Knowing When It's Time To Leave

Over two years ago, the folks over at the athenahealth kindly invited me to submit columns to their Health Leadership Forum, and I have done so on an occasional basis since them. As I recently reviewed the columns, I realized that my own thoughts on the topics of leadership and coaching have evolved a bit, and I thought my readers over here at Not Running A Hospital might enjoy witnessing the transition. So for several days, I will be reprinting the posts from the Forum over here. Comments are welcome at the original site and here. Today's reprint, with some additional embedded links, is from a post dated March 27, 2014, "Knowing When It's Time To Leave."

In a recent article on the HBR Blog Network, Manfed F. R. Kets de Vries asks the question, “How long should a CEO stay in his job?” He answers by saying, “seven years in probably the period of maximum effectiveness for most people in what can be a very stressful job.” He goes further to describe three phases that characterize the tenure of many CEOs — entry, consolidation, and decline.

He asks, “So what can be done when a CEO starts to decline? The best scenario, of course, is if that the CEO himself realizes what is happening, acknowledges his increasing ineffectiveness, and looks for new horizons when the going is still good. Ideally, that is at the point when they are in the sweet spot of being at the peak of their performance, just before decline.”

In my case, I arrived at Beth Israel Deaconess Medical Center in January of 2002, with the assignment to lead a financial turn-around of an extremely troubled organization. By September of 2003, we officially declared the end of the turn-around, as the hospital had returned to sustained profitability.

Having survived, it was then time to engage in a full-fledged series of strategic plans—focusing on the three parts of this academic medical center’s mission–clinical care, education, and research. By engaging the faculty and staff, we were able to reach a consensus on the overall direction of the place.

Meanwhile, due in great measure to the recruitment of Dr. Mark Zeidel as chief of medicine, we began an intense program in safety and quality improvement. Mark’s commitment to this journey was soon matched by the other incumbent chiefs and supplemented by the recruitment of new chiefs of pathology, radiology, and anaesthesia. My role in this effort was to initiate unprecedented levels of transparency with regard to clinical outcomes. Our Board was on board, too, adopting a four-year goal of eliminating preventable harm in our hospital, and posting on our corporate website—for the world to see—progress towards that goal. Every quarter, the actual numbers and types of cases of harm in our hospital would be made transparent.

In March of 2009, we faced a new crisis as the financial meltdown occurred in the US economy. Having started the fiscal year with projections of a $20 million surplus, by mid-year we were instead looking at a likely $20 million deficit. My COO and CFO recommended laying off 400 people to balance the budget.

I refused and instead asked people in the hospital to suggest ways in which they were willing to absorb personal financial sacrifices to help avoid layoffs. The response—which received national attention—was overwhelming. We not only avoided the layoffs, but we were able to exempt the lowest paid workers from having to participate in any of the sacrifices chosen by the others.

In August of 2009—right in line with de Vries’s timetable—I woke up one morning and realized I was tired. I was tired from a job that had extremely demanding physical and psychological components. I was also tired of the job, having felt that I had done my most creative work. I was ready for new challenges. In terms of my personal health and well-being, it was time to leave. Also, it was time to let a new person with more energy and enthusiasm handle the next stage of challenges facing the hospital.

But I decided to stay on. Why? Here’s where I let myself be trapped by the close personal relationships that had grown between the staff and me. Hospitals are compelling and emotionally complex places, and an empathic CEO feels the joy and pains of the staff and builds a deep personal bond with these well intentioned people who devote their lives to eliminating human suffering caused by disease.

In this case, there was an additional anchor. I felt an obligation to our generous staff to stay long enough to see the hospital through its financial crises and to restore the pay cuts and reductions in benefits that they had voluntary taken. I knew that this new turn-around effort might last at least another year, and I decided to commit myself to staying the course.

Sure enough, by the fall of 2010, our fiscal health had been restored. I was able to restore the cuts in pay and benefits. I was even able to award everyone with a $500 bonus out of gratitude for all they had done to help to the hospital and one another.

This was a source of great personal satisfaction for me, but as I look back on the experience, I realize that it was a mistake to stay beyond the seven years. While my motivation in staying was not selfish—it fact, it was just the opposite—it was self-centered. Was I the only person who could have led the organization through that recovery? No, there were many able leaders in the hospital who would have done just fine without me. But my dedication to the staff made me want to stay long enough to feel that I had delivered the goods to them.

As de Vries suggests, it is at such a moment when a Board needs to step in. They need to closely monitor not only the performance of the CEO but his emotional mindset. They must overcome inertia in governance, the natural reluctance to change horses when the race is going well. The loyalty and friendship that a Board feels towards a successful CEO is, ironically, a danger. It leads to complacency on the Board’s part, particularly during moments of corporate triumph. It is precisely then that a Board needs to carry out its most important function—telling themselves and the CEO that it is time for him to move on.

The Wrong Map

Over two years ago, the folks over at the athenahealth kindly invited me to submit columns to their Health Leadership Forum, and I have done so on an occasional basis since them. As I recently reviewed the columns, I realized that my own thoughts on the topics of leadership and coaching have evolved a bit, and I thought my readers over here at Not Running A Hospital might enjoy witnessing the transition. So for several days, I will be reprinting the posts from the Forum over here. Comments are welcome at the original site and here. Today's reprint is from a post dated February 7, 2014, "The Wrong Map."

My good friend and negotiation guru Michael Wheeler includes an anecdote in his new book, The Art of Negotiation: “Many years ago, a military patrol was caught in a fierce blizzard in the Swiss Alps. The soldiers were lost and frightened, but one of them found a map tucked in his pocket. After consulting it, the men built a shelter, planned their route, and then waited out the storm. When the weather cleared three days later, they made their way back to the base camp.”

Wheeler continues, “Their commanding officer, relieved that his men had survived the ordeal, asked how they made their way out. A young soldier produced the life-saving map, and the officer studied it carefully. He was shocked to see that it was a map of the Pyrenees Mountains that border Spain and France, not the Alps.”

He suggests three reasons how the wrong map could help save climbers lost in the Alps: it rekindled the soldiers’ confidence, provided an impetus to get moving, and sharpened the soldiers’ awareness.

While Mike uses the anecdote to draw lessons for negotiators, perhaps it also offers suggestions to leaders in health care. Their institutions face formidable challenges, and the way forward is not always clear. They know that standing still — failing to act — is more dangerous than going in slightly the wrong direction. But how do you motivate your staff to take action and deal with the ambiguity of the situation?

The traditional wisdom is that you have to “create a burning platform.” Such an approach uses the threat of imminent financial disaster or major loss of market share as an incentive to those in the organization. Well, maybe. But the problem with a burning platform is that your people fear that the only way to go as they step off the platform is down.

Few people want to take accountability for initiative in that situation. Frankly, most people are risk-averse, and telling them that the world depends on them for decisive action is not highly motivational.

So, how do we get people past their natural risk-averse tendency? How do we suggest to them that any (thoughtful) action is better than sitting back and waiting? How do we get them moving in a direction that has some probability of being correct? How do we help them sharpen their awareness so they are alert to the need for mid-course corrections if the original path proves to be off target?

What map of the Alps can we offer our staff?
 
The traditional one is a strategic plan: We engage in a long process to survey our strengths, weakness, opportunities, and threats. We fan out through the organization and create working groups to enhance buy-in of our analysis and the alternatives we choose. We overlay the process with nifty charts and graphs, careful to include the “levers” that will make a difference in our financial situation or competitive posture. Then we assign the strategic initiatives to various inter-disciplinary groups and create key performance indicators for each division of the company to measure our progress in carrying out the plan.

