[EXTERNAL] Re: [IMPROVEDX] [No SPF Record] [IMPROVEDX] Culture

Elias Peter pheski69 at GMAIL.COM
Mon Jun 18 14:36:12 UTC 2018


There is also the perspective of the referring PCP.

My patients gave me lots of feedback, both positive and negative, about the other clinicians involved in their care. I often arranged to see patients in follow-up after referrals because the was the most efficient way to stay in the loop. As part of that, I would ask ‘How did your visit with XYZ go?”'

As a result, I had a great deal of data, admittedly anecdotal, about both the process and outcomes my patients experienced. But what to do with it? Among my questions…

If I told a clinician that a patient complained about them or their office, would that patient or subsequent patients I sent be treated better or be punished? (I took pains to ask permission before I provided negative feedback.)
What are the expectations of the patient when they report back to their PCP? That we will fix it? That we will see that they get an apology? That we will stop referring to that clinician? That we will sympathize?
How should it impact future referrals? What if one patient out of 10 says they were unhappy? One out of three? What if it is all old people, all patients with no insurance or Medicaid, all women, or all people of color who complain? What if the clinician has special expertise that is not easily available elsewhere, common in areas like mine where population density is low? What if one of two partnered clinicians who cross-cover is the issue?
And what if my institution wants me to refer to the in-house jerk rather than the better option associated with a competing system? (I add that because the pressure existed - not because it was EVER an issue in my mind. There was an instance where our practice was called on the carpet because most of our urologic referrals left our system. Our response was to agree, vigorously that it was a problem, and that the pattern should be telling them that they needed to do something about the poor quality urology services being offered within the system. Not much happened until we provided the response in writing, certified mail…)


Peter


On 2018.06.18, at 7:08 AM, Bob Latino <blatino at RELIABILITY.COM> wrote:

Thank you Andrew for the layman's analogy.  It helps people like me.
 
As most are aware I am not a clinician but a medical error investigator.  I know more than the average person about what goes on behind the curtain in a hospital setting, so I am more cautious in my dealings with clinicians and staff.  
 
I often will not return to a specialist because it is obvious they are following a script with my treatment, and are not interested in the eventual outcome.  They are not using a differential approach to look at my case uniquely and are following a prescribed series of steps which is likely laid out by the insurance companies.  I am constantly being given appointments for follow ups after one specialist refers me to another specialist.  
 
The patient can only deduce 'why am I being pushed for a follow up where that specialist is not providing any active treatment to follow up on (they just referred me to someone else)?'  The logical answer to the patient is just to secure another visit (another co-pay to the patient).  I am not sure if this is true or not, but this is what the patient perceives.
 
Long story short, I often leave specialists without ever letting them know why, and I have never had one specialist call me up and ask me why I chose not to return.  Can this lead the patient to think the specialist doesn't care about the eventual outcome? Could the patient feel like they are viewed as a number and a means to only getting appointments for revenue? 
 
I will use analogy like you, for the fellow laymen in the group.
 
How many go to a restaurant and receive bad service or an unacceptable meal, but don't choose to tell the restaurant owners/managers about it?  Instead we just choose not to return and the restaurant owners/managers never know you were dissatisfied?  As a result they feel they are delivering quality service and a quality product.  In these very frequent type of occurrences, 'no news, is not necessarily good news'.  Just like 'practice doesn't make perfect', 'practice makes permanent'.
 
These are just views from a patient who tends to see the other side of the equation.
 
Thanks for patience.
Bob
 
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/>
<image001.jpg> <https://www.linkedin.com/company/958495?trk=tyah&trkInfo=clickedVertical%3Acompany%2CclickedEntityId%3A958495%2Cidx%3A1-1-1%2CtarId%3A1464096807851%2Ctas%3Areliability%20center%2C%20inc.>
 
From: Andrew Olson [mailto:olso5714 at UMN.EDU <mailto:olso5714 at UMN.EDU>] 
Sent: Sunday, June 17, 2018 10:53 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] [EXTERNAL] Re: [IMPROVEDX] [No SPF Record] [IMPROVEDX] Culture
 
This is a valuable discussion that gets to the heart of much of what we do.  I think as we discuss arrogance/overconfidence and intellectual humility we should think about these as products of the systems in which we learn and practice rather than personal traits, and thus it is easier to be less defensive.
 
Physician training in the US primarily occurs in an open loop system, where we generally do not know the downstream consequences of our decisions.  It is human nature that we consider unknown outcomes to be positive (no news is good news) and thus we all just think we are very good at diagnostic decision-making since we receive little effective or timely feedback.  
 
Take, for example, if you played golf but only hit a drive on each hole and then someone else on the team took over to finish each hole. You assume that they will tell you if your ball was a great shot or went in the rough, but it turns out that the system doesn't encourage that; you still hold that assumption.  Thus, since there is no drive-related feedback, we would all come to quickly believe that we are better than we are.
 
