan’s software comes with a sepsis simulation scenario.”

“Well at least if he exhibits oliguria, there won’t be much of a puddle to clean up.”

“iStan is a new addition to our staff and has been used thus far for orientation of new hires. His use will grow as people get more familiar with his operation. I’m looking forward to being impressed whenever I can arrange a demonstration.”

“So what else is new, Curmudge? The links to Affinity documents in Sepsis 2 suggest that our hospitals are doing the right things in sepsis diagnosis and management.”

“There’s more to be told, Julie, but I promise…no clinical details. We have been using IHI’s Surviving Sepsis Guidelines since 2005 and the IHI Sepsis 6-Hour Resuscitation Bundle. These have been translated into pre-printed order sets, the Severe Sepsis Screening Tool and the Severe Sepsis Septic Shock Order Set: 6-Hour Resuscitation Bundle. If you read any of these, they would look pretty familiar.”

“And that’s the Lean standard work you were talking about. The value of these is that for severe sepsis and septic shock, one can’t afford to overlook any of the critical steps.”

“The ICU’s also use spreadsheets to track their compliance with each step in the resuscitation and management bundles for each patient.”

“Our procedures sound impressive, Curmudge. Are we saving lives?”

“I have some data from Mercy Medical Center, Julie. In 2004 the nation-wide mortality rate for sepsis was 28.6% (215,000 deaths). For MMC, the sepsis mortality rate was 11% in 2005-2006 and 6-7% in 2009. MMC treated 22 patients for sepsis from January 2011 through early August.”

“What might one do to avoid becoming a sepsis patient?”

“Avoid sepsis by avoiding infections. You and I talked about avoiding infections back on January 29, 2009. Although that posting was about nosocomial infections, one should also practice good hygiene at home. Teach your children about washing their hands and not neglecting a cut or scrape. If because of joint or other prior surgery you are directed to take a prophylactic med before having dental work, do it.”

“The mortality rate from sepsis in U.S. hospitals is worrisome enough. It’s undoubtedly higher in hospitals in the Third World.”

“One who travels to undeveloped countries should certainly have air-evacuation coverage in their trip insurance. If you contract sepsis in one of those strange-sounding places, your life may depend upon being airlifted out ASAP.”

“I understand that you found a valuable lesson in your reading last night. (Hey, Curmudge, get a life.)”

“The Smiths took their ill 7-year old son to the ED. Aside from nausea and a heart rate of 148, his vitals were normal. While he was at the ED his heart rate decreased and he was able to receive fluids. The Smiths wanted to leave, although results from the complete blood count were not yet back from the lab. The doctor, believing the child had a urinary tract infection, discharged the patient and told his parents that he should be better in 24 hours but to return if he is not.”

“I see impending trouble. What happened?”

“Within the next few hours, the child developed severe sepsis. He survived but suffered organ damage. The lesson: Stay with your sick child; lose a night’s sleep if necessary. If his condition deteriorates, don’t delay in returning to the ED. Incidentally, this scenario can occur with other illnesses such as appendicitis.”

“Actually Curmudge, that’s one of the perennial concerns of ER docs…that a patient will come in with a condition not well enough developed for a definitive diagnosis. Then the condition intensifies and clobbers the patient within 24 hours after he is sent home. So, Student of Medieval History, do you have a final perspective on sepsis?”

“Back in 1348 when the Black Death ravaged Europe, about three-fourths of the population of Great Britain died. The survivors were possibly not exposed to the sick people or the fleas carrying the disease, or perhaps they possessed a natural immunity. One of the three forms of the medieval plague was septicemic plague (the others were bubonic and pneumonic); its symptoms were similar to modern severe sepsis. In the 14th century, the mortality rate from septicemic plague was 99-100%. Patients sometimes died the same day they contracted the disease. The lesson: Sepsis was—and still is—a deadly condition.”

Affinity’s Kaizen Curmudgeon

Sepsis 2

2011-09-07T10:50:00.000-05:00

“Hey Curmudge, it was fun last week doing our folksy introduction to sepsis laced with ten-dollar words, but why so much technical stuff?”

“It’s hard to express the complexity of the human body without a few big words, which, you may have noticed, were all defined in the text. I also felt that any terms as hard to learn as those deserved to be spread around. By the way, I haven’t been holding my breath as you recommended last week. I’ve been reading about how health care handles sepsis. May I share?”

“You may, as long as you haven’t been reading a medicinal biochemistry text.”

“Articles on sepsis often start with its diagnosis. In reality, when a patient arrives in an ED, the ED doc’s first question isn’t, ‘Does this person have sepsis?’ His first mental query must be, ‘What’s wrong with this person?’ Then a lot of things happen almost simultaneously. The doc tries to alleviate the patient’s distress (she wouldn’t be in the ED if she didn’t have distress), performs a history and physical, and begins tests and interventions indicated by the history and physical.”

“Of course, several things can help the doc avoid starting at square one. If someone is accompanying the patient, they can help with the history. If the patient can’t communicate, that person would be essential. Similar information might also come along with the patient if she is sent from a skilled nursing facility. In addition, they should know if the patient has a fever and perhaps an infection and what organ is affected. In that case, the physician would order a blood culture before starting a broad-spectrum antibiotic.”

“In the physical—and possibly in triage—the first indication of sepsis will likely be signs of an infection, hypotension, a systolic BP of less than 90 or mean arterial pressure (MAP) less than 65. This tells the provider that time is of the essence, not only because of the crowded ED waiting room but because the patient’s life may be in the balance. All of the actions below should be taken within one hour of the patient’s arrival at the ED. IV access is established, and a fluid challenge and vasopressors (to raise blood pressure) would be ordered. An arterial line to measure consistent and accurate blood pressure and a central venous catheter to deliver IV fluids and vasopressors to the larger veins of the body should be placed immediately.”

“Now that sepsis is suspected, Curmudge, the next task is to learn how bad it might be. Here’s a useful algorithm:
1. SIRS (Systemic Inflammatory Response Syndrome): Temperature >100.4F (38C) or <96.8F (36C), heart rate >90, respiratory rate >20, WBC >12,000 or <4,000. Patient already found to be hypotensive.
2. Sepsis: SIRS plus source of infection.
3. Severe sepsis: Sepsis plus organ dysfunction.
4. Septic shock: Persistent hypotension and organ dysfunction despite aggressive fluid resuscitation.
If sepsis isn’t found, seek an alternative diagnosis. If sepsis is found, admit the patient to the hospital—the ICU for those with severe sepsis or septic shock—ASAP.”

“Transferring the patient to the ICU and to the care of intensivists and critical care nurses will bring the hospital’s best resources to bear on her condition. In general, these are the kinds of therapies that will be used:
1. Increase perfusion to organs and tissues by increasing blood pressure with fluid resuscitation and through the use of vasopressor medications (examples are norepinephrine and dopamine).
2. Treat the underlying infection through use of antibiotic therapy or surgery.
3. Provide oxygen and treat respiratory distress (if present).”

“Here are some (there are more) specific things to be done at Affinity hospitals (and elsewhere) for the sepsis patient. They should occur within the first six hours, and are called Early Goal-Directed Therapy.
1. Draw labs for blood cultures and obtain specimens from other sources for identification of infection. Serum lactate levels are an indicator of oxygen deficits (Curmudge, I put this in because I knew you’d be interested in the biochemistry).
2. Perfusion: If mean arterial pressure is <65, give sufficient IV fluids to assist in raising blood pressure. Start norepinephrine or dopamine to keep systolic BP >90 and mean arterial pressure >65. When fluid challenge therapy is not effective, implement Critical Care Nursing Considerations.
3. Oxygenation: Keep oxygen saturation >90%. Mechanical ventilation if needed.”

“Julie, putting the patient on a ventilator is certain to impress the patient’s relatives of the seriousness of her situation. The only patients that I’ve seen on a ventilator were at death’s door."

“Remember, Curmudge, that not all sepsis patients come in through the ED. Some are inpatients who have taken a turn for the worse. Nurses in the medical/surgical units are taught to watch for these observable symptoms in their routine rounding on the patients under their care:
1. Chills, shaking, low body temperature, or fever.
2. Rapid breathing (hyperventilation), lightheadedness, rapid heart beat.
3. Decreased urine output (oliguria).
4. Confusion or delirium.
5. Warm skin or skin rash.
These should trigger the nurse’s concern about SIRS. She should immediately initiate quantitative measures, like BP and temperature, and should contact the physician. More specific quantitative indicators of sepsis, used to augment routine bedside assessment, are listed in Affinity’s Cellular Perfusion Assessment Parameters.”

“Next week, Julie, let’s focus on Affinity’s experience with sepsis. We’ll point out how our care of sepsis patients exemplifies standard work, which is essential in implementing a Lean culture.”

“Lean, Curmudge! I was afraid that you’d forgotten about Lean.”

Affinity’s Kaizen Curmudgeon

Sepsis

2011-08-26T11:34:00.000-05:00

“You know, Curmudge, the human body is quite amazing.”

“I agree, Jaded Julie, but it’s not always amazingly good. The body I know best seems to be getting older and slower, and the body I loved most shut itself down rather suddenly a few months ago. Perhaps I need more explanation of this ‘amazing’ stuff.”

“Okay. As an example, let’s use the condition called sepsis. Were you aware that only one out of three Americans has ever heard the word ‘sepsis’ and that it is the tenth most common cause of death? In sepsis bad things occur because of actions taken by parts of the body to protect themselves.”

“Julie, if you are inspired by the same sepsis I’ve been reading about, you have a mighty morbid sense of amazement. But as a compulsive learner, if there’s more that I need to know, let’s get on with it. Tell me about sepsis.”

“Well Curmudge, old codgers like you might recognize the term, ‘blood poisoning,’ but that’s an inadequate description. Sepsis is not an infection in of itself; it’s a systemic (whole-body) response to infection or injury. Specifically, bacteria, a fungus, or a virus overwhelm the bloodstream. This is called septicemia.”

“So far so good (or bad), Nurse-Educator, but where do these bad guys come from?”

“Lots of places: the bowel (peritonitis), the kidneys (pyelonephritis), the lining of the brain (meningitis), the lungs (bacterial pneumonia), the skin (cellulitis). In hospitalized patients, common sites of infection include IV lines, surgical wounds and drains, and bedsores.”

“Thus far, everything I’ve heard is bad. Where does the ‘amazing’ stuff occur?”

“Let’s start simple. When the body incurs an insult—from a minor injury to the entry of bacteria and bacterial toxins into the bloodstream—the immune system is activated. Cells of the endothelium—the lining of blood vessels—respond by initiating the inflammation process. This involves dilation of blood vessels and consequent leakage. The cells—seeking to maintain internal equilibrium (homeostasis)—try to reestablish control through the process called coagulation, the formation of blood clots. They are an interlacing fibrous network of a substance called fibrin.”

“Hooray for blood clots. That’s why I grew a beard…so I wouldn’t have to worry about cutting myself shaving.”

“Don’t speak too soon, Curmudge. There’s a lot more biochemistry going on. The body views blood clots as an abnormality, so it cranks up the process of fibrinolysis to get rid of them. Sort of like when a bruise loses its purple coloration. Tissue plasminogen activating factor (t-PA) forms plasmin, the workhorse of fibrinolysis.”

“Hey Julie, I know about t-PA. That’s what they give victims of an ischemic stroke, the type of stroke often caused by a blood clot.”

“Unfortunately in sepsis, inflammation and coagulation overpower fibrinolysis, and the sepsis victim has microvascular thrombosis, i.e., blood clots in his capillaries.”

“I can see now that when that happens throughout the body, the patient is in deep trouble. As you said originally, the human body is amazing; each of these processes is essential. But problems arise when one process becomes dominant and forces homeostasis out of balance. It is just too much of a good thing. So what happens to a body when it is full of little blood clots?”

“It would seem as if the body is trying to self-destruct. Back during inflammation, when the blood vessels are dilating, the body senses that blood pressure is dropping. It’s time to set priorities, so vasoconstrictors are released to constrict blood vessels and elevate blood pressure in order to maintain blood flow to the vital organs, the heart and brain. Of course, that shunts blood away from the ‘non-vital’ organs such as lungs, kidneys, gastrointestinal tract, and skin.”

“Obviously Julie, the patient, who has a whole-body outlook, takes a dim view of the so-called ‘non-vital’ organs’ losing their blood supply and shutting down. It’s evident that without major assistance from skilled health care, the patient will expire.”

“I hate to leave the patient in such a precarious situation, but we won’t talk about the role of health care in sepsis until next week. Until then, Curmudge, please hold your breath.”

Affinity’s Kaizen Curmudgeon

Hardwiring 2

2011-08-18T11:40:00.000-05:00

“Curmudge, in our last conversation about hardwiring you said you would tell me how to hardwire Lean.”

“If I said that, Jaded Julie, I spoke too soon. Lately I’ve been thinking a lot about learning and hardwiring. May I share my cogitations with you?”

“Sure, as long as ‘cogitations’ aren’t something you’ve been drinking or smoking.”

“Back on May 8, 2008 we talked about how leadership often requires doing things which are not truly natural. The things that a young baby does that are natural are cry, nurse, and soil its diapers. As life progresses most of our actions have been taught to us until they become hardwired. You might think that brushing your teeth in the morning is natural, but in fact it was hardwired into your brain by your mother’s repeated insistence and reinforcement. We might feel that driving on the right side of the street is natural, but don’t try it in Great Britain.”

“I’ve got it, Curmudge. Hardwiring requires repetition, reinforcement, and sometimes intense study until it feels natural. If any element is most important, it’s repetition. That’s why my mother took me to religious services every week. We hardwire our morals and the elements of our character, and a society hardwires its mores.”

“So if repetition and reinforcement are essential for hardwiring, how much of it can we achieve in a one-week kaizen event or a one-day Lean Overview class?”

“I’m afraid not very much, and I’ll bet that was the conclusion that popped out of your cogitations. At least an event is usually a hands-on and brains-on activity for the participants. I’ll also bet that we won’t recommend subjecting the students to increasing amounts of ‘death by PowerPoint.’ “

“Excellent perception, Julie. How about this? Although we have the participants’ bodies for only the single day or week of the event, perhaps we could stretch their experience with pre-work and post-work. The pre-work could put their minds in learning mode, and whatever was done after the event would serve as reinforcement.”

“The event should include videos, games, discussions, and team activities. Perhaps even a pop quiz on the preliminary reading. If the event itself is memorable, perhaps more of the subject material will be retained. Of course, if any of the students is like you, Curmudge, we’ll need to keep him/her awake.”

“Although we’d like participants to retain details of the Lean tools used in the event, our most important goal is to hardwire the principles of the Lean culture.”

“Perhaps, Curmudge, we should shout them from the top level of the parking ramp at St. E’s. ‘Show respect for people.’ ‘Eliminate waste.’ ‘Use standard work.’ ‘Promote continuous improvement.’ We could do it every day at noon, just like a town crier.”

“I’d prefer to stay in out of the weather and just write a blog like Kaizen Curmudgeon. Every week we send a reprint of an earlier posting to each graduate of the Lean Overview course. But in the absence of organized reinforcement, you have to do it on your own. For example, there are blogs from many sources that one should follow to get a regular Lean ‘fix.’ Examples are http://dailykaizen.org/, http://leanhealthcareexchange.com/, and http://www.leanblog.org/ (although that author seems to feel that there is only one health care organization in town). While the blogs tend to be repetitive (and sometimes self-serving), they present Lean fundamentals from many different perspectives.”

“I think I know your bottom line on hardwiring, Curmudge, but I’d prefer to hear it in your trite, but umforgettable, manner.”

“A man on the street in New York City asked a passer-by how to get to Carnegie Hall. The passer-by’s answer was, ‘practice…practice.’ “

Affinity’s Kaizen Curmudgeon

Hardwiring

2011-08-12T11:01:00.000-05:00

“Curmudge, when a fact or concept is ‘hardwired,’ does that mean that it will never be forgotten?”

“To me, Jaded Julie, the term ‘hardwired’ (which most of us learned from the writings of Quint Studer) is not an absolute. Without reinforcement, most of the professional stuff we learned years ago will eventually slip away. However, it’s interesting that sometimes personal experiences will stick with us forever. An example is when my older playmates kicked me out of the sandbox because I was only four years old.”

“I must admit that during the years we have worked together I’ve become impressed by the leakiness of your memory. Is it true that you tell your educated friends that their advanced degrees expired after 40 years?”

“Although I’m just kidding, for most people the concept is probably correct. Exceptions would be some professors and physicians who teach or use their professional knowledge on a daily basis. They support my contention that reinforcement is essential.”

“If as you say mental ‘wiring’ comes in varying degrees of hardness, you must know some convincing examples.”

“At the extreme end of hardness are the connections between the mind and fingers of the professional musician. These people are able to see a multitude of notes on a score and translate them into actions of their fingers (and sometimes feet) at a frequency of several per second. It takes years of practice to develop those connections; and if they stop practicing, they lose their performer’s ‘edge.’ But they never totally forget basic fingering.”

“Do we see some of this in the practice of medicine, Curmudge?”

“We know that it takes years of residency to train a specialist, but the Army is finding that their special skills begin to erode after about four months of deployment away from their specialty. (1) Thus it’s a bit of a surprise when an OB/GYN volunteers to serve a year in a battalion aid station.”

“What about the other end of the ‘forgettable’ scale? We all recall from our formal education years that information in which we had little interest was pretty transitory.”

“Julie, my retention of some courses—especially those that were required—is zilch. In fact, I suspect that when I walked out of the final exam, my brain dumped the whole course content right there in the hallway.”

“I hate to disturb your reverie, Curmudge, but how can we apply these insights to Lean training?”

“Our goal, Julie, is to impart a Lean mindset to everyone and to help them retain and use what they have learned. It’s pretty lofty, but it is expressed well in this quote from Masaaki Imai (in the 6/22/11 posting of leanblog.com), ‘engage everybody in improvement every day, everywhere in the organization.’ We’ll talk later about how to do that.”

Affinity’s Kaizen Curmudgeon

(1) Deering, S. H., et al. Am. J. Surgery vol. 201 (May 2011)

Note: We last wrote about hardwiring three years ago (May 22, 2008). The current posting is consistent with our belief that some repetition of principles is necessary to reinforce knowledge.

Conventional Wisdom

2011-08-08T09:26:00.000-05:00

“Curmudge, if we’re going to talk about conventional wisdom, I hope you will define it for me.”

“O course, Jaded Julie. In my view, conventional wisdom is the generally accepted knowledge about a topic at a given point in time. For example, in medieval times, the accepted way to treat an open wound was to pack it in goat dung. And until the time of Galileo, most everyone believed that the sun went around the earth once per day.”

“Wow! I’m sure glad things had changed by the time I was a child and skinned my knee.”

“Conventional wisdom can do two things; it can stagnate and become unassailable dogma, or it can evolve with the growth of knowledge. Although new knowledge in medicine seems to be slow in its adoption, we’ve seen amazing advances in our lifetime. I remain intrigued by the oft-quoted medical school professor who told entering students, ‘About half of what we teach you here will eventually be proven to be incorrect, but we don’t know which half.’ “

“What about that ‘unassailable dogma’ stuff, Curmudge? How does that come about?”

“It is easy to scare people but hard to ‘unscare’ them. When something frightens people, it is very difficult to change their view. A pertinent example is radiation. Some people fear radiation whether it’s the small amount used in medical imaging or the massive amounts confined in nuclear power plants.”

“Confess, Curmudge. Are you making this up, or do you actually know something about radiation?”

“The latter, Doubting Julie. I spent most of the summer of 1970 studying it in Oak Ridge, Tennessee. Of course, during the intervening 41 years I’ve forgotten most of what I learned. And to make matters worse, the international pooh bahs changed the names of the units of measurement. So I guess the most truthful answer to your question is that I read a lot.”

“So what did you read that catalyzed your concern about radiation and conventional wisdom?”

“Well, years ago we learned that any amount of radiation—no matter how little—had the potential of causing cancer. A plot of cancer occurrence vs. exposure, based on high levels of exposure, could be extrapolated to the origin, i.e., there was no threshold below which there was no effect. This was called the ‘linear no-threshold theory’ (LNT). It was the conventional wisdom then, and over time it became dogma and even the basis of laws and regulations. Additionally, it justified the anxiety of those who were extremely fearful of all radiation.”

“Does your reading suggest, Curmudge, that the LNT theory no longer represents the consensus regarding radiation exposure?”

“That is certainly implied in several review articles published during the past ten years. Here is a typical conclusion, ‘Based on a review of epidemiological and other data for exposure to low radiation doses and dose rates, it was found that the LNT model fails badly.’ (Vaiserman) Other authors have discussed protective effects from low radiation doses, ‘Irradiated cells protect themselves (a) by immediate defense, repair, and damage removal mechanisms and (b) by delayed and temporary protection also against renewed DNA damage, irrespective of its causes—that is, through adaptive responses.’ (Tubiana, et al.)”

“But Curmudge, there have been articles in the recent scientific and popular literature suggesting that the growing use of diagnostic computed tomography (CT) scans might increase the incidence of cancer. (Brenner & Hall, Landro) It sounds as if conventional wisdom is up for grabs.”

“It seems to be. Others have said: ‘There is no credible evidence to support the contention that current routine usage of CT scans in clinical settings in the United States will cause future cancers. Rather, the available data indicate that occasional exposure to diagnostic x-rays could possibly reduce the risk of future cancers among irradiated adults.’ (Scott et al.)”

“How do we resolve issues like this, Curmudge?”

“As you know, Jaded Julie, we’re not qualified to address that question. However, there is one more bit of older conventional wisdom that we should consider even though it contains regulations based on the LNT theory. It’s called ALARA, the acronym for As Low As Reasonably Achievable. Although the regulations might change, the concept is common sense: don’t expose anyone—patients, workers, or yourself—to more radiation than is absolutely essential. In the case of CT scans, one should be especially protective of children and pregnant women.”

“In your work long ago and for more recent diagnostic purposes you have been exposed to a variety of kinds of low-level radiation. Do those exposures leave you concerned?”

