You might have read my blog post from last week about an unsafe taxi driver and medical errors – Said the Unsafe Taxi Driver, “Well, Did I Hit Anybody?”
In a colossal coincidence, the New York Times columnist Maureen Dowd wrote a piece called “Giving Doctors Orders” that was published the exact same day. No, I'm not part of a “vast left-wing conspiracy” here. My post had YouTube videos of a bad driver, while Dowd name dropped the actor Alec Baldwin and cited him on how to confront unsafe cabbies. Data would probably show that systemically unsafe healthcare practices harm and kill more people each year and probably deserve more of our attention.
In Dowd's column, she wrote of how her brother died after coming down with FOUR hospital-acquired infections.
She asked the doctor what might have caused it:
Wearing a white lab coat and blue tie, he did a show-and-tell. He leaned over Michael and let his tie brush my sedated brother's hospital gown.
“It could be anything,” he said. “It could be my tie spreading germs.”
I was dumbfounded. “Then why do you wear a tie?” I asked. He shrugged and left for rounds
As Dowd points out, best estimates show that hospital-acquired infections lead to 100,000 deaths annually in the U.S. As she points out the UK National Health Service banned long ties, long sleeves, lab coats, long fingernails and other known germ havens that can lead to passing on germs to patients. For a profession that talks about being “evidence-based” (or aspiring to that, as Dr. Brent James points out), why haven't we followed that practice in the U.S.? Is this the new patient protection norm in your country?
It's easier to identify my taxi driver's dispatch distractions or Alec Baldwin's newspaper-reading drivers as patently unsafe practices. It's very usual. We all drive and we all know the risks of distracted driving. But we're not all doctors. It's not obvious that a neck tie that's hardly ever cleaned can spread germs. It's visual and obvious that a long neck tie can kill the wearer in the factory, but it's less visual that the long necktie can harm OTHERS in healthcare.
There are also societal norms of different sorts in play, where Dowd and I struggle with speaking up to a cab driver, it's even harder to speak up when it's a highly educated physician. We're taught to respect physicians while cab drivers are more often the butt of jokes from stand up comedians. We should respect all people regardless of their job, as there is honor in work of any kind.
Dowd repeatedly found it difficult to speak up when she saw ICU clinicians not following proper hand hygiene. She cites Dr. Peter Pronvost, a leading patient safety advocate:
“There's no doubt that it's really difficult to question physicians,” Dr. Pronovost says. “It's hard even for me when my wife or my kids are ill. Many clinicians aren't the most welcoming. They give verbal or nonverbal clues to say, ‘Hey, I have the answer.' We just need to change the culture. The patient really is the North Star.”
That's why I question the efficacy of campaigns that urge patients and families to “speak up.” That unduly puts the burden on the customer to maintain quality. Does a car dealer ask the customer to “speak up” to ask if the steering wheel was put on properly? Maybe if you drive a Chevy Cruze you should. The auto industry generally takes care of its quality without asking the customer to play final inspector. I think healthcare owes patients as much.
Healthcare quality is arguably WAY worse than your run of the mill automaker, as recent studies point out the lack of adherence to even the most basic of infection control measures:
The study of intensive care units released Wednesday, for instance, found that health care workers wore gloves only 82 percent of the time when such precautions were specified, donned gowns only 77 percent of the time and washed their hands after only 69 percent of patient contacts. The lead author, Dr. W. Charles Huskins of the Mayo Clinic in Rochester, Minn., noted that those numbers were “not woefully bad,” as previous studies had found hand-washing compliance to be as low as 50 percent.
Not woefully bad? Wow, that sets the bar VERY low, don't you think? It's better, but nothing to brag about, as an industry.
You can also argue that transparency leads to better quality. Studies like JD Power and the book The Machine That Changed the World
Those who push for quality transparency data in healthcare make the same argument that transparency will force the whole industry to improve. Paul Levy's recent blog post called “Second thoughts on transparency in Ontario and Denmark” suggest that there might be a backlash against the transparency movement from at least some providers. Paul reports how some medical leaders thinks transparency will get in the way of proper quality improvement and one person suggested that the general public can't be trusted to handle such quality and patient harm data responsibly. Hogwash.
One comment on Paul's post passed along a second hand quote:
“I presented the Kumar and Nash article to our hospital's CME committee and one ‘long-time' psychiatrist reacted quite passionately – ‘we can never let the public know about this bad medicine…it is embarrassing' “
It's “embarrassing”? The cat is already out of the bag with studies from the Institute of Medicine that estimated almost 100,000 deaths from preventable medical error each year (in addition to the infections) and a Health Affairs study that suggests 1 in 3 hospital patients will suffer an error or an adverse event.
