AW: [IMPROVEDX] AW: [IMPROVEDX] AW: [IMPROVEDX] death certificates-litigation

Xavier Prida dr.xavier.prida at GMAIL.COM
Sun May 8 15:28:20 UTC 2016


Yskert,
            I agree with your framing of the human biologic element of our
"production" as different from industrial production of inanimate objects.
Widgets don't feel, emote, or retort other than in the specification of
their performance(more on the humanistic side below).
           To your organizational analysis, the simple paradigm of the Iron
Triangle applies-which has been grossly co-opted and distorted by* CMS *"triple
aim"[*CMS*-*C*enter for* M*edicare and Medicaid *S*ervices in the U.S] .
Where one has cost, quality, and speed as the 3 points of the Iron
Triangle, it has been shown in the military/industrial complex, education,
and aerospace safety(e.g. the shuttle disasters) that only 2 of 3 can be
controlled or constrained. 1 of 3 must always be set free.

Reviewing your principled and erudite manuscript on *IMS*(*I*ndividualized
*M*edical* S*trategy), I would add to this the concept of "*Well Being*" as
that which incorporates all that patients(and society) desires and is the
ultimate outcome measure. The National Academy of Medicine's white
paper on* "Well
Being In All Policies"* defines and addresses this emerging concept-
advocating substitution of  well being for health, the former more
expansive and relevant to patients(link below).


http://nam.edu/well-being-in-all-policies-promoting-cross-sectoral-collaboration-to-improve-peoples-lives/

Xavier

On Sat, May 7, 2016 at 2:50 PM, Kodolitsch von, Yskert <kodolitsch at uke.de>
wrote:

