Do everything right!

A funny comment and a serious one.

I went up to one of the floors of our hospital one night this past weekend to visit a patient. As I walked past the nurses' station, one of the nurses recognized me and jokingly called out to her colleagues and the interns, "Look who's here! Do everything right!"

We all had a good laugh.

The serious one is offered by IHI's Jim Conway on the post below, "Our systems are too complex to expect merely extraordinary people to perform perfectly 100% of the time. We as leaders must put in place systems that support great practice by people who suffer from being human and will make mistakes.” Health care takes great people AND great systems. No matter how good you are as a healthcare professional you will make mistakes. We must have systems that catch your “humanness” before it gets to patients and causes harm.

Do patients want to punish?

There is a great debate set forth in the IHI's Open School discussion of the wrong-side surgery case that occurred at our hospital a few years ago. (I have written about this below, but there are some new postings.)

Kimberlee Ziga writes: I, as an RN working in an ICU, have also made mistakes. Thank God they have not been life threatening but nonetheless, they were mistakes. I was educated thoroughly and proven to be competent with testing. When I made that mistake, I was written up. I totally understood why. I am a licensed professional who is competent at her job, and that calls for accountability and responsibility. I believe all the medical staff involved should have been held accountable and disciplined accordingly. If that was my family member, I would have been irate for what they had to go through.

In contrast, Jessie Moon says: Paul Levy . . . made it out like it was a serious situation, but one that could happen to any surgery team. He* did not punish any one person, but instead he took care of the situation by asking, "how can we lower the chances of this ever happening again", which makes the person and the family that this happened to feel better (or so I would assume), the public, as well as the workers in this hospital.

There are two parts to this question. What is the most effective way to reduce the likelihood of a similar event happening in the future? I have addressed this topic fully below. At heart, the answer goes to the definition of the "just culture" that has been adopted by a hospital.

But let's talk about the second one: What makes the patient and family feel better in a situation like this?

The literature on the topic of disclosure and apology suggests that patients and families are not interested in having the doctor or nurse be punished when a medical error occurs, if (and this is an important if), the clinician makes clear that he or she is clearly regretful about the error, is empathetic with the patient, and if the clinician and hospital show that they plan to learn from the error to help avoid repeats with other patients.

We can speculate on why this is the case. I heard IHI's Jim Conway discuss this once, and I think he had it right. Jim said that patients want to trust their doctors and nurses. That trust is enhanced when a clinician makes a clear and honest admission of an error and shows that s/he cares about the additional pain and suffering imposed on the patient.

However, the patient also wants to know that something has been learned from the experience. S/he wants an assurance that his or her pain is not in vain, that other patients will be less likely to suffer similar harm. This tendency comes from the inherent goodness in most people. We do not mind making personal sacrifices if other people are helped and a greater good emerges.

But, an additional step adds even greater value. As noted by Tom Delbanco and Sigall Bell:

Perhaps most important, building bridges to injured patients necessitates including them and other patients in the development of solutions. Patients and families will bring ideas to the table that expand the horizons of health care professionals. The yield from working in partnership could be enormous, both improving people's experience with medical error and preventing harm from occurring in the future.

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* A slight correction for Jessie: The decision about punishing a member of the medical staff for clinical errors generally lies with the Chief of Service and with the hospital's Medical Executive Committee, not with the CEO. But I certainly concurred in this case.

What makes this work?

I was on an airplane recently and came across this signage in the rest room. Of course, most of us would recognize that it signals the existence of a fold-down table for changing babies.

But I had one of those moments where I looked at the components of the pictogram and wondered why it worked. There are two detached circles. There is a wide horizontal line. There is a squiggle that looks like a broad "u" with a serif on its top left. And then there is this odd assortment of combined shapes: A vertical post, a trapezoid attached at an angle to a rectangle, a short vertical post, and another post at an angle.

How do we know this odd assortment is a woman? Would this be understood in a culture where women only wear floor length dresses?

Likewise, how do we know the squiggle and the circle are a baby?

How do the detached circles persuade us that they are part of people? Why don't we think both people have been decapitated?

I am hoping there are people out there who can explain why this works, both visually and culturally. Please comment.

Who's got attitude?

Two former teammates confer before Saturday night's Red Sox versus White Sox game in Fenway Park. Meanwhile, some young fans who have loyally followed Manny through his peregrinations show off shirts from the blue (i.e., Dodgers) period.

Space + time + energy + form = dance

Regular readers have noticed that my weekend postings offer stray far and wide from hospital and medical matters. For those who enjoy this, I am pleased.

Today's is in that category. My wife and I are fortunate to have two talented daughters, who have managed to teach us lots of things. This weekend, I got a lesson in choreography from Rebecca.

If you are like me, you enjoy dance concerts but don't really have much of an idea of what is going on it. You watch and see wonderful and creative movement and patterns on the stage and mainly wonder how those (mostly young) people can physically do what they do. But there is another participant, the choreographer, who puts together elements of space, time, energy, and form.

Rebecca now teaches this art to others, and one exercise she does to get across the concept of using the space on the stage is to assign the students to design a dance solely with walking, running, and standing still. In others words, no acrobatic movements, lifts, or the like are permitted. Students are often flummoxed by this at first, but then they get the concept.

The ultimate example of such a dance is Paul Taylor's Esplanade. He created the dance through movement pathways -- form and spatial direction -- without the traditional phrasing you have come to expect in a performance. I include the video here.

If you can't see the video, click here.

Will it survive Hurricane Earl?

I have received many requests for progress reports about our rogue tomato plant. Here's the latest view, as a major storm approaches.

Tom gives a Reason to Ride

Tom DesFosses is a grateful cancer survivor who has organized a biking event to raise funds for cancer research. It will be held on September 12, in Danvers, MA. See here for scenes from last year's ride.

You can register now, here.

Here's Tom making a pitch for the ride. If you can't see the video, click here.