What's embarrassing is the healthcare industry and medical professions moving more slowly after more than a decade of awareness. I guess the long sleeves and long ties are visible evidence of some of that denial and inaction? Bow ties are a great alternative as one of the letters about Dowd's column points out.
The good news is that Lean, checklists, six sigma, and other quality improvement methods show such benefits and such promise. We have hospitals that are pretty much eliminating central line associated bloodstream infections, ventilator associated pneumonia, MRSA infections, falls, bedsores, and other preventable harm. As the science fiction author William Gibson wrote, “The future is already here — it's just not very evenly distributed.” Will efforts and spending like this from CMS actually help reduce errors and spread better care more quickly?
My friend Naida Grunden shared a Lean-based good news story: “Study Finds Drop in Deadly V.A. Hospital Infections.” Maybe Lean implementors everywhere should call for a moratorium on 5S-ing the nurses' station until everybody has solved these important patient harm and safety challenges?
Where do we find the balance between being outraged at current quality levels while being optimistic that things are getting better?
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Every time I visit one of the more famous Philadelphia children’s hospitals and scan the filthy, dust-laden, dried ‘goodness-only-knows-where-that-came-from’ stains in the exam rooms, I find myself amazed that more children do not become sick because of their visit there.
After bringing this condition to the attention of the M.D. examining my child recently, I was reminded of my place in the American caste system- with a withering, indignant look.
If he doesn’t care, then no wonder the housekeeping staff doesn’t care.
Nosocomial infections are just another sign of loss of focus on the mission of a healthcare organization: to care for the health of the patient. Rather than driving trivial cost reductions by limiting laundry bills and personal protective equipment expenditures (so they can get the latest imaging equipment, new wing, etc.), administration needs to focus on providing a safe, clean environment for patients, staff and visitors. I agree – before 5S-ing nursing stations or other administration areas, focus on SHINING the patient care areas. Everyone should be involved in kaizen, from cleaning staff to food services to nursing/medical up through top administration.
I’ve personally had to endure unchanged linens and gowns, never-washed lab coats, unwashed/ungloved hands, cold or undercooked food, etc. Waiting for patient/family complaints to fix problems is simply too late in the process to prevent an infection.
This is one area where “good enough” just isn’t, and never will be, good enough.
I’m reading a great new book by Guy Kawasaki called Enchantment, and there’s yet another coincidence. He mentions both Pronovost and Gawande on page 52. He cites an experiment that Pronovost did at John Hopkins.
It turns out that doctors skipped at least one step for preventing infections form catheter lines 33% of the time. This resulted in 11% of patients getting line infections.
After Pronovost got the hospital to allow nurses to stop doctors if they didn’t stick to the list, the infection rate dropped to 0!
Kawasaki also says that a checklist helps with “enchantment” (or great marketing) because it shows that you have your act together and because people feel a sense of accomplishment when they check something off the list.
Anyhow, I just thought you’d be interested in hearing how some lean health care concepts are cross-pollinated with high-tech marketing concepts!
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Yes, as you and Kawasaki are pointing out, it’s not the presence of a checklist that’s matters, but how it’s managed and the culture around the checklist (a team environment and a willingness to stop the line to solve problems).
That sense of accomplishment from checking off something is part of the idea behind the “personal kanban” or “getting things done” personal productivity approaches, too.
These scale of these problems is huge. I believe it will take 20 different strategies to make the kind of gains we want. None 1,2,3 or 4 individual measures will be good enough. We should do them because they may help. But the key is adopting a philosophy that demands never ending improvement of patient care. Not mindless babbling about it. Actually doing it. Thankfully lots of good stuff is being done. Unfortunately far far too much is being left for people to speak up if they are subjected to things they never should be subjected to. That is a horrible answer.
I agree with you Mark that speak up campaigns do seem to put the burden of quality and safety measures on the patients and families. It is an undue burden when there is no actual empowerment associated with it. Perhaps if some of these “god-like ” behaviors were addressed during the initial recruitment phase and identified as unacceptable some employees would not be hired to begin with. As a culture we have been conditioned to accept a physican’s poor behavior because he/she is a physican. Do we teach our children that it is ok to be bullied by the quarterback simply because he’s the quarterback ? Why should a hospital be different ? As a professional recruiter I’ve seen some of the most successful surgery groups, privatepractices and hospitals thrive because they have refused to hire physicans and staff with prima donna personalities and the inability to speak up. Perhaps we all need to work as hard to change the culture of subservient acceptance in healthcare as our schools are with bullying.