It is hard to imagine a less inspirational start to a journey of change than this kind of centralized, highly numerical, and bureaucratic approach. Here’s a secret. Every strategic plan I have seen in the health care world says the same thing: “Let’s focus on what we are good at that pays us well, where we can gain market share, and do more of that. For the things we don’t do as well, or where payment is not good, it’s okay not to grow or even to shrink.”

I’m not suggesting that an organization should avoid a strategic vision. Indeed, having such a vision is a key role of senior management. I am suggesting that the way to give your “soldiers” the confidence to leave the campsite, engage in experiments, take risks, and be creative does not come from an externally generated strategic process. Instead, we need to allow confidence-building measures to grow organically from within the organization.

In previous columns, I’ve talked about the value of the Lean process improvement philosophy in reducing waste, i.e., improving the operating efficiency in an organization. With the Lean approach, the front-line staff is empowered, expected and encouraged to call out problems in the work place. Management is expected to swarm around those identified problems—in real time—and invent experiments to test out countermeasures to improve the delivery of goods or services to the customer.

Well, it turns out that Lean also provides that “map of the Alps” in an uncertain environment. The “map” here is a general philosophy, approach, and set of tools that is independent of the actual physical and competitive work environment. It maintains and enhances our confidence as a team. The “every person every day” theme of Lean provides ongoing impetus to keep moving. Finally, knowing that the organization expects and encourages the staff to call out workplace waste sharpens their awareness.

The “map” for dealing with the challenges of a health care institution is being held by every staff person in our organizations. Our job is to create an environment in which they can feel the map in their pockets and set off each day in the right direction — to reduce waste, improve efficiency, and deliver better service to patients and families.

Bridging the Gap Between Planning and Reality

Over two years ago, the folks over at the athenahealth kindly invited me to submit columns to their Health Leadership Forum, and I have done so on an occasional basis since them. As I recently reviewed the columns, I realized that my own thoughts on the topics of leadership and coaching have evolved a bit, and I thought my readers over here at Not Running A Hospital might enjoy witnessing the transition. So for several days, I will be reprinting the posts from the Forum over here. Comments are welcome at the original site and here. Today's reprint is from a post dated December 17, 2013, "Bridging the Gap Between Planning and Reality."

A colleague once said, “Every plan is excellent, until it’s tested. It’s execution that’s the problem.” And so it is.

Clay Shirky wrote an excellent article about the gulf between planning and reality. Although the focus was on the misadventures of Healthcare.gov, the US government’s insurance exchange website, the broader lessons that he presents are worthy of consideration in many other settings.

Shirky notes: The management question, when trying anything new, is “When does reality trump planning?”

In the case of Healthcare.gov:

For the officials overseeing Healthcare.gov, the preferred answer was “Never.” Every time there was a chance to create some sort of public experimentation, or even just some clarity about its methods and goals, the imperative was to deny the opposition anything to criticize.

Failure is always an option. Engineers work as hard as they do because they understand the risk of failure. And for anything it might have meant in its screenplay version, here that sentiment means the opposite; the unnamed executives were saying “Addressing the possibility of failure is not an option.”

Project advocates enter every endeavor with a theory of the case, a vision of how things should be. But, as my late colleague Donald Schön noted, reflective practitioners are constantly reviewing the evidence to modify their framework in response to reality.

A comment on Shirky’s article summarizes this nicely:

“Any personal opinion you had given really doesn’t mean anything.” This is the key principle behind making anything work well — from writing an essay to building a bridge to creating a website. If it doesn’t work, throw out your preconceptions and re-conceive.

There is a cognitive basis for our failure to be reflective practitioners. We are all people of habit. The attributes that permitted us as cavemen to recognize the saber-toothed tiger the second time we saw it and to respond in the appropriate way (“Run!”) work well in the highly simplistic natural world. In a Darwinian sense, we evolved perfectly for that world. We developed a learning style that gave us a competitive evolutionary advantage, a learning style based on memory, stubbornness, and brute force.

But the more difficult world of complex organizations — overladen with political, organizational, and cultural forces and with technological challenges — presents an environment in which those cognitive attributes now present as cognitive errors. We struggle with this. Indeed, as MIT professor Rosalind Picard has outlined, successful learning has three phases: interest, distress, and pleasure.

We feel distress in the second phase because it is during that portion of the cycle that we must overcome our prejudices and develop a new framework within which to proceed. We resist. Sometimes we recognize that we have hit a plateau and need to adopt a new approach to proceed. Sometimes we don’t recognize that our framework is flawed and we uselessly proceed apace, until disaster occurs or a competitor outruns us.

Learning Organizations & Lean Philosophy

Places that are true learning organizations have built in a structure that calls the question early and often. One such structure (but not the only) is offered by the Lean philosophy. By encouraging front-line staff to call out problems they encounter in their daily life, managers are given real-time signals as to flaws in their organization’s processes. The leadership team then visits the sites of the flaws and invents experiments to achieve incremental improvements in work flow. Using the scientific method, those experiments are tested and evaluated, with redesign being a constant part of the process. Lean organizations understand that there is no group of central planners clever enough to design an optimum complex process. Lean leaders do not lack for a strong purpose—indeed audacious goals are favored—but neither do they lack humility.

Lean and other similarly designed organizations can only exist where the senior leadership is a strong advocate for the proposition that reflective practice is the best way to achieve outstanding performance for their customers. The leaders of such organizations embed that modesty and reflection in every aspect of their lives.

I’ve had the pleasure of visiting a number of hospitals that work along these lines. The results are palpable — better service to patients, higher quality, less waste, and more staff satisfaction. Such results are irrespective of the type of payment regime employed to compensate the doctors and the hospital. They are irrespective of the societal form of health care, be it a national public system or a dispersed private pay system.

Such hospitals remain anomalies in their industry, although the number is growing. Adoption tends to center in systems with a strong communitarian spirit, where the trustees and clinical and administrative leaders view their job mainly as providing a public service as opposed to supporting the personal and institutional prerogatives of physicians. Thus, while a few academic medical centers have gotten on board, many have not, trapped by age-old patterns of deference to the doctors. Ironically, in those academic medical centers that have adopted Lean or a similar approach, physicians report tremendous satisfaction from their engagement with process improvement and from the enhanced sense of teamwork with members of the staff throughout the hospital.

The young cadre of rising health care leaders I see when I address clinical and administrative training programs, and when I speak at conferences and in hospital settings, understand that the future is brightest for learning organizations. They thirst for experience in trying out these approaches, and they intend to lead in the manner of reflective practitioners. I say to current health care leaders, when you find one of these rising stars, grab him or her for your place. They are going to teach you something special.

Advocating Through Inquiry

Over two years ago, the folks over at the athenahealth kindly invited me to submit columns to their Health Leadership Forum, and I have done so on an occasional basis since them. As I recently reviewed the columns, I realized that my own thoughts on the topics of leadership and coaching have evolved a bit, and I thought my readers over here at Not Running A Hospital might enjoy witnessing the transition. So for several days, I will be reprinting the posts from the Forum over here. Comments are welcome at the original site and here. Today's reprint is from a post dated October 31, 2013, "Advocating Through Inquiry."

Here’s a familiar story in America’s hospitals. An “old fashioned” surgeon decides that the protocols and procedures put in place by the medical executive committee or other governing body don’t apply to him. “I’ve done it this way for 30 years, and it works fine. I’m the busiest surgeon here, and no one is going to tell me how to do my job.”