“I have always respected radiation and tried to minimize my exposures. However, for old geezers like me who won’t be around long enough to experience long-term effects—good or bad—from low-level radiation, this literature is just interesting to read and share.”

Affinity’s Kaizen Curmudgeon

Literature Cited

Vaiserman, A.M. Radiation Hormesis: Historical perspective and implications for low-dose cancer risk assessment. Dose-Response 8:172-191 (2010). http://pubget.com/paper/20585444

Tubiana, M., et al. The linear no-threshold relationship is inconsistent with radiation biologic and experimental data. Radiology 251(1):13-22 (April 2009). http://radiology.rsna.org/content/251/1/13.full.pdf

Brenner, D.J. and Hall, E.J. Computed tomography—an increasing source of radiation exposure. N. Engl. J. Med. 357: 2277-2284 (2007). http://www.nejm.org/doi/full/10.1056/NEJMra072149

Landro, Laura. Radiation risks prompt push to curb CT scans. Wall St. J. (March 2, 2010)

Scott, B.R., et al. CT scans may reduce rather than increase the risk of cancer. J. Am. Physicians & Surgeons 13(1):8-11 (Spring 2008). http://www.jpands.org/vol13no1/scott.pdf

The Laboratory 5

2011-07-28T09:59:00.000-05:00

“Curmudge, at the start of our tour you said that laboratories of all sorts tend to have common characteristics, such as their need for accuracy, responsiveness, communications with clients, and keeping methods up to date.”

"That’s right, Jaded Julie, but there’s one more thing. Stress is endemic in laboratories, especially among lab managers. That’s why I appear to be in my 70’s but am only 50 years old.”

“Don’t give me that, Curmudge. You are really in your 70’s, but you appear to be 90; and you never worked in a clinical lab. In labs like the one we just visited, it’s certainly less stressful when one can be confident that results are correct and will be available when needed. How can they do that, day in and day out?”

“It’s dedicated people and good systems just like we teach in Lean. Well-trained professionals and technicians performing standard work. If a lab has those, the manager’s stress level is reduced considerably. And of course they have strict quality control protocols, which Mary Dikeman will describe to us. ‘Please tell us, Mary, how you make certain that your results are correct.’ “

“Each test has quality control (QC) samples that are run every day. These have known value ranges and that value must be produced each time, or we must find the reason for the aberration. Patient results are not reported unless the QC sample results are in the proper range. Some instruments also have calibrator samples that also assure that the instruments are working properly and the results are correct.

We also have to do proficiency testing for every test we do. We purchase sets of unknown samples 2-3 times a year and run them exactly like we run patient samples. Then we send in our results and they are graded and compared to others who perform the test. The results are reported to the Centers for Medicare & Medicaid Services (CMS), so they know we are proficient at what we do. If there are failures in any testing event, we have to make changes and improve for the next time, or they may take away our ability to do that test for Medicare patients.

In addition, every instrument has maintenance and monitoring procedures that are performed according to an established schedule of daily, weekly, monthly, and semi-annually. These maintenance tasks keep the instruments working well, prevent breakdowns, and maintain accuracy.”

“Years ago in my environmental lab we had to run proficiency tests, similar to what you do, for the EPA. We were always eager to learn how well we had done. One of our chemists, who happened to be of foreign origin, would complain vehemently when I didn’t share our results the moment they arrived in the mail. I think she learned her English from a drill sergeant. ‘In addition to QC, Mary, perhaps you can tell us about your sample workloads and typical turnaround times.’ “

“We average 2600 tests per day—that’s about 2000 samples. Some have multiple tests per sample. They come from inpatients, outpatients, clinics and other hospitals. Many tests are done within an hour of receipt in the lab. Some take several hours. Some noncritical tests can wait for a batch to accumulate and are run 2-3 times per week. Cultures may take 2-7 days, although TB and fungus cultures are held for 6 weeks. So you see, sometimes ASAP is dictated by how fast something is technically feasible.

The lab is staffed around the clock, with about 42 people in the various departments during the day Monday through Friday, 5-6 people working evening shift, and 2 people working night shift. However, there are fewer people in the laboratory on weekends.”

“So, Jaded Julie, do you have any questions for Mary?”

“I certainly do. If I were starting out in health care and wanted to work in a lab like yours, what sort of education and training would I need?”

“For detailed career information for Phlebotomist (6-12 months), Medical Technologist (BS degree), Medical Technician (associate degree), Cytotechnologist (BS + I yr), Histologist (associate degree + 1 yr), Pathologist (MD +specialty), visit the website of the American Society of Clinical Pathology or the College of American Pathologists.”

“We really appreciate your tour and discussions, Mary, and we now have a better understanding of the lab’s capabilities and complexity. Patients can certainly feel confident in the laboratory’s results. Nevertheless, I’ll try not to be the source of submitted specimens. Okay Julie, shall we go out for a jog?”

“Get real, Curmudge. How about a brisk walk up the stairs?”

Affinity’s Kaizen Curmudgeon

The Laboratory 4

2011-07-21T11:31:00.000-05:00

“Today we’re going to visit Pathology, Jaded Julie. One has to be impressed with what they do here, with the pathologists dealing with life-or-death issues on a daily basis.”

“C’mon, Curmudge, you know it’s not strictly life or death. The ultimate mortality rate is 100%; everyone dies eventually. It’s more correct to say, ‘death sooner or death later.’ “

“Thanks for making my day brighter, Julie. Shall we continue our tour of the laboratory with Mary Dikeman?”

“The next three rooms are the offices of our pathologists, each with a microscope on the desk. They work closely with Histology and Cytology, and they oversee the technical aspects of the entire lab. Their normal day includes examining and describing each tissue specimen, examining slides prepared from the tissue specimens for evidence of malignancy or disease, performing analysis of frozen sections of fresh tissue sent from the operating room, conferring with surgeons and oncologists about reports, reviewing Pap smears, reviewing new and changed technical procedures. They also perform autopsies when required.

Now we will walk into the histology department. Histology is the study of the microscopic structure of organic tissues. A tissue sample, such as a gallbladder, is removed during surgery, put in a fixative and send to Histology. There the next day the pathologist examines it and describes its appearance at the large stainless steel grossing station in Histology. Then he will cut portions of it to have microscopic studies. These sections are processed overnight in two instruments that move the tissues through various solutions to prepare them to be cut into very fine slices and put on a slide. There are four microtomes at the center table in this area that are used by the histotechnicians and histology assistant to cut the tissue into fine slices for slides. Once they are affixed to the slides, they are moved to an instrument where they are stained and a glass coverslip is put over the tissue. These are the same as the bright colored tissue slides they show on the CSI or Medical Examiner TV shows. Then they are taken to a pathologist for him to examine. They look at what kinds of cells and structures are present on the tissue slide and what characteristics they have. When fresh tissue is sent to Histology for a frozen section during surgery, a portion of the tissue must be quick frozen in a cryostat and then thin slices are cut and placed on a slide. After it is stained, the pathologist examines it and calls the results to the operating room. The surgeon will then decide how to proceed with his surgery. You will notice that there are two cryostats, so there is always one available in case one is in auto defrost at the time it is needed. The histotechnicians also perform other special stains and immunohistochemical stains on tissue to help the pathologists make disease diagnoses from these slides.

Now let’s go across the hall to the Cytology processing area. Here is another laminar flow hood to protect the users when they set up possibly infectious samples. Watch the cytology assistants take the Pap smear vials and run them through the processor to make a thin layer of cells on a slide. Then they spin down body fluids in the centrifuge and process them to make a slide. The slides are stained and coverslipped on the instrument in Histology. Then the slides are put on the computerized imaging system that will survey the slides and pick out 22 fields of interest that need to be reviewed. In another room with microscopes at 3 work stations, the cytotechnologists look at and determine if there are suspicious cells present on the 22 areas or anywhere on the slide. This uses both computerized and human expertise to provide a high level of detection. Any slides that have suspicious cells are taken to the pathologists to review and diagnose.”

“I remain totally impressed, Julie. So much of this requires painstaking work by the technicians and experience and judgment by the pathologists. Diagnosis of diseases by microscopic examination of tissue specimens can be very difficult, as is the case with interstitial lung disease. Different areas of the same specimen can look different, and even experienced pathologists can disagree.”

“With your poor eyesight, Curmudge, it’s a good thing that you didn’t become a pathologist. ‘It looks as if we are nearing the end of our tour, Mary.’ ”

“ Almost, Curmudge and Julie. Across the hall is a room where there is an industrial dishwasher, large sinks and an oven. Here the lab glassware is washed and equipment kept clean by the lab aide, who also orders supplies and fills orders for lab supplies.

Near the main lab is the Point of Care office. The POC staff maintain and oversee all the bedside testing that is done across the system. Also located in this area are the MT school coordinator, the student lab and classroom. Our technologists and pathologists support a school to provide a clinical year experience for 4th year medical technology students. They receive lectures and training in the student classroom and student lab, and then are integrated into the laboratory to learn about performing tests in most areas of the lab.”

“Although our formal tour is over, let’s get together next week and do a post mortem (oops, that might not be the best term to use here) on what we have seen.”

Affinity’s Kaizen Curmudgeon

The Laboratory 3

2011-07-14T10:18:00.000-05:00

“Here we are, Jaded Julie, back in Microbiology to continue our tour of the laboratory.”

“Before you forget everything, Curmudge, please tell me some of the things that you have already learned from the tour.”

“Do you remember the 1967 movie, The Graduate, in which Dustin Hoffman was advised to go into ‘plastics’?”

“The movie was before my time, but everyone knows the story.”

“Well Julie, this tour is teaching me that appropriate advice for today’s graduate would be to go into biology or perhaps automation. I’m becoming convinced that microbiology is an extremely powerful science. ‘So, Mary, continue the tour and teach me more.’ “

“Let’s move to the next area in Microbiology and see on the left an instrument that is used for Lyme disease testing. On the right is a small instrument for fetal fibronectin testing that helps tell whether a mom is at risk of early labor. You may also see the Newborn Screen cards that are sent to the State Lab to help detect more than 25 congenital conditions on all newborns, before they can affect the child. Ahead is a large table with four technologists looking at the culture media plates that were set up the day before and put in that CO2 incubator. They check each plate for growth and if there is something, they must decide whether it is important to know what it is. (Some bacteria are normally present in some areas, so they are not the 'bad guys' or pathogens.) If they need to identify some possible 'bad guy' bacteria, they might do some quick biochemical tests, or they might put the bacteria on the Vitek instrument that can perform a whole panel of tests and produce the name of the organism. This instrument will also put the bacterial organism with some dilutions of antibiotics and test what antibiotics will likely be effective in treating that infection. These identification and antibiotic results may be available in 5-12 hours. The results are passed to the Meditech computer system by an interface from the instrument. You will notice several microscopes in this area, since determining if bacteria are gram positive ( blue) or gram negative(red), or shaped like rods or round cocci is the important first step toward identification.

Across the room is another large incubator to keep the culture media and other tests warm for 2-7 more days. Next to that is a large Plexiglas box with a side chamber and access door. This is the anaerobic chamber. Some important bacteria called anaerobes are unique from other bacteria and do not like to be in the presence of oxygen. This chamber removes most of the oxygen and replaces it with a high nitrogen gas mixture that makes them happy. Cultures from deep systemic areas of the body may be checked for anaerobic bacteria. The specimens are put to special culture media and incubated in the anaerobic chamber for many days. The technologist puts their hands into the box through portholes with sleeves and examines the cultures. If anaerobes are present, they have certain growth characteristics that help identify them.

Off to the back is a small closet-like room, called the dark room. There is a fluorescent microscope in there, which is best used in a dark surrounding. Special fluorescent stains are used here to detect ANA antibodies, Cryptosporidia, and Giardia.

Let’s go out the back door and across the hallway to the very clean (smell the bleach) Molecular room. Here is where DNA amplification and target signal amplification are used to detect Chlamydia, Gonorrhea and HPV. In the next room is the area where Parasitology and Mycology (fungus) work is done. There is also a large laminar flow hood in this area for the fungus culture work to keep the fungus spores away from the people. So that fungus is not among us! A smaller incubator contains the fungus cultures; they require a lower temperature and special media for optimal conditions to grow.”

“As I was saying, Julie, microbiologists do really important work. They are certainly more than ‘little biologists.’ When I was a kid, microbiology might not have been part of a clinical lab, if such labs even existed then. Of course, it didn’t require a microbiologist to diagnose the ugly impetigo sore on my knee.”

“You told me that years ago engineers in industry used simple microbiology to identify the filamentous bacteria that hampered the operation of waste treatment plants. The science has come a long way since then.”

“And we’ll go a short way out the door and to the right. The next room on the right is the pathology transcription area. You will find two transcriptionists who handle the clerical work for the Cytology and Histology departments. They transcribe dictated reports from the pathologists, register client patients, and order tests.

The next room is the office for the two laboratory information system coordinators. They handle problems and changes to the lab computer module, some lab billing issues, and lab quality matters across our lab system.”

“Speaking of pathology, that’s the part of the lab that we’ll visit next week. Don’t forget to come, Julie.”

Affinity’s Kaizen Curmudgeon

The Laboratory 2

2011-07-07T10:50:00.000-05:00

“Here we are, back in the basement of St. E’s. Whenever I come down here I fear that some day I’ll ask about you and the answer will be, ‘Oh, Curmudge is over there in the morgue.’ “

“Don’t worry, Jaded Julie. If I’m there I’ll be in good hands. I have a friend who drives a hearse for a local funeral home. She often comes down here to pick up ‘clients.’ Shall we continue our laboratory tour with Mary Dikeman?“

“Now we leave the Blood Bank and head into the area where urines are examined, fecal occult blood tests and pregnancy tests are done. Good thing they keep it so clean or it could become very odiferous very easily! In the back aisle is the large Coulter instrument that does the CBCs—Complete Blood Counts—and also the microscopes used when a manual differential is required. And there is another smaller instrument that serves as backup to the CBC instrument; so important to have a backup so that CBCs can still be done even if the Coulter is having a time out to have maintenance done. There are an average of 100 CBCs done each day. Across the aisle are the two instruments that are used for Coagulation tests, such as PT, PTT; again there is a backup for the testing.

We continue around the corner and see a large screen that lists pending stat tests and how long they have been waiting. Turn to the right toward the Chemistry Department and see the two blood gas instruments where arterial blood gases are run. Straight ahead are the workhorses in the lab, the chemistry instruments that do the chem panels. The instruments are each the size of a small VW Beetle. Again there is two of each instrument that run different tests, but they can be the backup to each other in case one is not working. On average, about 200 chem panels are run each day. There are also two very large instruments that do hormone testing, cardiac testing, thyroid testing, and other specialty tests. These instruments pass the results to the lab Meditech computer via an electronic interface.”

“You must have noticed, Curmudge, that the lab seems to have two of each of the most critical instruments. They can’t afford to have a request for an essential test ‘stat’ and have to respond that the instrument is ‘down’ for maintenance.”

“ ‘Stat’ is another one of those medical terms that is not obvious to every layperson. It’s like ordering a gelato in Italy, and the waiter says ‘subito’ and brings the ice cream immediately.”

“Around the back corner there is the ECI instrument that does troponins (to diagnose a suspected heart attack), hepatitis and HIV testing. Also in that area are the Variant instrument that does hemoglobin A1C testing (to diagnose and manage diabetes) and the protein electrophoresis instrument that uses electric current to separate proteins in serum or spinal fluid. Testing for lead in patient’s blood takes place on the back counter in this area. Lead poisoning is still a problem in our community. You also notice the Plexiglas-covered instrument that is used for vitamin D, varicella, mumps and rubeola testing. The medical technologists and technicians (also ASCP certified) rotate through the operation of these instruments. You will notice the wall is completely covered by refrigerators and freezers that store reagents for the chemistry tests.

Now let’s walk past the lab office, which is the central area for clerical business and the lab secretary, and into the Microbiology area. On the left is the blood culture instrument that incubates the BC bottles and takes a reading every 10 minutes. It looks for an increase in CO2 production that would indicate the presence of bacteria. On the right are a long counter and a Plexiglas front cabinet. Watch the technologists put their hands under the opening to the cabinet and put the culture specimens onto the culture media. There is airflow that will capture any stray bacteria and pull them away to a filter, so the technologist/technician is protected from infection. Once the culture media is inoculated with the specimen (such as urine, sputum, wounds, throat), the media is placed into the large refrigerator-like box. This incubator is kept at a temperature of 35 degrees Celsius, which is close to the human body temperature that bacteria like to grow in. It also has 5% CO2 gas pumped into it to really make the bacteria happy so they will replicate while in the incubator. In 8-24 hours they will have multiplied hundreds of times and formed colonies of bacteria that are 1-2 mm in size. In this room, the rapid tests for influenza, RSV (respiratory syncytial virus), strep, rotavirus and Clostridium difficile are performed, and there is a microscope for looking at gram stains of the specimens that came in.”

“I must admit, Julie, that many of the tests performed in Mary’s lab are new to me; and they might be fairly new to the lab. For example, their vitamin D testing was started in the fall of 2010. Not only must a hospital lab be responsive and accurate; it must stay up to date. When a test is developed that can answer a critical diagnosis question, the laboratory needs to be able to do it. Of course, if the test is not requested often and the results not needed ‘stat,’ it can be sent out to a so-called reference lab.”

I’m impressed by the measures taken by the lab to protect the technicians from infection. We wrote about C. difficile on February 5, 2009, and I still shudder when I think of it.”

“You can shudder for a whole week, Julie. Mary has other work to do, so let’s continue our lab tour in the next posting.”

Affinity’s Kaizen Curmudgeon

The Laboratory

2011-06-30T11:45:00.000-05:00

“Hey, Jaded Julie, we’re going to leave the crystal ball and talk about the hospital laboratory.”

“Curmudge, when you see a modern lab, you’ll think that everything in your crystal ball had already happened.”

“Some things don’t change, Julie. While clients tend to take them for granted, labs of all types have always needed to demonstrate excellent accuracy and responsiveness. And here’s another example: My industrial labs used to solve people’s problems, while clinical labs provide more than 70% of the data used by physicians to manage patient diagnosis and treatment.”

“If we are going to talk about laboratories, we should probably begin at the beginning—with the patient. My years of experience with this blog tell me that the curtain is about to go up on another of our Curmudge-and-Julie theatricals. I might as well roll up my sleeve.”

“You are going to play the patient, Julie, and here comes a phlebotomist to draw some of your blood”

“To a phlebotomist, the world consists of two kinds of people, ‘hard sticks’ and ‘easy sticks.’ Fortunately I’m an easy stick…see, that didn’t hurt a bit. My blood was drawn into little evacuated tubes labeled with my name, date of birth, specimen number, and a bar code. Of course, before starting the procedure, the phlebotomist asked me to recite my last name and birth date to be certain she had the right patient. She also smiled at me, introduced herself, and gave me an empty cup to take into the ladies’ room.”

“Here we are in the hospital basement, Julie. The morgue, down that hall, is not going to be part of our tour. When the lab was expanded a few years ago, it was relocated down here. Design of the laboratory’s space—to increase efficiency and reduce wasted motion—was one of the hospital’s first Lean projects. Our guide through the lab will be Mary Dikeman, Laboratory Manager.”

“It’s a good thing that you aren’t the guide, Curmudge. You never knew much about clinical labs, and what you did know is 40 years out of date. ‘Good morning, Mary. Thank you for taking time to show us around.’”

“Welcome to our laboratory, Julie and Curmudge. Most people don’t know how large the laboratory is and how many interesting things go on here. This is a walk through St. Elizabeth Laboratory, but it describes some of the same things that go on at any of the hospital labs.

So come on in the front door to Specimen Processing; be mindful of the phlebotomists with their carts leaving the lab to go draw blood from patients. And here comes a courier with a cart full of coolers that contain specimens from other clinics and hospitals. Once in the lab you will notice the technologists and support service technicians are emptying the coolers and then ‘receive’ each specimen in the computer; this tracks the movement of the specimens from site to site. These are sorted and then delivered to the departments such as Chemistry, Hematology, Blood Bank, Microbiology, Cytology, and Histology that will perform the testing. Located in Specimen Processing, the pneumatic tube system also brings specimens to the lab. Centrifuges sit on the counter and are used to spin and separate the cells from the liquid in some of the blood tubes when the tests require serum or plasma instead of whole blood.”

“As we go through the lab, Julie, please notice how important computers are for everything from sample tracking to operating many of the instruments. In my environmental lab, 20 years ago, all we had was Lotus 1-2-3 for sample log-in.”

“And for an old chemist like you, Curmudge, I’d better help Mary by defining some of her terms. Cytology is the study of cells, and histology is the study of tissues.”

“Regrettably, from the experience of my late wife, I have learned a bit about histopathology. “

“Okay, visitors, let’s move on to the right and head into the Blood Bank area. Here you may see boxes that held blood products that were delivered from the Community Blood Center. On the left is a Medical Technologist that has certification from the American Society for Clinical Pathology [MT(ASCP)] that is doing blood typings and cross matches to see what unit of blood will be the best match for the surgery patient. There is an instrument that uses a gel technology to help determine the antibodies that are important to finding a good blood match.

Notice the large refrigerator that holds all the blood bags and blood products. It has a special temperature recording chart that is so important to keeping the blood at the proper temperature at all times to keep it safe. There is also equipment used to prepare platelets for transfusion.”

“All I know about my blood is that it is type A-negative.”

“And Curmudge, it’s being pumped through your ancient circulatory system at glacial speed. Let’s take a break and return next week to continue the tour with Mary.”

Affinity’s Kaizen Curmudgeon

The Crystal Ball 8

2011-06-13T12:40:00.000-05:00

“Golly, Curmudge, I can hardly wait until we get to the end of Christensen’s The Innovator’s Prescription. It’s like a novel; I’m eager to learn what health care will be like in the future.”

“It’s not a sure thing, Jaded Julie. The future will depend on which of the following two philosophies of health care will be dominant. (1) Improving the value of health care can’t happen unless those who receive health services know what they cost and bear at least a share of the cost burden. (2) Some people believe with near-religious fervor that employers or the government are morally obligated to cover health-care costs. In that scenario, reimbursements are administered prices; they are insulated from market forces and the efficiencies that would result from disruptive innovation.”

