Guarantees in Healthcare

I would like you to take a moment to think about what is the longest guarantee period offered for a product that you know of. Months, years, decades? What about life-time guarantee? For instance Toyota offers an 8 year guarantee for their Prius battery for the electrical motor part of their hybrid system. Some manufacturers and some body works repairers offer life time rust proof guarantee. Pizza companies say that you can have the pizza for free if it does not reach you within a defined time after your order. Well you can surely name a few more yourself.

Here is a jaw dropping guarantee. 2000 years.

Yes, you read it right The Sweet Little Sugar Softener offers a 2000 year guarantee. Yes that is offered for a product that is very simple. Okay, I am not sure if any of us are going to be around for 2000 years to vouch for this. But just imagine the confidence of the manufacturers in their product that they are able to offer it. It is a product made by simple artisans in rural America, not highly educated, with no great facilities etc


Guarantees in Healthcare

Health care is full of educated, highly intelligent and motivated people. Many if not all clinicians would have two post-graduate degrees. Healthcare managers and insurers are very large players in terms of the total money spent on healthcare especially in the western world. What kind of guarantees can healthcare offer to patients? As far as I know, none. In fact, professional bodies may not look at you very kindly if you started offering any guarantees, they will come down on you with a tonne of heavy scientific bricks and with a high moralistic tone accuse you of potentially misleading patients. Why is that? Why is it that healthcare which consumes so much of our resources unable to offer any sort of guarantees to our patients?

It is high time that we started backing our intelligence, education and skills and experience to think about what guarantees we can offer our patients and how we can make those guarantees work. We then need to put some money to back those guarantees. Doctors should perhaps take the lead on this one. Doctors always claim that they are consistently in the top 2% of the top performers in the society - well that is indeed true. If the top 2% performers cannot guarantee any of the activity they do and back it with some money we do need to either question their performance or their motives.

Healthcare needs some guarantees, patients need some guarantees. Yes, you healthcare folks, time to up your game, I know you cannot yet reach the level of guarantee offered by rural native American artisans but surely you could start with something small. How about no charge for patients if their bowel anastamosis leaked? How about completely free care if you did not meet the expected discharge date? How about paying a penalty to the patient every time you cancel or postpone their appointment/operation/etc.

Healthcare just dazzling and blinding people with asymmetrical power, high intelligence and skills is not simply good enough any longer. It has to be matched with some performance guarantees.

Being the change you want to see - the oft repeated Gandhian saying; on that basis let me go first.


OFFER OF MONEY BACK GUARANTEE IN HEALTHCARE
(possibly for the first time in the world)

One day the whole of healthcare especially doctors including me may be able to offer guaranteed clinical end results; right now it seems we cannot. So what can I guarantee can I give my patients? Before we get into that let me also explain that I work in the NHS on a salaried basis in a surgical department. NHS allows me to do private practice but I am not in regular/routine private practice. I cannot as an NHS doctor offer any individual guarantees to my patients. I am like the rest of the British people, own the NHS but do not run it. However I can offer some guarantees to my potential private patients.

Here are the guarantees I am willing to offer to any private patient who cares to find me and pay me a fee for service (self paying private patients).
Open primary inguinal hernia repair: if you have a recurrence within 3 years I will refund you the my fee i.e. the surgeon's fee.
Colonoscopy: if I do not reach the caecum (provided it was not poor bowel preparation or a confirmed bowel narrowing) and hence you had an incomplete colonoscopy I will not charge you my personal fee for the procedure.
Obviously all other charges will apply, have to be paid for and not be refunded.

As I have already said, right now I am not in active private practice. But if there were any patients who paid me privately for these two procedures that is the money back guarantee I am able to offer. If there were takers for this service/offer I might be stimulated to think of what further guarantees can be designed in healthcare.

What is important is if many others in healthcare provision are able to offer firm money back guarantees in healthcare. That might be a disruptive innovation in clinical provision. Let us go for it.

What are the guarantees that you are able to offer your patients?


Update: 1 Nov 2012: W Fischer informs me that there are guarantees in healthcare at Geisinger, Danville, PA since 2006. Very nice to know. So obviously I am not the first or the only. Here is a write up on their warranty: http://www.ihi.org/knowledge/Pages/ImprovementStories/GeisingerWarrantyonCABGSurgerySignalsCommitmenttoExcellence.aspx There are press stories about it, find it on the net. They do not seem to pay the patients any money back (I suppose that will be an issue for the insurers) but they do not charge the insurer to fix any complications.

©M HEMADRI 

Follow me on twitter @HemadriTweets
 

Mark the site campaign

MARK THE SITE
 

A Surgeon's interaction in the Operating Theatre

This is a real conversation that happened in a real surgical operating theatre in India a few weeks ago. It probably happens every day.

Surgeon, standing to the right of a patient under general anaesthesia for hernia repair asks: 'which side is the hernia?'