This seems ridiculous, but mirrors closely the system we have in medicine and medical education today.  It is fundamental that we build systems to ensure we know the outcomes of our decisions.
 
On Fri, Jun 15, 2018 at 8:39 AM, Grefe, Rosemary <RGrefe at childrensnational.org <mailto:RGrefe at childrensnational.org>> wrote:
No,  I have attached a summation of the study that I am referring to.
 
From: Tom Benzoni [mailto:benzonit at GMAIL.COM <mailto:benzonit at GMAIL.COM>] 
Sent: Thursday, June 14, 2018 8:26 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: [EXTERNAL] Re: [IMPROVEDX] [No SPF Record] [IMPROVEDX] Culture
 
ATTENTION: External Email! Do not click attachments/links unless sender is known.
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1731967 <https://urldefense.proofpoint.com/v2/url?u=https-3A__jamanetwork.com_journals_jamainternalmedicine_fullarticle_1731967&d=DwMFaQ&c=Zoipt4Nmcnjorr_6TBHi1A&r=iMpVRgI4Jb8qPZsZHXUj0g&m=A8yt_8zuAdOoCYOTkAPV5uooOtZKYKBDp6hLmtZ9Qgw&s=I0LqetjOjuhBykUNvo57ymTJ2pTt6G-jREMpk0h04wk&e=>
 
Is this the study to which you refer?
tom
 
 
On Thu, Jun 14, 2018 at 2:05 PM NANCY GENN <nancy.genn at comcast.net <mailto:nancy.genn at comcast.net>> wrote:
There was a study, either Harvard or Johns Hopkins, contrasting PCP's and specialists, along 2 variables, diagnostic accuracy and diagnostic certainty.   Although specialists had a greater degree of accuracy than PCP's, their error rate was still measured very high (I remember it being about 17%), but they were astoundingly certain that their diagnosis had been correct and rejected  the notion that they needed either further objective testing or another opinion (70%).  The interpretation of the researchers was that it was arrogance that contributed to the high rate of diagnostic error.  It was about 5 years ago.  If I find it, I'll send you the citation.

 

Nancy Genn

On June 14, 2018 at 12:51 PM ROBERT M BELL <0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG <mailto:0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG>> wrote:

Thanks Tom and Bob,
 
Is that the the lack of caution that comes with any degree of arrogance?
 
Does arrogance itself have a role in diagnostic error?
 
Has that ever been studied?
 
Does anyone know?
 
Rob Bell
 
 
 
 
On Jun 13, 2018, at 8:52 PM, Tom Benzoni <benzonit at GMAIL.COM <mailto:benzonit at GMAIL.COM>> wrote:
 
From 35+ years in the front lines of health care, this is for sure so.
And the arc is increasing.
I've recently moved from an area that always felt a bit inadequate to one that is self-assured.
The prior was much safer than the latter.
Ever hear the phrase "Fat, dumb and happy?"
 
tom benzoni
 
On Tue, Jun 12, 2018 at 12:26 PM Bob Latino <blatino at reliability.com <mailto:blatino at reliability.com>> wrote:
While this is referencing the Oil & Gas industry, there are some interesting stats related to the 'zero commitments' we were talking about earlier.  

 

"Unsurpirsingly, there is even a correlation between committing to a ‘zero accident’ vision on a project and killing more people. In a thoughtful recent study, British colleagues have demonstrated that projects subject to a ‘zero safety’ policy or program actually slightly increase the likelihood of having a serious life-changing accident or fatality (Sheratt & Dainty, 2017)."

 

Just an FYI.  

 

http://www.safetydifferently.com/oil-and-gas-safety-in-a-post-truth-world/#comment-3802 <https://urldefense.proofpoint.com/v2/url?u=http-3A__www.safetydifferently.com_oil-2Dand-2Dgas-2Dsafety-2Din-2Da-2Dpost-2Dtruth-2Dworld_-23comment-2D3802&d=DwMFaQ&c=Zoipt4Nmcnjorr_6TBHi1A&r=iMpVRgI4Jb8qPZsZHXUj0g&m=A8yt_8zuAdOoCYOTkAPV5uooOtZKYKBDp6hLmtZ9Qgw&s=LzE7bFvl0m-4xp0DTbBt6K-Sd1BSveeYSBvV-WQgo8g&e=>
 

Robert J. Latino, CEO

Reliability Center, Inc.