“Whether it’s through taxation or cash on the barrelhead, health care has to be paid for. It sounds as if Christensen’s ideas will function better under Scenario 1. How will that work?”

“As mentioned last week, the integrated fixed-fee providers will charge patients an annual fee (capitation). Employers who directly manage their employees’ health care use a combination of high-deductible insurance (to protect against catastrophic illness) and health savings accounts (HSAs). The employer puts before-tax money in the employee’s HSA; the employee can also add (before tax) to the account. The employee pays for health care out of the HSA up to where the high-deductible insurance kicks in. Upon retirement, the employee can keep any funds left in the HSA.”

“Hey, this sounds like my 401(k). I can see where it is to the employee’s advantage to frugally manage his health-care costs and to everyone’s advantage for him to stay healthy. But what about the ‘uninsured poor?’ “

“They could use HSAs too; but instead of employers (which they may not have), governments could match by formula the HSA contributions made by the low-income citizens. Governments would also need to subsidize their high-deductible insurance.”

“Curmudge, under any system—including the present one—someone is doing well financially. It’s human nature for them to want to protect their rice bowl. What kinds of resistance is disruptive innovation likely to encounter, and how might it be overcome or circumvented?”

“Virtually every innovation we have discussed in the past few weeks will be opposed by some group or organization that wants to protect the status quo. Their most common vehicles are regulations covering certification and licensure that control who gets paid. Usually the regulations were established to protect the public; but when they become outdated due to technology, they will end up protecting the economic interests of the providers. This means that head-on attempts to bring about change in the health care system are likely to fail.”

“So are we stuck in our present system? Was everything in Christensen’s book just an intellectual exercise?”

“The feasibility of the improvements has been demonstrated by the examples in the book. Organizations like the integrated fixed-fee providers and the employers who directly manage their employees’ health care are not directly bucking the present system. They are going around it by setting up systems of their own. Their success will bring about success elsewhere as others adopt their innovations. Changes that seem impossible at present will become feasible.”

“In his book Christensen suggests that regulations will ultimately change in reaction to the innovators’ successes. ‘The focus of regulations such as licensure and certification needs to keep pace with technological change.’ ‘As care moves through empirical medicine toward precision medicine, the focus should shift to accrediting processes, and ultimately to guaranteeing outcomes.’ “

“Julie, in countries like Great Britain where the government ‘owns’ the health care system, there is no place outside the system where innovators can bring about changes. Their needed modifications will require a head-on approach, which will be extremely difficult.”

“Okay, Curmudge, is there a simple solution to all of this?”

“As I said once before, for every complex problem there is a solution that is quick, simple, and wrong. In the U.S., that sort of ‘solution’ would be to handcuff our health care system in a way that makes disruptive innovation impossible.”

Affinity’s Kaizen Curmudgeon

The Crystal Ball 7

2011-06-03T10:52:00.000-05:00

“As promised, Jaded Julie, today we are going to share the highlights of Clayton Christensen’s observations regarding chronic diseases. The spectrum of chronic diseases is extremely wide, ranging from myopia (nearsightedness), which I have had since age 13, to Alzheimer’s, which one of my friends will likely die from before this blog is posted.”

“I understand that Christensen divides chronic diseases into two major categories: (1) Intuitive chronic diseases. Their lack of clarity in diagnosis and treatment necessitates the type of medicine practiced in a multidisciplinary solution shop. (2) Rules-based chronic diseases. A single practitioner can diagnose and prescribe evidence-based or rules-based therapy.”

“Let’s look at the first category, Julie. Dyspnea (difficulty breathing) is a symptom common to several pulmonary diseases that could involve interdependent molecular pathways, genetic differences, and environmental factors. A definitive diagnosis might require extensive tests interpreted by a team of experts who can knit together their extensive experience. Their judgment would guide the decision between rigorous but unpleasant therapy and palliative care. For pulmonary medicine, highly regarded solution shops include Mayo and National Jewish Medical Center.”

“Let’s be a bit more up-beat, Curmudge, and talk about the second category, the rules-based chronic diseases. With these diseases, diagnoses and treatments are usually straightforward, but a common problem is getting the patient to comply with the prescribed therapy. For some, the effects of noncompliance are evident and unpleasant. Celiac disease is an example; if the patient doesn’t avoid eating foods containing gluten, he/she most often will have gastrointestinal problems. At the other extreme is obesity, where the results of noncompliance are more subtle and usually delayed.”

“There is also a reimbursement issue for the provider. He/she will be reimbursed for diagnosing and prescribing but not for calling the patient to remind her to take her medicine, watch what she eats, and come in for her periodic check-up. More generally, there is no procedure code for keeping the patient well. According to Christensen, ‘the fault is the misapplication to chronic diseases of a business model that was developed for the practice of acute medicine long ago.’”

“It seems to me that Christensen has laid the groundwork for eventually solving some of the problems that are plaguing health care. In short, how are we (not you Curmudge; this may take longer than your expected lifetime) going to pull this off?”

“Christensen has described the so-called ‘integrated fixed-fee provider.’ ‘They don’t need to orchestrate a disruptive value network; they can create it.’ Obviously, this must be a very large organization like Permanente in California and Intermountain Healthcare in Utah. Most of the essential elements of health care that we have discussed—the disruptors and the disruptees—are under the corporate umbrella. Care is provided in the most cost effective venue. The annual fee paid by each patient provides an incentive for the organization to maintain their wellness—not to just treat their illnesses.”

“Don’t forget, Curmudge, Christensen’s criteria of an ideal entity for managing a health care system: (1) have a long-term perspective, (2) make money by keeping us well, not beginning when we become sick, (3) care about us personally, (4) be geographically nearby and convenient, and (5) be able to make needed changes decisively. Hey, that sounds like something an employer could do.”

“And some do, Julie. Christensen’s example is Quad/Graphics.”

“Of course. They’re next to highway 41 just south of Fond du Lac.”

“They operate four medical centers—free to employees and their families—offering family practice, internal medicine, pediatrics, OB/GYN, minor surgery, lab work, rehabilitation , and physical exams. Quad is self-insured and contracts with local hospitals and specialists for advanced care. Their emphasis is on wellness, and they have programs to combat chronic illnesses. Their physicians and nurse practitioners are salaried employees.”

“I read about another company in Wisconsin, Serigraph, that ‘took the problem of employee health insurance costs into its own hands.’ Their CEO even wrote a book about it, The Company That Solved Health Care (1). For your continued study, Curmudge, there’s a pretty good review of the book in Amazon. The important teaching is that these companies have found ways to make the ‘employers as integrators’ concept work.”

“A more general conclusion is Christensen’s five- to ten-year forecast regarding integrated fixed-fee (IFF) providers. ‘Where they use disruptive business models to provide better care at lower cost, they will prosper; and overall health-care costs will drop without a compromise in quality or convenience. This is because quality comes from correct integration, and lower costs come from low overheads that are enabled by focus.’ ”

“I think his examples are easier to understand than his summary. By the way, is there more to this story?”

“Actually, Julie, there is. And we should be able to wrap it up next time.”

Affinity’s Kaizen Curmudgeon

(1) Torinus, John. The Company That Solved Health Care.

The Crystal Ball 6

2011-05-31T09:13:00.000-05:00

“You know, Curmudge, if a reader surfed onto this posting without having read those that preceded it, he/she would think, ‘who are those two presumptuous people who write as if they know so much?’ Of course, those who have read our postings all along realize that we are just messengers trying to convey the teachings in Clayton Christensen’s book, The Innovator’s Prescription.”

"Don’t worry, Jaded Julie. Anyone acquainted with us knows that we more closely resemble copy-cats than visionaries. So let’s pick up the story where we left off. Christensen proposed that in the future precise diagnoses and predictably effective therapies will move providers upward on the scale of medical practice. Nurse practitioners will disrupt primary care physicians; primary care physicians will disrupt specialists, etc. Next, Christensen considers how changes of this sort will impact hospitals and other health care institutions.”

“Even in my lifetime, Curmudge, there will remain some afflictions that can’t be diagnosed and treated by precision medicine. Patients with these problems will go to hospitals that specialize in intuitive medicine, which Christensen (inelegantly) calls ‘solution shops.’ The Mayo Clinic is a modern-day solution shop where a team of world-class specialists—paid a salary—will diagnose your illness and then use state-of-the-art therapies to test their hypothesized diagnosis and hopefully effect a cure.”

“Actually, a large part of most of today’s general hospitals is, effectively, a solution shop. Their diagnostic efforts require large laboratories, an array of advanced imaging instruments, and specialists of (almost) every description. Christensen calls the other part of a general hospital’s business their ‘value-adding process (VAP) activities.’ Here they fix problems after definitive diagnoses have been made. Things like hip and knee replacements, CABG and angioplasty heart repairs, and hernia and cataract surgery.”

“I’ve read about dedicated VAP facilities, Curmudge. Everything is standardized and focused on doing a limited number of procedures very efficiently and for a flat fee. Shouldice in Canada does only hernia repair, and there are others that patients travel to in Asia (‘medical tourism’). In Pennsylvania, Geisinger charges insurers a flat rate for heart bypass surgeries and effectively provides a 90-day warranty.”

“Christensen sees general hospitals as attempting to implement two different business models under one roof, i.e., acting as a solution shop as well as a VAP facility. He suggests that the high overhead of the low-volume solution shop part of the hospital is subsidized by the hospital’s high-volume routine surgeries. Typically, a solution shop bills on a fee-for-service basis, while a dedicated VAP facility can charge a flat rate because their outcomes can be forecast.”

“So put it all together, Curmudge, and tell me how disruptive innovation can at some point in the future impact today’s general hospital.”

“A dedicated VAP facility using standardized procedures is likely to be more efficient and effective and less costly than a general hospital. ‘Toyota taught the world that if we do a task differently every time, it’s very hard to improve the result.’ “

“That sounds like an endorsement for standard work in health care.”

“In the future, a general hospital’s solution shop business is apt to get pinched from both sides. Recall, Julie, our discussion of the enhanced diagnostic power that technology and telemedicine will bring to the primary care physician’s office. That will disrupt the solution shop side of the hospital for the more straightforward diagnoses. Finally, the tough diagnoses that remain will be best tackled by a focused solution shop like the Mayo Clinic or the Texas Heart Institute. For his own diagnosis Dr. Grossman, Christensen’s coauthor, went to National Jewish Medical Center in Denver. The cost of traveling to such a place will be trivial compared to ‘thousands of dollars spent on the wrong prescription drugs and devices that were the result of inaccurate, incomplete diagnoses by a stream of individually operating specialists.’ “

“Let’s move on to the next subject. What did Christensen say about chronic diseases? And who will be able to pull off these disruptive changes in health care?”

“That will be next time, Julie. Don’t go away.”

Affinity’s Kaizen Curmudgeon

Happy Fourth Birthday

2011-05-20T09:45:00.000-05:00

“Curmudge, did you forget that May 23 will be the fourth birthday of the Kaizen Curmudgeon blog? Here, blow out the candles that I put on this cupcake.”

“Pooof…”

“Hey, you missed one.”

“At my age, three out of four isn’t bad. So by way of celebration, let’s reflect a bit on what we have done and what we are doing. Four years ago you, Jaded Julie, were just a straight man for Curmudgeon.”

“Straight person, Old Guy. A little political correctness, please.”

“Now you are a valued colleague with a growing vocabulary and a tolerance for an occasional profundity in a foreign tongue. You even read the same books that I do, and you waken me when I fall asleep in mid-sentence.”

“I must admit that we occasionally stray from our original subject, Lean in health care. At least we adhere to our plan of sharing the essential lessons of books and papers that our readers are unlikely to have time to read.”

“And sometimes we discuss things we have experienced that just cry out to be shared.”

“You are of course referring to universal concerns like the end-of-life issues in our postings on Way to go! and The Old Men’s Table. It would be unfair to our readers to depict life as always a rose garden. They need to understand that we at Affinity are thinking about serious things.”

“Speaking of serious things, Julie, do you realize that our birthday has popped up right in the middle of our series on the future of health care, which we have termed The Crystal Ball? Let’s cut out of this birthday frivolity and get back to work on health care’s future.”

“I’m right with you, Curmudge.”

Affinity’s Kaizen Curmudgeon

The Crystal Ball 5

2011-05-19T10:30:00.000-05:00

“In our last discussion, Curmudge, we talked about Clayton Christensen’s book, The Innovator’s Prescription, and we introduced his concept called disruptive innovation. I see the book as a 441-page Lean exercise. He defines a problem and then develops countermeasures.”

“Good observation, Jaded Julie. The problem is that ‘the growth in health care spending in the United States regularly outpaces the growth of the overall economy.’ The insights of Christensen and his coauthors provide the basis for some mighty convincing countermeasures. Christensen even provides biblical justification for his efforts, ‘Where there is no vision, the people perish.’ (Proverbs 29:18)”

“Wow! This sounds ominous, and we’ve only written two paragraphs. Speaking of writing, we must remind our readers that what appear to be our statements and conclusions are actually the paraphrased or quoted words of Christensen and coauthors.”

“Here’s the thrust of Christensen’s thinking. While much of today’s political dialogue is focused on how to pay for increasingly expensive health care in the future, this book is aimed at reducing costs and improving health care’s future quality and accessibility.”

“As we explained last time, the first step in disruptive innovation is the development of sophisticated technology that simplifies. Shall we start with that?”

“We shall, and let’s consider how technology impacts diagnosis, the first step in one’s visit to the doctor. The human body’s vocabulary is pretty limited in telling us what’s wrong with it. Because there are many more diseases than there are symptoms, many symptoms have to be shared. If a man went to the doctor complaining of a headache, the symptom could indicate a problem ranging from a brain tumor to having too much to drink the night before. Many years ago the diagnosis would have totally depended on the doctor’s experience, intuition, and acquaintance with the patient. This is called intuitive medicine, which leads to trial-and-error therapies with the hope of mitigating the symptoms. Now, modern imaging techniques would take a lot of guesswork out of the diagnosis. As Christensen states, ‘the technological enabler for disruption in health care is the ability to diagnose precisely, which then opens the door for a predictably effective therapy.’ “

“Curmudge, we’ve certainly progressed in the diagnosis of infectious diseases. Identification of the microorganism in a throat culture will allow selection of an antibiotic to wipe out a strep throat pretty predictably.”

“That’s called precision medicine, Jaded Julie. It is ‘the provision of care for diseases that can be precisely diagnosed, whose causes are understood, and which consequently can be treated with rules-based therapies that are predictably effective.’ ”

“It would be really great if we could use this precision medicine for everything. Not only would the patient be cured, but it would cost less than trying this and that therapy with the hope that the symptoms would subside. I presume, Curmudge, that more definitive diagnoses will be matched by development of more directed therapies.”

“That’s the other half of the story, Julie. Recall our stating that the body can’t express enough gross symptoms to tell us what’s wrong? If fact, the body is quite articulate in terms of genetic expression. Although we wish there were more, there are a few specific molecular tests that can identify certain cancers quite specifically. These tests can be teamed with pharmacogenomics, a new branch of pharmacology that aims to develop rational means to optimize drug therapy, with respect to the patient’s genotype, to ensure maximum efficacy with minimal adverse effects. Of course, we’re looking a bit into the future for this kind of personalized therapy."

“Yes, but we already have a name for it. It’s called ‘Personalized Care.’ So how will these changes affect the practice of medicine?”

“We’ve seen examples of how many diagnoses will become more specific and less intuitive and therapies will be more precise and less trial-and-error. Retail clinics staffed by nurse practitioners already diagnose and treat lists of illnesses and conditions, and the lists will undoubtedly expand. Their diagnoses are straightforward, and their therapies are evidence based. One might expect that they will disrupt the primary care physicians, but because of the clinics’ speed, convenience, and affordability, Christensen feels that they compete predominantly against nonconsumption. For a variety of reasons, their patients would skip their vaccinations and tolerate their illnesses until they went away or became serious.”

“Our earlier postings on Information at Your Fingertips and Amazing Devices foretell big changes in the primary care physician’s office. Christensen suggests three innovations that will move primary care docs into the realm of specialists: (1) analytical and imaging capabilities at the point of care, (2) online decision tools, expert system software, and algorithms that guide diagnosis, and (3) telemedicine (remote consultation with an expert).”

“And what about the specialists?”

"They are likely to disrupt one another. Cardiologists doing angioplasty have been disrupting cardiac surgeons for years. Interventional radiologists are disrupting surgeons by their instruments’ enhanced ability to visualize the area requiring surgery.”

“Golly, Curmudge, with a surgical robot even I could perform surgery. So how might these big changes impact the hospitals?”

“Hang in there, Julie. We’ll talk about hospitals next time.”

Affinity’s Kaizen Curmudgeon.

The Crystal Ball 4

2011-05-12T09:30:00.000-05:00

“Curmudge, I understand that you actually bought a book. Typically, you just read the reviews in Amazon and wing it from there. What inspired your investment in the real thing?”

“Well, Jaded Julie, we’re going to push our crystal ball into the somewhat-distant future, right? For that we’ll need some high-powered insight, and that doesn’t come free. So I dug down into my dresser, blew the lint off a credit card, and purchased The Innovator’s Prescription by Clayton Christensen and two MDs, Jerome Grossman and Jason Hwang.”

“We mustn’t forget that material in Kaizen Curmudgeon can’t be controversial. So how can we present Christensen’s forecasts without generating controversy?”

“For the most part, Christensen writes about several years into the future and supports his position with data from the fairly distant past. People tend to get riled up over the present, the immediate future, and the recent past. That, as well as Christensen’s compelling arguments, should keep the discourse civil. Additionally, we are going to simply convey parts of Christensen’s message and do it diplomatically and selectively.”

“The focus of Christensen’s earlier writings—and they were not about health care—was disruptive innovation. What is that, anyway? It sounds both disturbing and encouraging at the same time.”

“In Christensen’s words (signified by single quotation marks), ‘the disruptive innovation theory explains the process by which complicated, expensive products and services are transformed into simple, affordable ones.’ “

“Curmudge, even a mind as swift as mine would appreciate an example.”

“It’s coming at you, Julie. Back in the 1960’s (ah, it seems like yesterday) only a few talented engineers could build IBM’s room-sized, mainframe computers. They were sold directly by IBM to institutions for hundreds of thousands of dollars. Then along came a technological disruptor, the microprocessor, that simplified computer design and assembly and enabled personal computers to be assembled from parts in Michael Dell’s dorm room. Soon virtually everyone, like me who had never thought about computers, could afford a computer and had one on his desk.”

“But this transformation involved more than just the advent of the microprocessor, didn’t it?”

“Right. IBM set up a new business model to make money with low margins, low overhead, and high unit volumes. In addition, components became commodities, marketing was done by independent vendors, and software was developed for unsophisticated users. Lots of organizations could participate in and profit from this so-called economically coherent value network.”

“I think I have the basics, Curmudge. For successful disruptive innovation, the requirements are ‘(1) sophisticated technology that simplifies, (2) low-cost, innovative business models, and (3) an economically coherent value network.’“

“You got all of that from what I just said? You must have been reading the book. Come back next time and we’ll begin to explore how Christensen translates these concepts into health care.”

Affinity’s Kaizen Curmudgeon

The Crystal Ball 3

2011-05-05T10:04:00.000-05:00

“Do I detect, Curmudge, that we are slowly tuning our crystal ball to look further into the future?”

“What do you expect, Jaded Julie? Everything I do is done slowly. I even sleep slowly. One of my friends once said, ‘Sleep is just practice for being dead.’ I practice slowly so I don’t get too good at it.”

“I understand that today we discuss the last of the health care ‘knowledge purveyors’ on our list, Sg2. This is another organization supported by membership dues and fees for services they provide. Fortunately, Affinity is a member.”

“On the Kaizen Curmudgeon scale of consultancies, Sg2 is neither a supermarket nor a ‘mom-and-pop store.’ Their team includes MDs, PhDs, RNs and health care leaders with extensive strategic, operational, clinical, academic, technological and financial experience. According to their home page, they ‘help build a foundation for improving care delivery and overall organizational performance.’ Their logo includes ‘health care intelligence.’ That certainly suggests a forward-looking focus.”

“Sg2 offerings include meetings, courses, and web seminars. Their EDGE intelligence system provides in-depth reports, growth guides, and technology guides on a wide range of medicine-related topics.”

“Jaded Julie, if your aim is to be in health care administration, these statements by the CEO of Sg2 ought to catch your attention: ‘This is 2001 in the airline industry. Make no mistake, the Southwest Airlines equivalents in health care are going to wreak havoc on the mainline health care providers.’ ‘Growth is not going to come from performing more procedures and getting more referrals, it is going to come from providing a fundamentally better product at a lower price point.’ “

“The CEO of Sg2 is obviously a bit of a salesman, but Curmudge, what he said is enough to waken you from your afternoon nap.”

“You be sure to be awake next time, Julie, and we’ll try to conjure up some countermeasures for the day of reckoning.”

Affinity’s Kaizen Curmudgeon

Note: An observation on the practice of emergency medicine in a primitive location may be accessed via this link.

The Crystal Ball 2

2011-04-27T10:35:00.001-05:00

“Jaded Julie, during my days in industry there was an organization, supported by the industry, whose mission was the development of knowledge regarding the industry’s impact on the environment. This knowledge was for use in the near term, and it was developed in response to process changes and proposed government regulations. Basic research was done elsewhere, and an industry association handled government lobbying.”

“That’s all very nice, Curmudge, but why are you telling it to me?”

“I thought that for once I’d start by discussing a topic about which I knew something.”

“Well, that’s a switch, and it’s better than your usual prattle. But what does it have to do with health care?”

“Fortunately, there are similar organizations—developers and purveyors of knowledge—serving health care. People in hospitals are too busy with patient care, daily management (ready-to-serve time), hoshins (discretionary time), and other local issues to contemplate a global near-term future. That has created the need for outfits like the Institute for Healthcare Improvement (IHI), The Advisory Board, Sg2, and others. They are supported by membership dues and/or fees for participating in educational offerings and consortia devoted to specific issues.”