Assisting surgeon: 'I don't know. I did not see the patient.'

Surgeon: 'Who saw the patient?'

Assisting Surgeon: 'The house surgeon from the previous shift'

Surgeon: 'What does it say in the notes and consent?'

Assisting Surgeon: 'Hernia repair, obviously'

Surgeon in anger: 'Obviously!! But which bloody side?'

There were a large group of people in that operating theatre, junior nurses, medical students and other staff. None of them will speak to the chief unless they are spoken to. Silence for a few moments.

Surgeon in exasperation: 'Does anybody know the side?'

Medical Student puts her hand up.

Surgeon very impatiently: 'Tell us. What are you waiting for?'

Medical student says: 'I don't know for sure, but I was standing on the right of the patient's bed when I examined him and I had to reach out across to feel the hernia. So it must be the left side.'

Surgeon: 'Left it is then. Let us get this done'

Very lucky day. The patient did have a left hernia. The medical students had seen two other hernia pre-op patients the same day and extremely fortunately they were all left groin hernia.

Wrong Site Surgery WSS

(and wrong site procedures: wrong site anaesthetic, implement fitting, etc)

Sadly not all patients have lucky days like the above patient.

Wrong site surgery happens 40 times a week in the USA. http://www.washingtonpost.com/national/the-pain-of-wrong-site-surgery/2011/06/07/AGK3uLdH_story.html

Wrong site surgery is estimated to happen once a year in a typical hospital with 300 beds Clarke, J.R., Johnston, J., and Finley, E.D.  Getting surgery right.  Annals of Surgery;246(3):395-405, Sept. 2007.  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1959354/pdf/20070900s00006p395.pdf

Surgeons have a 1 in 4 chance (i.e a very high chance) of being involved in a wrong site incident

Wrong Site Procedures: Wrong side anaesthetic – is happening more and more with not much attention paid to it. There are a number of interventions done in wrong patients, a large number of unnecessary procedures done on right patients. Even the statistics for these are difficult to find.

Though the evidence comes from the west there is no reason to believe that other countries (such as India) have any less incidents or better practices.

The impact of these are dreadful with life long suffering. Life long dialysis if the wrong kidney is taken out or a kidney transplant with the complex lifelong medication to be taken after that, wrong eye – blindness, wrong leg, etc. It does not need to be major operations even after lesser wrong procedures it is possible to have wound infections, chronic wound pain etc. These are just physical. The psychological effects are much worse and affects not just the patient but families, friends and whole communities. Trust in healthcare providers – hospitals, doctors, nurses – irreversibly damaged.

The internet is full of events, episodes and tragic histories of patients who have suffered wrong site surgery. If you want examples they are only a couple of clicks away.

Solutions

It is very easy to write about solutions but it is well recognised that any solutions against wrong site surgery is very difficult to put into place, difficult to practice and not always successful. That is no reason not to try to reduce it by any means possible.

Some of the more effective solutions are thought to be:

The operating surgeon to see the patient on the day of the surgery and MARK THE SITE on the incision or as close to the incision as possible.

If the procedure involved a symmetrical organ the opposite side i.e. the side without the pathology is marked with a big NO; that may help.

Some surgeons write the name of the procedure (including the side if appropriate) on the incision line – that helps.

Check lists that include surgical site marking

Improving the culture so that any member of staff however low down in hierarchy is able to speak up when WSS issue is suspected

Our own suggestion (though not research based) is to empower the patient by asking a competent patient (any one who is able to give consent should be a competent patient) or a competent relative to mark the site of the procedure in the presence of the operating surgeon. After all it is reasonable to assume that the patients have a vested interest in the surgeon not operating on the wrong part of their body.

Even if it is a non-symmetrical organ procedure or a midline procedure make it a habit to mark the patient so that you can have standardised preparation protocol. It will really help a patient some day, if you are a doctor it will surely help save your career.

MARK THE SITE

This is a campaign we are specifically starting for South Asian countries (e.g. India) but is also relevant to many developing healthcare systems (e.g. African continent).

Surgeons

Please pledge today that you will mark the site of the incision on all patients on the day of the surgery.

Anaesthetists

Please pledge today that you will not begin anaesthetising a patient unless you see the site marked on the patient's body. If there is no mark please ask your surgeon to check and mark it before anaesthesia is commenced.

Nurses

Ward Nurses: Please pledge today that you will not let any surgical patient leave your ward to go to operating theatres unless their surgical incision site is marked by the operating surgeon.

Theatre Nurses and allied theatre staff: Please pledge today that you will not allow patients through the main doors of the theatre unless you see the surgical incision site marked.

PATIENTS (and relatives)

Please pledge today that you will not leave the ward/bed and enter operating theatres unless there is a mark on your body at the surgical incision site.

