Spring Cleaning—This Isn’t “Happy Talk”

“Curmudge, I googled it.  ‘Happy Talk’ is a song that was sung by Bloody Mary in the musical, South Pacific.  But I was hoping that as you cleaned out your files this spring you’d find quotations that were cheerful and encouraging.”

“For the most part, it didn’t turn out that way, Julie.  And most of these quotes are fairly recent.  They suggest that health care should still be in intensive care.”

“Well I hope that our readers realize that these are quotations from notable authors and not original with you and me.”

“Julie, after 200 postings our readers should realize that nothing is original with you and me.  So sit back and shudder at what you are hearing.”

“Health care remains fundamentally unsafe.”  (L. Leape, runningahospital.com, 3/20/12)

“Too often, doctors think they are infallible, communication between doctors and nurses is poor, and accountability is virtually non-existent.”  “There is difficulty admitting that well-meaning, highly trained, competent doctors predictably and continuously make mistakes.”  (Peter Pronovost, Wall St. Journal, 2/17/10)

“We (physicians) can’t know it all.  We can’t do it all by ourselves.”  “Holding on to that old culture (complete autonomy) has been a disaster.”  “We need pit crews, not cowboys.”  (A. Gawande, TED talk, April 2012)

“You can’t practice medicine by committee.”  “Uniformity of practice is a nonsensical goal that fails to allow for differing expression of disease states.”  (S. Greenfield, Wall St. Journal, 9/07/10)

“It sounds, Curmudge, as if Dr. Greenfield doesn’t favor standardized work, algorithms, and checklists.”

“That’s why a goal of evidence-based medicine is to accommodate variation between patients while minimizing variation between clinicians.”   

“Most clinicians and nurses believe quality improvement is done to them rather than something they do.”  “Without physician leadership, quality improvement efforts are unlikely to succeed.”  (P. Pronovost, beckershospitalreview.com 2/28/12)

“The average Medicare patient sees two physicians and five specialists a year.”  “You (patient) have to be the central communicator…there is no little Tinkerbell picking up your medical records and automatically delivering them to the physicians in your life who should know what is happening with you.”  (B. Gray, kevinmd.com 4/09/12)

“We don’t often talk about money, Julie, but here are some ways to achieve big savings:”

“Decrease the practice of routinely administering untargeted chemotherapeutic false hope and real suffering to patients with widespread metastatic cancer.  Recognize death to be normal, and endeavor to make it as dignified and free from pain as possible.  Do not prolong dying to keep the revenue flowing.”  (George Lundberg)  “Stop overtreatment with unneeded antibiotics, surgery, and intensive care, especially at the end of life.”  (Donald Berwick)  (Both found in kevinmd.com 5/07/12)  

“Whether happy or not, physicians set the tone at their places of work.”  (G. Hood, Survey of physician happiness.)

“L.A.M.E. = Lean as mistakenly executed.”  (M. Graban, LeanBlog 4/10/12)

“No one can guarantee the right outcome from a treatment for an individual patient.”  (P. Hartzband & J. Groopman, Wall St. Journal, 3/31/12)

“Creating a culture of safety includes: Admitting our own errors and mistakes when they occur, and feeling empowered and supported to speak up when we see another’s. (and)  Learning from errors so that we don’t repeat them.”  (O. Peskovitz, runningahospital.com 3/16/12)

“Julie, you should find this example of precise performance to be encouraging:”

“An aircraft carrier is an airport on top of a nuclear power plant (run by) a bunch of 19-year olds.”  (S. Patterson, runningahospital.com 4/18/12)

“That’s an oversimplification, Curmudge.  You know that those 19-year olds are led by the best of the best and that all critical functions—especially on the flight deck—are exquisitely choreographed and perfected by repetition.”

“Our local hospitals will never go to sea, Julie, but I’ll bet that those kids could teach them a thing or two about the value of standard work.”

Kaizen Curmudgeon

Spring Cleaning--Safety and Quality

“Hey, Julie, I’ve been doing some spring cleaning.”

“Your messy office or your cluttered basement?”

“My office is not messy, but my files are overloaded.  I’ve been sorting them to discard the junk and retain the classics.  Although this stuff goes back to 2006, the gems shine as brightly as they did originally.”

