If Google ran healthcare..................

A couple of days ago Mark Brittin, CEO, Google UK was speaking to a couple of hundred of healthcare people on improvement Google style. The first 7 on the list below are from his slides as principles that drive Google; the last 6 are what he said in his talk that I thought may have relevance to healthcare. 

Here are my early thoughts on what the Google CEO said and my understanding of how it might work in healthcare? I need to think more about it and am likely to post an update or change what I have written in the coming months. In the meanwhile....

What Mark Brittin said....	How I think it might work in healthcare.....
Focus on the user	Patient defined personalised pathways. Experience based design. (Current designs/pathways are built around  facilities and staff)
Open will win	Facilities as platforms for anyone to provide clinical care as long as care standards are met.
Ideas will come from everywhere	Other industry models. Customer service from hotels, safety from aviation, etc. To improve patient care 'copy shamelessly' principles
Think big, start small	More PDSA and roll up (rather than the current roll down)
Never fail to fail	I suppose we already do that more often than other walks of life but learning not to repeat the failures. Learning to fail safely.
Launch early and iterate	Continuous Improvement principles. Model for improvement. Evolution by stepwise changes.
Make it matter	Best quality, best cost at right time, every time to every patient
If you can’t spell it is our problem	If the patient will not take medication as prescribed it is our problem. If a patient comes in with MRSA/DVT from a nursing home, secondary care takes responsibility for this as well
You should get the answer even before you complete the question	Pro-active, extensive, repeated information in many formats
Internal ‘open’ is very important	All research, improvement can be presented/published after and only if it was rolled in and out within the organisation
Very small team to deal with big problems	Smaller MDTs, smaller numbers in meetings, smaller/shorter meetings. Enablers only
Speed is the forgotten killer app	Its not 4 hours, 2WW, 31/62, 18 weeks; it happens when the patient wants it to happen. In the quality puzzle we often forget time.
Aim to delight the user and figure out how to make money later	No need to reframe this one, I suppose

Here is a template for your use. Why don't you print this off and do your own list on how it might work in healthcare? Oh, if you did that, please share it by posting some of your thoughts as comments on the basis that 'open will win' and 'ideas will come from everywhere'.

What Mark Brittin said....	How I think it might work in healthcare.....
Focus on the user
Open will win
Ideas will come from everywhere
Think big, start small
Never fail to fail
Launch early and iterate
Make it matter
If you can’t spell it is our problem
You should get the answer even before you complete the question
Internal ‘open’ is very important
Very small team to deal with big problems
Speed is the forgotten killer app
Aim to delight the user and figure out how to make money later
©M HEMADRI

Will this work in healthcare? I think it will. What do you think?

©M HEMADRI

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Likeability and Interviews

Guest Blog from SAMI (Success At Medical Interactions)

One of the main factors in being successful in an interview is likeability.

Some may say that is unfair, some might be surprised. Let us explore this.

Once you are shortlisted and invited for an interview it means you have met the essential criteria which means you are appointable. On that basis you have an equal chance of actually getting the job as anyone else. If you are invited for an interview it may also mean that you have met many of the 'desirable' criteria. The chances are that the content of any answers you may give is also going to be more or less the same as the other candidates at an inteview, i.e. the knowledge is likely to be equal amongst the shortlisted candidates.

Well, if you have the essential criteria and your knowledge level is also the same then how can an interviewer make a decision?

The decision is therefore likely to be based on whether the interviewer likes you.

Jobs for the boys, known candidates, mentors on interview panels, old school ties, social networks and many other link-ups all mean just one thing in an interview context. It means that the interviewer likes the interviewee.

Likeability is very important. It will be pretty difficult, if not just impossible to work with someone that you do not like. We at SAMI, argue that the likeablility should be based on contextual performance based 'professional likeability' rather than personal links history based 'social likeability' (which is important and relevant in general/social life). This means that the interviewer makes a decision on whether the candidate is likeable purely on the interview performance of the day rather than any prior knowledge of the candidates that the interviewer might be aware of.

That will be the basis of Success of people in healthcare.

That is part of what we try to train you in when you attend the SAMI interview courses - on how to be likeable within an interview context thus potentially outshining anyone who may have social or personal links with the interview panel. Its not easy, there are no guarantees but no harm in trying!

Reposted from SAMI blog

http://successatmedicalinteractions.blogspot.co.uk/2012/05/likeability-and-interviews.html

Toyota for you doc

Toyota for you doc, what will it be for your patients?

