Another great example of failure to diagnose

DR WILLIAM CORCORAN williamcorcoran at SBCGLOBAL.NET
Sun Feb 14 17:08:10 UTC 2016


 
·     Punishment
 
It is an inescapablefact that firings[2]and other personnel punishments usually amount to red herring scape goatingsthat distract attention from the systemic incompetence, lack of integrity,noncompliance, and lack of transparency and leaves in place the accomplices,accessories before the fact, accessories after the fact, and the cover-upartists.





[2] Examplesinclude the Detroit Emergency Manager fired over his role in the Flint WaterScandal, the Secretary of DVA fired over the Wait Time Gaming, the Davis-BesseFederal Indictments, etc.

 Take care,
 
Bill Corcoran

 
William  R. Corcoran, Ph.D., P.E.
21 Broadleaf Circle
Windsor, CT 06095-1634
860-285-8779
William.R.Corcoran at 1959.USNA.com
http://www.linkedin.com/in/williamcorcoranphdpehttps://www.box.com/shared/kfxg1lt9dh 

 

    On Sunday, February 14, 2016 12:17 AM, Vic Nicholls <nichollsvi2 at GMAIL.COM> wrote:
 
 

 With all due respect Dr. Bell, hit up the administration for criminal 
charges that stick for years in prison, they'll help MD's with 
diagnostic issues with a huge attitude change. You won't see a lot of 
flogging HCP's to take in 30+ patients a day in 10 minute increments so 
admin can pay for their vacation home and Lexus.

Let THEM lose their license to be managers, can't work in the field any 
more, they'd change their song faster than the speed of light.

Leaders are to lead by example not by financial incentives for their 
year end bonuses.

However, I doubt any one on the list would agree that admin probably are 
a bigger contributor to diagnostic problems than any one wants to admit.