Pharma companies and their sales reps
Please provide doctors with a skin marker pen as a part of the various complimentary items that you provide and ask the doctors to use them to mark the surgical incision site

Everyone

Please forward the link for this blog to at least two persons. Alternatively cut and paste and send the information to at least two persons.

Write to hospitals, politicians, news media outlets or any other action that spreads the message.

Let this be a campaign be owned by us the normal public (such campaigns are normally lead by institutions/organisations/etc)

Primum non nocere is a fundamental principle of medical practise. Causing permanent harm by wrong site surgery is against that principle. It may not have happened to you yet but look at the numbers it is happening all over the world, it may happen to you unless you take definite action about it; irrespective of whether you are a healthcare professional or general public.

MARK THE SITE

©M HEMADRI 

Follow me on twitter @HemadriTweets

Increased Quality and Reduced Cost - Possible in India

I have a long held view that quality is inversely proportional to cost which means as for a given activity as the quality improves cost decreases. This is actually possible in India as well.

Let me share a clinical anecdote that may illustrate my point. It may be dated and trivial to many current readers but was very relevant to the patients and clinicians at that time.

In the late 1990s I was working as a surgeon in Sir Ivan Stedford Hospital, Ambattur, Chennai, India (http://www.ammfoundation.org/SirIvanStedefordHospital/index.html). This is a charitable hospital where we used to charge very small nominal amounts of money to provide services. A few rupees for out-patients, few tens of rupees for scans and so on. Being India, one of the commonest operations performed happened to be surgery for hydrocele. The way it was conventionally performed may be very familiar to many of you. The operation of course ended with a large bandage tightly applied to the scrotum with the purposes of avoiding problems like pain, infection, haematoma, oedema etc. These patients were also put on antibiotics for 10 days or more. Many of these patients used to come back with soiled dressings and the exact problems that doctors were trying to avoid. Doctors used to wonder what else could be done to improve the situation.

Not using a bandage was thought to remove an all important barrier that avoided exposure of the scrotal wound to the unhygienic toilet situation in India and despite using 10 days or more of antibiotics infections were happening. Barrier and antibiotics thought to be bulwarks against contamination and infections were not working.

I actually thought the tightness of the bandage caused oedema and increased pain. The presence of the bandage increased sweat and moisture in an already humid perineal area in a warm country. The bandage also easily became wet because of the toilet washing habits of the country and acted as a rich environment to create infections.

Having worked in England where the scrotal bandage was not routinely used after scrotal surgery, I took the bold step of not using scrotal bandages to hydrocelectomy patients much against the advise of my friends and colleagues. Of course, I suggested the use of the proper scrotal support clinical hosiery which was either not available or when available was very expensive. An alternative had to be found. I simply asked my patients to buy 7 of the cheapest 'A' or 'Y' front underpants from the shops opposite the hospital otherwise I would not operate on them. I used these normal commercially sold underpants over a couple of pieces of sterile gauze placed on the scar, changed once a day by the patients themselves, in the place of scrotal bandages for my patients changed by clinical people. Most of my patients found this very amusing. Some were resistant, perhaps hesitant, because the had not worn such a type of undergarment before. My colleagues were of course greatly humoured by what they thought was my naivety and enthusiasm.

In a few weeks, post operative follow up clinics were showing that my patients were walking in and walking out in super speed and for the rest of the surgical team there remained the usual levels of post op problems with pain, oedema, infections. Having eliminated the scrotal bandage which I thought was causing the problems, I then moved to single dose prophylactic antibiotic as I used to do in Britain.

Word of mouth and social observations in a local context those days was of course as fast as twitter or facebook now. The talk was about how patients spent less money on changing bandages and buying antibiotics while getting good results. Soon my colleagues avoided scrotal bandages, used undergarments as I recommended and moved to a shorter course of antibiotics often just 3 doses (instead of the usual 10 days).

Of course the people who charged for the change of dressings and the people who sold antibiotics were not happy. But I can tell you who were happy, the guys who sold the undergarments. They were really happy. 7 undergarments per hydrocelectomy patient in a hospital that did hundreds of hydrocelectomies, they must have been ecstatic. Well, I know they were, as one of them approached me and offered a commission to me (his bloody nerve) if I could recommend patients to buy the undergarments specifically from his shop – no different from the drug store chap then!

Clinical complications reduced – i.e. quality improved. Cost reduced.

Okay, this example is not about whole systems, scientific proof, published evidence and other high & mighty things. It is one little example. What I cared and what our patients cared is that we had lesser clinical problems and we achieved it by doing/using/costing less. Perhaps hydrocele surgeons in India are no longer using scrotal bandages and 10 days antibiotics - that is why this anecdote may be very dated but the general lessons are in my view still valid.