In a recent Medscape survey it was found that doctors’ choice of cars were as follows: Toyota (16.73%), Honda (14.8%), Lexus (8.3%), BMW (7.5%), and Mercedes-Benz (5.32%). Ford came in a very close sixth at 5.24%, and Chevrolet came in eighth at 4.13%.

It is apparent that 25% of doctors chose Toyota directly (since Lexus is manufactured by Toyota) and 31.53% come from the the lean methodology (since Honda also follows similar methods) constituting the top two car choices of American doctors. If other Japanese manufacturers were included it would be much more. It is a 2012 survey that means the doctors were probably aware of Toyota’s problems from 2010.

Why would doctor’s chose cars manufactured with lean methodology despite Toyota's recent problems? It is possible that the doctors feel those cars are still highly reliable despite the odd headline problems. The doctors are perhaps really impressed with the degree of honesty with which Toyota has recalled to rectify problems and the degree of humility shown in offering a public world wide apology. It may be the case that Toyota, Honda and those who share their lean philosophy still offer great value for money – doctors also do look for value for money.

What is fascinating is that the majority of doctors, the same doctors who like Toyota lean methodology despite its problems, do not follow the healthcare adaptations of lean methodology despite undeniably proven examples within America. Virginia Mason is a small scale system and Intermountain is a large scale system that has excellent versions of clinical lean (there are others too). There is huge resistance to even begin to look at the methodology.

Human beings and healthcare, are not cars and car manufacturing, so I do understand if we did not want industry people directly applying their methods to healthcare. Clinical lean and healthcare delivery lean is specific and different (as practised at a few places in the world), the translation and adaptation has already been done and fine tuned for nearly a quarter of a century. Clinicians need to show the relevant leadership to make it work in their patch where ever they are in the world.

It is not too much to ask is it, to deliver value to your patient; the same or more value that you expect from your car? I know patients are not cars and healthcare is godzillion times more complex that the automotive industry. That is why I talk about value creation and the application of healthcare specific lean (not other industry lean) from proven systems. Clinicians only have to learn and apply clinical lean in healthcare – if you can learn and practice medicine with all its complexity, applying clinical lean where possible, with its eventual elegant simplicity is a piece of cake. Or is it?

©M HEMADRI

Taste the sampler menu of clinical lean by attending the Clinical Quality Improvement Course

Find some of the high level the outlining principles HERE

Demanding consultant delivered acute care

Who should deal with the most urgent and severe emergencies?

The following runs in every healthcare worker's mind but we usually do nothing about this. Let me describe it.

First time elective referrals at out patients for major conditions gets seen usually by consultants
First time elective major operations usually done by consultants (especially the major ones)

However,
Redo operations after complications due to first time elective surgery - quite often done by registrars or 'middle grades'
First time major emergencies in Resuscitation rooms and dire post operative emergencies in wards and ICUs are usually dealt with by registrars or 'middle grades'

Is that logical? Is that sensible?

Of course in some specialties like vascular, neonatal and a few other, the senior most persons often deal with the most dire things but I am talking about most specialties. For instance in internal medicine an elective referral for a chronic cough or chest pain will normally be seen by a consultant but a severe acid base imbalance, a pneumothorax, undiagnosed sepsis will be first seen often by very junior doctors fresh out of medical school or if the patient was extremely lucky by a registrar or middle grade.

This anomaly should be addressed. But it will not be easy to address. Clinical severity of the condition and clinical severity of any potential adverse outcomes should decide who will see/treat the patient and not mere availability, convenience, historical residual legacies and other administrative/managerial issues. This will demand consultant delivered care (not consultant 'led' care). People will rightly be concerned about the cost; it would be important to recognise that the improvement in clinical quality and the enhanced clinical accountability for outcomes could result in lower overall costs. If on the other hand there was a clear increase in quality the richer economies should accept that as the new benchmark for cost.

Success in Healthcare will depend on the proper utilisation of its very valuable human resource; the utilisation of the human resource should be exclusively based on clinical need - more severe the presenting situation - the more senior should be the primary attending human resource.

Here is where patients could play a part in improving the quality for themselves and in shifting the culture within healthcare. Patients and families could use the consent process to influence better care. Consent is a legal requirement before professionals can provide care hence any caveats in that legal process carries significant weight. Patients and families may or may not be able to define what should be done but they can define what cannot be done; for instance you cannot say you have to be given a blood transfusion but you can say that you should not be given a blood transfusion.  In the same manner I think patients probably cannot demand that only a fully trained healthcare profession should treat them but can possibly decline to accept care from anyone who is not fully trained without them being directly supervised.