Victoria

On 2/13/2016 3:45 PM, Robert Bell wrote:
> The diagnostic infrastructure is grossly flawed and needs to be repaired first.
>
> Rob Bell, MD
>
> Sent from my iPad
>
> On Feb 13, 2016, at 9:26 AM, "Jackson, Brian" <brian.jackson at ARUPLAB.COM> wrote:
>
>> Re: the CEO.  A few years ago I heard Don Berwick present the argument that hospital administrators need to be governed by the same medical ethical expectations as doctors and other providers.  Personally I believe this needs to apply to all who work in healthcare, including Pharma and device companies.  This is a huge issue.
>>
>> --Brian Jackson
>>
>> Sent from my iPad
>>
>> On Feb 13, 2016, at 8:36 AM, Regan, Elizabeth <ReganE at NJHEALTH.ORG<mailto:ReganE at njhealth.org>> wrote:
>>
>> I just listened to the podcast for This American Life that is linked to a companion NY Times article. (Link from the NYTimes website). It tells the story of a young man with bipolar illness who sought care in a Houston hospital when he had an acute manic episode.  He told the ER staff he was manic. They didn't listen. Later, his father who was a physician asked for a psych consult. The nurse didn't listen or take action. He was then shot in the chest by Houston police officers moonlighting as security when he became agitated.
>>
>> Listen to the story. It makes me want to weep for a profession that is allowing administrators to make decisions about how a mentally ill patient is managed when he decompensates.  I also want to rage at nurses and doctors who can't see the faces of suffering and illness and would mindlessly turn a patient over to security guards instead of calming and caring for him.  I am really tired of hearing people say, "I told them, but they didn't listen".  I've heard it myself and it is part of an arrogance in the profession that denigrates those we serve.
>>
>> There were many great nurses and doctors there who clearly did right - recognized his need, saved him from the GSW, but for those who didn't....
>> I don't want them to go forward as caregivers in our profession.
>> The CEO  of St Joseph hospital in Houston says they would do it again.  He needs to lose his job and leave healthcare. He doesn't understand what the job is.
>>
>> Liz Regan
>> Sent from my iPad
>>
>> On Feb 13, 2016, at 4:25 AM, DR WILLIAM CORCORAN <williamcorcoran at SBCGLOBAL.NET<mailto:williamcorcoran at SBCGLOBAL.NET>> wrote:
>>
>>
>> ·      Involvement of Authority
>>
>> An inescapable fact is that conditions, behaviors, actions, and inactions were what they were[2]<https://us-mg5.mail.yahoo.com/neo/launch?.partner=sbc&.rand=09r61vkpotg98#_ftn2> because those in authority wanted them that way, tolerated their being that way, or didn’t know that they were that way. This applies from the work location to the top governance.
>>
>> ________________________________
>>
>> [2]<https://us-mg5.mail.yahoo.com/neo/launch?.partner=sbc&.rand=09r61vkpotg98#_ftnref2> Posted at the interesting article at http://lifelinestrategies.com/2016/01/31/supervisors-gone-rogue/#comment-145
>>
>> Take care,
>>
>> Bill Corcoran
>>
>>
>> William  R. Corcoran, Ph.D., P.E.
>> 21 Broadleaf Circle
>> Windsor, CT 06095-1634
>> 860-285-8779
>> William.R.Corcoran at 1959.USNA.com<mailto:William.R.Corcoran at 1959.USNA.com>
>> http://www.linkedin.com/in/williamcorcoranphdpe
>> https://www.box.com/shared/kfxg1lt9dh
>>
>>
>>
>> On Friday, February 12, 2016 12:57 PM, Peggy Zuckerman <peggyzuckerman at GMAIL.COM<mailto:peggyzuckerman at GMAIL.COM>> wrote:
>>
>>
>> I spoke to a head nurse in a Seattle hospital who was so frustrated about her team being on the hunt for necessary materials, from linens to band-aid, that she tracked the number of lost hours per shift.  Only when the administration was shown that over 3 hours per 8 hour shift were lost in the searches, did they institute a series of changes which had those supplies refilled automatically in multiple locations by non-nurses.
>>
>> The administration was clearly concerned, but had no idea of the magnitude of the problem.  But providing the metrics in terms of the loss of time/money made the difference.  Certainly the same approach will be effective when those observations can be linked with the analysis of costs to the institutions and patients.
>>
>> Peggy
>>
>> Peggy Zuckerman
>> www.peggyRCC.com<http://www.peggyrcc.com/>
>>
>> On Fri, Feb 12, 2016 at 3:05 AM, DR WILLIAM CORCORAN <williamcorcoran at sbcglobal.net<mailto:williamcorcoran at sbcglobal.net>> wrote:
>> One of my mentors loved to repeat:
>>
>> A short pencil is better than a long memory.
>>
>> Take care,
>>
>> Bill Corcoran
>>
>>
>> William  R. Corcoran, Ph.D., P.E.
>> 21 Broadleaf Circle
>> Windsor, CT 06095-1634
>> 860-285-8779
>> William.R.Corcoran at 1959.USNA.com<mailto:William.R.Corcoran at 1959.USNA.com>
>> http://www.linkedin.com/in/williamcorcoranphdpe
>> https://www.box.com/shared/kfxg1lt9dh
>>
>>
>>
>> On Thursday, February 11, 2016 10:27 PM, Bob Latino <blatino at RELIABILITY.COM<mailto:blatino at RELIABILITY.COM>> wrote:
>>
>>
>> Hi Peter
>>
>> I thought you might like this concept.
>>
>> Care Journals by The Josie King Foundation
>>
>> http://www.josieking.org/carejournals
>>
>> I have always liked this idea of providing patients Care Journals to keep records during loved one's stay in a hospital.  I think all involved 'win' when everyone actively participates in the quality delivery of care.
>>
>> Just an FYI.
>>