1.800.457.0645

blatino at reliability.com <mailto:blatino at reliability.com>
www.reliability.com <https://urldefense.proofpoint.com/v2/url?u=http-3A__www.reliability.com_&d=DwMFaQ&c=Zoipt4Nmcnjorr_6TBHi1A&r=iMpVRgI4Jb8qPZsZHXUj0g&m=A8yt_8zuAdOoCYOTkAPV5uooOtZKYKBDp6hLmtZ9Qgw&s=s4ZisNB7ZIdiDNqZD7xVCvGpv4Lwkj9cnU2iERVQjWo&e=>
 

 

From: Mark Graber [mailto:Mark.Graber at Improvediagnosis.org <mailto:Mark.Graber at Improvediagnosis.org>] 
Sent: Tuesday, June 12, 2018 11:07 AM
To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>; Bob Latino <blatino at reliability.com <mailto:blatino at reliability.com>>
Subject: Re: [IMPROVEDX] [No SPF Record] [IMPROVEDX] Culture

 

That Decker article on ‘getting to zero’ is amazing – thanks for forwarding it Bob.


It was exactly this question, can we get to zero, that prompted my first-ever paper on diagnostic errors, arising from assertions at national meetings that we could completely eliminate serious safety events.   Don Berwick had it right: “The search for zero error rates is doomed from the start”.

 

Its also the wrong question; Better questions are:  How can we make progress, and how can we measure that?  And… now with the knowledge that unintended consequences will accompany whatever we do, how do we minimize those while maximizing accuracy, timeliness, and safety? 

 

Mark

 

Mark L Graber MD FACP

President, SIDM

Senior Fellow, RTI International

Professor Emeritus, Stony Brook University

 

  

 

 

From: Bob Latino <blatino at RELIABILITY.COM <mailto:blatino at RELIABILITY.COM>>
Reply-To: Listserv ImproveDx <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>, Bob Latino <blatino at RELIABILITY.COM <mailto:blatino at RELIABILITY.COM>>
Date: Tuesday, June 12, 2018 at 10:03 AM
To: Listserv ImproveDx <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>
Subject: Re: [IMPROVEDX] [No SPF Record] [IMPROVEDX] Culture

 

Along this thread I thought this article may be of interest.  Declarations of 'zero' metrics, often has unintended consequences.  While on the surface they seem logical and admirable, they can suppress feedback loops for fear of affecting the zero metric (such as zero harm). 

 

The article is authored by noted safety researcher Sidney Dekker.

 

Does this 'zero' mentality fall into the realm of how success in reducing Dx error is measured?  Is it applicable?

 

Regards

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 <https://urldefense.proofpoint.com/v2/url?u=http-3A__www.reliability.com_&d=DwMFaQ&c=Zoipt4Nmcnjorr_6TBHi1A&r=iMpVRgI4Jb8qPZsZHXUj0g&m=A8yt_8zuAdOoCYOTkAPV5uooOtZKYKBDp6hLmtZ9Qgw&s=s4ZisNB7ZIdiDNqZD7xVCvGpv4Lwkj9cnU2iERVQjWo&e=>
 

 

From: Rory Jaffe [mailto:rjaffe at CHPSO.ORG <mailto:rjaffe at CHPSO.ORG>] 
Sent: Monday, June 11, 2018 3:04 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] [No SPF Record] [IMPROVEDX] Culture

 

The other studies show a reasonably strong link.

 

Some of the problems in making an overall assessment is that culture is very local, varying broadly from department to department within an organization. Within-organization variability is generally much higher than between-organization vulnerability on safety culture surveys. So studies that look at “culture” in the organization as a whole tend to have weaker results. The specific papers do show a decent link.

 

Also backing this conclusion is that, in other industries, this has been studied and there is a definite link between culture and safety.

 

I think there is a consensus in health care that there’s a link. Look at “to err is human” and subsequent publications from the National Academy of Medicine. These publications strongly presume that culture is important driver of safety.

 

 

From: ROBERT M BELL <rmsbell200 at yahoo.com <mailto:rmsbell200 at yahoo.com>> 
Sent: Monday, June 11, 2018 10:47 AM
To: Society to Improve Diagnosis in Medicine <IMPROVEDX at list.improvediagnosis.org <mailto:IMPROVEDX at list.improvediagnosis.org>>; Rory Jaffe <rjaffe at chpso.org <mailto:rjaffe at chpso.org>>
Subject: Re: [No SPF Record] [IMPROVEDX] Culture

 

Thanks Rory Jaffe,

 

Very kind.

 

Do you yourself have an overall opinion? I looked at the Weaver article which evaluated many studies. and, from my limited interpretation, that did not seem too positive.

 

Is there a general consensus amongst the medical profession as to whether culture is important in preventing errors?

 

Is to ERR more resistant to intervention than we think?

 

Rob Bell

 

 

On Jun 11, 2018, at 9:58 AM, Rory Jaffe <rjaffe at chpso.org <mailto:rjaffe at chpso.org>> wrote:

 

Weaver SJ, Lubomksi LH, Wilson RF, Pfoh ER, Martinez KA, Dy SM. Promoting a culture of safety as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158(5 Pt 2):369-374. doi:10.7326/0003-4819-158-5-201303051-00002.

 

 


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<image002.jpg><image006.jpg><image006.jpg><image003.jpg>
 

 

 

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


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