Increasing quality while decreasing costs can be achieved in India as well. Perhaps due to the large number of people who are around the poverty line this concept becomes even more relevant to India. We must remember that though the GDP is high the per-capita money is very low in India. Individual doctors are not dealing with the mighty high GDP India; individual doctors deal with the individual patients of low per-capita India. That is why low cost high quality care becomes essential.

©M HEMADRI 

Follow me on twitter @HemadriTweets

Scheduled airlines are safe, just like out patient clinics

There are constant comparisons between aviation and healthcare especially in terms of how safe aviation is.  There is no doubt that aviation in general has a low mortality rate for passengers. I have already written about the need to learn from how aviation achieved it, I have also pointed out to the limitations of the comparisons (http://successinhealthcare.blogspot.co.uk/2012/04/healthcare-not-similar-to-aviation-but.html). The term aviation or air transport in my view, includes many things, which starts from the booking process, airport formalities, baggage, catering, flying, etc. It also includes transportation of animals and goods.

In general, the whole of aviation is considered arguably to be better than healthcare. What is not arguable is that commercial scheduled airlines have a very low mortality rate for passengers. Here is my problem, death is not one of the eventual natural outcomes of transportation when transporting essentially healthy persons from one place to another; quite rightly in aviation is mortality is unacceptable. Hospitals on the other hand are not in the business of transporting passengers, people come in with illnesses and diseases many of which are really serious; mortality is one of the eventual outcomes of serious illness and disease. In other words healthcare routinely battles against death and sometimes death wins.

To compare error rates could be valid as error is often a measurable part of process failure but to compare the impact of those errors is probably a false comparison. In aviation all mortality is avoidable mortality, in healthcare it is not. So to put it in context the comparison if we must is between all mortality in aviation and avoidable mortality in healthcare (i.e. the result of process failure). That is what I mean by impact. The impact of errors that result 'morbidity' is of course hugely different like losing a bag vs losing a leg. Hence let us not compare impacts of errors such as mortality morbidity between aviation and healthcare which skews the public discourse. Let us look at error rates and see what we can learn.

Variation the enemy of quality

People talk about variation of care across hospitals and locations; it is true that there is wide variation and reducing the variation will improve outcomes.

Aviation which is often looked upon as a beacon of safety also has variation. Looking at 2004 accident rates for North American airlines Delta scored 0.30 and Value Jet/Air Tran scored 5.88 – well, you work out the how wide the variation is even in an ultra safe industry. If you start looking at international comparisons the variations are of course much worse. (http://www.airdisaster.com/statistics/) There is also a five times variation of fatalilties per million flight hours with scheduled airlines being lowest compared with general aviation.

When there is human to machine interaction as in aviation, there is such a large degree of variation. Healthcare is human to human interaction so it is hardly surprising that variation exists and could be expected to be more than other industries. Looks like variation in performance is not a problem exclusive to healthcare industry; variation is a human problem or to put it better, variation is a function of human performance.

That does not mean we must accept variation especially when it causes harm, we should work very hard to reduce it to ensure safe healthcare.

Fatalities in Aviation

The human fatality rate is very low indeed in the scheduled airlines part of the aviation industry. The air transport of animals, however has suffered bad press. Airlines are apparently not even required to report animal deaths. The mortality rate of animals in air transport is thought to be 0.2%.(http://www.dailymail.co.uk/news/article-2102733/More-HALF-pets-died-airline-travel-year-flew-Delta.html)

The post surgical 30 day mortality for day case surgery in humans which is about 0.01%. In-hospital mortality for day cases is probably as low as the scheduled commercial aviation segment.

CRM and Simulation are of course extremely valuable tools and has a lot to teach us in healthcare. The number of air accidents and the number of fatal air accidents have remarkably decreased over the past few decades. That is truly fantastic. What is interesting though, is that the pilot error rate has been at about 50% since the 1950s to the 2000s, percentage of accidents attributed to pilot errors has not shown a significant decrease. The proportions of various reasons for crashes have also remained more or less the same. This is in a way a tribute to the aviation industry, since the planes have become technologically very superior it would not be surprising if pilot/human error played a bigger part and it has not, that is creditable. However, I wonder if it would be valid to argue that if CRM and simulation were indeed really powerful should the pilot error rates be falling?

Survival rates of passengers in aircrafts involved in fatal accidents has not improved (and averages about 25% since the 1930s to 2000s) (http://planecrashinfo.com/cause.htm) Military aircraft, fighter planes, aircraft engaged in warfare and private planes are thought to have much higher accident and fatality rate.

Some Aspects of Aviation are Safer than Others; Some Aspects of Healthcare are Safer than Others

I suppose in clinical healthcare delivery terms, scheduled airlines are possibly the equivalent of out patient care – not many patients die in out patient clinics. The risk to life is also very low for elective investigations, day case surgery and obviously the risk increases with emergencies and trauma.