“These groups sound valuable, Curmudge. I understand that they are staffed by highly competent people whose job is to study, think, listen, talk, and write on behalf of the health care industry. Health care administrators are probably aware of the problems they will be facing, but they might feel overwhelmed by all of the countermeasures they could be implementing. According to their literature, these specialized consultancies help support and steer our thoughts in the direction of viable results with evidence and data to support them. Can you give me more specifics about these outfits?”

“As we said once before, IHI’s web site is a bit like a supermarket. If you have a problem, push your cart down the aisle; and you might find a solution. On our crystal ball timeline, IHI deals mostly with the present. However, its teachings will help organizations improve their near-term future. ‘IHI focuses on motivating and building the will for change; identifying and testing new models of care in partnership with both patients and health care professionals.’ IHI’s work is funded through their fee-based program offerings and services, and also through the support of foundations. Their reports, such as White Papers and Improvement Stories, are available to the public. Among the many subject areas are Office Practices and Patient-Centered Care. Here is an example of one of their forward-looking, fee-based colloquia to be held in 2011, ‘Thriving in an Era of Health Care Reform.’ ”

“Curmudge, I like your term, ‘purveyor of knowledge.’ Did you ever get paid for ‘purveying’ knowledge?”

“Not much, Julie, and any knowledge that I still have is free to a good home.”

“So what other purveyors of knowledge for the near term do we have for health care?”

“According to The Advisory Board, they are ‘the leading provider of comprehensive performance improvement services to the health care and education sectors—including operational best practices and insights, business intelligence and analytic tools, management training, unbiased technology evaluation, and consulting support.’ Note that they don’t work for health care exclusively. They have recently acquired Southwind, a ‘management and advisory firm focused on hospital-physician alignment and physician practice management.’ “

“It’s been awhile since we reminded our readers that a blog is not an encyclopedia or a textbook; all we hope to do is stimulate the readers’ interest. We can put them ashore, but they will have to explore the island by themselves.”

“For example, Julie, these are some of the programs accessible to corporate members of the Health Care Advisory Board: Strategy and Operations Research, Clinical Research, Leadership Development, Business Intelligence and Analytics, and Physician Performance. In our case, an Affinity employee can simply guide his mouse to the information of interest.”

“Curmudge, I understand that The Advisory Board has developed a lot of information on accountable-care organizations (ACOs). What’s an ACO anyway?”

“Good question, Julie, to which the answer is not completely defined. Here is the March 28, 2011 Wall Street Journal’s answer: ‘In broad outline (ACOs) propose to unite doctors and clinics or hospitals in groups that pool their resources with the goal of trimming spending while boosting the quality of care. When the group can show that it is improving care and delivers it for less than the cost projected—arrived at by crunching historical patient data for that market—a share of the savings goes to the ACO’s bottom line.’ This concept is part of the 2010 health care law and is not yet fully developed. It initially only applies to Medicare patients and, you’ll note, contains some features reminiscent of the medical home.”

“So what’s next, Curmudge?”

“What’s next will be in our next posting on this topic. Anyone who has read much about accountable-care organizations looks forward to quitting for the day, and c’est moi (that’s me). See you next time, Julie.”

Affinity’s Kaizen Curmudgeon

The Old Men's Table

2011-04-18T10:25:00.000-05:00

“When I arrive early for the weekly meeting of our service club, I get my food at the buffet and find a spot at a table that’s occupied by other old guys who came early. Although it’s not official, this has become a sort of Old Men’s Table. Looking around the room, I can identify the unofficial Politicians’ Table, the Successful Women’s Table, and several tables of younger men and women on their way up in the community.”

“So, Curmudge, what’s so special about the Old Men’s Table? I presume that it is populated by old codgers like you.”

“Sometimes, Jaded Julie, I am the youngest. Sadly, our tablemates tend to die off. Then we hear, ‘Carl died on Saturday? But he was sitting right in that chair last Tuesday. I can’t believe he’s gone.’ Well, my wife died three months ago, and I can’t believe she’s gone. Then someone else says, ‘My wife died four years ago, and I think about her every day.’ “

“That certainly sounds depressing; but I suspect that you are headed toward some sort of lesson, so I’ll keep listening.”

“After a few more comments about Old Carl, we return to our old-guy jokes. ‘I’m so old that I have to pre-pay when I order a three-minute egg.’ ‘I never fill my car’s gas tank because I’m afraid I won’t live long enough to use it all.’ ‘Who wants to live to be 90? Someone who is 89.’ “

“Curmudge, I surely hope you live long enough to get to the point of this story.”

“Don’t leave yet, Julie. Our old-guys group is about evenly divided between widowers and those with a living wife. The outlooks of the two groups are dramatically different. Those with a wife are concerned about dying and leaving their wife to fend for herself.”

“Of course we all know that widows fare better than widowers, but it’s easy to appreciate why a husband would be worried.”

“I certainly was. My wife couldn’t even stand on a ladder and change a light bulb. And because she was almost three years younger, it never occurred to me that I might outlive her. We even joked about the traveling she would do with her second husband.”

“So Curmudge, how does one’s outlook change when he becomes a widower?”

“Death is always worse when it disrupts the ‘orderly march to the grave,’ i.e., older people are expected to die first. So when one loses a younger wife, his grief is doubled. But he also is freed from his worry about his wife living by herself.”

“Perhaps, Curmudge, that explains why you appear cheerful on the outside but are grieving on the inside.”

“Another difference in the widower’s outlook is that death has lost much of its sting. We don’t fear death as long as it is not slow. One of the ‘old guys’ recently suffered a disabling stroke; everyone fears that. But at the same time, we don’t seek death either. We are not like Job, who ‘long(s) for death but it comes not,’ (Job 3:21). We are more like my mother who said long ago, ‘It doesn’t matter when I die…but not today.’ “

“So do we have a lesson to take home, Curmudge?”

“A Muslim friend said to me a few years ago, ‘Death is a part of life.’ There will be times in your life when you’ll need to remember that simple truth.”

Affinity’s Kaizen Curmudgeon

The Crystal Ball 1

2011-04-15T09:48:00.000-05:00

“Today we’re going to play one of our ‘Curmudge-and-Julie-make-believe’ games.”

“Ooh, Curmudge, the last time we did that I was seriously ill.”

“Don’t worry, Jaded Julie. This time the outcome will be better. Your role is to be a middle manager in a health care organization—one whose operating philosophy is command-and-control and where everything is done the way it has always been done.”

“Hey, that outfit is suffering from organizational obsolescence. They are really behind the 8-ball. Don’t they read or use computers? They must think that Google is a character (Barney Google) in a silly song. But say, Curmudge, I thought we were going to explore the future, and here we are talking about an organization living in the past.”

“We have to start somewhere, and even today there are probably command-and-control organizations out there. It wouldn’t be proper to just blow right by them. Their first need is to realize that employees are more productive when they are respected and that problems are best solved by the people in gemba…”

“…and that traditional hospitals tend to be wasteful, and that systems are best understood and improved after they are mapped. I’ve got it, Curmudge. Making these improvements is just common sense. Understanding this is where a traditional organization has to start if they want to join the rapidly changing world of health care.”

“One problem, Julie. People have their own, unique concept of common sense. We would have chaos if every person went his own way making improvements. People’s creative energies need to be harnessed and focused by using a structured program like Lean. We’ve talked about Lean in this blog for the past four years. However, for the total neophyte’s remedial reading we recommend a review of similar programs in the April 14, 2011 posting in Curmudgeon’s Wastebasket. ”

“People use lots of names for their improvement program, including those that are unique to their organization. Most of them are based on the principles of the Toyota Production System. But tell me, Curmudge, how should the wayward outfit whose role I am playing get their culture change under way?”

“Since Affinity began their Lean journey several years ago, a ton of books have been written and an army of consultants have come out of the woodwork. However, the absolute least expensive way to learn about Lean is to read Kaizen Curmudgeon. You’ll also want to benchmark organizations that have been describing their Lean successes at meetings. At some point you will probably want to contract with a sensei (honored teacher) for guidance. The best way to find such a person is to talk with people who have been where you want to go.”

“After I have done a lot of reading and become a dedicated change agent, what’s my next step?”

“Julie, leading from the middle of an organization is like pushing a rope. Nevertheless, it’s essential that those higher in the organization—especially at the top—become emotional, vocal, and physical supporters of the proposed new culture. However, your task should not be impossible if these (paraphrased) comments from a recent meeting of the American College of Healthcare Executives are valid: ‘They have heard, and hopefully understand, that they are going to have to change their organizations in major, cataclysmic ways especially if they haven’t started to do so already. Leaders in general are now much more knowledgeable about the steps they will have to take. They understand they have to adopt Toyota and Lean manufacturing strategies.’ “

“Whew! That helps. Let’s assume that I am successful and that the organization has set sail on its Lean journey. Can I sit back and relax?”

“No way! It may have taken herculean efforts to get the flywheel turning, but it is not frictionless. Maintaining a Lean program requires dogged determination and almost religious dedication. And ideally, it never ends.”

“Perhaps it’s a bit like marriage, Curmudge. You’d better hardwire the whole concept, because it’s going to be your partner for a long time.”

“In addition, Julie, as the resident futurist you will want to expand your horizon. Instead of thinking how better to organize a supply closet, you’ll want to know what’s coming down the pike that will impact your organization.”

“Wow! That’s a gigantic expansion. I assume we’ll talk about that next time. By the way, Curmudge, are you a futurist?”

“Of course I am, but for me the future is tomorrow. That’s why if I wake up in the morning, every day is a beautiful day.”

Affinity’s Kaizen Curmudgeon

The Crystal Ball--Prologue

2011-04-07T10:47:00.001-05:00

“Curmudge, in this turbulent world, how were you able to stay employed so long?”

“Well Jaded Julie, I kept reinventing myself. I was always looking for ways in which my experience matched my employer’s needs. Often it was difficult to anticipate what those needs would be. Ultimately I became ‘retired’ when I ran out of inventions.”

“The outlook for health care in the U.S. appears to be even murkier than what you experienced in industry. Nevertheless, are there people or organizations who are trying to foresee our admittedly cloudy future?”

“Of course, Julie. But forecasting becomes more risky as one tries to peer farther into the unknown. Let’s start with the near term. Because most everyone already knows that we must become more efficient tomorrow, next month, and next year, we can forge ahead with process improvements with no concern that we might be wasting our effort. But planning ten or twenty years ahead is much more difficult.”

“C’mon, Curmudge, at your age planning ten years into your future is overly optimistic and twenty years out would be a waste of time.”

“Regrettably, that’s true. As you already know, I don’t even buy green bananas. However, for those folks like you anticipating a long and successful career, let’s try to look ahead anyway. Of course, you are not going to make it into the future unless you can make it through today. So we’ll start by describing resources that every health care organization should be using right now. And along with being contemporary, this knowledge is used locally, i.e.; it’s applied by the workers in gemba.”

“It sounds as if you are talking about Lean, which all of our readers should understand pretty well. But why should I, a nurse, push my knowledge horizon out into the future?”

“Be optimistic, Julie. In health care, nursing can be the gateway to most anything in the organization. The business unit and corporate leaders of the future had better understand what will be going on around them.”

“I’m convinced, Curmudge. May I sign up for your trip over the rainbow?”

“Of course. Pack your carry-on; we depart in a week or two.”

Affinity’s Kaizen Curmudgeon

I've always done it that way.

2011-03-24T11:09:00.001-05:00

“Curmudge, today’s title looks as if it might be a sequel to last week’s We’ve always done it that way.”

“Very perceptive, Jaded Julie. Let me give you a ‘heads up.’ Today’s lesson is that standard work is more efficient, less costly, and usually easier than when everyone does things as they have always done them in his or her own way. Most importantly, standard work enhances patient safety.”

“That sounds intuitive, Curmudge, but I’ll bet that you have some evidence to back it up.”

“You recall my mentioning my senior citizen friends that I see every Independence Day. Although it’s depressing, we often talk about health issues. It is discouraging to learn that among that group and my other friends and acquaintances, many people have incurred surgical site infections. Of course these people were the fortunate ones, because they lived to tell about their experience. My circle of close friends is small (and its diameter is being reduced by the Grim Reaper); but even without hard data, the frequency of these presumably preventable infections is shocking.”

“So much for anecdotal evidence. There must be some information out there that supports your thesis that standard work makes patients safer.”

“Have patience, Julie, we’ll get to it. It’s my understanding that individual surgeons favor specific instruments, sutures, prosthetic devices, and other replacement parts for a given procedure. This is called their ‘preference list.’ So surgeon A would have his/her preference list for procedure X, while surgeon B might have a different list for the same procedure.”

“That doesn’t sound like standard work to me. But it’s not surprising, because surgeons A and B might have learned the procedure from attending surgeons in institutions hundreds of miles apart. In each case, the surgeon might say about his technique and preference list, ‘I’ve always done it that way.’ That must be pretty common, Curmudge, but how does it relate to surgical site infections?”

“In his leanblog.com posting on March 7, 2011, Mark Graban cited a study of a procedure that historically yielded from 2 to 5% frequency of surgical site infections. At the start, the study group members used 14 different pre-printed order sets for the same procedure. After weeks of deliberations, the surgeons and anesthesiologists reached consensus on standard order sets.”

“Wow! Those meetings must have required a talented facilitator. What was the outcome of their having adopted standard infection control procedures?”

“The study group went 11 months without a single occurrence of the target infection. And when a single infection ended their record, the group was able to investigate its root cause without blaming an individual. Overall, their surgical site infection rate dropped 63%. Furthermore, the team agreed that they would make changes that are best for the patient rather than the provider.”

“That’s really impressive. It’s critical to realize that the changes were made by the physicians themselves. They most likely would not have been adopted if they had been imposed on the physicians by someone else. By the way, Curmudge, do you have a standard procedure for writing this blog?”

“Sometimes I ruminate on a topic for weeks; sometimes for only a few minutes. Then I just sit at the computer and write. I’ve always done it that way.”

Affinity’s Kaizen Curmudgeon

Kaikaku, a countermeasure for "We've always done it that way."

2011-03-18T10:06:00.000-05:00

“Jaded Julie, here’s a new Japanese word for you to learn. It is kaikaku, meaning radical or transformational change.”

“Another word! Curmudge, I thought we topped off my Japanese vocabulary years ago.”

“Now Julie, you’ve known for a long time that there are single words—in several languages—that substitute for phrases, sentences, or even paragraphs in English. Often there is no comparable English word, and the foreign word says exactly what we want to express.”

“I get it, Curmudge. We have already learned that gemba is the workplace or ‘where the action is,’ and muda is waste that comes in at least eight varieties. And of course, kaizen, ‘continuous improvement’ or ‘small changes for the good,’ is one of the central principles of Lean. So why kaikaku? Doesn’t kaizen cover all the changes that need to be made?”

“Not always. Think of the all-too-common expression, ‘We’ve always done it that way.’ That statement usually represents a historical practice that was implemented without a lot of forethought and has been ‘grandfathered’ into everyone’s thinking. To a change agent, that is abhorrent and is a candidate for immediate evaluation and perhaps radical change.”

“Okay, armchair insurgent, please provide an example.”

“Julie, we talked about this back on July 16, 2009. It was part of our series of postings on queuing theory and level loading or heijunka. Scheduling—especially in hospitals—tends to follow tradition and leads to hills and valleys in people’s workloads, i.e., poor heijunka. Because this is a big, always-been-done-that-way problem, it would require a big, kaikaku countermeasure.”

“Does kaikaku always refer to a big change applied to a big problem?”

“Not always, Julie. The critical difference between kaikaku and kaizen is timing. Kaikaku is quick and total; kaizen is continuous and incremental. Not all processes can be changed incrementally. For example, if you are taking your car through the ‘chunnel’ from France to Britain, you drive on the right in France and immediately change to the left in Britain.”

“Okay Rick Steves, but do you have a Lean example?”

“If a three-day or one-week small-team ‘kaizen’ or rapid improvement event yields a clear, definitive solution to the problem at hand, that’s a kaikaku. We’ve heard about a lot of these in our monthly kaizen report-outs. On the other hand, if a favorable outcome will require incremental improvements and several plan-do-check-act cycles, that’s kaizen.”

“Let’s get real, Curmudge. Does it truly matter which word we use, kaizen or kaikaku?”

“Probably not, but it might if you are Japanese. Here’s a different sort of problem. Suppose you are involved in an effort that ends up with neither a kaikaku nor a kaizen. Unfortunately, some of these might begin as a kaizen event, get bogged down because the traditions are so strong, and end up where they started—doing it the way it’s always been done.”

“And do the Japanese have a name for those?”

“Very likely, but as in English, it would be too profane for posting in Kaizen Curmudgeon. Maybe we should call those ‘teachable moments’ and return later in our Lean journey to tackle the seemingly intractable problems.”

“Old Guy, it has occurred to me that not all traditions are bad. Here’s a good example of something that has always been done that way. On Fridays we’d knock off work early and enjoy some Gemütlichkeit, ‘good living’ in German, at a local oasis.”

“At my age, Julie, my kaikaku for traditional Gemütlichkeit is to go home and go to bed early.”

Affinity’s Kaizen Curmudgeon

Complacency 2

2011-03-10T11:27:00.000-06:00

“Wake up, Curmudge! It’s too early for your afternoon nap.”

“I’m not napping, Jaded Julie. I’m concentrating on our colleagues’ one-page papers and trying to extract lessons that are worthy of being shouted from the roof of the hospital’s parking structure. As in last week’s posting we are sharing with our readers portions of our guest authors’ interpretations of John Kotter’s quotation, ‘Never underestimate the magnitude of the forces that reinforce complacency and that help maintain the status quo.’ Now it’s Rick’s turn. He focuses on the threat of complacency following a critical period in the life of an organization.”

“Kotter lists nine sources of complacency, but I want to briefly describe two that are intertwined. They are, ‘Absence of a major and visible crisis,’ and ‘Too much happy talk from senior management.’ I recall the story that our CEO told our Lean class, ‘Several years ago the threat facing the organization wasn’t how to take the next step in our growth as an organization, but rather how to avoid taking our last step as an organization.’ Wow! That really grabbed our attention. At that point, there was most definitely a major and visible crisis, and senior management certainly wasn’t bragging about the bright future of Affinity. There were tough decisions that were made and hard work that was done and Affinity is now in a stronger position. However, now that the existential danger is lessened, a new threat, complacency, may be present out there in the organization. We need to praise all the hard work and success that everyone made to get us to our current position. But by doing so, do we risk negating the sense of urgency within the organization that is needed to make the next step? The threat is that we might rest on our laurels because the danger of the organization’s collapsing appears to be no longer imminent.”

“The other part of our newer colleagues’ assignment was to explain how they would use Lean to manage their staff in challenging the status quo. In brief, they have been asked to present a problem with complacency—as they have done above—and then propose appropriate countermeasures. Since Rick just described his problem, let’s read how he will tackle it.”

“The challenge facing the organization is to make sure that we don’t lose our sense of urgency. We need to develop Lean leaders that have the self-motivation and internal urgency to be the best. With those qualities, they will retain our focus on the corporate vision.”

“I believe what he is saying is that middle managers’ dedication to Lean must be visceral.”

“My knowledge of anatomy is pretty sketchy, Julie, but I suspect that in this context, visceral is the same as hard-wired.”

“I believe we all agree with Justin, who feels that the most effective way to challenge staff in implementing change is to create a high sense of urgency.”

“To effectively change the status quo, you must start to change culture, which is typically is very difficult to accomplish. Escalating the sense of urgency counterattacks complacency in individuals who are not resistant to change. This escalated sense of urgency pushes individuals to the edge of their comfort zone and reiterates the need for change. The sense of urgency should also make it difficult for employees to revert back to their old habits, either by eliminating the possibility or by encouraging a need of abandonment.”

“Ieva maintains a sense of urgency not by injecting Lean into an existing system but by totally changing the system. In this case, the change is from traditional primary care to the Medical Home model.”

“In my role as a Lean coach, I have committed to bring this sense of urgency to life by teaching and helping our staff look at our processes with new eyes. I specifically have been blessed to work with our Medical Home sites in implementation of a new care delivery model. While it is easier to spot changes that need to take place at the new sites, I continuously challenge our existing Medical Home sites to look at the new and improved processes and evaluate and adjust as needed. We do not always figure out the best way first—there is always improvement to be had.”

“We haven’t quoted Jerry in this posting yet, but I believe he has a viable countermeasure for incorrigible resisters to change.”

“There are mindsets in organizations that are rooted so deeply that they are nearly impossible to change unless they are eliminated through a transformation, total renewal of mind, or in some cases radical surgery.”

“It sounds as if sometimes people just have to be asked to ‘get off the bus.’ That seems pretty harsh.”

“Congratulations, Curmudge. For once you used a five-dollar word, ‘harsh,’ when you might have used a ten-dollar word, ‘draconian.’ But tell me Curmudge, are we going to post our guest authors’ writings on complacency and change leadership without putting in our own two cents?”

“We have been there and done that three years ago, Jaded Julie. I hope you haven’t forgotten our postings on Change Leadership for Middle Managers.”

Affinity’s Kaizen Curmudgeon

Complacency

2011-03-03T10:14:00.000-06:00

“Curmudge, if you were going to give just one book to a new Lean Coach-in-Training, what would it be?”

“Without question, Jaded Julie, it would be John Kotter’s Leading Change. But you know that I am too cheap to buy a book for every hard-working, intelligent, and talented person to come down the pike.”

“Okay Scrooge. What would you recommend?”

“Of course I’d recommend Kotter’s book, but for someone who is short of time and money, I’d advise reading Kaizen Curmudgeon. And a good place to start would be our posting ‘way back on October 29, 2007, A Funny Thing Happened on the Way to the Transformation.”

“Well as it turns out Curmudge, the newer members of our team already have Kotter’s book, and they have been asked to write about a topic close to John Kotter’s heart, complacency. Furthermore, they are willing to contribute their writings to Kaizen Curmudgeon.”

“Guest authors? Saints be praised; it’s a miracle!”