People in the risk management field will advise you that such a person is a high risk. His attitude often carries over to treatment of people in the OR. At best, he is uncompromising and lacking empathy. At worse, he is psychologically or perhaps even physically abusive to lower level staff. He also tends to treat patients with a lack of respect. He has more patient complaints on file compared to his peers. When he finally makes a mistake that causes a patient harm, he is a likely candidate for a large malpractice lawsuit.

And yet, notwithstanding this behavior, the hospital leadership is unlikely to do much to correct the problem. The surgeon has a great reputation in the community and is the source for many referrals. So, at most, when an egregious incident is reported to his chief, the reaction might be, “Yeah, I guess I won’t give him his full bonus this year.”

Clearly, such an approach is inadequate and will not resolve the underlying problems. It fails because the message is not delivered at or near the time of the incident. Also, there is not always a nexus drawn between the financial penalty and the behavioral issue. Finally, financial penalties do not have a lasting impact on behavior, if they work at all.

Institutionally, we are advocates for greater adherence to clinical approaches that are safer and deliver higher quality care. We also seek behavior between doctors and colleagues—and doctors and families—that is mutually respectful and reflects a partnership in delivering care. When a doctor has been habitually misbehaving on any of these fronts, we need a way to persuade him to change his ways.

Authority vs. Awareness Intervention

An alternative and more effective approach is outlined in several articles by Gerald Hickson and others from the Vanderbilt University School of Medicine. One article presents a hypothetical example about an emergency room doctor who has misbehaved:

Dr. Trauma has high productivity. Nonetheless, you cannot offer excuses for his performance. Others in the department conduct themselves professionally. In addition, this is not the first time that Dr. Trauma has behaved this way. During the past two years, other team members submitted event reports that describe similar behaviors. Some of the coworker and patient complaints suggest that Dr. Trauma gets angry in pressured circumstances.

You previously spoke with Dr. Trauma about several complaints from coworkers and patients. You find it concerning that Dr. Trauma failed to self-correct after this feedback. Given the accumulation of patient and staff complaints and the current event analysis, you decide that what is right for Dr. Trauma and the organization is for you, as his chief, to . . . require Dr. Trauma to undergo a comprehensive mental health evaluation and, if indicated, a defined treatment plan. Failure to comply would subject the physician to a loss of privileges.

Certainly this kind of “authority intervention” would get someone’s attention, but hospitals are wary of this approach, in that it has the potential of knocking a high performer off the clinical rolls. Also, chiefs often have a personal relationship with the doctor in question, one that makes it difficult to suggest that his colleague is medically impaired.

But Hickson, et al., also point out that a preliminary step can be effective and help avoid the authority intervention. They term this an “awareness intervention” by a peer. Awareness intervention is based on the premise that “each professional has a responsibility that colleagues and systems do no harm” and that “concerted effort to remove systemic or behavioral threats to quality must include willingness to provide feedback to others observed to behave unprofessionally.” It relies on “sharing aggregated data that present the appearance of a pattern that sets the professional apart from his/her peers.”

The key element of awareness intervention is to have a trained peer “messenger” present the data (e.g., the high relative number of patient complaints) and encourage the physician to reflect on what might be behind that pattern, but not to provide directive or corrective advice. The reason? “If a messenger offers a plan that does not ‘work,’ the high-risk doctor can blame the plan and the messenger. We therefore want messengers who promote ‘awareness’ and encourage self regulation.”

The Vanderbilt experience suggests that this form of intervention is often successful. When it is not, the organization moves up the ladder to the type of authority intervention mentioned above.

Some readers might be surprised that awareness intervention would achieve any result. But let’s look at the underlying psychology. First, doctors view themselves as scientists and can be persuaded by data. Second, the troubled physician is treated respectfully. Third, the remediation plan is not prescribed by another and therefore cannot be viewed as externally imposed. It is his own creation based on his understanding of his problems.

If we think about it more generally, though, the Vanderbilt approach is based on an old theory of persuasion, one put forth by St. Francis: “Grant that I may not so much … be understood as to understand.” Or as Steven Covey restated it, “Seek first to understand and then to be understood.”

Hickson and colleagues have designed a program that achieves advocacy through inquiry. We stimulate the troubled doctor to consider the reasons for his behavior and the results that stem from it. We ask him to reveal his understanding of those reasons by designing and acting on a plan to remediate them. We learn things about that doctor that can be very helpful in our dealings with him but may also be useful more broadly in our institution. Ultimately, through this process, he understands, too, where we are coming from and adopts behaviors consistent with the greater good. Our advocacy has succeeded.

Negotiating on Purpose

Over two years ago, the folks over at the athenahealth kindly invited me to submit columns to their Health Leadership Forum, and I have done so on an occasional basis since them. As I recently reviewed the columns, I realized that my own thoughts on the topics of leadership and coaching have evolved a bit, and I thought my readers over here at Not Running A Hospital might enjoy witnessing the transition. So for several days, I will be reprinting the posts from the Forum over here. Comments are welcome at the original site and here. Today's reprint is from a post dated September 25, 2013, "Negotiating on Purpose."

After her fifteen year-old son Lewis Blackman died from a series of preventable medical errors, Helen Haskell diagnosed the problems in the hospital by saying, “This was a system that was operating for its own benefit.”

What she meant was that each person in the hospital was unthinkingly engaged in a series of tasks that had become disconnected from the underlying purpose of the hospital. They were driven by their inclinations and imperatives rather than by the patient’s needs. Indeed, they were so trapped in that form of work that they could not notice the entreaties of a seriously concerned mother as her son deteriorated.

I once heard a Harvard business professor describe the financial imperatives of many hospitals in a less personalized, but analogous fashion. He called hospitals “business cost structures in search of revenue streams.”

What he meant was that the business strategies of the hospital had become detached from the humanistic purposes that had led to the creation of the hospital. There was thus a parallel to the individuals’ behavior noticed by Helen.

What a perversion of human endeavor when things reach this point! Activity for the sake of activity in the context of an organization that has lost its soul.

Lest we get distracted by the current debate about the incentives that might correspond to different payment models—fee for service, bundled, or capitated rates–is important to note that this kind of perverted personal and corporate behavior is not driven by rate design. The failure of Lewis Blackman’s doctors and nurses had nothing to do with financial incentives. No, the systemic forces at work that killed this young man were based on ego, fear, poorly functioning hierarchy, lack of communication, and cognitive errors.

Likewise, the corporate search for revenue for the entities that constitute our hospitals and health systems has not been driven by rate design. Under any payment regime, the underlying issue is that hospitals are huge fixed-cost enterprises, and the incentive to “feed the beast” often drives corporate strategy, driving out humanistic concerns. Indeed, it may be that a movement to provider risk-sharing will simply compound the problem in that it will require hospital systems to accumulate greater financial reserves to hedge the actuarial risks that are being transferred in their direction.

Let’s not lose the irony of this kind of situation. The people who have chosen to be in the health care field are, for the most part, the most well intentioned people in the world. They have devoted their lives to alleviating human suffering caused by disease. They are intelligent and thoughtful and highly trained.

Indeed, if each of us in health care were asked to state the purpose of our institution in our own words, I bet we would say something similar. In my former hospital it was codified as follows: “We hope to take care of patients in the manner we would want members of our own family cared for.”

People’s behavior in the moment, though, often is at variance with such purposes. Corporate imperatives likewise go awry.

It is at time like this that we search for leadership that will help steer the ship and those in it in a more humanistic direction. Surely the leader cannot be agnostic with regard to financial concerns, but he or she needs to act to help the organization put purpose above all. What can we expect and hope for from great leaders at this juncture in medicine’s crisis of purpose? The usual answer—inspiration—is not correct.

