Sunday, November 14, 2010

Teamwork Improves Surgical Safety and Reduces Mortality

Like the cockpit, the operating room (OR) is fraught with high intensity, high complexity, high velocity, and high stakes. And as a capital intense location which serves as the financial engine of many or not most hospitals, there is pressure to use the OR efficiently. Like the cockpit, there is hierarchy, and a deep culture which includes strongly held rituals and customs. Unfortunately, there are also errors of omission and commission which lead to adverse outcomes including patient mortality.

Airlines have proven that teamwork in the cockpit improves safety substantially to the extent that commercial airlines demand and licensing now requires evidence of team competency.

Some hospitals have used the airline team training model – called crew resource management – to improve teamwork in the OR. The Veterans Health Administration (VHA) has 130 hospitals providing surgery and in 2006 mandated team training nationwide. Since it took time to arrange the training for each hospital, a study was instituted to compare surgical mortality between those hospitals which had already undergone training and those which had yet to do so (Journal of the American Medical Association, Oct 20, 2010 – both the article and accompanying editorial.)

The mandatory team training included working as a team, challenging each other as to perceived risks or safety lapses, checklist guidance, and preoperative briefing and post operative debriefing. Team members were also taught various communication strategies, how to step back and reassess, how to communicate during care transitions and basic rules of conduct.

The major measure was surgical mortality which was reduced by 18% in the 74 hospitals that had received the training compared to a 7% reduction in the 34 hospitals yet untrained (the controls.) The risk-adjusted mortality rates dropped from 17 per 1000 patients before training to 14 after training.

The study demonstrated the value of team training in reducing mortality. I would add that, although not studied, it is likely that errors were reduced overall. Surgical teams are often excellent at responding to problems including those resultant from human error. Reducing mortality was obviously important, indeed very important, but reducing preventable errors overall – as I will presume occurred – will have meant a better outcome for many patients.

The concept of team training is relevant not just in the OR but in many hospital settings such as bedside patient care rounds and with procedures done in the cardiac As I have written about before, the more team training is fostered, and indeed mandated, the lower will be the rate of preventable errors.

Wednesday, November 10, 2010

Leadership In Medicine – New Expectations

What should we expect of a physician leader today? I believe it should be something much different than what leaders do now.

Today, a hospital physician CEO might be expected to develop new or improved clinical programs, in part by recruiting the best and the brightest, by building new wings, and by purchasing new technologies. The measure of success would be improved finances as a result of added admissions. A dean might be expected to develop new research programs by building new facilities and recruiting the needed scientists. The success measure would be rising on the NIH rankings of total research dollars awarded. A pharmaceutical company physician leader might be expected to find new drugs that will be “blockbusters.” His measure of success will undoubtedly be financial as well. A similar picture extends to the CEO of a health insurer.

Are these the right measures? Are our medical leaders really leading? Or at least leading toward truly valuable goals?

Leadership is all about success in three sequential activities, as outlined by John Kotter at the Harvard Business School. The first is generating a vision for what needs to be done. Perhaps it will be the clinical program, new research activities or a new drug. The second step in leadership is to convince others that the goal is worthy. Aligning everyone involved with the desired outcome can be difficult but without alignment there will be no action. And the third, often overlooked, is to get the needed individuals to actually help to achieve the goal, the vision. These are difficult steps, especially in or university setting where lines of authority are diffuse and responsibilities overlapping or in a community hospital where the physicians are mostly in private practice and not hospital employees.

But the question is what should be the vision and what should be the measure of success in achieving that vision?

An article in the Journal of the American Medical Association by Dr Robert Brook [July 28, 2010, pages 465-6] got me to thinking about this issue.

We know that despite spending more per capita on medical care, we still have far from the best care. We do not lead in infant mortality or total life expectancy. We do poorly at coordinating the care of those with chronic illnesses, such as diabetes and heart failure, and the result is less than adequate care and care that is much more expensive than it needs to be. As a society, we have rampant adverse behaviors such as overeating and lack of exercise plus many of us still smoke, all leading to more chronic illnesses, increasingly occurring at an earlier age.