“The specific assignment for the new Lean coaches is to explain in their own words Kotter’s statement,’Never underestimate the magnitude of the forces that reinforce complacency and that help maintain the status quo.’ Here are their one-page papers, Curmudge, but please spare the red pencil when you edit them.”

[Later] “The first thing I noticed, Julie, is that no one has defined complacency. We’d better do that: ‘A feeling of quiet pleasure or security, often while unaware of some potential danger; self-satisfaction or smug satisfaction with an existing situation.’ With the help of dictionary.com, we all should now be on the same page.”

“Let’s start with Ieva’s contribution, slightly edited. Despite her European heritage, it looks as if she started writing English composition at the age of three.”

“Instead of looking at others, I would like us to take a look at ourselves. Our organization adopted the Lean philosophy approximately four years ago and has come a long way in not only talking but also walking Lean. Even with impending health care reform, we feel that our present organization is a good place to work, is competitive, and provides outstanding care to our patients. Sounds complacent?? …Perhaps. This is how easy it is to slide down the slippery slope of complacency. Complacency is not a single sin that we commit; it is comprised of various elements that usually involve human nature, happy messages from senior management, low overall performance standards, and internal measurement systems that focus on the wrong performance indexes. We have been diligently working on aligning our goals and strategies and also set our bar high when it comes to metrics. But still, once in a while, we encounter the presence of the ugly ‘c’ word, complacency. As Kotter wrote, ‘People will find a thousand ingenious ways to withhold cooperation from a process that they sincerely think is unnecessary or wrongheaded.’ Thus other people’s complacency—or even obstruction—may be out there, but we might be too self-satisfied to realize it. Even high performing organizations can slip into the lull of ‘we are doing so great.’ The above quote to me means that we need to always be vigilant and aware that despite our progress, we may not let our guard down and feel that we have ‘finally made it.’ The sense of urgency needs to be ever present in our actions to ensure that we do not become too comfortable.”

“Justin takes a somewhat different tack. He believes that Kotter was writing about the difficulty in changing the culture in an organization, specifically addressing those individuals who don’t actively resist change, and who don’t necessarily support it either.”

“In a well-established organization, the cultures and habits of employees can be difficult to change. Employees who have had exposure to current corporate culture my actively resist or thwart efforts to implement change. These characters are obviously the easiest to identify, due to their visible determination to disrupt change, and are usually the clear target for ‘reeducation’ by those implementing change.

In addition to the employees who actively resist change, there are also those who don’t voice their opposition to change. They might even verbally agree with the proposed changes, but act in a way that doesn’t support them. There could be many ways these types of employees discourage change, such as: overstating performance measures, rigging surveys and systems to ensure no issues arise, downplaying or denying crises, and denying the urgency for change. These individuals are subtle in how they enhance complacency, and are usually difficult to immediately identify. They often pose a larger risk to change than those who actively disapproved of it because they quietly but persistently spread their views to others. Kotter states ‘… those who were relatively unaffected by complacency … and thus concerned about the firm’s future were often lulled back into a false sense of security by senior management’s ‘happy talk.’’ Senior management may unintentionally discourage the need for change by influencing those who once believed change was urgent.”

“Curmudge, it seems to me that Kotter was being overly tough on management. Managers have to walk a tightrope between sharing good news when the news is good and reducing the sense of urgency.”

“Speaking of tightropes, Julie, you and I must be careful in our editing that we don’t discourage the writers from future participation.”

“Hang in there, Curmudge. As a last resort, we can say that you really are a curmudgeon, i.e., a nasty old man. Meanwhile, let’s invite our readers to come back next week to read the work of more guest authors.”

Affinity’s Kaizen Curmudgeon

Way to go! 2

2011-02-24T10:13:00.004-06:00

“Jaded Julie, in last week’s posting you were playing the role of a senior citizen hospitalized with a serious lung disease. Please bring us up to date on your condition.”

“Do I have to, Curmudge? I don’t want to be an ill person, even though it’s just imaginary. It was much more fun when you and I were pretending to watch the sun come up over the city of Florence, Italy 400 years ago.”

“That posting was a year ago in Curmudgeon’s Wastebasket. Now please, Julie, let’s go back to the script.”

“So there I am in my bed on a med/surg floor. It is around 11:00 Saturday night and oxygen is flowing through the cannula into my nostrils, but the percentage oxygen saturation in my blood is dropping. Crisis! I would have died then and there, but the ‘partial code’ on my chart directs the hospital to try to maintain my respiration until the rest of my family can arrive from out of town. That requires that I be moved to the Intensive Care Unit (ICU) and be put on a ventilator.”

“Why must crises occur in the middle of the night? The physician and available family members are called, and they rush to the hospital. There you are, apparently asleep, intubated with the ventilator puffing regularly for you, IVs in each arm, and monitors blinking out your condition in impersonal digits. What can we do? The experienced nurse is seeing to your every need, and the doc feels that you can hang in there for a few more days.”

“But Curmudge, aren’t the family members going to stay with me and keep a vigil?”

“Some families do, but we are confident that you are in good hands. For us, it’s back to bed.”

“It’s now Sunday, and I sense that some of my family have returned. Of course, I can’t say anything with all of this hardware down my windpipe. In addition, the IVs are giving me fentanyl (more potent than morphine), lorazepam to manage anxiety, and vecuronium bromide, a paralyzing agent. The result of all these meds is that I am feeling no pain and not attempting to breathe in opposition to the ventilator. Oh, I almost forgot; there are electrodes stuck to my forehead to sense my brain activity.”

“Family members say, ‘good morning,’ and squeeze your hand. We believe you can hear us because your brain monitor goes up. Actually, I now know that you could hear us because of a story I heard (1). A man was on a ventilator in an ICU, and his nurse kept singing the familiar polka, ‘Roll in the Barrel.’ After he recovered and was off the ventilator, he asked why the nurse couldn’t get the lyrics right for ‘Roll out the Barrel.’”

“Despite the nurse’s combing my hair occasionally, I must be quite a sight. Friends who hadn’t seen me for a couple of weeks come into my room, look at me and squeeze my hand, and walk out with tears in their eyes.”

“It is evident that you are failing irreversibly. The nurse turns off the monitors so visitors will focus on you and not on the steadily falling numbers. You are being weaned off the drugs so your body will not be paralyzed and will be physically able to attempt to breathe when the ventilator is turned off. The high carbon dioxide content of your blood is acting as your body’s own sedative.”

“I am able to rest more easily after my sons arrive—one on Monday and one on Tuesday. The end is near.”

“The family members are ushered out of the room; and according to your wishes, the ventilator is turned off and all the tubes and IVs are removed. The family and clergy return. You make a few snoring-like sounds and become quiet. The physician puts his stethoscope to your chest and pronounces, ‘she’s gone.’ After prayers appropriate for your religion and last good-byes, it is over.”

Affinity’s Kaizen Curmudgeon

(1) Personal communication, Bernardine Nitz.

Note: An observation on the practice of emergency medicine in a primitive location may be accessed via this link.

Way to go!

2011-02-17T08:59:00.002-06:00

“Curmudge, our title sounds like the congratulation that a ball player receives upon returning to the dugout after hitting a home run.”

“No way, Jaded Julie. Our topic is an end-of-life issue, and the title might be more appropriate if we changed it to A Way to Go. We’ve all heard the chilling announcement, ‘Code Blue,’ in the hospital. It has been described quite graphically in Nurse Gina’s codeblog.com, ‘How do you suppose being coded feels?’ For the patient whose heart has stopped, the process involves starting IVs, intubation, defibrillation, and chest compressions. None of this is comfortable for the patient, but for about 20% of 40-year old heart attack victims it might be the key to a longer life.”

“It’s been a long time since there were 40 candles on your cake, Curmudge. I’ll bet that your interest is what happens when a ‘code’ is called for an elderly patient with multiple diseases and infirmities.”

“Right as usual, Julie. The odds of success go down and the discomforts go up. Resuscitation (CPR) is apt to fracture the elderly patient’s ribs, and to what avail? To my knowledge I don’t have multiple diseases and infirmities, but I don’t want to have my chest crushed under any circumstance. I guess I’m a good candidate for ‘No Code’ or DNR (‘Do Not Resuscitate’).”

“But, Old Guy, what if you are unable to say that? Pulseless, non-breathers are also non-speakers.”

“That’s why one must have an advance directive. Your health care power of attorney authorizes someone who knows your wishes to speak for you if you can’t. You should discuss this with your providers and have a copy of your document put in your file.”

“Are there special situations where one might want something between a ‘Full Code’ (which seems to be the default) and a DNR?”

“There can be a ‘Partial Code’ that specifies actions to be or not to be taken, but Gina’s blog doesn’t speak very highly of them. But let me tell you about a case where a partial code was ‘just what the doctor ordered’ (literally, because your physician must order your code status to be put on your chart). You are going to be our model patient, Julie, and you have just been brought to the ED with a severe respiratory problem.”

“But I feel fine, Curmudge.”

“C’mon, Julie, play your role. You are a senior citizen and you are critically ill.”

“Okay, I know what happens now. They see that I am gasping for breath despite breathing oxygen from the tank on my lap and take me right back. Someone sticks an IV catheter in my arm, and someone else takes the list of medications that I brought and starts doing the med rec (medication reconciliation). An emergency medicine physician comes in, performs a brief, focused examination, and asks a lot of questions. After viewing my chest x-ray, he and my pulmonologist (who happens to be on call) decide to admit me to a med/surg floor in the hospital. Of course, more time than I would wish passes before I am taken upstairs.”

“Wow, Julie, you really know the drill. When you are settled in your room the hospital provides lots more oxygen than you could get at home; it’s either via a mask or a cannula in your nostrils. Because pneumonia seems to have catalyzed your chronic lung disease, you are given antibiotics via IV.”

“Now I feel better. Maybe I’m on the road to recovery.”

“That may be wishful thinking, Julie. When your pulmonologist comes by, you ask, ‘Do you think we should call our son home from overseas?’ His answer is, ‘yes.’”

“That’s a real bummer. I must have had a premonition that things were not going to go well. Because our son’s trip will take several days, perhaps we should revisit the DNR order on my chart.”

“Actually, that’s the whole point of this posting. You definitely don’t want a code blue if your heart quits, but you will accept more help with respiration until your whole family is here. And in the interim you want to be kept comfortable without pain or gasping for breath. We are all in accord, and your pulmonologist specifies the partial code on your chart.”

“And to end this chapter of our two-part posting, night is falling and I am left in the care of the excellent nurses on the floor.”

“Hang in there, Julie, so we can bring this to a conclusion next week.”

Affinity’s Kaizen Curmudgeon

The Middle Years

2011-02-09T09:28:00.002-06:00

“Curmudge, it doesn’t look as if we’re going to talk about Lean.”

“Right, Jaded Julie. We are going to talk about health, especially in one’s middle years.”

“Do you mean middle age? It’s been many years since you were that young.”

“No. I mean the years between when one is in his/her 70’s or 80’s and death. To a younger person, good health is almost assured, but for those in these middle years, poor health at some point is almost inevitable. Here is an example. A group of us senior citizens gets together every Independence Day. On average, one group member dies every year. The wife of one of the men is his third; one widow has buried two husbands, and both members of another couple are deceased.”

“Thanks, Curmudge, for cheering me up. I assume the multiple spouses you mentioned were successive and not concurrent.”

“Let’s look more specifically at the health of older couples. When both spouses are healthy, they are able to do the normal retired-couple things, like traveling, attending concerts, serving as volunteers, or even working part time. But when just one member of the couple becomes ill, everything comes to a halt. The healthy person often becomes the caregiver for the one in poor health.”

“Although it’s obvious, I never thought of it that way. I always felt that as long as I am in good health, I’ll be able to do all the things I want to do. But in reality, what I can do depends on the good health of both my husband and me. It’s sort of like ‘a chain is as strong as its weakest link.’ In marriage, it’s a two-link chain.”

“Here, Julie, are some extreme examples among our acquaintances. A middle-aged woman suffered a traumatic brain injury in a car accident; her husband was her caregiver for the next 20 years. A couple in their 60’s drowned together when their tour bus ran off a mountain road in Switzerland and into a lake. As you see, the caregiver’s role can last from zero in the case of simultaneous deaths to many years, with all sorts of durations in between. I was a caregiver for only a week but was willing to go on for much longer. In all cases the ending is sad, but in some instances it is a blessing and in others it is tragic.”

“Curmudge, all I can do is shudder. So what’s our lesson?”

“It’s pretty simple. Do the things you want to do in life while you are young, i.e., younger than 70. Take care of your health, stay safe, and be lucky. And also, choose a spouse who appears healthy. As our family doctor—a horserace enthusiast—used to say, ‘pick a lean horse for a long race.’”

“But it doesn’t always work that way, Curmudge. As you know so well, your originally-lean spouse’s race was much too short.”

Affinity’s Kaizen Curmudgeon

What shall we do with you?

2011-02-02T10:37:00.001-06:00

“During the past Holiday Season Mrs. Curmudgeon entertained quite a bit.”

“You’ve told me about those events, Curmudge. Apparently your role was door-opener, drink-mixer, sandwich-cooker, cleaner-upper, and all-around lackey.”

“That’s right, Jaded Julie. Most of the guests were musicians; and when they gathered around the grand piano in the living room to sing, I chatted with the non-singing spouses in the family room. Sometimes we talked about what we do for a living, or in my case, as a volunteer.”

“Presumably you described your writing about health care and occasionally, management.”

“One woman, who doesn’t work in health care, was distraught over her supervisor’s seemingly exasperated question, ‘Penny (not her real name), what are we going to do with you?’”

“Wow, Curmudge! In these days of big organizational changes, that sounds ominous, and in any case it’s an outrageous thing for a supervisor to say. When you hear a question like that, you almost expect to see Alice in Wonderland’s Red Queen run into the room shouting, ‘Off with her head.’”

“It’s almost that bad, Julie. One would certainly anticipate being fired later if not sooner. A young employee would conclude that her future lies elsewhere, and an employee over 50 would experience gross insecurity.”

“How did you feel, Curmudge, when you heard Penny’s story?”

“I was appalled. Irrespective of the supervisor’s intent, she shouldn’t have spoken that way. It reflected a lack of sensitivity as well as poor training of middle managers by her employer. We have the Affinity Learning Center. Don’t other major employers have something comparable? If they don’t, a middle manager should train herself. There are easily a hundred books on management in Barnes & Noble and the Public Library. I’ll bet that not one of them advises a manager to brow-beat her employees.”

“I fully expect that you, Old Manager-from-Long-Ago, have some advice for the offending supervisor.”

“I certainly do, but it’s from my reading, not from my experience. According to Marshall Goldsmith (1), ‘Good manners is good management.’ What distinguishes an advancing manager from one who has hit a plateau has nothing to do with experience and training and everything to do with behavior.”

“I’m not sure that I agree totally, Curmudge, but poor behavior is certainly a death knell for advancement.”

“Another characteristic of a successful manager is ‘mindfulness.’ You must always be aware of who you are, what you are doing, and to whom you are speaking. And this doesn’t apply only to managers. At Walt Disney World, each member of the ‘cast’ (all employees) is expected to remain ‘in character’ except for emergencies.”

“We once talked about one’s personal brand, the way a person acts consistently. Mindfulness sounds like an essential component of a positive personal brand.”

“That’s right, Julie. If one’s personal brand is an old grouch, his career will be limited to either a manure shoveler or a blog writer.”

Affinity’s Kaizen Curmudgeon

(1) Goldsmith, Marshall. What Got You Here Won’t Get You There. (2007, available from Amazon)

Autonomy 2

2011-01-27T09:24:00.002-06:00

“Today, Jaded Julie, we’re going to continue our discussion of the assertion in Daniel Pink’s book, Drive, that autonomy is the principal workplace motivator. To an arm-chair psychologist, that sounds as if autonomy is the major component of self-actualization, the pinnacle of Maslow’s well-known pyramid.” (1)

“Whoa there, Abraham. You lost me with self-actualization.”

“It’s not hard, Julie. Self-actualization is just another way of describing the life force that will ultimately lead to maximizing one’s abilities. Like the old Army slogan, ‘Be all you can be.’”

“Now I see; you and I talked about that years ago. Now the slogan is ‘An Army of One.’ Pink would like that, but I don’t. An army must be a team—not a bunch of autonomous warriors.”

“You are getting at the problem, Julie. Autonomy leads to self-actualization only in certain instances. In Europe I’ve seen Grieg’s and Mahler’s composer’s cabins—actually one-room buildings with a big piano overlooking a lake—where they wrote beautiful music in solitude. Autonomy certainly worked for those guys.”

“But it won’t work in a hospital, Curmudge. A surgeon is likely to be the most autonomous person in the building, but he would never have gained his skill without the collaboration of an anesthesiologist and the rest of the OR team.”

“Great insight! Now let’s look at the broader problem. If autonomy won’t lead to one’s maximizing their potential in a hospital, what will give one the freedom to be the best they can be in any endeavor that requires teamwork?”

“I know the answer you’re waiting for, Curmudge. It’s ‘Lean.’ But you’re going to have to explain it, beginning with this question. If autonomy and standard work are opposites and people seem to like autonomy so much, why will they accept the standard work aspect of Lean?”

“Imai provides a short answer. ‘Where there is no standard, there can be no improvement’. (2) Thus improving and reaching your full potential require a starting point—the standard.”

“That seems reasonable. How about some examples?”

“Most everything done in a hospital or clinic is part of a system or process. Consider a housekeeper who cleans inpatient rooms. She is right in the middle of the patient discharge-new patient admission process. Because she works alone, she has a degree of autonomy. She might modify the way she cleans a room so as to lessen the pain in her back.”

“That would be autonomy all right, but it doesn’t sound like self-actualization. Of course, anyone with back pain would do almost anything to obtain relief.”

“Because of her dedication to the hospital, the housekeeper doesn’t dare to vary from the standard cleaning protocol for fear of leaving a room inadequately cleaned and sanitized. So she proposes her modification to her supervisor and team. They test it, approve it, and adopt it, and she receives the appreciation of her teammates who might also have had back pain. To a housekeeper, using Lean to make her standard work easier may constitute self-actualization.”

“It seems that in a team environment, a bit of autonomy can be the first step in improving a standardized process. Thus autonomy and standard work are not always opposites.”

“That’s the idea, Julie. Now let’s consider an example at the other end of the health care food chain. Improvements in accepted medical procedures or medications often begin with an ‘a-ha’ moment in the mind of an individual physician or medicinal chemist. That’s autonomy. But before it becomes an evidence-based procedure or an FDA-approved medication, a lot of teamwork and trials are required to make it a new standard. So once again, autonomy and standard work are complementary.”

“Back to our original concern, Curmudge. How can one achieve self-actualization—being all you can be—through teamwork?”

“Although their tangible rewards range from promotions to reduced back pain, the people in our examples, from the highly-educated professionals to housekeepers, are rewarded most of all by feelings of personal accomplishment and contributions to something with a purpose—be it knowledge, the welfare of their patients, or an organization—that is bigger than they are.”

“Hey, Curmudge, for once you are writing about something that you know.”

“I had almost forgotten, Julie. Several years ago I had a compression fracture in my back.”

Affinity’s Kaizen Curmudgeon

(1) http://en.wikipedia.org/wiki/Self-actualization
(2) Imai, Masaaki. Gemba Kaizen

Note: An observation on the practice of emergency medicine in a primitive location may be accessed via this link.

Autonomy

2011-01-06T11:09:00.001-06:00

“Jaded Julie, a few weeks ago I was reading a book by Daniel Pink. The title is Drive: The Surprising Truth About What Motivates Us.”

“Okay, Retired Guy, I know you are going to tell us what’s in the book. I also know that you’re too cheap to buy a book unless it is a true classic. So why don’t you confess as to the circumstances of your reading Pink’s book?”

“I saw the book on the shelf in Barnes and Noble, picked it up and read part of it. Then I found an extensive review in Amazon.com. That may sound like education on the cheap, but remember, I received my last paycheck in 2004.”

“So what, O Thrifty Scot, did you learn?”

“Pink said that ‘people would prefer activities (at work) where they can pursue (1) Autonomy: People want to have control over their work. (2) Mastery: People want to get better at what they do. (3) Purpose: People want to be part of something that is bigger than they are.’”

“Those sound reasonable. They remind me of Quint Studer’s ‘Purpose, Worthwhile Work, and Making a Difference.’ But there are instances where one can’t have all three of Pink’s preferred activities. For example, it’s hard to have complete autonomy—each individual doing what he wants to do—in an organization with a unified purpose like a symphony orchestra, a drill team on parade, or more appropriate to our concern, a hospital.”

“A very astute observation, Jaded Julie. And it’s unfortunate that of Pink’s three ingredients of drive, the one he emphasizes is autonomy. An individual in most organizations can’t be truly autonomous, although that might be possible for a hermit in a cave…”

“…or a curmudgeon in a cubicle.”

“Let’s go back to our hospital example, Julie. Can people be motivated in an organization that precludes complete autonomy?”

“Curmudge, the best answers for that are in a combination of Studer’s Hardwiring Excellence and Lean. There’s no question that a well-run hospital has the right purpose, and that as a nurse, my job is worthwhile and can make a difference in a patient’s outcome.”

“It sounds as if you like what you do. You, hopefully like all nurses and others who have chosen a career in health care, are motivated when you walk in the door. In that case, an important task for the hospital or clinic is to prevent your becoming de-motivated.”

“You know it, Curmudge. Without the right culture, i.e. Lean, a hospital can become a hotbed of de-motivation and frustration. In a place like that, nurses are always on a treasure hunt for supplies, buried in paperwork, harried and overworked, and forced to spend their shift on devising workarounds rather than caring for patients. That would squelch anyone’s motivation.”

“For the moment let’s return to Daniel Pink’s book. Recall his three components of drive: autonomy, mastery, and purpose. In my opinion, the principal driver for people in health care is not autonomy or the freedom to do whatever they want. That’s not going to overcome a hospital’s potential de-motivators. Our biggest motivator is purpose or being part of something bigger than you are. We’re going to talk more about Lean, autonomy, purpose, and motivation later, Julie. So until we study the subject further we can’t condemn Pink. He appears to have a valid list of motivators, but he prioritizes them in an order that doesn’t fit health care.”