Professors often draw a distinction between management and leadership, noting that leaders have the ability to inspire people in an organization to a higher purpose. Yes, there is the kind of inspiration that occurs during a crisis, like that offered by Winston Churchill during World War II or Franklin Roosevelt during the Depression. But for most organizations involved in the day-to-day work of providing a service to the public, the professors’ description is off point, for the leader’s ability to inspire is not germane. The ability to inspire can provide a shot in the arm, but it seldom leads to sustained and mindful action on the part of people in an organization in support of its purpose.

My view is that inspiration comes from within and is tied to those ethical standards and good intentions that caused people to enter the health care professions in the first place. The leader’s job, then, is not to inspire. It is to use his or her influence to help create a supportive environment that permits the waiting reservoir of such intentions to be tapped.

Paul O’Neill, former Secretary of the Treasury and CEO of Alcoa Aluminum, has set forth a three-part test for an organization seeking to empower its staff to fulfill its mission:

1. Are my staff treated with dignity and respect by everyone, regardless of role or rank in the organization?

2. Are they given the knowledge, tools and support they need in order to make a contribution to our organization and that adds meaning to their life?

3. Are they recognized for their contribution?

The leader’s job is to carry out an ongoing negotiation with the various constituencies in a hospital to persuade them that it is in their interest to organize their work and behavior in such a manner as to permit these conditions to take hold. You might find it strange that I frame this responsibility as a negotiation, but that turns out to be a more apt description than others that might be used.

Hospitals are filled with highly trained professionals who want to spend their time doing the things they are trained to do. Those people are not generally trained in the kind of interpersonal skills and team behavior that is required to support Mr. O’Neill’s desired conditions. The leader has to persuade those individuals that their own role will be enhanced if they learn to behave in such a manner as will help develop O’Neill’s conditions. In negotiation parlance, they have to be made to feel that agreeing to such an approach is a better path than their alternative, i.e., not agreeing to it.

People who are likely to be the future leaders of health care institutions in America and abroad often come to me for career and training advice. My constant refrain is to learn the principles and framework of negotiation strategy. Negotiation can be defined as means of satisfying parties’ underlying interests by jointly decided action. You cannot be a leader if you do not know how to help a hospital’s constituencies understand that their interests are coincident with the purpose of your organization and if you cannot help them jointly decide on the actions needed to carry out that purpose.

Disclosure and Apology Must Be Taught Before They Can Be Learned

Over two years ago, the folks over at the athenahealth kindly invited me to submit columns to their Health Leadership Forum, and I have done so on an occasional basis since them. As I recently reviewed the columns, I realized that my own thoughts on the topics of leadership and coaching have evolved a bit, and I thought my readers over here at Not Running A Hospital might enjoy witnessing the transition. So for several days, I will be reprinting the posts from the Forum over here. Comments are welcome at the original site and here. Today's reprint is from a post dated July 23, 2013, "Disclosure and Apology Must be taught Before they Can be Learned."

If our objective as leaders is to gradually transform the health care system to make it more patient-centered, we need to ensure the rising classes of young doctors are trained to carry out this form of medicine. Unfortunately, as noted by the Lucien Leape Institute, “[M]edical schools and teaching hospitals have not trained physicians to follow safe practices, analyze bad outcomes, and work collaboratively in teams to redesign care processes to make them safer.”

As Dennis S. O’Leary, MD, President Emeritus of The Joint Commission and a member of the Institute has said, “Educational strategies need to be redesigned to emphasize development of the skills, attitudes, and behaviors that are foundational to the provision of safe care.”

Among the most important skills to be taught to doctors is how to disclose medical errors to patients and families. Yet, training in this topic is often relegated to a single lecture sometime during medical school. Is there any question why the material doesn’t “take” when it is treated so casually?

The great basketball coach John Wooden liked to say, “You haven’t taught until they have learned.” How best to design a curriculum that truly enables young doctors to learn the fundamentals of disclosure?

David Mayer, MedStar Health’s VP for Quality and Safety, is one of the country’s leaders in undergraduate and graduate medical education. He explains, “Disclosure training is a process, not a fifty-minute lecture.” He and colleague Tim MacDonald developed the first four-year, longitudinal patient safety curriculum for medical students in the country. That curriculum started on the very first day of school at 8:30 a.m. He notes:

During the first half of the hour-long session, I always asked the students to share with me the fears they had on this first day of school, the starting point on their journey to becoming a physician. Each year I did this, two fears rose to the top – the fear of failure and the fear of hurting a patient. Students read the newspapers that share personal stories of harm or talk about the medical error crisis; many students had a family member harmed from a medical mistake. As an educator, it was a great teaching moment to start the safety conversation, and the reason why we started the conversation on the very first day of school.

Over the years, the students were taught the “Seven Pillars” disclosure and apology model developed by David and Tim for the University of Illinois Hospital in Chicago. This model comprises a rapid response to all unanticipated outcomes, full disclosure related to the care, apology and early compensation, if warranted, and using transparency and disclosure to learn from all our mistakes so that we implement the necessary changes to our system to reduce risk to others. (The Seven Pillars approach was cited by Agency for Healthcare Research and Quality [AHRQ] director Dr. Carolyn Clancy and led AHRQ to fund a three-year project to spread the model in 10 Chicago-area hospitals.)

For the last two years, I’ve had the pleasure and privilege of joining David, Tim, and other colleagues in Telluride, Colorado to conduct week-long training programs for residents and medical students on this and other aspects of disclosure and apology. What emerges is often a cathartic experience for these trainees. Many have borne witness to medical errors being committed in front of them, often by senior residents or attending physicians. They bear the guilt of being afraid to say anything that might arouse the wrath of their instructors. When provided a safe environment with their peers and empathetic instructors, they often tearfully relate their experiences.

Together, we design strategies that they can personally employ when they return to their hospitals. But we also require them, as a condition of attending our seminar, to design and carry out a safety-related transformational project in their hospital.

The results from even this one-week session are impressive. Pharmacy resident Quyen Nguyen stated: “One of the most important lessons I have learned from the past three days is the urgency in which we need to act to bring ethics back to the forefront of healthcare systems. Too often the best interests of the patients and their families are put behind financial, legal, and personal factors. It may never be possible to prevent every error, but we have a professional duty to take responsibility and put patients’ and their families’ needs first in the aftermath of a medical error.”

Resident Pat Bigaouette said, “The most important thing that I learned while in Telluride was the importance of passion. I sat and listened as passionate after passionate lecturer shared their experience and expertise with me. I learned how they have all made a difference in their respective healthcare systems by being enthusiastic and passionate. I found myself going home and discussing patient safety for hours after the conference had ended.”

Suresh Mohan returned to his residency program in Rhode Island and noted: “Discussing my week with peers back home, I was shocked to realize how little they knew (and, thus, cared) about the topic of safety. I received responses of, ‘Well, I guess every field has its downsides’ to ‘Whoa, I didn’t know you were, like, super into that primary care stuff.’ It reaffirmed my decision to have attended, and the value of what we learned.”

And Garrett Coyan left us all with an agenda: “The last week I spent at Telluride was very eye-opening for me. Reinvigorated with ideas for improving communication and decreasing risk to my patients, I couldn’t wait to get back to my institution and start implementing change. However, as I returned to the hospital today, I was quickly reminded of the main reason why this goal will be so difficult. Not only does cultural change need to occur in the hospital, but I would argue that even more importantly, cultural change needs to occur in the education of students in the health professions.”