> Rob, I like your way of reasoning.
>
> I write on a manuscript for the Journal of multidisciplinary care right
> now and while I do this I follow the improvedx discussions, which appear
> quite productive to me especially the discussion that is ongoing these days.
>
>
>
> So, to err is human. Ok. But why does medicine seem to struggle more than
> “other industries”?
>
> Quite simple: our “product” is not a dead thing, it’s a human being with
> autonomous behavior – so our troubles are amplified. Therefore, production
> industry is not a good model for us – something to learn from, but also a
> lot that does not apply to us.
>
>
>
> But I think that there is some good news also. I believe that “error” in
> medicine differs from “error” in industry in many ways. One way is, that
> deviance from standards quite often is, what the autonomous patient asks us
> to do. And there are many ways where such deviance in not error but respect
> for the patients autonomy. Moreover, therapeutic success does not only have
> a physical dimension but also a social and a psychological dimension. So
> even if therapy may be suboptimal in one dimension, it may be quite good in
> the other two. I could list a lot thoughts along this line (you may look
> at: http://cogentoa.tandfonline.com/doi/full/10.1080/2331205X.2015.1109742
> ), but I briefly want to address another line of thougt, which is more
> pertinent to the manuscript that I write now:
>
> Establishing an “error-friendly” organization is possible and probably
> provides the key strategy for lowering the error-rates. The primary
> barriers to such organization is not legal concerns, I believe, but
> cost-concerns. Hospital managers want to save money. In industry there is
> the sand-cone model and so on that tells managers that they have to go for
> quality first, and then achieve the rest. But I do not think that
> healthcare managers share this attitude. They attempt to reduce costs by
> reducing staff, and errors are then the personal issue of those who get
> caught. Now here is my suggestion: The NIH and others introduced “clinical
> governance” to improve quality, but they should also introduce
> “organizational governance” to improve healthcare quality. Staffing has to
> have certain rations per patient, resting times for physicians have to be
> respected (even against the will of senior physicians, ho often want to
> take home the extra- money at the expense of their own and their patients’
> health, … and so on. This would help. I am sure.
>
>
>
> Best
>
>
>
> Yskert
>
>
>
> *Von:* Robert Bell [mailto:rmsbell200 at yahoo.com]
> *Gesendet:* Samstag, 7. Mai 2016 19:59
> *An:* Society to Improve Diagnosis in Medicine <
> IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>; Kodolitsch von, Yskert <
> kodolitsch at uke.de>
> *Betreff:* Re: [IMPROVEDX] AW: [IMPROVEDX] AW: [IMPROVEDX] death
> certificates-litigation
>
>
>
> More good thoughts Yskert,
>
>
>
> Maybe the expression should be "To Err Occasionally is Human." Perhaps
> from country to country in medicine the error rate is fairly standard, but
> in some countries there are extenuating circumstances that increase it -
> here perhaps a lack of sleep. In another country a greater fear of
> admitting guilt despite despite little litigation. All are hindrances to
> occasional human error, should be well understood, and dealt with. A few
> studies where the hindrances are controlled would get the ball rolling.
>
>
>
> Do other industries better understand the hindrances to error reduction
> than we do?
>
>
>
> it is sad that we still do not even know the error rates by country in
> medicine. And also very sad, when we do nothing happens, e.g. Guns. What is
> the hindrance there?
>
>
>
> Rob
>
>
> Sent from my iPad
>
>
> On May 6, 2016, at 11:02, "Kodolitsch von, Yskert" <kodolitsch at UKE.DE>
> wrote:
>
> An argument that support Joe´s is that in Germany litigation is not such a
> big problem (jet), but error is.
>
> We only can fix things when we stay authentic as physicians. Physicians do
> not want to harm patients. That is why we fight error – and truthfulness is
> a prerogative to succeed.
>
> We have colleagues who had the courage to fight Ebola. We all should have
> courage enough to fight error.
>
> Right?
>
> Yskert
>
>
>
>
>
> *Von:* Joe Graedon [mailto:jgraedon at GMAIL.COM <jgraedon at GMAIL.COM>]
> *Gesendet:* Freitag, 6. Mai 2016 17:41
> *An:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> *Betreff:* Re: [IMPROVEDX] AW: [IMPROVEDX] death certificates-litigation
>
>
>
> Robert,
>
>
>
> We have heard for years (decades) that litigation is the problem. Mean,
> nasty, aggressive plaintiffs lawyers are what prevents transparency. If we
> could only institute tort reform and reduce the risk of litigation and
> large settlements, then everyone could live happily ever after and report
> errors and the system would function superbly well.
>
>
>
> Sorry, I hate to play devil’s advocate on this, but where is the evidence
> that would make any difference? A lot of people who are severely injured as
> a result of medical mistakes are left in limbo when tort reform prevents
> legal recourse.
>
>
>
> If I am not mistaken, Tim McDonald, MD, JD, demonstrated that the Seven
> Pillars program he initiated at the University of Illinois demonstrated
> that transparency works and does not result in outrageous settlements. If
> anything, it saves money.
>
>
>
> Here is a link to our interview with him and an overview of his research:
>
>
>
>
> http://www.peoplespharmacy.com/2015/09/23/show-1007-coming-clean-on-medical-mistakes/
>
>
> Seven Pillars of Transparency:
>
> "Despite the fear, some health care institutions have found that
> transparency with respect to errors actually reduces lawsuits and generates
> good will. Learn about the Seven Pillars approach to disclosure and
> remediation utilized successfully at the University of Illinois. Should it
> be adopted elsewhere?”
>
> Joe
>
>
>
>
>
>
>
> On May 6, 2016, at 1:05 PM, Robert Bell <
> 0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG> wrote:
>
>
>
> Yskert, a real step forward. We need solutions.
>
>
>
> Your thoughts, where appropriate, should also be extended to every private
> doctor''s office and all other medical facilities outside of hospitals.
> Although it could be harder to do.
>
>
>
> However, I have been recommending for years a system of having at least
> one person assigned as a "Safety Officer" in HCPs offices with periodic
> discussion and remedies of ALL the negative events collected. Call back
> failures, appointment problems, lost lab work, 911 calling, etc., etc.
>
>
>
> But to my knowledge I have had no offices that have recently introduced
> such an arrangement. But I may not have heard of them. I have heard by
> hearsay that a very, very small number of larger offices have such a system
> in practice, but that was some years ago. Not recently.
>
>
>
> The lack of interest I think is because no one wants anything to do with
> errors/mistakes, or any record keeping of these in case they are
> discoverable in future law cases. Cost may be a minor problem.
>
>
>
> And this presumably is the same reluctance that hospitals have to
> collecting decent error data.
>
>
>
> So this gets back to my point in this thread of can we achieve ANYTHING
> significant without first fixing the litigation issues?
>
>
>
> Without this are we just perpetually committed to talking, talking,
> talking but doing nothing very concrete to remedy the injury and loss of
> life!
>
>
>
> Rob Bell, MD
>
> Sent from my iPad
>
>
> On May 6, 2016, at 2:33, "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, or
> 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 <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> 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> 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> 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> 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>
> To: IMPROVEDX <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
>
>
>
>
>
> Moderator: David Meyers, Board Member, Society to Improve Diagnosis in
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-- 
Xavier E. Prida MD FACC FSCAI
Assistant Professor of Medicine
USF Morsani College of Medicine
Department of Cardiovascular Sciences
2 Tampa General Circle
STC 5 th Floor
Tampa, Fl 33606
813 259 0992(O)






Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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