Strike out Sepsis tourney returns

For those in or near Ohio, please note and join in!

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A thoughtful approach to public safety

A friend reports from the Algarve (the northern Portuguese coast):

At the westernmost point of Europe, fishermen sit at the edge of the cliffs across the bay and cast their rods into the waters below. While we were here, a marine policeman came around and administered breathalyzer tests to the fisherman. Apparently, after a morning of fishing, they have lunch out on the cliffs, often with wine. Sometimes, they have a bit too much, and someone will get tipsy and topple over the cliff edge! Then, the coast guard helicopters have to be called in for a search and rescue. Much better to prevent it!

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Annette teaches patient safety in a way we can learn

A key concept in Lean is that of standard work, but it goes beyond Lean.  A major cause of harm to patients worldwide is the large variation in how common medical procedures are carried out.  By definition, if there is a lack of standardization, not all approaches can be based on the best available clinical evidence.  We seek then, to adopt protocols that embody the best knowledge about how to do something right.

Brent James explained this a few years ago:

1 -- Select a high priority clinical process;
2 -- Create evidence-based best practice guidelines;
3 -- Build the guidelines into the flow of clinical work;
4 -- Use the guidelines as a shared baseline, with doctors free to vary them based on individual patient needs;
5 -- Meanwhile, learn from and (over time) eliminate variation arising from the professionals, while retain variation arising from patients.

Part of adopting protocols is to enable people to learn them, and it is here that there's "many a slip 'twixt the cup and the lip," as the old proverb goes.  In many hospitals that have adopted protocols, the sequence of steps is presented in written form in a hospital manual or on its intranet site.  Perhpas a nurse or resident is taught the protocol on the floor, but the teaching is uneven--sometimes not reflecting the entire protocol--and many times it occurs once, and then the clinician is left to try to remember it. Variation sneaks in and standard work is eroded.  Patient safety problems emerge.

It is our nature to vary from the protocol we are taught, especially if the training occurs in just a few episodes and especially if the training material that remains is only in written form.

Annette Koning from the hygiene department at Jeroen Bosch Ziekenhuis in the Netherlands realized this was a problem with regard to the hospital's protocol for cleaning and maintaining central lines.  So, with a colleague, she prepared this short video as a teaching tool, but also as a reminder tool for the staff.  I think it is an elegant presentation, and I offer it to you as an excellent example of (1) a Lean appraoch, where every person feels empowered to engage in process improvement; (2) quality and safety instruction; and (3) pedagogical excellence.  I hope you enjoy it and will consider using it or a similar approach in your hospital.

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These people are not camels

Dr. Victor Trastek is a thoracic surgeon at the Mayo Clinic.  To his surpise, an important part of his professional education came from a nurse, Shelly Olson, well after he became an attending physician.  They tell their story in this video.

Congratulations to Shelly for having the guts to stand up to an abusive and powerful member of the medical staff.  Congratulations to Vic for having the guts to tell the world an embarrassing story about himself--for the purpose of helping others see the way.

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We never stop getting better

A sign of a learning organization (e.g., those which have adopted a Lean philosophy) is the unending commitment to getting better.  When you go to one of these hospitals and say, "How are you doing?" the answer is inevitably something modest like, "Pretty well, but we have so much too learn."  Also, such hospitals are keen to celebrate the improvement activities of their front-line staff and managers. One such example is Gundersen Lutheran Medical Center in LaCrosse, Wisconsin, under the leadership of CEO Jeff Thompson.  Every Friday, 200 managers and staff gather at 8:00am to celebrate and recognize recent improvement activities, and then a written summary is distributed throughout the hospital.  Here's last week's summary:

March 28^th Improvement Event Recap:

At last week’s Improvement Event there we saw three examples of our Staff’s passion, initiative and talent!  Here’s a few highlights:

·         Shawn Stevenson (Business Development and Marketing) presented on “Managing Staff Workloads and Stress”.  Being unsatisfied with his department’s EPS Results, Shawn decided to take some unique and effective steps.  In working with his staff, he determined an imbalance in workload was the primary driver of increased stress and lower than desired engagement scores.  He worked hard with is team to fix this.  Using the A3 tool and the PDSA (Plan, Do, Study, Act) process he’s expecting big things in the next employee survey!  Check in with Shawn if you didn’t get a chance to see one of the tools he invented – THE STRESS-O-METER!

o   Observation:  Some would say “Attitude is Everything”.  Poor attitudes in our staff can be a result of being Overwhelmed – and that one is on us!  Shawn did a great job in recognizing this and doing something about it!

·         Lynn Dosch (Purchasing) and Michelle Tilson, RN (Wound Center), teamed up to present on “Reduction in Rental Equipment Expense”.  They noticed a significant increase in the use of Low Air Loss Overlays for the prevention of Pressure Ulcers.  They wondered whether we were truly using these rented overlays only when they would help our patients, or if their use had become routine.  As a result of asking the question, and deciding to take action together (using a PDSA data-driven process) they were able to reduce expenses by more than $23,000 per year while seeing improved outcomes.

o   Observation:  If every leader at the improvement event found similar savings in their departments we would reduce expenses by $4mil!  This is a great example of what we can accomplish when Supply Chain and our Clinical Areas work together!  Go team!