>>
>> Robert J. Latino, CEO
>> Reliability Center, Inc.
>> 1.800.457.0645
>> blatino at reliability.com<mailto:blatino at reliability.com>
>> www.reliability.com<http://www.reliability.com/>
>>
>> From: Elias Peter [mailto:pheski69 at GMAIL.COM<mailto:pheski69 at GMAIL.COM>]
>> Sent: Wednesday, February 10, 2016 4:45 PM
>> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
>> Subject: Re: [IMPROVEDX] Researchers want a better system for fixing bad science | The Verge
>>
>> " I kept daily lists of the errors and worked with the Risk Managers to resolve.”
>>
>> If I had a magic wand, I would require that all hospitals create a group of 'safety observers’ that would include patients, provide some training in systems and medical care, and then pay them to sit and observe and take notes and report regularly (monthly at least) to administration/risk management and involved departments to identify, prioritize, and address safety issues.
>>
>> I think there is a simple logic to this: direct observation of process by independent individuals with different perspectives will see and find things that no fancy internal risk management system will see.
>>
>> Peter Elias, MD
>>
>> On 2016.02.09, at 7:50 AM, Bob Latino <blatino at RELIABILITY.COM<mailto:blatino at RELIABILITY.COM>> wrote:
>>
>> The U.S. spends ~17% of its GDP on Healthcare or about $3 Trillion/yr (or ($9,323/person).  It is hard to believe we do not throw enough money at it.  It is how we use the monies so inefficiently and ineffectively that is the problem.  For all of the money thrown at HC, our mortality rates as compared to the rest of the world do not demonstrate ours was money well spent.  Why not?
>>
>> To put this into perspective France and Switzerland spend 11% of their GDP on healthcare.  The Middle East spends much less (see below).
>>
>> <image003.png>
>>
>> Source: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/highlights.pdf
>> Source: https://www.cia.gov/library/publications/the-world-factbook/rankorder/2066rank.html
>> Definition: The crude death rate is the number of deaths occurring among the population of a given geographical area during a given year, per 1,000 mid-year total population of the given geographical area during the same year.
>>
>> Because the manner in which death rates are collected, deaths due to 'medical' error are not uniformly collected or collected at all in many countries.  So the only uniform measure of death is called the 'crude death rate' around the world (see definition above).  Deaths due solely to medical error are included however, the split (%) is not discernible.  Regardless, when you look at the investment in HC as opposed to GDP, and overall crude death rate/1000 total population, the numbers are varied and quite startling.  Why do these countries with the lowest investment in HC as a % of their GDP, also have the lowest crude death rates in the world?
>>
>> I know there are many researchers on this forum who will chew this up and explain to us the reasons; but as a layman, I am interested in learning why.
>>
>> Irrespective of what the studies in the link Rob provided conclude, just sitting in any hospital for a day and observing, one can make a list of errors for themselves.  To me, it is hard to imagine a hospital stay without an error occurring the course of the delivery of care.  Both of my parents passed in the last 9 years and both were in ICU's for 2 - 4 weeks.  We stayed with them 24/7 during those stays.  I kept daily lists of the errors and worked with the Risk Managers to resolve.  I know what I am looking for, just think of those who do not and just 'trust' their care givers and their delivery of care systems. Are they told of these errors?
>>
>> I believe Rob's point is not that the errors are not occurring, but what is the scope and magnitude of them?  How do we accurately identify, quantify and prioritize them so we can focus on solving them in a logical manner?  How do we do this in a fashion where actions replace words and change can be observable in the near term (instead of during our lifetime)?  Certainly there are more complex issues that will take longer to resolve but I believe the 80/20 applies here as well.  I suspect that 20% or less of the error types (Failure Modes we call them in my business) account for 80% or more of the total occurrences.  Certainly we can act on this 'low hanging fruit' in the 20% range (or what we call the Significant Few).
>>
>> Bob Latino
>>
>>
>> Robert J. Latino, CEO
>> Reliability Center, Inc.
>> 1.800.457.0645
>> blatino at reliability.com<mailto:blatino at reliability.com>
>> www.reliability.com<http://www.reliability.com/>
>>
>>
>> -----Original Message-----
>> From: Robert Bell [mailto:0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG]
>> Sent: Monday, February 08, 2016 10:09 PM
>> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
>> Subject: [IMPROVEDX] Researchers want a better system for fixing bad science | The Verge
>>
>> http://www.theverge.com/2016/2/3/10897938/science-correction-process-problems-report-university-alabama
>>
>> This supoports the concept that the diagnostic infrastructure is overall in a bad state. Is money the big problem - too much or too little?
>>
>> Rob Bell
>> Sent from my iPad
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Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine

  

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