In healthcare we talk about morbidity as well. Airlines perhaps should take into consideration DVTs, respiratory illnesses, musculo-skeletal problems and other health issues that happen after a flight. Non-health related morbidity for aviation perhaps include lost baggage, wrong meals............... no let me stop there before it gets silly. Hold on, why not, non-flying errors are also errors and results in 'airline industry morbidity' to passengers, perhaps not that silly.

What has to be said is in healthcare there is clearly much avoidable mortality - that is unacceptable. In healthcare the error rates in day to day activities are simply too high, that is again unacceptable. That is where learning meaningfully from other industries will help.

There is a fundamental problem with my writing here. I am not comparing like for like, I am comparing apples to pears. In my defense, I did not start that comparison. Comparing aviation to healthcare was not my original idea. There is a second problem with this manner of writing, it may sound like I am being defensive of healthcare and its practices, I am certainly not defending any poor healthcare practice or result. I acknowledge the superior results that aviation has had as a result of dedicated persistent efforts in the field of human transportation in scheduled airlines. I recognise the need for healthcare to learn from every source possible including commercial scheduled airlines. All I am saying is, let us stop comparisons and let us focus on learning. Let us look for clinical adaptations of these techniques rather than attempted direct transfer of airline techniques. Let us recognise the uniqueness and the intimacy of human to human interaction that healthcare involves.

A word of warning: This is not a 'hate aviation' piece of writing, this is not aviation versus healthcare writing. This is a plea to learn the lessons in a way that is appropriate to healthcare - clinicians and patients.

©M HEMADRI 

Follow me on twitter @HemadriTweets

Letter to my nieces

A letter to my nieces

Sam (USA)

– who has just joined med school this year

&

Mayank (India)
- who completes med school this year

Dear Sam and Mayank

Congratulations. Sam you have done well to get to med school. Mayank you have done great and will finish med school later this year. You are in the top 2% of the academic performers and you will continue to remain there at least till you begin independent clinical practice, hopefully many decades into your clinical practice.

I write this in joy but more relevantly to provide you another window for your intellect and for your practical development.

I did Anatomy, Physiology and Biochemistry in my first year at med school. There are not many more accurate and fact based subjects than these in medical education. Fact after fact, learnt day after day. We realised that these facts were the foundations of our future careers, we took it really seriously. We demonstrated our mastery (okay, personally I just demonstrated my mere competence) by passing tests and exams. It was tough. It was worth it. I was satisfied that my foundations were good.

These fact based subjects left an indelible impression in my mind that medicine and its practice was based on accuracy and facts. When the facts varied, such as when the cystic artery was double or it was low lying and so on, they were grouped into sub-facts to be remembered for future reference and practice. Some facts were actually a range of facts as in the normal range of plasma sodium values and so on. Later on while attending physiology classes at the Royal College of Surgeons at Edinburgh, the tutor would squeal in dominant delight ‘either you know it or you don’t’; no more powerful, explicit message for post-graduate doctors about the need to be precise and accurate. A message that I heard many years earlier in first year med school and repeatedly thereafter.

As we moved along we recognised that subjects like pathology and microbiology begin to interfere with subjects like anatomy and physiology and gives rise to trouble in real people. Help was at hand for us to understand that. Pathology text books showed clear microscopic slides on how every pathology looked, again where there were variations they were classified as yet another group of facts.  I got the impression at that time that if that’s how it looked, that is what it must be. That kind of thinking was compatible with the fact based approach of anatomy and physiology. All this knowledge was then put to practical use by learning even more glamorous and glorious subjects such as surgery, internal medicine, gynaecology, et al. Those were exciting days.

We continued to learn from revered text books on the one hand and from revered teachers on the other. Patients had clinical problems, we used our knowledge to diagnose them (CT scans were extremely rare when we were medical students and ultrasound scans were just taking off and x-rays in general provided basic support) and applied our knowledge to treat them. Of course things did not always go well for patients, we still call them complications or morbidity, sometimes patients died, we classify that as mortality.

As we gained experience often as post-graduate doctors we began to realise that all of our revered teachers did stuff very differently from each other while they were dealing with similar problems. The cleverer of the lot justified their different styles of practice by references to science, the rest told us that their experience suggested that their practises were valid. Our professors and consultants told us that they acquired their wealth of knowledge so that they can give their opinions. One sudden day we recognise that we learn medicine on the basis of knowledge and practise it on the basis of opinion. On the basis of very very widely varying opinion.

We begin to wonder. If the learning in undergraduate medicine was based on accurate facts, why is the practice of real world medicine on the basis of hugely varied opinion? We brush aside these discomforting thoughts. We have not only made a huge investment in our knowledge but also in our method of acquiring and practising that knowledge.

Pathology text books did not tell us that two pathologists looking at the same slide could give you two different opinions, not often but certainly possible in the definition of complex cases. We were never told that the text books that we read were by definition about five years out of date or that at worse some of the editors edited those books while travelling in their ultra-luxury cars between various locations of their private practices or at best after a couple premium alcoholic drinks in their study. We were realised that when our teachers said the words ‘in my experience’ it did not mean objectively measured operational experience but meant their personal subjective understanding of how they thought they performed.