·         Alan Eber (Facility Operations) and Tammy Anderson (Inpatient Psychiatry) presented on the “New Inpatient Behavioral Health Building”.  We saw a great example of how the Process Improvement Tools, when applied collaboratively between Facility Operations and Clinical Operations can make a lasting impact!  As a result of this kind of collaboration, we now have a beautiful facility that fosters a “best-in-class” healing environment for our patients and is one of the most energy efficient buildings of its kind in the world!

o   Observation:  With an annual energy cost savings of ~$50,000 and a 50-year building design life, we will be “stuck” with saving millions of dollars over the coming decades.  Imagine what we would have been “stuck” with if we did not have such a talented team working together to bring this kind of value to our patients and our community!

And remember:  “The best way to predict the future is to create it!”  I am very excited to see the future we will create together!

Mark E. Platt

SVP Business Services

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How NOT to set an example

[First, a bit of a rant:  Why can't JAMA allow its articles of general interest to be viewable by the public? Other journals, like NEJM, do so. Now, on to the substance.]

JAMA has just published a research letter entitled "Academic Medical Center Leadership on Pharmaceutical Company Boards of Directors," in which it presents a list of deans and other high officials from academic medicine who are on the boards of directors of the top pharma companies.

Since we can't read the article, we go to the reports of two health care journalists to find out what's up.

John Fauber from the Milwaukee Journal Sentinel provides a more appropriate title: "Medical school leaders cash in on drug company boards."  Excerpts:

While university doctors who moonlight for drug companies have faced intense scrutiny in recent years, new research suggests much larger sums of money are being paid to their bosses — the leaders of medical schools and hospitals who serve on drug company boards.

Looking at the world's 50 largest drug companies, reseachers found that 40% had at least one board member who held a leadership position at a U.S. academic medical center — including medical school deans, chief executive officers, department chairs and university presidents.

The average annual compensation from the drug companies was $313,000, according to the paper published today in JAMA.

"These relationships present potentially far-reaching consequences beyond those created when individual physicians consult with industry or receive gifts," the researchers wrote.

He quotes an national expert on such matters:

"I don't know how they can manage a conflict like that," said Susan Chimonas, an expert on conflicts of interest in medicine. "My gosh, there is so much money they are making for a little side job.

Serving in dual roles raises so many potential conflicts that it would be wiser to eliminate them, said Chimonas, associate director of research for Columbia University's Center on Medicine as a Profession.

And also me:

"You cannot serve two masters, even if you are highly intelligent. In fact, if you are highly intelligent, you will rationalize the problems away by saying that you cannot be personally corrupted."

Charles Ornstein at ProPublica offers another take: "Leaders of Teaching Hospitals Have Close Ties to Drug Companies, Study Show."  Excerpts:

Pharmaceutical company payments to doctors extend far beyond rank-and-file clinicians — and deep into the leadership of America’s teaching hospitals, according to a study published today in the Journal of the American Medical Association.

All told, the research team found that 41 of the companies’ 2012 board members held leadership positions at academic medical centers. Six of the 41 were pharmaceutical company executives who served on hospital boards of directors or held other leadership posts. 

Excluding the industry executives, the academics earned an average of nearly $313,000 that year for their board service.

As board members of drug companies, academic leaders take on a fiduciary duty to those companies’ success. That can “conflict or compete” with their other responsibilities, the study says. 

“Given the magnitude of competing priorities between academic institutions and pharmaceutical companies, dual leadership roles cannot simply be managed by internal disclosure,” the authors conclude.

Here's the list.  I think it is humorous (and maybe hypocritical) that JAMA decided not to include the names of the board members since the whole article is about transparency and since the names are available from the web sites of all of the companies.  For example, one notable board member of Alnylam Pharmaceuticals--not listed below--has been Victor Dzau, who is leaving his position as chief executive officer of the Duke University Health System to head up the Institute of Medicine. (He was also on the Medtronic Board.)

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Life isn't fair

Joe Carlson over at Modern Healthcare has written a nice piece about some discussions that took place in Denver this last week at the Association of Health Care Journalists.  The topic was the forthcoming disclosure that would be required of industry payments to doctors and hospitals.

He relates a touching moment (really, I'm not being sarcastic), when a doctor expressed frustration at the idea that a legitimate commercial relationship between his hospital and a pharmaceutical company might now be viewed with suspicion.  After all, federal law encourages such relationships to help commercialize and spread the clinical advantages of NIH funded research:

"It seems to me that transparency has morphed into a form of bias," said Dr. Paul Offit, director of the Vaccine Education Center at the Children's Hospital of Philadelphia. "Everyone gets painted with the same brush."

Offit noted in a different session that his hospital has received money from the drugmaker Merck. He said the money consisted of royalties paid for the RotaTeq vaccine, which was developed at his hospital and sold to the drugmaker. In the past he has declined to say what share of the royalties went to him personally.

[Susan] Chimonas [from Columbia University] countered Offit's argument by recalling the case of Dr. Charles Nemeroff, who secretly accepted more than $800,000 from drugmaker GlaxoSmithKline while managing a $9.3 million study on depression at the National Institutes of Health. GSK is the maker of the popular antidepressant Paxil.

"Unfortunately, those guys have poisoned the well for you," panelist and former Boston hospital CEO Paul Levy told Offit. "Life just isn't fair."

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