“One might say that he is in the right church but the wrong pew.”

“If you say so, Julie.”

Affinity’s Kaizen Curmudgeon

Stan's Story Redux

2010-12-29T11:18:00.000-06:00

“You’ve already heard most of this story, Jaded Julie, but not the ending. In January of 2007 I visited Stan (not his real name), a very close friend from my college days. When Mrs. Curmudgeon and I entered their house, Stan recognized me and said, ‘hello,’ but I couldn’t understand much else that he said.”

“I remember our posting the original Stan’s Story on October 30, 2008. I guess more has happened in Stan’s life since then. In any case, because of its lessons on patient safety, the story merits retelling. Please repeat the original Stan’s Story and bring us up to date on what occurred after it was posted.”

“Shortly after his retirement, Stan, who lived very far away from here, suffered a stroke. While he was recovering in the hospital, he sustained a tragic fall that injured his brain much more than the stroke had. After the fall, Stan, always a gentle giant, could not speak a coherent sentence. Although he was cared for by his devoted wife, this was not the way Stan planned to spend his ‘golden years.’

Here are some of the details as provided by Stan’s wife: Stan experienced a severe stroke early one evening a few years ago, and his wife rushed him to the hospital a few minutes away. She anticipated that Stan would be treated with thrombolytics within the ‘golden three hours.’ (However, I never did learn whether the stroke was ischemic or hemorrhagic.) Stan was first seen by a physician in the ED two hours after they had arrived; he apparently did nothing. At 2:00 a.m., a cardiologist appeared, and he pronounced that it was ‘too late’ for treatment with t-PA (or whatever). So Stan was admitted to the ICU.

While in the ICU, Stan fell and crushed the bones around one of his eyes. The eyeball was out of the socket, and 15 stitches were required to close the cut. After performing the necessary repairs, the physician checked the sight in Stan’s eye by holding up three fingers and asking Stan to count them. At that point, Stan was in no condition to count anything.

When Stan’s wife left the hospital the night of his fall, the rails of the bed were up and an alarm was in place. Stan’s condition would have prevented his lowering the rail by himself, and the alarm should have alerted the nurse had he done so. Yet the nurse in the ICU said that the rail was down when Stan fell (of course it was, but who lowered it?). Stan was her only patient. And so the risk management and legal issues began. Ultimately, Stan and his wife had to accept what they considered a very inadequate settlement from the hospital.

The final outcome as of January 2007 was as I described at the beginning of our conversation. Stan’s wife became his constant caregiver. Stan recognized me but not the names or anything about many of our close college friends. He could say ‘hello’ and ‘good-by,’ but his long sentences were quite incomprehensible. We planned to see Stan and his wife whenever we visited the far-away city where they lived, but reminiscing about our college days would have been pretty difficult.”

“Curmudge, that is so sad. And it appears to have been preventable. So what occurred in Stan’s life between your last visit and now?”

“It was not good. Stan experienced a botched removal of a kidney stone that resulted in a nosocomial infection that kept him hospitalized for a month. Then on December 18, 2008 Stan died of an apparent heart attack.”

“The latter years of Stan’s life appear to have been a tragedy of errors. I guess that explains why you became a patient safety zealot.”

“Julie, everyone should be a patient safety zealot, but it’s inevitable when tragedy strikes close to home.”

Affinity’s Kaizen Curmudgeon

Note: An observation on the practice of emergency medicine in a primitive location may be accessed via this link.

Fifty More Curmudgeons

2010-12-22T13:39:00.000-06:00

“Golly, Curmudge! Isn’t one Curmudgeon enough?”

“I hope there’s only one Kaizen Curmudgeon, because that’s my nom de plume. The world may be filled with curmudgeons (lower case ‘c’) or nasty old men. But, Jaded Julie, what I was referring to were the fifty more Kaizen Curmudgeon postings since October 29, 2009, when we celebrated the first hundred.”

“So we’ve had 150 postings on 150 ideas of things to write about. It’s too bad that most of the ideas weren’t very good.”

“Many thanks for your vote of confidence, Julie. Please remember that you were co-author. So what can we do for our readers to celebrate this sort-of anniversary?”

“It’s really hard to find a specific posting unless you know when it was posted. So why don’t we add to this note the Table of Contents for our most recent 50 postings? Then the reader can scan down the list, find a title of interest, and then click on its Date Posted to be linked to the posting.”

“Setting up all those links will be a lot of work, Julie. I trust that you will do that for me.”

“Of course, Curmudge. (I’d do most anything for the old codger.)”

Kaizen Curmudgeon Blog Title--Date Posted

101 Curmudgeons--10/29/09
Change Your Primary Care Mindset—the Physician 2--11/05/09
Change Your Primary Care Mindset—the Rest of the Team--11/12/09
The Medical Home Team Comes Together--11/19/09
It Takes More Than a Team--12/04/09
“I’m from Corporate, and I’m here to help you.”--12/10/09
Holiday Greetings from Curmudge and Jaded Julie--12/17/09
Volunteering: the Seniors’ Raison D’être--1/07/10
Curmudgeon’s Wastebasket--1/13/10
Father Clark’s Sequence--1/22/10
“Welcome to my (our) world.”--1/28/10
The First Step in New Health Care Construction: the Voice of the Patient--2/04/10
From Customer Ideas to Project Choices--2/11/10
Heart, Lung & Vascular Center: From Current State to Future State--2/18/10
Lean Lessons from Long Ago--2/25/10
Packrattery, Chaos and their Countermeasure, 5S--3/04/10
Kanban--3/11/10
What do you say after, “Lean is based on the Toyota Production System”?--3/18/10
A Culture of Elegance--3/25/10
Mistakes--4/01/10
Mistakes 2--4/08/10
Operas and Hospitals--4/15/10
Assisting Clinical Excellence (ACE) Awards--4/22/10
Hey patients, checklists are okay.--4/29/10
The Sensei is Concerned--5/06/10
Twice Blessed--5/13/10
Teamwork—It’s the People--5/20/10
Happy Third Birthday--5/28/10
The Guys in the Yellow Shirts--6/10/10
Judgment--6/18/10
AIDET Redux--7/01/10
Docs on a Treadmill--7/15/10
Mistakes 3--7/22/10
Amazing Devices--8/05/10
Amazing Devices 2--8/12/10
The World Health Congress--8/19/10
Medical Home Workflows--8/26/10
Amazing Devices 3--9/02/10
Amazing Devices 4--9/09/10
Evidence-Based Medicine—The Patient’s Perspective--9/23/10
Evidence-Based Medicine—The Patient’s Perspective 2--9/30/10
Evidence-Based Medicine—The Patient’s Perspective 3--10/14/10
Evidence-Based Medicine—The Patient’s Perspective 4--10/14/10
Evidence-Based Medicine—The Patient’s Perspective 5--10/21/10
The Robot--11/03/10
Superbugs--11/04/10
The Old Scout’s Funeral--11/18/10
The Evolution of Lean Education at Affinity--11/26/10
Why Lean?--12/02/10
The Evolution of Lean Education at Affinity 2--12/09/10

Affinity’s Kaizen Curmudgeon

Holiday Greetings from Curmudge and Jaded Julie

2010-12-16T10:57:00.001-06:00

“Get with it, Curmudge. The holiday season is upon us.”

“I know, I know, Jaded Julie. It’s a joyous time for most folks, but for blog writers, it’s a real challenge to say something new and profound every year. Over the past three years we’ve written about political correctness, family gatherings, and macro and micro happiness and unhappiness.”

“How about something about Lean? It’s hard to relate Lean to the holidays, but you should be safe from criticism.”

“I’ve got it, Julie. W. Edwards Deming’s Eighth Point, ‘Drive out fear.’ I could preach a sermon on that, and I’m the world’s least likely person to be a member of the clergy.”

“Go to it, Curmudge. I’ll be right here wave’n my arms and shout’n ‘Amen’ or ‘Hallelujah’ periodically (oops, that’s not politically correct).”

“To begin with, the intensity of fear is a continuum. In addition, fear can be only an occasional raising of the hairs on the back of your neck to a continuous gnawing in one’s innards.”

“I believe the fear that Dr. Deming had in mind was a low-level, obsessive feeling of insecurity within an organization. But I don’t see what that has to do with holidays. Perhaps if you provided some more examples…”

“A very low-intensity fear might be a teenager concerned about acceptance by her peers. At the highest end of the scale would be a soldier on a mission in Afghanistan fearful that his next step will be on an IED that could blow him to bits. Also at the high end would be an Afghan woman’s continuous fear that she could be beaten or her nose cut off by her husband (see page 39 in the December 2010 National Geographic). Here is an example that is downscale a bit: A senior citizen concerned that her next illness will be ‘the big one’ that will be debilitating or terminal.”

“I think I have the picture, Curmudge, and it’s not a pretty one. How can these people drive out their fear, and what does it have to do with the holidays?”

“In some cases the fear will be permanent, like the Afghan woman’s having to live with her fear, mutilation, and humiliation. However, she might be able to hold out some hope for her daughter. The soldier’s fears will be temporarily allayed when he is back at the forward operating base (if it is not mortared) eating a big holiday meal in the mess tent or opening a package from home. The senior citizen’s worries about her health will be momentarily forgotten with the first hug from her grandchild. And the teenage girl’s concerns about her social life will be swept away by an invitation to a holiday party.”

“I’ve got it, Curmudge. Holidays are for driving out our fears. Occasionally the respite is permanent, most often it is temporary, and sometimes it is just not in the cards. But with the help of our friends and families during the holiday season, we’ll give it our best shot.”

“Merry Christmas, Jaded Julie.”

“Happy Holidays, Curmudge.”

Affinity’s Kaizen Curmudgeon

Note: An observation on the practice of emergency medicine in a primitive location may be accessed via this link.

The Evolution of Lean Education at Affinity 2

2010-12-09T10:10:00.000-06:00

“Curmudge, you promised to start today’s discussion with one of your illogical-and-funky-but-true tales from long ago.”

“Albert Einstein would occasionally visit Professor Hubert Alyea’s lectures on physical chemistry at Princeton University. When the professor made a particularly important point in his lecture, he would look to the back of the room and see Einstein’s white head nodding in approval. Alyea’s tacit and illogical conclusion was that if Einstein understood, everyone in the class would understand.”

“I’ll admit that your story is nonsensical, but does it have a parallel in our teaching of Lean?”

“Sure, Jaded Julie. If you can design a course that is viewed as worthwhile by a physician, it will be worthwhile for everyone.”

“Well Curmudge, it took you a long time to point out that several physicians have attended our one-day Lean Overview class, and they haven’t gotten up and walked out. For docs to view something as valuable, it must help their patients, their practice, or their personal life. Lean should do all three. Our congrats to the course designers and presenters.”

“Julie, in my professorial days I taught for just 50 minutes several times per week. Standing before a class for almost eight hours would require exceptional concentration and physical stamina. Our Lean presenters have to make that sacrifice in order to cover the Lean essentials in a one-day time period acceptable to physicians and others who require a basic knowledge of Lean.”

“From my experience I know that nurses follow the physicians’ lead. That’s why physicians—especially those in a position to influence others—must learn the Lean basics. One cannot do anything of real significance in a hospital or clinic without the understanding and support of the physicians. So Curmudge, just what is in this one-day blockbuster Lean Overview course?”

“Everything…sort of. The principles and most of the tools of Lean; they are familiar to most of us and don’t need to be recited here. However, it’s important to note that it would be futile to attempt to cover every detail of Lean manufacturing discussed in The Toyota Way and The Toyota Way Fieldbook.”

“I agree. It would be sort of like insisting that one study the Bible in the original Hebrew and Greek.”

“In addition to the Lean manufacturing classics, there are several books available now that are devoted exclusively to Lean in health care. These would be efficient resources for the course presenter and appropriate for the students’ further reading.”

“Okay, Curmudge, some examples please.”

“One might use Graban’s Lean Hospitals as a how-to-do-it fieldbook. For case studies on ‘how we did it,’ read Grunden’s The Pittsburgh Way, Toussaint’s On the Mend, and Kenney’s Transforming Health Care (about Virginia Mason Medical Center—just published). Of course, one could remain a strict purest and stick to the classics on manufacturing, but that’s a route I haven’t followed. When I was a student I might have used ‘Cliff’s Notes,’ but they hadn’t been invented yet.”

“Thanks for being a paragon of virtue, Old Guy. So in addition to appropriate resources, are there other features of the Lean Overview course that are worthy of mention?”

“The handout booklet of PowerPoints has space beside each slide for the student to take notes. When the presenter makes a point that’s not on the slide, the student should feel compelled to write it down. That keeps the brain engaged in moving one’s fingers and hopefully paying attention in class. Another valuable feature of the course is the showing of the video, Hospitals Healing Themselves. That should convince the students that Lean in health care is for real. And finally, the students put to use what they have learned in a simulated process that they perform, study, and improve. Recall the quotation from Benjamin Franklin, ‘Tell me and I forget. Teach me and I remember. Involve me and I learn.’”

“If you haven’t already forgotten them, do you have any final thoughts?”

“Lean education at Affinity is a good example of kaizen—continuous improvement. The courses are continuously being revised and improved. Stay tuned for updates.”

Affinity’s Kaizen Curmudgeon

Why Lean?

2010-12-02T13:27:00.000-06:00

“Hey Curmudge, last week we had the cart before the horse. We talked about Lean training before we explained why it is Lean, and not something else, that we are teaching.”

“Good catch, Julie. We older folks who wish we could live life backward sometimes get things out of order. Let’s go back one step and explain why we are doing what we are doing.”

“I understand that you have some stories from long ago—back when you were middle-aged—that illustrate the need for more efficient processes in health care.”

“There was a story about Pope John XXIII. In an audience with the Pope, a visitor asked the Holy Father, ‘How many people work in the Vatican?’ He answered, ‘Oh, about half of them.’ When I was living in the Northwest, I went to the local hospital for some outpatient testing. There were employees all over the place standing around and chatting. I thought, ‘This must be the Vatican. Which way to the Sistine Chapel?’”

“You concluded that health care back then was not very efficient and needed help?”

“That’s it, Julie. Fast forward to six years ago. My last paying job had ended, and like the city’s other derelicts I spent a lot of time in the public library. I found books on Six Sigma, Gemba Kaizen, Total Improvement Management, and other systems for process improvement. In my last employment I had worked with ISO 9001 and had learned about the Baldrige Award. All of the programs had some common elements, but ISO and Baldrige were very heavy on documentation. Six Sigma was felt to require a lot of training before any payoffs could be achieved.”

“So Curmudge, of the documents you could find, you favored Gemba Kaizen.”

“Right. Kaizen was used not only at Toyota but throughout Japan’s manufacturing sector. It might have been properly called, ‘The Japanese Production System.’ The focus of Kaizen was process-oriented management, as contrasted against results-oriented management used in the West. As Masaaki Imai (1) stated, ‘Many Japanese management practices (Kaizen) succeed because they are good management practices.’”

“Then, somewhat later, you learned about Lean.”

“It appears that Kaizen came to the U.S. and for most users acquired a new name, Lean manufacturing. An English word (Lean) that is often misinterpreted is better than a phrase in Japanese (Gemba Kaizen) that happens to be trademarked. It is also more palatable to Americans to speak of the Toyota Production System than the Japanese Production System. The two systems are essentially identical—same tools and same management principles.”

“Okay Curmudge, back to my original question. Why are we adopting Lean as our culture at Affinity?”

“What really matters is what one does and not what name one gives to the program. (Whenever I write that I am reminded of the line in ‘My Fair Lady’ that says the exact opposite, ‘The French don’t care what they do, really, as long as they pronounce it correctly.’) We could just as easily call Lean the ‘Affinity Performance Excellence System.’ One reason for keeping the term, Lean, is that it identifies, in general, what we are doing to all who are also striving for performance excellence.”

“So much for terminology. What I am really asking is why Lean—irrespective of its name—was selected by Affinity management to be the cultural target for Affinity Health System?”

“Our top management appreciated the value of continuous improvement, a hallmark of Lean. Our immediate boss learned about Lean in his graduate studies. Lean has been used with success in many health care locations. And Lean’s successes at Affinity are validating their choice on a daily basis.”

“Curmudge, you once told me that culture is the summation of everyone’s perception of ‘the way we do things around here.’ And that’s why Lean education is essential for as many people as possible in the organization.”

“You’re exactly right, Jaded Julie. You must have been reading my mind. I’ve always wondered how you do that.”

Affinity’s Kaizen Curmudgeon

(1) Imai, Masaaki. Kaizen (McGraw-Hill, 1986)

Note: An observation on the practice of emergency medicine in a primitive location may be accessed via this link.

The Evolution of Lean Education at Affinity

2010-11-26T11:43:00.000-06:00

“Most people speak of Lean training, Curmudge, but we have education in our title. Is there a real difference between the terms, or are you just being curmudgeonly in your old age?”

“Me? Curmudgeonly? I’ve read that education is for people and training is for dogs. We do have some poodles as hospital volunteers to cheer up our patients, but none has signed up for a Lean course.”

“So other than the hominid vs. canine situation, what are the differences between education and training?”

“In my opinion, Jaded Julie, education tries to answer the questions, who, what, where, and especially why, and training teaches us how. Although a dog sometimes cocks his head in presumed wonderment, I’ve never heard one ask ‘why?’ Lean learning contains both education and training. Education involves leaning the Lean culture and principles, and training teaches us how to apply the Lean tools.”

“Despite your semantic nit-picking, Curmudge, training is used more than education in health care; so let’s consider training to include ’why’ as well as ‘how.’ I trust your ossified brain can handle that.”

“No problem, so let’s get on with our topic. Attendees at the initial Lean instruction at Affinity, the Lean Health Care Tool Kit, came from two populations: (1) top management, directors, and some managers, and (2) Lean facilitators-in-training recently selected to staff the incipient Kaizen Promotion Office (KPO). Those in the management group had been told that Lean represented Affinity’s future, and they attended the initial training to prepare them for service in Affinity’s guiding coalition for change. Two weeks of comprehensive Lean training might have been excessive for this group, but it was essential that they receive training at the outset of Affinity’s Lean journey.”

“In contrast with the management folks, the first crop of Lean facilitators needed the comprehensive training to prepare them to spread Lean to the far corners of Affinity. They would require a command of Lean principles and culture, Lean tools and examples of their use, and—as you would say, Curmudge—the whole geschäft. Like you once advised, ‘they should always know more than they teach.’”

“This training ran for two weeks, contained a lot of PowerPoints, and had an open-book exam at the end of each topic. Presenters were from WCM (World Class Manufacturing) and were affiliated with the Milwaukee School of Engineering. Participants received several books (Liker, Dennis, Kotter, Rubrich & Watson) that are now considered Lean classics. Those two weeks were undoubtedly a busy period for course participants. For the KPO people, a one-week course on being a facilitator was presented later.”

“That sounds pretty intense, Curmudge, but the KPO staff taking the course knew that their future at Affinity depended on their ability to apply what they learned. Everyone appreciates that a mid-career course correction can’t be taken lightly. Learning is not very easy when one has to sit and watch PowerPoints fly by, but they did it.”

“For the record, Julie, the two-week course ran through 2007 and attracted 151 participants. For any adult learner, the gain from a course must be worth the time required. Two weeks is a pretty big time demand for busy people, so the KPO decided to shorten the course to one week for 2008. Participation by mid-level management is key to a Lean transformation, and the KPO felt that a one-week course would be attractive to managers and provide them with an adequate introduction to Lean.”

“How did the one-week course differ from the two-week course?”

“Topics were not covered as extensively, and there were no exams. The PowerPoints were from WCM, but the course presenters were from our Kaizen Promotion Office. The shorter duration of this course and the lack of out-of-class assignments made it easier for the middle-management participants to keep their fingers on the pulse of work in their regular jobs. In 2008 and 2009 the one-week course had 58 participants.”

“And then in 2010 the one-week course was subdivided into three one-day classes. These include one on Lean principles (Lean Overview), and two on tools (A3 Problem Solving and 5S and Kanban). I presume we’ll discuss the rationale behind these changes, Old Guy?”

“We will, but not today. It’s time for lunch followed by my afternoon nap.”

Affinity’s Kaizen Curmudgeon

Note: An observation on the practice of emergency medicine in a primitive location may be accessed via this link.

The Old Scout's Funeral

2010-11-18T11:02:00.000-06:00

“A few weeks ago I attended the funeral of a former assistant scoutmaster of the troop to which our sons belonged. It seemed as if about half of the attendees were either former scouts or parents of scouts.”

“I assume, Curmudge, that you were there to show your respect for the deceased.”

“If it were only respect for the deceased, Jaded Julie, we should have visited him while he was alive. It was more than that. I believe it was respect for what he stood for and for what Scouting—with the involvement of all of us—had done for our sons many years ago.”

“That sounds pretty important; and since we are talking about it here, it must have something to do with Lean.”

“Although Scouting and Lean occur at different points in a person’s life, i.e., they are not contemporaneous, they are quite complementary. Here are some Lean (and Scouting) examples: Respect for people (Do a good turn daily. Help other people at all times. A Scout is trustworthy.). Continuous improvement (advancement from Tenderfoot to Eagle Scout). Leadership (Patrol Leader, Senior Patrol Leader, and leading a team in the scout’s Eagle project).”

“Let’s talk about that ‘not contemporaneous’ thing, Curmudge. A lot of time can pass between Scouting in adolescence and when an adult assumes a leadership role in industry, the military, or a hospital. What keeps the lessons of Scouting from being lost in the interim?”

“They need to become hardwired, Julie. That comes from repetition, dedication, and advancement, and that’s why Eagle Scouts are valued in any organization. I know of a young man who enlisted in the Marines and because of his Eagle rank was promoted almost immediately.”

“Scouting sounds like a unique opportunity for boys, Curmudge, but these days being unique is not always considered a virtue.”