“Then, Curmudge, let’s share some of them with our readers.  They are all quotations, but we won’t have room for complete references.  Perhaps we can just state the name of the author or the blog or publication in which the quote appeared.”

“Okay, Tonto, you type while the Lone Ranger shuffles papers:”

“99,000 patients die each year as the result of hospital-acquired infections and errors.  That’s the equivalent of one fully-loaded 747 crashing each day for 200 days out of a year.  About 7,000 people per year are estimated to die from medication errors alone with three-fourths of the adverse drug events due to failures at the system level.”  (Graban 8/09/09)      

“Curmudge, I find these numbers astonishing, yet the original sources of these values are quite believable.”

“The only way to crack down on error is to admit its inevitability.  Being aware of the mistakes we make that lead to error is the only way to curb it.”  (K. Schultz in ‘Being Wrong’)

“After surgical technique, most surgical error was caused by human factors: judgment, inattention to detail, and incomplete understanding, and not to organizational/system errors or breaks in communication.” (pubmed/18847639)

“In the arena of skill- and experience-based errors, the research is clear.  Nothing can take the place of repetition.”  (emsresponder.com)

“Checklists seem able to defend everyone, even the experienced, against failure in many more tasks than we realized.  They provide a kind of cognitive net.  They catch mental flaws.” (A. Gawande)

“About 15 percent of patients are misdiagnosed.  In fact most cases are due to mistakes in the mind of the doctor.”  (Jerome Groopman)

“Studies have demonstrated that geographical location strongly determines specialty care access and procedural decision making.”  (Harrington, Quality Digest, 2006)

“In Pennsylvania alone, the mortality rate during a hospital stay for heart surgery varies from zero in the best-performing hospitals to nearly 10% at the worst performer.”  (NY Times, 5/17/07)   

“There’s also a very complex social and organizational hierarchy that makes it difficult for people lower on the hierarchy to critique or speak up when they see a problem with someone higher up.”  (WebM&M, Nov. 2006)

  

“All health care providers performing invasive procedures must adopt the Joint Commission Universal Protocol, including performance of a time out immediately prior to the procedure.”  (medscape.com/17053)

“Out-of-hospital sudden cardiac arrest survival to discharge generally reported at less than 10%, and survival from in-hospital sudden cardiac arrest estimated at 18%.”  (WebM&M, July/August 2007)  “A 2010 study of more than 95,000 cases of CPR found that only 8% of patients survived beyond one month.”  (G. Hood, 4/16/12 Medscape)

“Please note, Julie, that if one ‘codes’ in a hospital and somehow manages to survive, he still has his original ailment, and in addition, a crushed chest.”

“Wow, Curmudge, I can see why old guys like you in a hospital want their chart to indicate ‘Do not resuscitate.’ ”

“(A patient safety officer’s) job ethically is to transparently promote a reliable and safe environment.  To do that, you need transparency.”  (A. Frankel, MD, WebM&M, Dec. 2006)

“The single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes.”  (L. Leape, 2008)

“Environmental cleaning is so important that when it is not done regularly and rigorously, placing a patient in a room previously occupied by a patient with Clostridium difficile can be a fatal mistake.  Cleaning hands with soap and water is essential, because alcohol sanitizers are often ineffective against C. diff.”  (hospitalinfection.org, Jan. 2009)

“There is compelling evidence that performance measurement leads to performance improvement.” (However) “Good performance is not necessarily good care, and pressure to improve performance can come at the sacrifice of good care.”  (R. Werner, Medscape 555953)

“For employees, it is the culture of the organization that is the reality, not the mission statement that hangs on the wall.”  (A. Yelton, GE Healthcare)

“Lean Thinkers now have the tools to reform healthcare delivery.”  (Jim Womack)

“It takes 18 years for proven best practice to become the industry standard in healthcare.”  (Brent James, 2009)

“I was hoping, Curmudge, that we would find quotations that would cheer me up.  If these are ‘up,’ I’d hate to see what ‘down’ is.  As we continue to rummage through your files, will we find material that is more encouraging?”

“No guarantee, Julie.  I suspect we’ll find lots of suggestions of the right things to do, but examples of resounding successes are apt to be rare.  It will take a lot more work before every hospital is as safe and efficient as a nuclear-powered submarine and as customer-friendly as a Ritz-Carleton Hotel.”

Kaizen Curmudgeon