There are steps in the education of young doctors that are our obligation if we are associated with health care institutions. As David Mayer notes: “The day has now come for greater accountability in medical education around safety and quality.” In a series of blog posts, he has set out the elements of an education program characterized by rigor, thoughtfulness, and pedagogical excellence. If you are in a position to influence the education program in your hospital, please read David’s three posts by clicking the following: part one; part two; part three. Then, use your leadership position to move your institution forward in designing and implementing this kind of educational program for your medical students and residents.

There is a potential bonus in all of this for hospital administrators. It is well-documented that the incidence and size of medical malpractice claims are reduced when physicians show empathy and apologize after errors are made; when they accurately portray the nature of what occurred; and, when they demonstrate that the hospital will learn from the experience so that future patients might be spared the same type of harm. Many older doctors are not adept at carrying out such a disclosure and apology. Raising a new generation of doctors who are skilled at this might therefore produce ancillary benefits for hospitals.

When Good Teams Go Wrong

Over two years ago, the folks over at the athenahealth kindly invited me to submit columns to their Health Leadership Forum, and I have done so on an occasional basis since them. As I recently reviewed the columns, I realized that my own thoughts on the topics of leadership and coaching have evolved a bit, and I thought my readers over here at Not Running A Hospital might enjoy witnessing the transition. So for several days, I will be reprinting the posts from the Forum over here. Comments are welcome at the original site and here. Today's reprint is from a post dated May 28, 2013, "When Good Teams Go Wrong."

When things go wrong in a hospital—on either the clinical or administrative front—we are often left wondering how a dedicated and thoughtful team of people could have jointly participated in the decisions and actions that led to the failures. Recent stories in the news may give us a clue.

Problems recently uncovered at the Internal Revenue Service are typical of those found in many organizations when a team of people become isolated and feel unsupported. The team might be doing a job that nobody else wants to do or is out of the mainstream, work often characterized by a large number of repetitive tasks. Things appear to go well for a while but then take a turn for the worse.

In a Harvard Business Review article I authored in March 2001, I named this syndrome “The Nut Island Effect.” I told the story of a team of skilled and dedicated employees working at the Nut Island sewage treatment plant who became isolated from distracted top managers, resulting in a catastrophic loss of ability to perform an important mission, preventing the pollution of Boston Harbor. The irony was that from the outside, the team had all the attributes of an ideal working group: dedication, collaboration, a strong sense of integrity and values, and indefatigable energy with regard to doing the job.

The employees at Nut Island had set up their own team without the direction and guidance of management, and it had become a priority among the group to avoid contact with upper management whenever possible. Indeed, they viewed senior management as a common adversary.

This isolation led to a lack of accountability with regard to the strategic objectives of the agency. It also precluded an infusion of new ideas and approaches, so that the group began to make up its own rules. The rules, though, were insidious because they fostered within the team the mistaken belief that its operations were running smoothly. Yet, the rules actually resulted in improper operation of the plant and increased pollution of the harbor.

In the years since publishing “The Nut Island Effect,” I have often heard from doctors, nurses, and hospital administrators who have said, “I felt like you were writing about my place! You could have written this story about my operating room (or ICU, or administrative division.)”

Look at these excerpts from a recent New York Times story, “Confusion and Staff Troubles Rife at Cincinnati IRS Office.” Then think of your own hospital and see if you might apply some or all of those descriptors to a functional area in your organization:

Low-level employees, in what many in the I.R.S. consider a backwater, processed thousands of applications a year. Inside the agency, the unit was considered particularly unglamorous. Interviews paint a more muddled picture of an understaffed Cincinnati outpost that was alienated from the broader I.R.S. culture and given little direction. There were times where staff came up with shortcuts that were efficient but didn’t take into consideration the public perception.

In the world of Washington politics, there is a tendency to blame the front-line staff in this kind of situation. Unfortunately, the same tendency often exists in the health care world. But within the IRS, as in your organization, the responsibility has to be shared with the top management.

The Nut Island story prompted me to generalize a five-step process that defines the progression from management-employee alienation to employee self-regulation of critical processes to, finally, mission failure:

1) Senior leadership, focused on high-visibility problems elsewhere in the organization, assigns an important, but behind-the-scenes, task to a team and gives that team a great deal of autonomy. The team members become adept at organizing and managing themselves, and the unit develops a proud and distinct identity.

2) Senior leadership takes the team’s self-sufficiency for granted. Ironically, the unit may often be viewed as an exemplar of “team spirit.” At the same time, team members are ignored when they ask for help or try to warn of impending trouble. The team feels betrayed by management and becomes resentful.

3) As a result, an us-against-the-world mentality takes hold within the team, along with a heightened sense of being a band of heroic outcasts. Now, the team grows skillful at disguising its problems, driven by a desire to stay off the radar screen of the senior leadership. Team members never acknowledge problems to outsiders or ask them for help.

4) Senior leadership, for its part, is more than happy to assume the team’s silence means that all is well. The team begins to make up its own rules and tell itself that the rules enable it to fulfill its mission. In fact, though, these rules mask grave deficiencies in the team’s performance.

5) Both sides, senior leadership and the team, form distorted pictures of reality that are very difficult to correct. They shun one another until some external event, often a catastrophe, breaks the stalemate.

It is far better to avoid the circumstances that lead to The Nut Island Effect than to try fixing the syndrome after it has developed. Traditional management theory suggests the way to avoid the problem is to impose key performance indicators (KPIs) on the department, division, or group. KPIs are supposed to be reflective of the broader strategic priorities of the organization, but there are thousands of examples where the existence of KPIs has been ineffective in solving the underlying sociological problem of a good team that has gone wrong.

The ultimate way to avoid The Nut Island Effect is to foreclose the possibility of isolation in the first place. The most effective way to do this is create a culture of process improvement in which it is the management’s job to be physically present and responsive when people working on the front-line call out problems and obstacles in their day-to-day work. Management has to assume the role of “servant leaders,” in which they work for the staff and not vice-versa. This approach to the design of work is inherent in the “lean management” philosophy but can exist in any organization. Where it does not, it is a symptom of leadership failure that will some day lead to catastrophic results.

Learning from Mistakes

Over two years ago, the folks over at the athenahealth kindly invited me to submit columns to their Health Leadership Forum, and I have done so on an occasional basis since them. As I recently reviewed the columns, I realized that my own thoughts on the topics of leadership and coaching have evolved a bit, and I thought my readers over here at Not Running A Hospital might enjoy witnessing the transition. So for several days, I will be reprinting the posts from the Forum over here. Comments are welcome at the original site and here. Today's reprint is from a post dated May 3, 2013, "Learning from Mistakes."

As a leader, you must do everything you can to encourage people to admit mistakes they have made and to call out problems they have found in the organization. (As Amy Edmondson of Harvard Business School similarly suggested in an earlier post). If people think they will get in trouble for having erred, or for having brought up a systemic problem in the organization, those errors and problems will go unreported. The person and the organization will thereby lose an opportunity to grow and improve. Accordingly, a strong commitment not only to transparency but to a just culture is essential to achieve continuous improvement.

Leadership’s role in such matters is determinative of process improvement in the organization. Equally important, it also empowers the personal and professional growth of people in the firm.