“The Venturing program of the Boy Scouts includes young women aged 13-21. Many cultural mores similar to those of Scouting are taught in other organizations ranging from Girl Scouts to kindergarten to Sunday school. Even in service clubs for adults, like Rotary International. It certainly appears, however, that Scouting is more fun. Here’s an interesting observation: ‘Scouting's genuinely egalitarian goals and instincts are more important now than they've ever been. It's one of the only things that kids do that's genuinely cooperative, not competitive.’ (1)”

“It would appear that former Scouts and members of many other groups will have a head start in learning Lean.”

“You’re right, Julie. They already have a humanizing background and should readily understand Lean principles and culture. Next they’ll need to hone their leadership skills and learn to use Lean tools and procedures. Ultimately, these people would be ‘early adopters’ and perhaps members of the organization’s guiding coalition. If you found these people in a Lean Overview class you were teaching, you’d feel glad all over.”

“I certaily would. But what if people had become corrupted by working in a command-and-control, dog-eat-dog environment?”

“They would need to start Lean training at square one. If they couldn’t adapt to a Lean culture, it might be better if they ‘got off the bus.’”

“Although over 30 years have passed, Curmudge, you seem to be as enthusiastic about Scouting as you are about Lean. What did you do in Scouting that was so great?”

“Camping with the troop in the north woods and running the Pestigo River rapids in open canoes. Developing the required coordination between father (paddling in the stern) and son (paddling in the bow) builds a bond that lasts a lifetime.”

Affinity’s Kaizen Curmudgeon

(1) Applebome, Peter (2003). Scout's Honor: A Father's Unlikely Foray Into the Woods. http://en.wikipedia.org/wiki/Boy_Scouts_of_America

Note: An observation on the practice of emergency medicine in a primitive location may be accessed via this link.

Superbugs

2010-11-04T10:38:00.000-05:00

“Jaded Julie, a couple of weeks ago Mrs. Curmudgeon had some minor surgery, and I was really concerned.”

“Why should you be concerned, Curmudge? It was performed by an experienced surgeon, in a hospital that you respect, and the three little incisions were less than an inch long.”

“Perhaps I’m just an old worry-wart, but I was concerned that my wife might contract a nosocomial infection. I read a lot about infections a couple of years ago, and we talked about them on January 29 and February 5, 2009. It’s still a hot topic in the literature, and I read some newer stuff last month. When it comes to nosocomial infections, one may be either concerned or clueless; there’s no middle ground.”

“Despite your advanced age, Curmudge, you are rarely clueless. That makes me concerned as well. So what did you read that put the pepper in your Metamucil?”

“Dr. David Shlaes, MD, PhD has spent his career in the development of antibiotics, and he recently published a book, Antibiotics-the Perfect Storm. The book’s price as around $150, so I’ve had to be satisfied with reading his blog by the same name.”

“So what is the good doctor’s thesis, Curmudge? It must be mighty serious if he calls it a perfect storm.”

“Despite the appearance of new drug-resistant bacteria almost every day, the major pharmaceutical companies in the U.S. are abandoning the development of new antibiotics. If this continues, we’ll soon be as defenseless against these new ‘superbugs’ as we were against their predecessors 100 years ago.”

“I now appreciate your concern. But why are the drug companies getting away from antibiotics?”

“It’s a matter of economics, Julie. When a new drug is developed for a chronic illness, a patient might take it (buy it) for the rest of his life. Contrast that against a new antibiotic; the patient will take it for perhaps two weeks or until the infection is cured. With the latter scenario it’s very hard for the company to sell enough of the drug at a reasonable price to recoup its multi-million dollar development cost.”

“As I understand it, Curmudge, clinical trials are an essential and expensive part of new drug development. We talked about trials just a few weeks ago, on September 30. They are required to prove the drug’s safety and effectiveness.”

“The drug people call that efficacy, Julie. Recruiting participants for the traditional clinical trial of an antibiotic is especially difficult. People with a potentially deadly infection would be reluctant to join a trial in which they had only a 50% probability of receiving the medication. Those in the control group might die before the trial’s conclusion.”

“So what’s the answer? Or to use a term you brought from industry, what’s the path forward?”

“Approaches to this problem involve definitions of safety and efficacy, trial design, ethics, and controversy. Any one of these puts their discussion beyond the scope of this blog. I invite you to read Dr. Shlaes’ blog, or if your rich uncle just died, his book. If you need some grisly statistics to catalyze your concern, consider these from the Centers for Disease Control: ‘As many as 90,000 people die in the nation’s hospitals every year from bacterial infections. About 70,000 of these deaths are from drug-resistant bacteria—well above the 58,000 U.S. soldiers who died during the Vietnam War era.’”

“Okay, Curmudge, you’ve really got my attention.”

“Here’s another statistic that I’ve been thinking about in recent weeks: ‘Of all the complications that occur in the 30 days after surgery, such as infection and blood clots, almost half will surface after the patient leaves the hospital.’(1) That’s why I scrubbed my hands thoroughly before I changed the dressings on Mrs. Curmudgeon’s incisions.”

Affinity’s Kaizen Curmudgeon

(1) Landro, L. Patient, Heal Thyself. Wall Street Journal, October 26, 2010.

The Robot

2010-11-03T10:13:00.000-05:00

“Wow, Jaded Julie! That da Vinci robot is the greatest thing to hit the OR since anesthesia.”

“No way, Curmudge, am I going to let a robot operate on me. It might run amok and start ripping out my innards.”

“This isn’t ‘Star Wars,’ Julie; this is the ultimate in modern surgery. The robot simply mimics the movements of the surgeon’s hands and fingers. In a demonstration, I sat at the console and remotely maneuvered pumpkin seeds around inside a jack-o-lantern. Except for the fact that I don’t know anything about anatomy, even I could be a surgeon.”

“I shudder at the thought. As I understand it, the robot is an enhancement to laparoscopic surgery, which I already considered a great innovation. However, I’ve been both amazed and somewhat apprehensive at major surgery performed through three little incisions.”

“Before we reassure and further astonish you, let’s set the stage. The patient has at least three small incisions, one for the camera and two for the robotic probes. The surgeon sits at the console, puts his hands on the controls, and views the inside of the patient (‘the field’) through a binocular scope. What the surgeon sees is also projected on a monitor above the patient so the nurse can follow the action and anticipate the surgeon’s need for different probes.”

“Hey, Curmudge, this is getting interesting. I can appreciate why you got a kick out of ‘operating’ on a pumpkin.”

“There are two features of the robotic probes that provide the da Vinci’s great advance over conventional laparoscopy. At the end of the probe is a ‘wrist’ that can rotate and allow the probe to reach areas that are inaccessible to a conventional probe. The other enhancement is the da Vinci’s ability to shrink the surgeon’s motions by a factor of 5, i.e., when the surgeon moves 1 cm, the probe moves 2 mm. This permits delicate work that would be impossible with a conventional laparoscopic probe or extremely difficult with gloved fingers in open surgery.”

“I’m sold, Curmudge. Buy me one for Christmas with your Social Security check, or more realistically, donate your check to the hospital foundation. But seriously, what kinds of operations can be performed with the robot?”

“Most things that are currently done with conventional laparoscopy: hysterectomies, radical prostatectomies, cholecystectomies, nephrectomies, and several others. I suspect that all of these can be done better and safer with the da Vinci robot. And following surgery, the patient has less pain and can go home sooner.”

“For a surgeon, training in any new technique has to be a serious undertaking. That is undoubtedly true with learning to use the robot.”

“Julie, I believe they start by observing, and then they practice on pigs. Initial surgery on human patients is closely observed by experienced surgeons. That’s facilitated by the monitor above the patient that we described earlier.”

“Considering your enthusiasm, Curmudge, I assume that you will volunteer for robotic surgery as soon as possible.”

“My last major surgery was 51 years ago, Julie. I’m quite willing to wait another 51 years for the next.”

Affinity’s Kaizen Curmudgeon

Evidence-Based Medicine--The Patient's Perspective 5

2010-10-21T10:51:00.000-05:00

“As you forecast, Curmudge, another week has passed and I am very much affected by my affliction. I don’t understand it. My physician diagnosed my illness and prescribed what she felt was the best evidence-based treatment. Quite honestly, she gave it her best shot.”

“Jaded Julie, it appears to be time for a second opinion. Consider your situation: (1) Your disease is serious and even life-threatening. (2) Your treatment doesn’t seem to be working or leaves you feeling worse than your disease. (3) Your diagnosis was difficult, performed by just one person, or was somewhat uncertain. Any one of these would lead us to consider a second opinion.”

“But won’t my physician be offended when I propose getting a second opinion?”

“If her primary goal is your good health and if she recognizes that no one can know everything, she will support your decision. That’s why there are specialists, subspecialists, and world-renown academic medical centers. If you look hard enough, you have a good chance of finding someone who can make a conclusive diagnosis and has successfully treated people with your disease. As we discussed back on June 18, 2009, errors in diagnosis do occur. When your disease is life-threatening, you want it to be diagnosed and treated by those who know it best. Remember, it’s your life.”

“Okay, Curmudge, I’m convinced. So please step down from your soapbox and tell me how to proceed.”

“Recall, Julie, that the objective of this series of postings was to teach you how to become a more informed and effective member of your health care team. So if you feel the need for a second opinion, begin by discussing it with your physician. Ask for her thoughts and guidance. Ask, ‘If you were in my situation, where would you go and whom would you see?’ Her answer might be someone across the street or across the country. She (or someone in the office) will tell you how to make the appointment and get your records sent to the appropriate destination.”

“A few weeks ago you quoted Meg Gaines as saying that one should ‘become an active patient ready to make your own way through your disease.’ What do I do if I feel that my physician’s suggestion for a second opinion is a bit conservative and I want to arrange the second opinion on my own?”

“Don’t go away, Julie, it’s possible. Let’s assume that you want your case reviewed by the specialists in an academic medical center and are uncertain where to go. Here’s one approach: Start with the U.S. News Best Hospitals rankings. Then select the specialty that fits your problem (you might not know the exact diagnosis, but you certainly know whether it’s Gynecology or Ophthalmology). A list of the best hospitals, in order, for that specialty will appear. Then follow your mouse for more detailed information.”

“I’ve found one whose reputation appears to be world class in my specialty. What do I do next?”

“The hospital’s Web site should tell you how to proceed. Oh, and by the way, you should probably check with your health insurance to learn if your second opinion will be covered. At some point you will need to authorize your physician’s sending your medical records—including labs, radiology, and pathology—to the second-opinion hospital.”

“This sounds like a big undertaking, Curmudge, especially if the medical center is a thousand miles away.”

“Some hospitals will evaluate your case on the basis of your records alone without your going there personally. The Cleveland Clinic (MyConsult) and Johns Hopkins (Remote Second Opinions) do this. Most commonly, their reports go to your personal physician. Partners Online Specialty Consultants is a physician-to-physician online second-opinion service provided by physicians affiliated with Harvard Medical School. The appropriateness of these programs may depend on the nature of your illness.”

“You wrote on May 13, Curmudge, about how we in the Fox Valley are blessed with quality medical care. In addition, there are two academic medical centers within the state and the Mayo Clinic only two hundred miles away. No wonder so many people around here simply die of old age.”

Affinity’s Kaizen Curmudgeon

Note: An observation on the practice of emergency medicine in a primitive location may be accessed via this link.

Evidence-Based Medicine--The Patient's Perspective 4

2010-10-14T09:59:00.003-05:00

“I’ve forgotten, Jaded Julie, where our story ended last week.”

“I’m not surprised, Curmudge. You tend to forget everything except when it’s time to take a nap. As a patient with a life-threatening disease, I had learned how to learn about my disease by studying review articles, journal articles, and clinical trial results. I had become the local expert on me. So what’s next?”

“In a discussion with your physician you agreed on an evidence-based treatment plan. After following the plan for a couple of months, you were astonished to realize that your condition had not improved. In fact, you even felt worse.”

“What? Not improved! The treatment was evidence based. Clinical trial results indicated that I should have improved. What’s wrong? Did science fail me?”

“No, Julie, science is alive and well. Your problem might be that you are unique and not average. I wrote about this four years ago when I had a different name, Quality Curmudgeon, and you were not yet a member of the team. Readers of Kaizen Curmudgeon probably never saw my original note, so perhaps we should reprint part of the original posting.”

“Do it, Curmudge. By the time I have read it I might not feel cheated by evidence-based medicine.”

The Evidence Behind Evidence-Based Treatments

“Evidence based” is one of today’s health care buzzwords. If a clinician is faced with a patient whose disease may be mitigated by a medication shown to be effective in a large clinical trial, i.e., “evidence based,” he/she can confidently prescribe it and go on to the next patient. This sounds great, but there is more than meets the eye.

Let’s begin with the basics. Assume a pharmaceutical manufacturer’s preliminary studies have, in general, suggested that Compound A at a determined dosage is safe and effective against disease X. The final test is a clinical study in which large numbers of patients with disease X are recruited and divided randomly into two groups. One group is treated with Compound A; the other group is treated with a competing medication or a placebo. At the conclusion of the test, results from both groups are averaged. If the average outcome from the Compound A group is more favorable, the study is written up, peer reviewed and published. Treatment of disease X with Compound A becomes evidence based, and a new “blockbuster” drug is born.

So what’s the problem? The study has shown that the average outcome from a population of hundreds of patients was positive; but it has not answered the clinician’s most important question, “Will it help my patient?” The test population contained some patients with severe symptoms and some with mild symptoms, some with a host of other ailments and some who were otherwise healthy, and some young and some old. Many individual patients were helped by Compound A, but other individuals may have experienced no effect or might even have been harmed. These individual results were obscured by the magnitude of the test population, which on the average demonstrated a favorable outcome.

“I’m sure it won’t make you feel any better, Julie, but if you had been a participant in the trial of this treatment, you would have been part of the population that the treatment didn’t help.”

“Understanding the reason doesn’t make me feel any happier, Curmudge. So what do I do next?”

“I’m afraid that you are going to have to stay sick for another week, Jaded Julie. Then we’ll talk about a possible path forward.”

Affinity’s Kaizen Curmudgeon

Note: An observation on the practice of emergency medicine in a primitive location may be accessed via this link.

Evidence-Based Medicine--The Patient's Perspective 3

2010-10-14T09:44:00.000-05:00

“Here we are again, Curmudge, back in Kaizen Curmudgeon. A week ago we thought our third discussion of evidence-based medicine would be too technical for this blog and would have to go in Curmudgeon’s Wastebasket.”

“Well, Jaded Julie, I asked Mrs. Curmudgeon to review this. If she can understand it, anyone…”

“Stop right there! One more word and you might not get supper tonight. So back to our topic, how I can learn more about my disease, become a more knowledgeable patient, and achieve a better outcome. I guess you’ve been reading the scientific literature for a long time, Curmudge.”

“Reading a lot and writing a bit for about 50 years, Jaded Julie. But clinical research is different from the industrial type, and the layperson needs some guidance in order to learn from it. When we last talked about this, you were playing the role of a patient with a disease who had learned how to use the major secondary sources of information such as Cochrane Reviews, emedicine, and clinicaltrials.gov. Today we are going deeper into the subject. Oh, and one thing further. If anything in your reading leads you to suspect your diagnosis, share it with your physician. There’s not much value in a patient’s studying a disease that she doesn’t have.”

“So here I am, a patient with the full text of what looks like a valuable article in hand or on my monitor. How do I proceed?”

“The sections of articles in most disciplines follow a similar order dictated by the journal: Abstract, Introduction, Experimental Methods, Results and Discussion or Outcomes, Conclusions, and Literature Cited. What you should learn in each section is described in Gaeta and Nagurney’s Evaluating the Literature. Your first objective is to decide if the article is really pertinent to your interest; that should be evident in the Abstract.”

“But, Curmudge, what if the Abstract is a bunch of medical gobbledygook?”

“It shouldn’t be if the article is truly pertinent. Your previous reading of reviews and other secondary sources should have taught you a lot of essential terms. The Introduction will describe what is unknown about the topic and how the proposed research will fill in some of the gaps in our knowledge. From the Methods section you will learn which of the several types of experimental design was used. Common designs include retrospective (looking backward at patient records) and prospective (following subjects forward in time and collecting data as they are generated).”

“My guess is that the design will tell me a lot about the validity of the results.”

“It should, Julie. Let’s assume that you are looking at a prospective study of a treatment that might cure your disease. The findings should be more meaningful if the treatment groups were randomized with everyone equal at the baseline, double-blind with neither patients nor physicians knowing who received the treatment or a placebo, and accounting for all patients.”

“I’m still with your train of thought, Curmudge. The next stop should be Outcomes. All aboard!”

“Look at the figures and tables of results. You might not know all of the words, but an upward or downward trend means something happened; and it’s often a good something. In my earlier life I was sometimes able to interpret figures even if the captions were in a foreign language.”

“So then, how will I know that the study’s findings were not just by chance and that the treatment might really do me some good?”

“Julie, authors usually use statistics to characterize their results. The so-called p-value provides a useful guide for the reader. The smaller the p-value, the more significant the difference between results from the treated group and the control group. Look for p-values less than 0.05, or even better, less than 0.01.”

“Curmudge, you can’t imagine how delighted I am that you didn’t go any further into statistics.”

“Various organizations have adopted formal guidelines for evaluating the literature, including the evidence grading system from the Institute for Clinical Systems Improvement and the Infectious Disease Society of America—US Public Health Service Grading System for ranking recommendations for clinical guidelines. The latter system uses letter grades (A-E) for strength of recommendation and Roman numerals (I-III) for quality of evidence. You may have encountered these grades in your reading of review articles. In general, if you are interested in a specific intervention, look for prospective, randomized, controlled clinical trials.”

“You have made my brain very crowded, Curmudge, but I believe I can proceed with a little more confidence. Do you have any final words of wisdom?”

“Never final, Julie, but I do have two additional comments and one caveat. First, if you see an abstract to a promising article but can’t obtain the full text, see your medical librarian (Margo Lambert at St. Elizabeth Hospital or Michele Matucheski at Mercy Medical Center). Second, many widely used treatments have never been subjected to a controlled clinical trial and are not, strictly speaking, evidence based. They have been used successfully over time and represent the consensus standard of care; one might consider them to be ‘grandfathered.’ The caveat is that there seems to be nothing in the clinical trial literature about the eventual cost of a particular treatment or medication. So don’t allow your hopes to get too high. What does one do after learning that he can gain an extra four months of life at a cost of $93,000 per year?”

“Wow! That’s a problem in medical ethics that neither of us would touch with a ten-foot pole.”

Affinity’s Kaizen Curmudgeon

Note: An observation on the practice of emergency medicine in a primitive location may be accessed via this link.

Evidence-Based Medicine--The Patient's Perspective 2

2010-09-30T10:38:00.007-05:00

“Tell me again, Curmudge, why I should become an expert in the diagnosis and treatment of a disease that I presumably have. I’ve heard that a little knowledge is dangerous.”

“Jaded Julie, a little knowledge isn’t dangerous if you discuss it with your physician. Furthermore, it rarely stays little, especially if you have a life-or-death driving force to learn more. There may be a time when your physician will present you with a choice between two apparently equal therapies; you’ll feel better choosing based on understanding instead of just flipping a coin. There might also be instances when treatment decisions involve a trade-off between potential benefits and risks; you’d certainly want to be an informed participant in that discussion.”

“Have there been cases where the patient’s study of diagnosis and treatment made a difference?”

“Read Chapter 5 of Dr. Groopman’s book, Julie (1). A mother’s knowledge—and especially her persistence—saved her daughter’s life. And if you don’t have access to the book, read about Meg Gaines’s experience with ovarian cancer.”

“But, Curmudge, Ms. Gaines’s life was saved by a new procedure performed far from home that wasn’t evidence based.”

“True. But she wouldn’t even have known about the procedure had she not studied her disease and learned of the best medical centers at the forefront of clinical research on ovarian cancer. After her experience she founded the Center for Patient Partnerships in Madison (2). She advises patients to ‘act as if your life depends on it, because it does,’ and to become an active patient ready to make your own way through your disease and its treatment.”

“Okay, Professor, I’m convinced. Teach me more about how to become my own best caregiver.”

“As I promised last week, we’re going to be looking into more technical literature. A Cochrane Review is a scientific investigation into the literature on evidenced-based health care, including randomized controlled trials and sometimes non-randomized observational studies. Individuals without a subscription click on Browse Free Summaries at the bottom of the page and then enter the disease of interest under Search Abstracts and Summaries.”

“Without your instructions, Curmudge, I would have had to follow my nose through these documents like you did.”

“It’s called trial-and-error, Julie, but it’s amazing what one can learn. You next select a title that interests you from those listed under your disease, and out pops a two-page summary. It contains a one-paragraph Summary of the disease, results of completed clinical trials of proposed treatments, and trials that are ongoing. The Main Results section is more technical listing numbers of patients, details of the trials, and some statistics on the results. Findings are summarized in the Authors’ Conclusions. Also given are the dates that the review was published online and when it was last assessed as up to date.”

“Okay, Curmudge, I think my brain is getting better at handling technical information. How can I find a discussion of my disease that is truly comprehensive?”

“Go to http://emedicine.medscape.com/. A page will appear inviting you to Browse by Specialty (within the main categories of Medicine, Surgery, and Pediatrics). Then search under disease categories such as these under Medicine: Emergency Medicine, Hematology, Pulmonology, etc. You should find a very detailed review of your disease, including results of clinical trials. The language will be technical, but the gist of the findings should be evident to the layperson. If I had to select the site that would yield the most information from just three mouse clicks, this would be it.”

“You have been mentioning clinical trials, Curmudge. If I wanted to participate in one, how would I learn more?”

“I’ve found a couple of routes to the same end point, Julie. Start with http://gateway.nlm.nih.gov/. At the home page, NLM Gateway, fill in the box with your request for ‘clinical trials on (your disease)’ and click on Search. Then under Consumer Health Resources click on ClinicalTrials.gov. That will yield a listing of trials that pertain to your disease. This will show for each entry the title, condition (disease), URL, and status (Terminated, Active, Recruiting, Completed). Click on the URL for details, including Purpose, Study Design, Criteria for Inclusion or Exclusion, Locations, and person to contact.”

“What about the second route?”

