death certificates

Elias Peter pheski69 at GMAIL.COM
Fri May 6 12:10:42 UTC 2016


I inadvertently left out the link to Deming’s talk, in which he does a shortened version of the Red Bead Game as an illustration of how things should NOT work. It is a 70 minute talk, to IHI, but worth the investment of 70 minutes, if you ask me. Here is the link:

http://blog.deming.org/2016/04/the-intellectual-foundation-of-modern-improvement <http://blog.deming.org/2016/04/the-intellectual-foundation-of-modern-improvement>

In terms of literature about management specifically in health care, I can’t name a point source, but I’m not convinced that we need literature that is specific to health care to do this. I would argue that claiming that health care is unique and different from other human endeavors has been one of the roadblocks to change. That said, Management Lessons from the Mayo Clinic (Berry and Seltman) and Transforming Health Care (Charles Kenney’s discussion of Virginia Mason’s journey) talk about some of the issues from the perspective of specific institutions.

There is plenty of material out there. Sitting here, I can see the following titles on the shelf next to my desk, all pertinent to this and formative for my perspective:

The Future of Management by Gary Hamel is about the replacing the old command-control model.
Etienne Wenger’s work, perhaps most accessible in Cultivating Communities of Practice, is a good way to envision the culture I think we need to build.
There is a mountain of academic work about human behavior and motivation. Some of this has been nicely collected (and simplified/popularized) in Deci’s Why We Do What We Do and Pink’s Drive. 
Scott Page’s Diversity and Complexity, and The Difference, which make a good case for the limitations and harms that stem from narrowed control and thinking, and the benefits of bad input.
Sidney Dekker’s The Field Guide to Understanding Human Error is very applicable to our discussions here.
John Gall’s The Systems Bible is a clever satire about how systems love to misfire.
Michael Millenson’s Demanding Medical Excellence (the new version has a pertinent afterword) talks about accountability and the internet’s age of information.
Being Wrong by Kathryn Schulz makes it clear that we have no intrinsic sensors that tell us we are wrong (the way we sense we are tired or thirsty) so we have to build structures and systems to identify error.
Medicine in Denial by Weed and Weed
Ignorance, How it Drives Science by Firestein.
Team of Teams by McChrystal