MIT Management Professor Edgar H. Schein has described the communications ethic inherent in such an environment as follows: “Team members have to learn how to analyze and critique their own and each other’s task performance without threatening each other’s face or humiliating each other. That means that subordinates have to learn how to tell potentially negative things to their superiors, and superiors have to learn how to not punish their subordinates for telling the truth if that truth is inconvenient. That, in turn, requires the ability to give and receive feedback in a constructive manner.” (Helping, How to Offer, Give, and Receive Help, Barrett-Kohler Publishers, Inc. San Francisco. 2009. Page 118.)

But true process improvement also requires leaders to go one step further, to take ownership of flaws in their organization. Paul Wiles, former President and CEO of Novant Health in Winston-Salem, NC, once told me and a group of hospital CEOs a heart-wrenching story about an infant’s death from sepsis in his hospital, which was tracked to an MRSA (antibiotic-resistant staph) infection. The infection was part of a spread of a bug in his neonatal intensive care unit (NICU) that reached 18 infants in all and may have contributed to the deaths of two others.

“This was a direct result of staff not washing their hands appropriately,” he said. Since that event, “We have been on a relentless hand hygiene campaign.”

The crux of his entire presentation was this comment: “My objective today is to confess. ‘I am accountable for those unnecessary deaths in the NICU. It is my responsibility to establish a culture of safety. I had inadvertently relinquished those duties,’ ” he noted, by focusing instead on the traditional set of executive duties (financial, planning, and such). Wiles ended his talk to the CEOs in the audience, saying, “If you cannot see the face of your own relative in a patient, or if you cannot see the face of your own son or daughter in the face of a distraught nurse or doctor who has made an error, I suggest that your executive talents would be better placed in other industries.”

But it is not just leaders in the hospital world who have come to these conclusions. Let’s head to an oil rig in the North Sea.

A number of years ago, Tom Botts was involved in a tragedy aboard an oil rig in which he personally had to call off the search for men missing at sea. Deeply shaken, when he later moved on to be Executive Vice President for Shell Oil Company’s exploration and production activities in Europe, he decided that he would implement the most comprehensive program possible to protect workers’ safety at these remote outposts in the ocean. Notwithstanding that new program—the best in the industry—two men lost their lives on a North Sea oil rig when they mistakenly went into a portion of the facility that should have been off-limits. It would have been easy to blame the two men who, after all, entered a prohibited area. Instead, Tom launched a thorough, top-to-bottom review of the organization.

He explained, “We decided to be as open and transparent about the incident as possible and went through a ‘Deep Learning’ journey involving hundreds of people that examined in detail all the root causes that contributed to the accident to get a clear picture of the system that produced the fatalities. Even though the two men who were killed could have made better decisions, my senior leadership team and I could find places where we ‘owned’ the system that led to the tragedy.”

“It was a defining moment for us when we, as senior leaders, were finally able to identify our own decisions and our own part in the system (however well intended) that contributed to the fatalities. That gave license to others deeper in the organization to go through the same reflection and find their own part in the system, even though they weren’t directly involved in the incident.”

Tom continued, “Once you take that step of committing to transparency and learning, it sets a high bar and it is very hard (probably impossible) to take it back. This approach has helped make us stronger and more aware of the impact of our daily decisions.”

Turning back to health care, Dr. Charles Denham wrote an article in which he related the practice of nursing chief Jeannette Ives-Erickson, Senior Vice President For Patient Care and Chief Nurse at Massachusetts General Hospital. When a nurse makes an error in caring for a patient, Jeanette calls the involved nurse into her office and asks one question: “Did you do this on purpose?” When the nurse answers, “No,” then Jeannette says, “Well then it is my fault… errors stem from system flaws … I am responsible for creating safe systems.”

Chuck notes, “In a few short moments with a caregiver after an accident, the leader declares ownership of the systems envelope, and the performance envelope of her caregivers, and creates a healing constructive opportunity to prevent a repeat occurrence.” (“May I have the envelope please.” Journal of Patient Safety. 2008 Jun;4(2):119–123.)

Chuck properly warns us that it is easy to “automatically fall in a name-blame-shame cycle, citing violated policies, and ignore the laws of human performance and our responsibility as leaders.” It is up to us as leaders to be mindful of the results of such behavior on our part. The bad example we set cascades through the organizations. Mistakes and near-misses go underground, as people fear that reporting will just get them into trouble. Opportunities to improve our systems are lost, along with the potential for personal and professional growth on the part of our staff.

In contrast, behaving like Wiles, Botts, or Ives-Erickson empowers those working with us. People evolve individually and collectively into a learning organization. Each person feels that he or she is valued, understands his or her place in the firm, and goes home able to say, “I accomplished something worthwhile today.”

Gene cites John: Makes great sense!

For some of us, one thing that makes Friday a great day is receiving Gene Lindsey's weekly email.  It's full of observations about the health care world, living in the woods of New Hampshire, and baseball--not to mention nostalgic visits to his childhood. (You can read previous editions here.)

Gene is a die-hard adherent of Lean, a process improvement and managerial philosophy that has both been used to great effect in the hospital world and has been an utter failure in the hospital world.  I am pleased that my hospital's experience fell into the former camp. In this week's edition, Gene reviews John Toussaint's latest book Management on the Mend, where he excerpts useful thoughts offered by one of the most successful employers of Lean.

Why has Lean succeeded in some places and failed in others? Gene summarizes the key lesson from the book:

"I think there is great evidence that John has walked the talk. Indeed the necessity that leaders be personally transformed if organizational transformation is to occur is a recurrent theme in the book which is really an open letter to healthcare leadership and their boards with the express purpose of convincing them that leadership is critical to Lean success. He introduces this idea on page three!

"The most common problem that I see [discussing the more than 145 organizations that he has personally visited that are in various stages of understanding Lean] is that leaders fail to recognize the magnitude of change that will be required and that change extends to leaders on a personal level."

I wrote back to Gene:

I went through it by osmosis, I guess, but as I look back on it later, I see a major maturation that took place in my leadership approach. 

Indeed, it was not until after I left my CEO post at BIDMC that I realized the extent of my own transformation and that I had adopted the mantra, "Lead as though you have no authority." Mark Graban interprets this:  "This doesn’t mean completely giving away your authority… it means not relying on that formal authority."  Or as W. Edwards Deming put it: "The leader is coach and counsel, not a judge."

As I meet with hospital clinical and administration leaders, I can quickly see which ones have reached this level of comfort in learning that their job is to work for the staff--not vice versa. And I can draw a quick correlation between their progress in doing so and the degree to which their institutions have become learning organizations.

If you are in a leadership position in a health care system, read John's book.  Then, lead or not.

Whole systems approach to product design at MIT SDM

A Whole Systems Approach to Product Design and Development

 

2015 MIT SDM Conference on Systems Thinking for Contemporary Challenges

October 7, 2015 at Wong Auditorium, MIT

Neal Yanofsky, Chairman, Cheddar's Scratch Kitchen; Board Member and Senior Advisor, Snap Kitchen                                               

Keynote — Can Managers Contribute to Design that Creates Competitive Advantage?

Everyone loves outstanding design, but how can it be used as a business tool that provides more than fleeting benefits? And how can left-brained managers effectively support and develop the work of right-brained designers?

In this keynote address, Neal Yanofsky will explore the benefits and challenges of elevating design to a strategic tool.

Additional speakers include: Todd P. Coleman, PhD; Steven D. Eppinger, ScD; Pat Hale; Matt Harper; Matthew S. Kressy; Shaun Modi; Joan S. Rubin; and Maria C. Yang, PhD.

We invite you to join us! Register today.

About the Conference

The annual MIT Conference on Systems Thinking for Contemporary Challenges, sponsored by the System Design & Management program, provides practical information from multiple disciplines for using systems thinking to address complex challenges, whether in industry, academia, government, or the world at large. All are welcome to attend.