“That one starts at http://clinicaltrials.gov/. Follow your talented mouse to the same details as above. If you see a trial that is recruiting and interests you, discuss it with your physician. Remember, however, that a trial is just what the name implies. You might be in the population that receives a placebo, or the treatment under study might turn out to be ineffective.”

“I suspect, Curmudge, that our discussion of this topic might turn out to be endless and increasingly technical. This might be a good time to pick up our pieces of new knowledge and go home.”

“You’re right, Jaded Julie, but I hope we can talk more about this next week. Meanwhile, happy googling.”

Affinity’s Kaizen Curmudgeon

(1) Groopman, Jerome. How Doctors Think. (Mariner Books, 2008)
(2) Center for Patient Partnerships: Comforting the afflicted.
http://www.patientpartnerships.org/

Evidence-Based Medicine--The Patient's Perspective

2010-09-23T09:47:00.001-05:00

“Jaded Julie, how would you feel if you were diagnosed with a serious illness?”

“I’d feel very much alone, Curmudge. Your family and friends can give you food, shelter and care, and they can even assume your debts. But no matter how much people love you, no one can be sick for you.”

“So what would you do?”

“I would have a choice. If I chose to be a totally passive patient, I could take the prescribed medicine, suffer its side effects, and hope and pray for the best. The other option—and that’s what I would select—is to become an expert on my disease and an active participant in my health care team. That way I could take full advantage of personalized care and maybe even help to cure my illness. Hey, the game of life vs. death is one that you can only lose once.”

“Sounds like a plan, Julie. How would you proceed?”

“Well, if I lived near a hospital with a library, like St. E’s or Mercy Medical Center, I’d seek the librarian’s help in learning all I could about my situation. But tell me, Curmudge, what should I do if a city is not nearby or if I were reluctant to share the details of my health with a librarian?”

”In the privacy of your home office, you or a relative or friend should use your computer to google your disease. That will open up a world of medical knowledge.”

“But I don’t want the world. I just want some stuff that I can comprehend.”

“There’s something for everyone out there, Julie, including a lot of sources that one can understand without an MD degree. Your Google search will provide a list of titles followed by a couple of lines describing the contents followed by the URL. Note, however, that the pages of your Google search results will show so-called Sponsored Links; some of these may contain testimonials and ads for non-FDA-approved treatments. Below are a few URLs that should be helpful; they will usually provide an overview of symptoms, diagnosis, and treatment in everyday language.
Mayo Clinic (www.mayoclinic.com)
MedLine Plus (www.nlm.nih.gov/medlineplus)
Merck Manuals (www.merck.com)
Wikipedia (en.wikipedia.org).”

“This sounds pretty useful, Curmudge, but where does evidence-based medicine enter the picture? It’s in our title, but you haven’t mentioned it once.”

“The sites mentioned above contain review articles written, for the most part, in everyday language. Procedures for diagnosis and treatment are evidence based as understood at the time of writing. To learn about new knowledge developed since then we’ll have to look into other—and often more technical—resources. We’ll also have to come back for more discussion next week.”

“So that I don’t go away empty-handed, can you give me a definition of evidence-based medicine?"

“Of course, Julie. Evidence-based medicine is the generally accepted best procedure for the diagnosis or treatment of a specific illness or condition. ‘It requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report (1).’”

“Thanks bunches, Curmudge. It will take me all week to figure out what you just said. But I do understand that I would want to receive the best care available. Presumably that will be evidence based unless my physician and I agree on a good reason to do otherwise.”

Affinity’s Kaizen Curmudgeon

(1) Agrawal, P. and Brown, C. A. An evidence-based approach to acetaminophen overdose. EBMedicine.net, September 2010.

Note: An observation on the practice of emergency medicine in a primitive location may be accessed via this link.

Amazing Devices 4

2010-09-09T11:04:00.000-05:00

“I’ve seen it, Curmudge. I’ve seen how your reading and writing about amazing devices has awakened the long-dormant scientist in you.”

"You’re right, Jaded Julie. As they say, ‘If you don’t use it, you lose it,’ and I’ve lost it. A whole new world of communication technology has passed me by. Those devices in Dr. Topol’s video that we saw last week went by pretty fast, so I decided to mosey through the literature and learn more about them. Before our readers have these things strapped onto their chest or put in their shoe, they are likely to encounter them in their doctor’s office; so let’s focus on that venue.“

“Can we begin with the humble stethoscope that we mentioned on August 5? I’ve continued to be amazed that it has remained virtually unchanged for almost 200 years.”

“Most of those you see around necks or in pockets are the old kind, but with the advent of the electronic stethoscope (Littmann 3200), the changes are dramatic. It looks similar to the classic design, except on the back of the chestpiece there is a handle and LCD display through which the features of the device are controlled. Variable sound amplification can adjust for the clinician’s hearing acuity or the patient’s obesity. Onboard recording can be played back through the eartubes.”

“Even with your hearing problem, Curmudge, you could use one of these.”

“Sure, although it would require medical education for me to understand what I was listening to. But Julie, there’s a lot more to these things than amplification. Bluetooth technology can be used to wirelessly transfer sounds to your computer for further analysis. This requires a USB wireless adapter inserted into the PC on which proprietary software has been installed. The software allows one to visualize what has been heard in a wave file format, save it in the patient’s record, or send it via the Internet across the world for further consultation.”

“Gosh Curmudge, with that perhaps I could be a cardiologist in my spare time.”

“That would indeed be a stretch, Julie. Let’s start our next topic with a trivia quiz. What is an ER doc’s first question to himself when he sees a patient with no visible trauma?”

“I’ve got it, Curmudge. He looks at the patient and asks, ‘What’s going on in there?’ Then he attempts to find out with history and physical, lab tests, and an armamentarium (see, I remember the word) of increasingly complex tests and procedures.”

“Great answer! However, one powerful procedure is noninvasive and fairly easy to perform, but it requires a trained eye to interpret. It is ultrasound, and it’s what we’re going to talk about next.”

“Hey, Curmudge, one of those tests was done on me several years ago in the ultrasound lab. I looked at the readout, and I appeared to be a confusing mass of angry storm clouds inside.”

“As I said, Julie, a trained eye is needed. A notable innovation is that now we have handheld ultrasound units that can be carried in one’s pocket (1). When not being used on a patient, the scanner (viewer) and probe sit on a docking station connected with a USB cable to a PC. Handheld ultrasound is being promoted for use by cardiologists, obstetricians, primary care physicians, in the ER, and probably everywhere a physician is asking himself, ’What’s going on in there?’ They might become as ubiquitous as the stethoscope.”

“(Ubiquitous? I’ll know what he means when I see them everywhere.) Okay, Wizened Wizard, give me an idea of some of the things that can be diagnosed by ultrasound.”

“With the handheld ultrasound and electronic stethoscope, a cardiologist might be able to avoid ordering a traditional and expensive echocardiogram. In a primary care physician’s office or an Emergency Department, an abdominal ultrasound might reveal an abdominal aortic aneurysm, gallstones, hydronephrosis, kidney stones… An ultrasound of the leg should be the easiest way to detect a blood clot (deep vein thrombosis). These ailments are not uncommon. Each has afflicted one or another of my acquaintances.”

“That, Curmudge, is because your contemporaries are so old. Aside from that, however, the beauty of these in-the-office diagnostic tools is that they can enhance the physician’s communication with the patient. The hand-held ultrasound can provide visual reinforcement of exam findings in real time. The patient can leave the office or the ED with a diagnosis and plan of care—not a schedule of additional tests. So, senior savant, although it should be obvious, what do you see as the lesson for today?”

“Lesson #1 is obvious, Jaded Julie. Advances in technology continue to make the practice of medicine more efficient and effective. However, unless these devices are used in an efficient environment, their effectiveness will not be fully realized. That’s Lesson #2. Here are some examples: an MRI machine that is used only five days per week, a Da Vinci robot on which few surgeons are trained, the report of a CT scan that is misplaced on its way back to the ordering physician.”

“I think what you are saying is that a hospital or clinic needs to have a Lean culture in order to get the most out of its technology.”

“You’ve got that right, Julie.”

Affinity’s Kaizen Curmudgeon

(1) Another handheld ultrasound system is the ACUSON P10.

Amazing Devices 3

2010-09-02T09:30:00.000-05:00

“You know, Curmudge, the curious thing about you old guys is that you are so easily amazed. I think the reason is that nearly all of today’s wonderful devices were invented after you had completed your education.”

“Au contraire, Sleeping Beauty. In our years together haven’t you perceived that my education has never been completed? I suspect that at least 90% of the knowledge I used in my professional life was gained either in kindergarten or after graduate school. Even now, every day is an eye-opening educational experience.”

“Okay, mind-boggled blogger, what was yesterday’s gem of new knowledge?”

“Jaded Julie, it’s right here in this video, The Wireless Future of Medicine by Eric J. Topol (1). Although it runs for 17 minutes, it is well worth the viewing time.”

(17 minutes later) “The video was truly impressive, Curmudge. Will you have some comments about it?”

“Perhaps, but not today. If a busy person has spent the past 17 minutes watching Dr. Topol, he will undoubtedly feel that he has learned enough about amazing devices for the moment.”

Affinity’s Kaizen Curmudgeon

(1) Topol, E.J. The wireless future of medicine (video). http://www.ted.com/talks/eric_topol_the_wireless_future_of_medicine.html

Medical Home Workflows

2010-08-26T10:52:00.000-05:00

“Jaded Julie, in a symphony orchestra, how does one make sure that all of the bass fiddles play the same notes?”

“I don’t know much about orchestras, Curmudge, but I suspect that each bass player reads from an identical musical score.”

“Closer to home, Julie, if a sample is sent to the hospital’s lab for a multi-step analysis, should the result depend on who the analyst was?”

“Absolutely not! The lab has a standard process and procedure for every step in the analysis that each analyst must follow. Even a non-clinical old geezer like you should know that.”

“And finally, in a medical home with several patient service representatives, should a patient’s phone call to renew a prescription be handled differently depending on the PSR that she speaks with?”

“Of course not. I get it, Curmudge. In the medical home we have workflows just like an orchestra has scores and the lab has standard methods. It’s like you taught me, ‘You can’t improve a process until you can control it; you can’t control it until you understand it; and you can’t prove you understand it until you document it.’ The workflows get everyone on the same page. You can’t have people running around willy-nilly ‘doing their own thing.’”

“You are mighty quick on the uptake, Julie. Can you think of ways in which Lean is used in developing workflows?”

“You know I can. Where do you think I’ve been for the past three years? To begin with, you assemble a team from gemba who know best the processes and procedures in present use. They use sticky notes that are color-coded to differentiate patient service reps, health care associates, and providers. Then they make a process diagram on the conference room wall for each of the clinic’s main processes. Sometimes ‘just do it’ improvements are introduced as the workflow is being constructed.”

“That’s the idea, Julie. What happens next?”

“Then the workflow is copied from the wall with Visio software for printing, discussion, and further improvements. Later the team looks into the individual sticky-note boxes to identify procedures that need to be documented. It looks to me, Curmudge, as if workflows are standard work for clinic-wide processes and individual procedures.”

“The drivers for this effort are the forthcoming implementation of the electronic health record (EHR) and ultimate recognition by the National Committee for Quality Assurance (NCQA). As we said last week, one must not try to overlay a good technology on a bad process. Workflows represent the medical homes’ development of effective paper-based process and procedure descriptions for incorporation into the EHR.”

“It’s pretty obvious, Curmudge, that one must know where she is ‘at’ before finding her way to someplace better. By the way, do you realize that the next generation might not even know what a paper-based process description is?”

“That’s likely, Julie, but if there still are bass fiddles, I’ll bet that bass players will still be reading Beethoven from paper scores.”

Affinity’s Kaizen Curmudgeon

The World Health Congress

2010-08-19T10:17:00.000-05:00

“I’ll bet, Curmudge, that during your professional career you attended a lot of meetings and conferences.”

“I sure did, Jaded Julie. Although I found the short courses associated with the conferences to be most valuable, I also tried to observe some of the local culture when the meeting was held in an exotic location. Let me tell you about what I saw as I walked down Bourbon St. in New Orleans one Halloween night.”

“You may, but not in Kaizen Curmudgeon. I understand that several of our newer colleagues recently attended the World Congress on Excellence in Health Care.”

“They did, and after their return they reported on the high points of the conference. My perception is that they brought home a strengthened conviction that Lean is the right culture for Affinity and that we are progressing well on our Lean journey. In fact, we are among the leaders in Lean health care. When a speaker asked—regarding the focus of his presentation—‘Who is doing this?’, our people could proudly raise their hands to signify, ‘We are.’”

“How about some examples, Old Guy. I presume since this meeting was held in Chicago, their examples will be free of New Orleans-style rowdiness and debauchery.”

“Not a problem, Julie. I believe that the essence of the presentations may be discerned by the following statements and quotations:

‘Philosophy—Patients and families first. Then support our people.’

‘Waste comes cleverly disguised as a lot of work.’

‘Lean is lead from the top down; change from the ground up.’

‘The first day of a kaizen event is usually a food fight, i,e., lots of blaming and finger-pointing.’

‘There is an affinity between Lean and Green.’

‘In their personal behavior, employees must distinguish between being on-stage (in view of patients and visitors) and off-stage (out of view).’

‘Lean is a part of the strategic plan (sounds like hoshin-kanri).’

‘Report-outs must be attended by everyone.’

‘The Joint Commission (TJC) is working to improve their consistency of standards interpretation (anyone who has been audited by anyone should appreciate that).’

‘The middle manager is no longer a problem solver but a facilitator of problem solving.’

‘Overlaying a new technology on a bad process is like shrink-wrapping a cactus.’”

“I think I understand, Curmudge. These statements are all familiar or obvious to us. They represent problems that we have solved, or are working on, or that we are aware of and need to work on. To someone totally new to Lean, they might be confusing. To an experienced ‘Leaner,’ they are an inspiration. Come to think of it, that’s what a conference is supposed to be—an inspiration.”

Affinity’s Kaizen Curmudgeon

Note: An observation on the practice of emergency medicine in a primitive location may be accessed via this link.

Amazing Devices 2

2010-08-12T11:16:00.002-05:00

“Curmudge, I trust that you read Affinity’s electronic newspaper, The Weekly, every week.”

“I do, Jaded Julie, and there was recently an interesting Library Services’ note on Mobile Devices: Health Care Resources in the June 7 Weekly.”

“I guess you are saying that the note demands a careful reading, which you did. My second guess is that your ancient but orderly mind wants to put the info from the Library note into some sort of historical context. Okay, Curmudge, have at it.”

“In our posting on August 6, 2009, Information at Your Fingertips, I envisioned a provider turning to his/her exam room desktop computer to access information via the Affinity intranet. During the past year, laptop computers have become more common throughout our hospitals and clinics. With these, the provider can use the computer while facing the patient and create a more personalized experience.”

“That’s an interesting observation, Curmudge. With the provider facing the patient I’m sure patients would feel like they are in a much more collaborative conversation.”

“Fortunately, now many providers use handheld devices, and those are what Library Services’ note in the Weekly tells us about. It references their PDA Road Map: its title is Mobile Computing for Healthcare: Smart Phones, PDAs, Pocket PCs, etc. Main headings include: Resources for Affinity Library Users, Free Starter Apps, Calculators (free), Clinical POC, Internet Gateways, and PubMed & Evidence-based Practice. In addition, here’s another resource for handheld users: How the iPad Can Change Emergency Medicine.”

“Very impressive! Perhaps this should be called Information at the Fingertips of Only One Hand.”

Affinity’s Kaizen Curmudgeon

Note: An observation on the practice of emergency medicine in a primitive location may be accessed via this link.

Amazing Devices

2010-08-05T09:47:00.001-05:00

“Curmudge, nothing documents your antiquity more convincingly than when you talk about the devices you used early in your career.”

“I recall that before the days of photocopiers I had to make 12 copies of an exam by dragging each page plus a so-called ‘master’ through some sort of magic bath. Then the copies were spread out on the counter to dry. I was grateful there weren’t more than a dozen people in the class.”

“That must have been when you had a moonlight job teaching chemistry in the early 1960’s. Since then, advances in all sorts of devices and instruments have really been dramatic. In health care even the simplest of measurement tools, like the glass rectal thermometer, have been replaced. There can’t have been many things that have remained the same. Can you think of one?”

“I sure can, Jaded Julie. What about the stethoscope? It’s not even a scope; it’s a hearing device and should be called a stethophone. It’s still used to listen to the heart and lungs and for measurements of blood pressure. There are anecdotal reports that replacing the stethoscope and manometer with electronic sphygmomanometers yields higher bp’s. However, studies reported in the literature suggest that the methods give comparable results (1, 2). When my wife was in a Czech hospital a year ago, the electronic sphygmomanometer in her room appeared to be the only modern device in the facility.”

“What about pulse oximeters, Curmudge, for measuring the oxygen saturation of blood? The devices clipped onto the end of one’s finger have been in use for a long time, but on your time scale you’d probably consider them a modern invention.”

“You’ve got that right, Julie. When I was studying the use of near-infrared spectroscopy for analysis of wood pulp in the late 1980’s, I met a woman in a short course who was studying near-infrared for clinical applications. Among her interests was pulse oximetry. It seems like only yesterday. Prior to that time, the test of O2 saturation was invasive and labor intensive.”

“I understand that you had in your lab a predecessor of today’s magnetic resonance imaging (MRI) device. That must have been at least 30 years ago.”

“It was a nuclear magnetic resonance (NMR) spectrometer. A solution of the sample was put in a small tube and spun at high speed for the measurement. Someone put a lot of work into scaling up the system to the point where the ‘sample’ is a human lying quietly (not spinning) in the magnetic field. I think they changed the name from NMR to MRI because the term ‘nuclear’ alarmed patients.”

“Speaking of laboratories, Curmudge, clinical labs have undergone great changes over time, haven’t they?”

“I never worked in clinical chemistry, Julie, but I was in a research group with people who did. Leonard Skeggs’ development of the AutoAnalyzer revolutionized clinical chemistry (he was in Cleveland; we were in Madison). He found that samples could be separated from one another by air bubbles as they were pumped sequentially through plastic tubing into as many as 12 concurrent analysis modules. By now, modern lab instruments have undoubtedly displaced the old AutoAnalyzers.”

“While Skeggs and others were automating the clinical laboratory back in the 1960’s, what were you doing?”

“As a research associate in biochemistry, I was developing an instrument for the continuous determination of cyanide in grass. And I’ll answer your question before you ask it; it was not the kind of grass that lots of people were smoking back then. Despite the student riots, Madison was a pretty stimulating place in the late 60’s.”

“Curmudge, other than ‘Gee Whiz,’ what’s the lesson from today’s discussion?”

“Lessons plural, Julie. Most importantly, one should embrace change, both technological and organizational as in Lean. Both kinds of change will make our lives more productive and enjoyable. The second lesson is that one should take a moment to look around and appreciate the astounding developments that have occurred in science and health care in a few short years. Everyone should be inspired to shout an emphatic ‘Wow!’ We’ll talk more about this in later postings.”

Affinity’s Kaizen Curmudgeon

(1) McManus, R.J. et al. Does changing from mercury to electronic blood pressure measurement influence recorded blood pressure?
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1314749/pdf/14960220.pdf
(2) Elliott, W. J. et al. A comparison of two sphygmomanometers that may replace the traditional mercury column…
http://www.ncbi.nlm.nih.gov/pubmed/17303984

Mistakes 3

2010-07-22T10:35:00.000-05:00

“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

Docs on a Treadmill

2010-07-15T10:45:00.002-05:00

“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

AIDET Redux

2010-07-01T10:35:00.004-05:00

“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

Judgment

2010-06-18T09:18:00.002-05:00

“Today, Jaded Julie, we’re going to talk about judgment.”

“You mean Judgment Day like in church with singin’, shoutin’, and wavin’ my arms?”

“No Julie, I mean personal and professional judgment, as in making important decisions. Consider a veterinarian who specializes in small animals. Her good judgment tells her not to go out to a farm to treat a sick draft horse.”

“How about some examples in human health care, Curmudge? I bet that’s where you were heading all along.”

“Let’s start with primary care and the ED. Most of the illnesses and injuries that patients come in with are low acuity. As they say in the ED, ‘treat and street.’ In these situations, mid-level providers like NPs or PAs are just what the patients need. I have a physician friend who is delighted with the NPs in her practice. She says they can do 90% of what a physician does.”

“That’s great, Curmudge, but where does judgment enter the story?”

“It’s the other 10%, Julie. It’s the NP’s judgment of when the patient needs to be seen by a physician. Of course she is limited by her license and state regulations, but I would favor good judgment any day.”

“Some people call NPs and PAs ‘physician extenders,’ but that sounds demeaning. ‘Advanced practice’ or ‘mid-level’ are more appropriate terms.”

“It isn’t just the NPs who need good judgment. The primary care physician needs to judge when a specialist must be consulted, and sometimes the specialist determines that the patient should see a subspecialist. In rare cases the patient must go to a world-class medical center for diagnosis and treatment. Excellent judgment by the providers and the patient is critical at each step along this pathway. If the patient has compelling concerns about her diagnosis and proposed treatment, she should seek a second opinion.”

“But Curmudge, doesn’t the patient stop when she reaches a physician whose credentials match her illness?”

“Ah, Jaded Julie, here is where judgment enters the picture big time. Credentialing cannot guarantee the best of all possible outcomes for every patient. I would personally have reservations about a provider who might be near the lower limit in relevant experience and would want to push the envelope of his proficiency. Examples of this have appeared in recent news articles about poor outcomes from robotic-assisted surgery, presumably performed by physicians with inadequate experience with the specific device.”

“So who makes the judgment about the best path forward for the patient?”

“The patient does, but not without help. She should go back to her primary care physician—hopefully in a medical home where she is well known—and review her diagnosis, proposed plan of care, and provider. Of course, she can use her computer to find evaluations of hospitals in CheckPoint and physicians in HealthGrades. In addition, she should get advice from people she trusts, including retired health care professionals and their spouses. It seems that every senior has a health care story to tell; Ms. Patient should listen. After careful consideration and the best judgment she can muster, she should make her decision and proceed with confidence and faith.”

Affinity’s Kaizen Curmudgeon