In medical practice there is evidence for everything and there is evidence for nothing. This provoked David Eddy, the American father of evidence based practice (oh, by the way evidence based practice has two fathers one American and one British) I believe to say something like that you can find two physicians to testify in court to the exact opposite views.

Nobody will tell you yet that

Substantial activity in clinical medicine is not performed on the basis of clear unequivocal evidence
Substantial activity in clinical medicine cannot after care delivery find evidence to back it
Substantial clinical care is delivered incompletely
Substantial amount of errors are found in the delivery of care
Substantial numbers of clinicians are either unable or unwilling to accept the above

These issues are not just academic, they have great direct impact on patients and their lives. We did not know at med school that there was an entity called avoidable mortality; when we first heard about it we found it unbelievable for the reason that if it was avoidable us clever and experienced doctors would have already avoided it. We did not know at med school that practice of healthcare is highly error prone and extremely unsafe; when we came to know about it we did not believe it. Despite this we and the public, trust ourselves - the medical profession; we trust our high intelligence, our extreme hard work or proven record of success for ourselves and for our profession. We are brilliant and we have faith in ourselves.  The brilliance of the medical profession is also blinding itself.

The lack of evidence and the opinion based practice results in hierarchical power games. Those who are unable to play become bad apples initially and ‘poor performers’ later. Now, imagine that, top scores at school graduation, long mind numbing hours of hard work for years, proven success in exams and other challenges, then eventually being called incompetent or poor performer or some other derogatory term by people who practice the art of medicine while imagining it to be based on facts and evidence. Worse still these phenomena perpetuate the wide clinician generated variations in practice. Doctors are intelligent and learned enough to be able to justify their individual practices as evidence based; that is of course true. What is important to understand is that their justification is based on the evidence they choose to base it upon. My evidence is the truth and nothing but the truth but not the whole truth. Simply because firstly the whole truth probably is not already known, secondly the whole truth is too vast to know and thirdly in healthcare the whole truth often has a tendency to contradict itself.

I write this not in despair, not to distract you, but to give you hope. Because the solutions for embracing a world of wrongness and still do good to the maximum number of your patients are already out there. I want to briefly introduce you to that world and I want you to be aware of it. These are the shades that you wear when you are out in the bright sun, it will also make you look cool. It might make you comfortable in a world of contradictory evidence.

In conventional science based research oriented world there is probably nothing that is absolutely true; there is a current hypothesis which we attempt to validate or reject and the hypothesis stands till it is rejected. You will find that most hypothesis in medicine are rejected over a period of time, this gives rise to problems in clinical practise as the research that is good today becomes ‘false’ very soon. However, that is how research and science works. That is how it should work. However, in our routine clinical practice we do not work as researchers, we work as operational practitioners. My suggestion therefore is to look at operational methods for a good clinical practise and use to them to the best benefit for your patients. These derive from the shared baseline approaches devised by Brent James and his team at Utah.

At a basic level, a good shared baseline method looks like this

-         - You agree with your immediate and local colleagues on a protocol for most common problems that are seen in your clinical practise

-         - You track the outcomes over time of some of the process and outcome parameters of the protocol that you have agree

      - You amend your protocol based on the outcome tracking

-         - You show deep and genuine respect for everyone who works with you

-         - You share and learn operational clinical day-to-day practise first and primarily with/from your immediate and local colleagues before you do so with the rest of the world

Intermountain Healthcare does this, they probably discovered this method. IHI recommends it (I suggest you become members of IHI open school), people at Mayo, Virginia Mason, Jonkoping and a few others have their own versions of this. The method though, is not one of a pick and mix buffet, one has to do them all or get no benefits from them.

I suggest that you start exploring this kind of thinking in parallel with your conventional learning, not for fact based subjects but for the rest of them. We are all creatures of habit, attitude and cultures. It will be very difficult to change once certain mindsets are established. The energy and effort required to do it now in parallel is much less than to do it later. Your patients will get remarkably far better results and your systems (your patients, insurance, hospital, yourself) will spend far less on a like for like basis.

Many doctors will understandably be either uncomfortable or unwilling to accept or follow this kind of practice. They will deride it as cook-book medicine run by technical managers interfering in clinical work. Obviously the ignorant will be prone to say what they want, that will be a reason to work to remove the ignorance not to forget the observed truth, unlike conventional healthcare practices and religion with its believed truth, this method is really the observed and demonstrated truth. Of course if you decide to choose conventional scientific research as a career then these methods are not suitable for you but if your life is that of a normal operational clinician then these are entirely relevant. I do not expect you to understand the new method fully, it will be a reason to learn it in due course. Enough for now to be aware that there are plenty of problems and there are proven solutions – just a matter of putting them together at the right time.