SEIU goes to the ballot to change hospital rates

Somewhat new to the issue, the SEIU has decided that it is unfair for non-Partners hospitals to get paid less than those affiliated with Partners Healthcare System. Priyanka Dayal McKluskey reports in the Boston Globe that the union "is pushing a ballot initiative that would divert millions of dollars from Partners HealthCare to lower-paid competitors in an effort to boost community hospitals and preserve union jobs."

My readers know that I am sympathetic to the cause of equalizing insurance payments to the hospitals and physicians in the state.  Now, they are set mainly on the basis of market power, something contrary to the public good. Some of us have been talking about this issue for over a decade.

But why is the union more recently interested in the topic?

My hypothesis is that they finally realized that the stated business strategy of Steward Health Care System to be the low-cost provider competing with Partners just doesn't hold water.  Steward has shown no ability to attract patients from the bigger system. The only thing that "lower costs"--read "lower rates"--has gotten the system is lower revenues and poorer earnings.

Years ago, the Steward CEO got the support of the SEIU when the Caritas Christi system was to be sold to Cerberus. Remember this story?

To steer the deal through, he orchestrated an unlikely alliance of the Boston Archdiocese, Democratic elected officials, the Service Employees International Union (SEIU), and community organizers in some of the state’s poorest cities – all to support turning the struggling nonprofit hospital chain into a for-profit operation owned by a group of high-flying financiers. In what may well be an example of the way de la Torre is always playing chess four moves ahead, the crucial SEIU support was an outgrowth of a nearly unprecedented overture he had made two years earlier, shortly after he joined Caritas, to invite the union to come into the hospitals and try to organize his workers.

Well, the deal starts to look vacuous if the hospital system can't earn enough money to cover those union contracts.

Can it be that the SEIU is actually a stalking horse for Steward on this proposed legislation?

The campaign seems to have started in earnest in 2013. Robert Weisman at the Globe reported on May 13, 2013: 

An unusual alliance led by the state’s fastest-growing health care company and its largest health care union will press for higher payments to community and safety net hospitals, saying Massachusetts faces a widening gulf between the quality of care in affluent and low-income areas.

The group, the Massachusetts Healthcare Equality and Affordability League, is being launched Thursday by Steward Health Care System, a for-profit cluster of community hospitals, and Local 1199 of the Service Employees International Union, which represents about 47,000 workers in the state.

The follow-up was reported on March 14, 2014, by Rachel Zimmerman on Commonhealth: 

A report released today by the Healthcare Equality and Affordability League (H.E.A.L.) — a partnership between the for-profit Steward Health Care System and the union, 1199 SEIU United Healthcare Workers East — finds that disparities in hospital costs and financing across the state are driving “a vicious cycle” of inequality in health care.

It's hard to be sympathetic to the financial concerns of a union that spent millions of dollars on a corporate campaign to disparage my former hospital.  (More on that story here.)

It's also hard to find sympathy for a union that, even in 2014, supported the gubernatorial candidacy of the former Attorney General who affirmatively acted to enhance Partner's market power.

And it's hard to be sympathetic to a hospital system owned by a private equity firm.

But the issue raised in the ballot proposition is a real one, and one that was aggravated--not reduced--by state legislation in 2012.

Referenda, as noted by the state hospital association's executive vice president in McCluskey's story, are not the best way to resolve complicated policy issues.  Instead, it's time for the legislature to revisit the matter.

When you have a hammer

Christopher Weyant in The New Yorker, June 8-15, 2015

It's well past time to talk about the elephant in the room when it comes to robotic surgery: The increased anaesthesia-related risks from these procedures.  The question I ask today is whether, as part of the informed consent process, patients are given information about such risks.  Under principles of shared decision-making between the doctor and the patient, such risks should be carefully explained well before the short stay at the pre-op area.

I've found little in the recent literature about this topic, although--based on my small sample of anaesthesiologists--it is a significant concern among their profession.  The concern most often expressed has to do with the extended length of procedures conducted robotically compared to traditional laparoscopic procedures or open procedures.  While anaesthesiologists are very good at handling long cases--and even unexpectedly long cases--they will generally tell you that, everything else being equal, the less time spent under anaesthesia the better.

The articles I have found about anaesthesia risk interestingly do not cover the extended time in the operating room.  This study from Henry Ford back in 2007, for example, focused on difficult airways and the like.

The length of robotic procedures results from two factors--the time it takes to accomplish pre-surgical "docking" of the machine and the time actually spent to conduct the procedure.  In the living donor liver resection case I discussed in a previous blog post, I noted:

Of particular note, the authors acknowledge that "the length of surgery was longer than that normally required for open right donor hepatectomy," but then state that "it must be considered that the complicated venous anatomy prolonged the total operating time." I can't evaluate the latter clause, but my understanding from experts in the field is that the 8-hour duration of this case was considerably longer than a standard open donor hepatectomy, which is usually 5 to 6 hours.

A colleague noted in a recent recent case that five hours had been budgeted in the operating room for a robotically assisted hysterectomy and uterine fibroid removal, well longer than would have been required for a manual approach.  Fully two hours of that time was budgeted for docking of the robot to align it and its instruments with the patient's body.

In another case, an esophogeal cancer resection in the early days of robotic surgery, the patient was under anaesthesia for 12 hours because of complications due to the use of robotic technique.

There seems to be a reluctance in the surgical profession to even acknowledge these more lengthy procedures.  Note the liver case above, where the surgeon's article--without support--ascribed the length to "complicated venous anatomy."  In the esophogeal cancer case, when the case was brought to departmental M&M's for review, no one in the room dared speak up about the wisdom of proceeding with robotic assistance because the surgeon in question was a favorite of the chief of the department and because the institution in question had invested heavily in being a national leader in robotic surgery.

Beyond the time concerns, there are other anaesthesia risks. One example comes from an early case involving a thyroid removal. As part of the consent process, a highly experienced anaesthesia attending informed the patient that in traditional thyroidectomies, he would normally be sitting at the head of the table during such a procedure. He noted that the instruments being used in a robotic thyroid removal had the increased potential to cause a unilateral or bilateral pneumothorax. Use of the robot would require him to be six feet away, making it challenging to detect such a complication as quickly, and he might thus respond more slowly to it.

This article mentions this kind of risk as well as others:

The endotracheal tube should be taped securely, appreciating that patient positioning may alter tube placement over time (unintended extubation or mainstem intubation), robotic instrumentation may dislodge a tube, and an obstructed view may delay recognition of a tube that has become dislodged. Replacing an endotracheal tube would be challenging for robotic surgery patients based on positioning and the time delay associated with undocking.
 
Others appear to be less concerned. A similar type of risk was noted in this 2009 article. but then it was quickly dismissed:

Finally, the bulk of the robot is positioned over the abdomen and chest. Although the incidence of airway or serious cardiovascular events are no greater in robot-assisted surgery, if they do occur, the position of the robot will interfere with effective cardiopulmonary resuscitation and airway interventions. The theatre team should practise and be familiar with an emergency drill for the removal of the robotic cart. With practise, at our institution, this drill has enabled us to be able to consistently remove the robot within 30 s. It is possible to deliver a DC shock with the robot docked in position if required.

In the thyroid surgery case, the patient inquired about the matter to the surgeon, who was very upset that the anaesthesiologist would convey these additional risks to "his patient." The anaesthesiologist was never asked to attend on another robotic procedure with that surgeon.