For instance my living will or perhaps my consent to treatment form could say 'I, having worked hard and paid my taxes, when I am ill, expect to be treated and cared for at every stage by fully trained clinical staff; if that does not happen I will take it as having possibly received substandard care. Being a responsible citizen and supporter of NHS I am aware of the need for trainees to learn so that future specialists can be created; I will allow trainees to care for me at any time as long as their trainer is physically present and actively training the trainee in a hands-on manner. If the trainer is not physically present and actively involved (for instance if it is a surgical operation the trainer must be scrubbed up and assisting the trainee) I shall consider it as a breach of my right to have received the highest quality of healthcare that I expect and a breach of the consent that I have provided' (** Caution: Using aforesaid statement is likely to negatively affect your healthcare and risk an adverse outcome. The statement is used to make a point and not necessarily for practical use**)

It is patients' choice, let us take it seriously. If you thought this was a bit too assertive - pause for a few seconds and reflect on the day when my above sentences will be cut and pasted by every patient on to their consents and living wills. Or even better, pause and think of what you would want for your child, spouse or parent when they are facing the most dire emergency circumstances of their life perhaps after something that had already gone wrong. Would you want someone who has left medical school recently (though they are very good trainees and keen to learn) or someone for whom you have already paid upwards of £1million to become fully trained and employed to care for you, when you are facing a potentially resolvable life threatening condition? I rest my case.

©M HEMADRI

Healthcare not similar to aviation but lessons can still be learnt

Healthcare learning from other industries needs a much higher degree of sophistication

When are you in control and when are your patients in control?

When a plane is flying the passengers are not in control. It is the pilot who is in full control. The pilot also has controls on him/her but that control is not exercised by the passengers. Well, when there are 50 to 500 passengers in the cabin it will obviously be a problem to let individual passengers be in control of the flight itself. The passengers do get some control over their pre-made choices such as seats and meals; the passengers also get some control over when they use the toilets and when they can walk about as long as they are prepared to sit down and belt up as soon as they are instructed to do so. It is actually against the law to disregard pilot or cabin crews instructions; you do not have to harm yourself or others as a result, just not following the pilots orders is an offence.

Healthcare has made big noises about learning from aviation. We can argue that there are some similarities and some differences in the way passengers are treated and patients are treated. Just within the context of this short write up, can a chief exec of a small healthcare organisation or a chief clinician of a large unit say ‘we have a large number of patients to treat and hence we cannot accommodate individual patient choices’? Can clinicians tell patients ‘you have a choice over meals but for the rest of your healthcare you will do as you are told when you are in the hospital’? Will it ever become law that if patients’ disregarded their doctor’s instruction in a hospital they will be prosecuted (for potentially adversely affecting other patients care as a result)? Clinicians 'orders' are not orders at all. Of course it is an entirely different debate on whether the patients will get good results even if they followed their doctor's instructions completely.

The similarities between healthcare and aviation or any other industry for that matter are quite limited. This is for the simple basic reason that healthcare is direct and personal to the recipient – as direct and personal as a professional poking fingers and instruments into various orifices with consent in an attempt to make the lay patient better. That directness and ‘personalness’ does not happen in the often quoted ‘ultra-safe’ industries such as nuclear power plants, scheduled airlines, European railways and so on. It is a totally different empathetic human to human interaction where the 'relationship' is the main driver/lever. The synthetic 'have a nice day' with an artificial smile will not work in healthcare. Its a kind of relationship that a pilot or crew might have when the plane has crash landed and they are trying to rescue frightened and traumatised passengers; not something that they would wish to do everyday and that is something that many in healthcare do every day.


That does not mean healthcare cannot be safer than what it is now. It also does not mean that the ultra-safe industries have nothing to share with clinicians; of course we need to learn more from crew resource management methods, etc. It only means that the lessons and methods can only indirectly be applied; the principles have to be adapted and only then adopted. We are really poor in translating the lessons from other industries into healthcare.

I am very passionate about patient safety and quality enhancement. I have learned a lot from other industries including aviation. Healthcare is a risky business. If we attempt a direct application of the principles from other industries, healthcare will continue to remain a risky business. The translation and transfer has to be much more sophisticated than what it is right now. It is possible.


HEMADRI

No mosquitoes in UK so our healthcare is costly

No Mosquitoes in Great Britain, hence our healthcare is costly

A groin hernia is surgically repaired by placing a synthetic mesh on the weakness and fixing it in place. In UK the mesh currently costs from £20 to more than £100.