The wrongness that exists in medicine will not go away, that can only be solved by scientific research and one day you may in your lifetime find that medicine is based purely on scientific evidence. Till that time, awareness of, learning and practising the shared baseline method will give you superior results despite the wrongness around you.

As you stand on the threshold of entering into a new world, I wish you every success and great happiness in the practise of your profession. There can of course be no greater professional joy for a doctor than to see more of their patients get better.

Affectionately

HEMADRI

August 2012

©M HEMADRI 

Follow me on twitter @HemadriTweets

Recurring 'errors', learning and some fundamental issues

Recurring errors

Many of you could be familiar with the Elaine Bromiley case where a young lady for a routine ENT procedure died due to intubation difficulty (http://www.chfg.org/resources/07_qrt04/Anonymous_Report_Verdict_and_Corrected_Timeline_Oct_07.pdf). There it was found that there was lack of situational awareness, poor decision making and poor leadership. This happened in 2005.The Harmer report on the tragedy is dated July 2005, the coroner inquest in October 2005. Marin Bromiley, Elaine's husband, an airline pilot, chairs the CHFG to promote human factors with a view to reducing avoidable errors.

Gordon Ewing died in May 2006 and the Scottish Sherriff’s fatal accident enquiry determination has been published (http://www.scotcourts.gov.uk/opinions/2010FAI15.html). I recommend that all of us read all the 108 pages patiently. Here the patient was scheduled for open reduction and internal fixation of terminal phalanx of little finger and died due to airway related difficulty.

Again, similar factors such as poor decision making and poor leadership has come up along with a host of other factors. The unwillingness to stop has been a common factor in both cases. I suspect it is just not these cases.


The link below is about 3 post cholecystectomy deaths in a 3 month period in 2006

http://www.scotcourts.gov.uk/opinions/FAI13%2014%2015.html



I feel that recurrence is probably an essential feature of an error, my guess is that there are no errors that have ever happened only once. It might have happened only once to a person or a location but the error itself would have happened a number of times. Vincristine and nuclear leaks come to mind.


Who should learn?

In meetings where we discuss morbidity, mortality and learning from SUIs, a phrase you might often hear is 'for the benefit of the juniors/residents/trainees', as though 'seniors' do not commit 'errors' or have nothing to learn from the discussion. Well, all the above cases are about very senior and experienced doctors; so these reports are not for ‘the benefit of the trainees’ or ‘for the benefit of the juniors’. It is for everyone, specifically for senior post holders. Also, though the specific examples are about anaesthetics, surgery, etc; these cases are not about anaesthetists, surgeons, etc; the lessons are for all of us clinicians and non-clinicians; the generic issues are relevant as lessons for everyone. Techniques are speciality specific and person specific, errors and learning are generic.

Learning

Elaine Bromiley's case is well known and is full of learning which have been described by many before.


In the Ewing case, the Sheriff says:

‘While the lead clinician has the over all responsibility to ensure safe use of equipment, individual clinicians have a professional responsibility to use only equipment with which they are familiar and competent to use. This is particularly so where the piece of equipment is rarely used.’

There are many gems in the Gordon Ewing report.

In the gall bladder surgery cases, the report speaks about:

Tunnel vision

Damaged confidence from an incident preventing speaking up at a subsequent incident, potentially causing harm.

Poor notes, missing notes

Breast surgeon doing cholecystectomy

Consultant surgeon not attending

Consultant radiologist refusing to do scans at night

Consultant surgeon who does not do lap cholecystectomy dealing with complications of cholecystectomy

The repeated failure that patients post operative problems could result from the surgical procedure

The report is very recent. The incidents happened not too long ago either. They are from a normal hospital with normal people like you and me working in it and dealing with typical/usual patients.


The learning is profound, not new - many of us would have faced these situations a number of times; errors are recurrent. The impact of errors are horrendous for the people involved in it especially for patients and families (see previous blog on impact of complications http://successinhealthcare.blogspot.co.uk/2012/02/complications-or-harm-and-their-impacts.html)


Fundamental issues

It is very heartening to note that courts and authorities who write the reports use a very respectful language towards doctors. They limit themselves to investigating and reporting event, post-event and agree with the given wisdom in practise as acceptable standards. I wonder whether this prevents an exploration of some fundamental issues.


Let me ask an awkward question. Why is a general anaesthetic even an option to deal with the terminal phalanx of the little finger? The report says that there was no record of non-GA options. My point is not that, my question is why was GA ever an option. Some of you are going to leap up and say 'patient choice' meaning that patients have to be offered a choice or patient choice to have a GA must be agreed with. Patients choices are mainly guided by their clinicians views, supplier induced demand, often felt to be well meaning, is alive and well in healthcare.


