“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
Friday, March 18, 2011
Thursday, March 10, 2011
Complacency 2
“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
“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
Thursday, March 3, 2011
Complacency
“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
“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
Thursday, February 24, 2011
Way to go! 2
“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.
“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.
Thursday, February 17, 2011
Way to go!
“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
“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
Wednesday, February 9, 2011
The Middle Years
“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
“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
Wednesday, February 2, 2011
What shall we do with you?
“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)
“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)
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