Peter


> On 2016.05.06, at 5:33 AM, Kodolitsch von, Yskert <kodolitsch at uke.de> wrote:
> 
> Dear Peter,
>  
> your comment is brilliant. Quite humanistic, I would say.
> The literature on hospital management seems quite uniform in suggesting a command and control model of leadership instead (see for example all the strange articles that currently appear in the N Engl J Med; e.g. http://www.nejm.org/doi/full/10.1056/NEJMp1502312 <http://www.nejm.org/doi/full/10.1056/NEJMp1502312>, or http://www.nejm.org/doi/full/10.1056/NEJMp1502419 <http://www.nejm.org/doi/full/10.1056/NEJMp1502419> ) .
> If this goes on, there will be a deadly avalanche of costs for control and external incentives that finally destroys motivated healthcare.  
> Do you know any good literature that substantiates your view in healthcare leadership?
> There has to be an organizational theory framework to ground your views (beyond the usual literature on “team motivation”).
>  
> Best from Hamburg
>  
> Yskert von Kodolitsch
>  
> Von: Elias Peter [mailto:pheski69 at GMAIL.COM] 
> Gesendet: Freitag, 6. Mai 2016 01:34
> An: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> Betreff: Re: [IMPROVEDX] death certificates
>  
> I didn’t say reward and punishment won’t work. I said (or I tried to say) that this is too simple a phrasing to be either accurate or actionable.
>  
> I think there is never a single simple thing that will solve a complex and multifactorial problem. But here are some ideas I would try if I were CEO of my institution and had a magic wand:
>  
> Essentially NO rewards to individuals based on individual metrics. (See Deming and the Red Bead Game for why. Here is a link to a talk where Berwick does a shortened but effective version:   )
> Set up the rewards (salary, bonuses, parking spaces, extra time off) so they are tied to outcomes across the institution, not by individuals. If complication X goes down by Y percent, EVERYONE (janitor to CEO) gets a piece of the reward.
> At least half of the items measured and tracked should be selected by a broad and open process rather than imposed. 
> Largely eliminate performance evaluations of individuals and replace them with performance evaluations of processes and teams.
> Publish the institution’s statistics. 
> Set up a process where, after an error is found (with or without actual harm) the involved individuals (including patients) are told what happened, the results of the root cause analysis, and what specific things are changing to prevent a recurrence. 
> When someone makes a mistake and harm occurs, provide counseling and support. (I have not fully healed from some mistakes I made 3 decades ago.)
> Make self-examination of processes and small tests of change for improvement a standard part of everyone’s job description, with budgeted time and support infrastructure.
> Make self-examination of errors and harm a standard part of everyone’s job description, with budgeted time and support infrastructure. (E.g., a weekly meeting of clinicians and office staff to talk about things that didn’t work well and how to improve them.)
> When something bad happens (from wrong side amputation to failure to notify a patient of a normal lab result) and is reported by someone involved who suggests an improvement, a thank-you note wet-signed by the CEO and included in the personnel file.
> Etc.
>  
> The overwhelming majority of people in health care are motivated (driven) by a desire to do the right thing for the right reason in the right time frame. Leverage this. Build on this commitment and the accompanying internal motivation. Avoid turning internal motivation into a materialistic economy, which is much easier to game and less likely to work.
>  
> All my suggestions are intended to make success something measured at the highest team level possible, remove or blunt a punitive mind set, make sure metrics happen at a level where there is at least a chance that they are meaningful (they are not meaningful at the individual clinician level), and focus all the talk and energy on making things better.
>  
> Peter
>  
>  
>  
>  
> On 2016.05.05, at 6:22 PM, Joe's New Gmail <jgraedon at GMAIL.COM <mailto:jgraedon at GMAIL.COM>> wrote:
>  
> So Peter...how would you go about changing behavior?
>  
> If reward and punishment won't work, what would improve the reporting process? 
>  
> Joe
> 
> On May 5, 2016, at 5:04 PM, Elias Peter <pheski69 at GMAIL.COM <mailto:pheski69 at gmail.com>> wrote:
> 
> I love blunt. I’ll also be blunt. 
>  
> Without disagreeing, I would add that it is important to remember that ‘reward’ is a simple two syllable word that codes for an incredibly array of possibilities. Big, small, intrinsic, extrinsic, immediate, delayed, proportional, disproportional; these all impact the effectiveness (or counter-productivity) of rewards.
>  
> Pilots, to my knowledge, are not rewarded *directly* for reporting errors, problems, incidents. They are ‘encouraged’ by a combination of culture, support when they do so, seeing positive results when they do so, and the knowledge that their fate is the same as the fate of the airplane.
>  
> Let’s not think that we can create a reward system for reporting errors and thereby change the culture.
>  
> Peter
>  
> On 2016.05.05, at 4:35 PM, Joe Graedon <jgraedon at GMAIL.COM <mailto:jgraedon at GMAIL.COM>> wrote:
>  
> I am a firm believer in the principles of reward and punishment. By that I mean, people, animals, and all sorts of other creatures do what gets them rewards, treats, food, toys, whatever. They also try to avoid the things that cause them distress. 
>  
> Our medical system rarely rewards health care professionals for reporting errors. If anything, physicians are punished by their employers, insurance companies and yes, malpractice lawyers, for being transparent about mistakes, especially those that lead to death. 
>  
> I only imagine we will see change if we come up with strategies to reward physicians, nurses and all others involved in health care to share mistakes the way pilots are encouraged to share close call information. We need billions of dollars in federal money (think the National Institute of Error Prevention-NIEP) to come up with solutions to diagnostic errors and treatment mistakes. And we need to punish institutions that hide their mistakes. 
>  
> Reward the behavior we wish to encourage. Punish the behavior we wish to disappear. 
>  
> Sorry to be so blunt.
>  
> Joe
>  
>  
> On May 5, 2016, at 3:57 PM, Phillip Benton, MD, JD <0000000697ec7b18-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG <mailto:0000000697ec7b18-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG>> wrote:
>  
> Liz,
> 
> Is such review not essentially what Lucien Leape and colleagues did in the Harvard Medical Practice study (N Engl J Med. <http://www.ncbi.nlm.nih.gov/pubmed/?term=Leape+L%2C+Brennan+T%2C+Laird+N%2C+et+al.+The+nature+of+adverse+events+in+hospitalized> 1991 Feb 7;324(6):377-84) 25 years ago, referenced in the IOM  report To Err Is Human (1999)? The several reviews that followed were systematically re-reviewed  by John James just 3 years ago (J Patient Saf. <http://www.ncbi.nlm.nih.gov/pubmed/?term=James+JT%2C+Journal+of+Patient+safety+2013> 2013 Sep;9(3):122-8.). 
> 
> Can we deny the problem?  NO.  Can we arrive at a consensus definition (wth qualifiers) and ascribe an ICD code (with modifiers)?  Most probably YES if anyone will take it on.
> 
> Phil Benton, MD, JD
> Atlanta, GA
> 
> -----Original Message-----
> From: Elizabeth Regan <lizregan53 at GMAIL.COM <mailto:lizregan53 at GMAIL.COM>>
> To: IMPROVEDX <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>
> Sent: Thu, May 5, 2016 2:24 pm
> Subject: [IMPROVEDX] death certificates
> 
> I would not favor adding medical error to death certificates for a variety of reasons but the chief one being that it is so hard to define and while is obvious to those who want to see improvement, it is less obvious to those who want to avoid the concept. At the point where there is broader consensus on how to identify and reduce medical error (especially diagnostic error) I think it will be easier to record and track the event.
> 
> I believe strongly that it is critical to do that, but we are not there yet.
> 
> I have just completed a project to adjudicate cause of death in nearly a 1000 deaths for a large cohort study. The project involves reviewing both death certificates and medical records. At that level of review I did not see evidence of diagnostic error or other errors. Now that I consider the project in light of this discussion - I guess that is interesting.
> 
> I don’t interpret this to mean that none of those subjects experienced error, but rather to reflect on the invisibility of error in our record keeping.
> 
> I wonder about the feasibility of re-reviewing the data with a more critical eye and finding more. However, I don’t really think I would find much.
> 
> Liz Regan
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