I would suggest, echoing Dr Brook, that real medical leadership today needs to focus on the important outcomes, not the ones that just improve our organization’s financial successes [not withstanding that strong finances are critical in order to accomplish a valuable end – “No money, no mission.”] This means that medical leaders must begin to accept the responsibility for aligning the various constituencies and power brokers both within and without of medicine toward real healthcare progress. Unless medical leaders accept this challenge, it will increasingly be done by others, and done without serious input from physicians and others in the field.

What then are the important issues and outcomes?

I would suggest that we must find a way to first markedly improve prevention of illness. Within medical care itself, this means assuring that primary care physicians are trained and have the incentives to do basic screening, administer vaccines, and give sound advice. It means actually advising about diet and exercise for the person with high cholesterol, not just giving out a routine prescription for a statin. And medical leaders need to take the initiative to change government policy regarding food and nutrition. For example, it makes little sense that the beef with the most saturated fat is marked “prime” by government inspectors or that food processors can label a cereal “healthy” because they have added some vitamins to what is manufactured from non whole grains plus sugar and salt.

Second is to develop methods to assure that every patient who has a chronic illness gets intensive care coordination among all of the providers involved. This means the development of multi-disciplinary teams of physicians, nurses, pharmacists and others who actually work collaboratively and with the patient’s interest foremost. There can be various models but among them is the creation of “centers” (cancer centers, heart centers, trauma centers) at academic medical centers and at community hospitals, developed with real authority to function effectively. Another is to use bundled payments or “capitation” to reward coordination. And most importantly is to have one physician, usually the primary care physician, serve as the coordinator – the orchestrator.

Third, medical leaders need to address the need for care delivery to be customer focused with the recognition that the customer is the patient and the patient’s family. Too often we develop programs or actions that continue the current provider-oriented approach rather than a patient/customer-oriented approach. If medical leaders do not address this now, a rising tide of consumerism will force the issue later. Eventually, patients will hold the physician directly accountable and will expect to pay only if the care is patient-focused.

Having addressed these basics, medical leaders then need to turn to the more global health issues, health not only of the individuals under their care or their institutions’ care but the care of the community, the population at large. This is critical if all Americans are to have a healthy life regardless of social or economic status.

To accomplish this will mean that hospital, insurance company and pharmaceutical company boards of directors and university boards of regents will need to give out new, different and clarified directions to their CEOs, presidents and deans, holding them accountable with new measures that reflect realistic progress toward these goals. Otherwise, although there will be various medical breakthroughs of great value for treating disease, American medicine will continue to stumble along, as it has, without making any real progress in what is truly important.

Praise for Dr Schimpff

The craft of science writing requires skills that are arguably the most underestimated and misunderstood in the media world. Dumbing down all too often gets mistaken for clarity. Showmanship frequently masks a poor presentation of scientific issues. Factoids are paraded in lieu of ideas. Answers are marketed at the expense of searching questions. By contrast, Steve Schimpff provides a fine combination of enlightenment and reading satisfaction. As a medical scientist he brings his readers encyclopedic knowledge of his subject. As a teacher and as a medical ambassador to other disciplines he's learned how to explain medical breakthroughs without unnecessary jargon. As an advisor to policymakers he's acquired the knack of cutting directly to the practical effects, showing how advances in medical science affect the big lifestyle and economic questions that concern us all. But Schimpff's greatest strength as a writer is that he's a physician through and through, caring above all for the person. His engaging conversational style, insights and fascinating treasury of cutting-edge information leave both lay readers and medical professionals turning his pages. In his hands the impact of new medical technologies and discoveries becomes an engrossing story about what lies ahead for us in the 21st century: as healthy people, as patients of all ages, as children, as parents, as taxpayers, as both consumers and providers of health services. There can be few greater stories than the adventure of what awaits our minds, bodies, budgets, lifespans and societies as new technologies change our world. Schimpff tells it with passion, vision, sweep, intelligence and an urgency that none of us can ignore.

-- N.J. Slabbert, science writer, co-author of Innovation, The Key to Prosperity: Technology & America's Role in the 21st Century Global Economy (with Aris Melissaratos, director of technology enterprise at the John Hopkins University).