I know a general anaesthetic is routinely one of the anaesthetic options for any surgical procedure; but so was Halstead's mastectomy for any breast cancer in the past. Would we offer it as a choice now? Hypothetically if a patient wanted a Halstead when a local excision would suffice, would we do it? When an easier, safer, quicker, better, cheaper method is available is it still valid to offer potentially high risk complex procedure as an option?


Here is another awkward question. Why are breast surgeons, colo-rectal surgeons and all surgeons doing gall bladders and hernias when hernia surgeons do not do breast or colo-rectal surgery? I do not mind good old style of general surgery where everyone did everything - at least that is what they were supposed to do.  But that is not the world we live in these days (even in 2006) at least in the western world in the era of sub-specialisation. The situation of anyone doing the so called 'simple' things, still persists in many hospitals. Toe nail problems are as profound as any other 'major' medical problems for that given day for that given patient; it is not a matter of scale or judgement.

I wish the various authorities recognise the need to ask very deep and fundamental questions. Such as was this really indicated in the first place? Were the right people dealing with issues to begin with? I wish they would not accept given wisdom based on pacts of convenience as acceptable. Not with a view to punishing but with a view to improving clinical quality.

I wish they recognise and point out that these are massive system and leadership failures.

©M HEMADRI 

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Fearless Healthcare is what we want

Recently read a book called 'Driving Fear Out Of The Workplace' by Kathleen D Ryan and Daniel K Oestreich. It was published in 1991 so obviously you can see that my wisdom is only now dawning. It is based on the 8th principle of Deming which is 'Drive fear out: employees must not be afraid to ask questions or take a position'. The book is written in an easy language and narrative style with enormous number of quotes gathered from their work with a variety of organisations but when read reflectively it can have profound impact on us and others.

The book wants us to
- be able to discuss the undiscussables
- realise behaviours that create fear
- understand the cycle of mistrust and break it
- acknowledge the presence of fear
- value criticism & reward the messenger
- reduce ambiguous behaviour
- move from participation to collaboration
- challenge worst-case thinking

The authors believe that driving fear out will overcome the invisible barriers to quality, productivity and innovation. The book is nothing to do directly with healthcare and has no direct examples but at a human level the threads are common. I recommend the book.




Healthcare & Fear

There are many reasons that driving out fear is even more important in healthcare. The very strong hierarchical structures in healthcare is an ideal culture medium for fear to thrive especially amongst the medical and nursing colleagues. The mostly pick and mix nature of evidence in healthcare delivery makes these hierarchical voices even more powerful. The difficulty with evidence generally creates poor systems, people who work within poor systems understandably do not do well and the culture of defensiveness and fear becomes greater.

Establishment is very strong in healthcare, in the UK clinical practice context you must submit to the clinical establishment (royal colleges, specialist bodies, et al) or to the research establishment (universities, funders) or face difficult consequences. Clinicians have a legal obligation to provide care recommended by NICE 'guidelines', there are armies of back office people who audit compliance to NICE guidelines which everyone fears of falling short. Providing the treatment recommended by NICE is a statutory duty i.e. law, I wonder why it is not called law and then define some exclusions. Why the euphemism? Now, would you have a fear of falling foul of a law?

The current economy does not help with many reduction in posts and changes in roles. It is also well known that in the context of the NHS the reorganisations are almost continuous and many non-doctor staff do live in fear of the next change that may adversely affect their role, skill and income.

Generally high anxiety and stress is understandably common for clinical professionals when dealing with patients given the very high emotional component involved in any healthcare advice or treatment especially acute care. The stress levels are even higher for patients and that is projected on to clinicians and reflects. This puts pressure to get it right every time, there is a fear amongst clinicians about getting it wrong; get it wrong in high finance and few points might drop of the footsie index, getting it wrong in healthcare could cost people a hand or a foot literally. But working with fear does not help the cause.

Constant comparisons with other industries (aviation, manufacturing, etc) while is very important for healthcare professionals who can understand the principles behind these comparisons and use them for improvement, is often taken out of context and has created an atmosphere where some of the public begin to have very high expectations that are difficult to service and some of the pubic fears healthcare. When let down, these lead to potential litigation which is a common fear amongst clinicians.

I could go on, but you get the idea. I do believe that fear should be driven out of the work place and especially so in healthcare; it would liberate the true power and potential of clinical professionals.

Fear could result in some of the effects discussed earlier in the blog, such as branding people as bad apples (http://successinhealthcare.blogspot.in/2012/07/bad-apple-theory-in-healthcare.html) or agreeing with persons so as to please them as in the Abilene Paradox and other not so helpful behaviours. In healthcare, these combined with the issues around evidence and process efficiency leads to the phenomenon of Clinical Wrongology.

What are your fears at work? What are its effects? How do you and your workplace deal with it?

©M HEMADRI 

Follow me on twitter @HemadriTweets