This is obviously a significant cost which the rural areas in the developing and poor countries cannot afford. The doctors face an ethical dilemma. Should they refuse to operate since the mesh is unaffordable? Should they do a non-mesh repair which is generally thought to have a many times the recurrence rate of the hernia compared to mesh repair?

Tongaonkar and Reddy, doctors from two small towns in India innovated by cutting mosquito net cloth to shape, sterilised it by autoclave and used it on patients (http://www.bioline.org.br/request?is03018). They had very good results that compare well with standard international/western results for groin hernia repair. They also had the mosquito net cloth mesh analysed by labs which generally showed it to compare well with commercially manufactured meshes like the ones we use in UK. 

The mesh costs a few pennies; it was 3688 times cheaper than the commercial mesh.

Of course surgeons in India accused the Indian Journal of Surgery of blasphemy for publishing Tongaonkar's paper.

Now here is the good news, a UK surgeon Prof Andrew Kingsnorth uses the mosquito cloth net mesh for hernia repair. The not so good news is that he does not use it in the UK, he uses it in a hernia charity in Ghana which he leads/supports www.operationhernia.org.uk  

One of my friends who has interacted with this blog wrote to Andrew Kingsnorth and the conclusion was that red tape will prevent us from using it in UK. I have discussed this with a number of people, at the very end of the discussion we always wondered why we in UK would not take this up even if we save money. Groin hernia mesh is only a £5million market with already many fingers in the pie. £5 million for the NHS is possibly small change. Our discussions normally end at that point.

We are a developed, rich economy, it may well be that our development and our wealth which prevents us from taking up innovations that save money. You would have never guessed that the lack of mosquitoes in UK was one of the reasons for our healthcare being costly!

Hemadri

EWTR - Sleepy Tired Doctors are Unsafe Doctors

A major newspaper ran a campaign last year in association with one of the surgical royal colleges against the European Working Time Regulation for doctors especially for surgeons. I am finding it uneasy that we seem to have lost balance on this issue and chosen to take the campaign mode. We learn that the Government could ask for an exemption from EWTR for British doctors. Having done training posts in the pre-EWTD era and regularly worked more than 80 hour weeks in surgery, I welcome the European Working Time Regulation especially for doctors in training; but it not just a matter of opinion.

Acute sleep deprivation has been shown to result in more errors, longer time to complete tasks, slower reaction times resulting in a deterioration in clinical performance. This is the case in both In simulated and real time environment. There are important consequences for chronic sleep deprivation as well. The issue is not just about the duration of sleep but also the importance of quality of sleep, which is indirectly reflected in some of the rules of the EWTR regarding continuous uninterrupted rest periods. Healthcare claims to be learning from the airline industry, the airline industry recognised the issue of working hours and rest and has very strict rules for the pilots regarding flying hours; it is well known that scheduled commercial airlines rank very high in safety.

Since the gradual implementation of the working time directive, now a regulation, this country has not seen any objective worsening of clinical standards such as mortality or complications; in fact most parameters have shown an improvement in standards of care, obviously there is no implication of cause and effect here. However, surveys showing perception that patient care has possibly become unsafe are not really borne out by objective evidence; as a profession based on science we must be aware of both the power and limitations that perceptions can have. Further, I am not aware of even a single consultant level doctor appointed in recent times who has stopped being a consultant and gone back to training due to any recognition that the EWTD allowed poor training. 


If indeed, as a country we wanted to act on a survey perception that EWTR is affecting training, instead of putting patients at potential risk by asking doctors to work longer hours, the powers in charge of training should have addressed the issue by prolonging the period required to complete the training. Part-time trainees do this all the time while providing equal quality of care and with the changing gender profile of the medical profession this becomes even more relevant.

Europeans, in consideration of a better quality of life have taken a societal direction to work lesser hours and for British doctors to some how claim that we are very different from the society we live in, is an attitude incompatible with modern life. Doctors are not super human, though it may seem some of us ardently wish to be so.

There is no scientific, operational or societal reasons to oppose the EWTR. I think it is time to recognise this before the society begins to wonder if there were considerations other than these in the medical profession's decision making; that would damage the image of the profession. There have also been recent suggestions that we can ignore the law, such a thinking does not bode well for a profession held in high esteem by the public. The issue is about safer healthcare, longer duration of working which is highly likely to result in sleep deprivation impacts adversely on safety. 


If I had the opportunity to choose my doctor I would obviously opt for a well qualified and experienced one who is not tired, I am not sure anyone would choose otherwise. Is it unreasonable to ask the government to ensure the same for me through the NHS?