My concern today is not risk per se, as all surgery involves a balancing of benefits and risks. The question I ask is whether hospitals have properly incorporated the full spectrum of risks into their informed consent and shared decision-making processes. I also have a concern that anaesthesiologists, because of professional risk and institutional commercial priorities, will not feel empowered to point out such risks to patients under their care.

The medical arms race made visible

With thanks to Priyanka Dayal McCluskey at the Boston Globe, we can get a glimpse of one "small" part of the medical arms race in action.  The story is about the expansion of Mevion Medical Systems Inc., a manufacturer of proton beam machines.  The company offers the "more affordable price tag of about $25 million" per machine, compared to the first generation $250 million models.

Here's the arms race quote:

Three Mevion systems are treating patients at hospitals in St. Louis, Jacksonville, Fla., and New Brunswick, N.J. Four others are being installed. The company is developing about 20 other orders. 

Here's the relevant context:

“In a perfect world, if the capital costs were the same, proton therapy is something you’d want all patients to receive,” [MGH's Jay] Loeffler said, “but because of the capital costs, it has to be limited in use to only the situations we believe it’s best for.” This includes tumors in children and tumors in adults that are in or near critical body parts like the brain or eyes.

Some hospitals use proton therapy to treat prostate cancer — even when there is no scientific evidence it’s a more effective treatment than traditional radiation, said Dr. Durado Brooks, director of cancer control intervention for the American Cancer Society.

“Because it’s newer doesn’t necessarily mean it’s better’’ for prostate cancer, he said. “At this point we just don’t know.” 

Here's an endorsement about the science behind the machine presented on the company's website:

What is American Shared Hospital Services?

American Shared Hospital Services is a publicly traded healthcare company (New York Stock Exchange AMEX symbol AMS) with a 25-year track record of leasing state-of-the-art medical equipment to hospitals and medical centers in the United States.

Through GK Financing, LLC (GKF), our majority owned subsidiary, we are the leader in Gamma Knife unit ownership with approximately a 16% market share in the United States. Our Gamma Knife model has been expanded to incorporate the financing of other technology solutions including Intensity Modulated Radiation Therapy (IMRT), Image-Guided Radiation Therapy (IGRT) and Proton Beam Radiation Therapy (PBRT).

In the corporate history, we note these items:

2006: We enter the proton beam radiation therapy (PBRT) market by acquiring an equity interest in Still River Systems, Inc., developer of the Monarch 250, a practical, cost-efficient, single room PBRT system. In turn, we are able to contract with Tufts Medical Center in Boston, MA. for a complete radiation therapy department upgrade that includes an IMRT/IGRT as well as a single-room PBRT system. 

We contract with Orlando Regional Healthcare M.D. Anderson Cancer Center in Orlando, FL on our second single-room PBRT facility. 

2007: We increase our equity interest in Still River Systems, Inc.

2008: We agree to provide Todd Cancer Institute at Long Beach Memorial Hospital, in Long Beach, CA with a single-room PBRT facility – our third to date. 

2009: We sign a letter of intent with the Todd Cancer Institute at Long Beach Memorial Hospital, in Long Beach, CA for a single-room PBRT facility – our third to date. 

I know you'll join me in being glad that ASHS has no vested interest in this product and is highly qualified to present a scientific opinion!

Let's recap. "We just don't know" if it's better, but Mevlon has sold or will sell 27 installations at $25 million, or $675 million.  Oh, aided and abetted by a Medicare pricing regime that provides higher rates for use of the machine.  The company notes:

Treatment sites where proton therapy is used:

Pediatric Tumors
Head and Neck
Brain
Eye
Prostate
Lung
Breast
Gastrointestinal
Gynecologic
Genitourinary
Sarcoma
Lymphoma 

The board has to be on board

Those of us who have run hospitals where we've been serious about achieving improvements in quality and safety know that without a highly committed board of trustees, the results will never be sustainable. And so it is lovely to see documention of that premise in a new article by Thomas C. Tsai, Ashish K. Jha, Atul A. Gawande, Robert S. Huckman, Nicholas Bloom, and Raffaella Sadun in Health Affairs. I reprint the abstract:

National policies to improve health care quality have largely focused on clinical provider outcomes and, more recently, payment reform. Yet the association between hospital leadership and quality, although crucial to driving quality improvement, has not been explored in depth. We collected data from surveys of nationally representative groups of hospitals in the United States and England to examine the relationships among hospital boards, management practices of front-line managers, and the quality of care delivered.

First, we found that hospitals with more effective management practices provided higher-quality care. Second, higher-rated hospital boards had superior performance by hospital management staff. Finally, we identified two signatures of high-performing hospital boards and management practice. Hospitals with boards that paid greater attention to clinical quality had management that better monitored quality performance.

Similarly, we found that hospitals with boards that used clinical quality metrics more effectively had higher performance by hospital management staff on target setting and operations. These findings help increase understanding of the dynamics among boards, front-line management, and quality of care and could provide new targets for improving care delivery.

Where would you rather serve?

Which is more hierarchical, the military or health care?

A medical student who had served as a corpsman in the military attended our Telluride Patient Safety session last week.  She noted her experience while on clinical rotations:

I thought that when I got into medical school that I would be in a safe place to learn. . . and it wasn't. 

I couldn't believe that I was now in a system where I couldn't speak up.

As a medical student, I feel like my concerns are disregarded. Coming from the military, where every concern is heard, it's critical.

On checklists

This article by Emily Anthes about checklists in Nature notes:

Poor use of checklists means that people may be dying unnecessarily. A cadre of researchers is . . . finding a variety of factors that can influence a checklist's success or failure, ranging from the attitudes of staff to the ways that administrators introduce the tool. The research is part of the growing field of implementation science, which examines why some innovations that work wonderfully in experimental trials tend to fall flat in the real world. The results could help to improve the introduction of other evidence-based programmes, in medicine and beyond.

Totally predictable, as Captain Sullenberger noted over four years ago:

A checklist alone is not sufficient. What makes it effective are the attitude, behavior and teamwork that go along with the use of it.

Silent sovereigns of the forest

In Travels with Charley, John Steinbeck portrays the physical and emotional grandeur of the great West Coast trees:

The redwoods, once seen, leave a mark or create a vision that stays with you always.  No one has ever successfully painted or photographed a redwood tree. The feeling they produce is not transferable. From them comes silence and awe. It's not only their unbelievable stature, nor the color which seems to shift and vary under your eyes, no, they are not like any trees we know, they are ambassadors from another time. They have the mystery of ferns that disappeared a million years ago into the coal of the carboniferous era. They carry their own light and shade. The vainest, most slap-happy and irreverant of man, in the presence of redwoods, goes under a spell of wonder and respect. Respect--that's the word. One feels the need to bow to unquestioned sovereigns.

And it persists even after their death. In a welcome break from hours of discussion about patient harm and clinical process improvement, our Telluride scholars made a visit to the Petrified Forest in Calistoga. There we saw massive trees that had been blown over by the St. Helena volcanic eruption 3.4 million years ago. Two-thousand-year-old trees were felled in an instant, then slowly petrified in the resulting ash.

Branch holes remained where limbs had been torn away by the volcano's force.

Rock-hard age rings, likewise, show the years of growth.

Even in their petrified form, these 300-foot trunks held us in awe. Steinbeck says:

There's a remote and cloistered feeling here. One holds back speech for fear of disturbing something--what? Can it be that we do not love to be reminded that we are very young and callow in a world that was old when we came into it? And could there be a strong resistance to the certainty that a living world will continue its stately way when we no longer inhabit it?