Archivi del mese: marzo 2012

ISQuA e il dibattito sull’efficacia dell’accreditamento

L’ISQuA (International Society of Quality in Healthcare) ha lanciato un dibattito su: “There really is no evidence that accreditation has improved the quality of care provided in hospitals or patient safety; in fact, the number of adverse events is increasing.”

Un moderatore e quattro interventi iniziali, due a favore e due contro, sulla “mozione”.

Il 67% dei partecipanti al dibattito non crede nella mozione: ritiene cioè che l’accreditamento sia efficace.

Appartengo a questo 67%!

Quali sono le chiavi del successo usando il metodo “lean”?

CEO CONSIDERATIONSWhat Are a CEO’s Keys to Success with “Lean”?
Properly executed as a core of a complete business strategy, “Deep Lean” can produce a trifecta for a healthcare organization — dramatically improving quality, financial results and satisfaction among both patients and staff.  However, most hospital lean implementations fall far short of what is possible, and some implementations ignore fundamental people values necessary for success. This issue of CEO Considerations — reissued by request — helps health care CEO’s zero in on the key things they need to know and do to succeed with a performance transformation based on so-called “lean” principles.
 A CEO’s Keys to Success With “Lean”1. Frame it in your mind as a whole-organization leadership system, not a set of quality-improvement projects and tools.

2. Be eager to “lead the learning.”  HealthEast CEO and former ThedaCare President Kathryn Correia says “How can I lead what I don’t know?” Being in front of the learning lets you be more confident about what to do next, and also models the core behavior you need from everyone.

3. Define the measures of success (quality/safety, cost and lead time / throughput) and maintain the focus on customers and business value on all those dimensions.  Lean correctly focuses on radically improving the processes that produce the results, but the leader has to make sure people are paying attention to the results, through regular checks, reviews and consultations.

4.  Go to “Gemba” (Shop Floor) say the Japanese — where the work is actually done.  Lean will help you focus the whole institution on where the value is actually produced in the organization, the front line, but only if you consistently model getting there and seeing, asking, listening, learning and coaching.

5. Focus on maintaining a safe environment — emotional, professional and physical.  Lean forces a lot of problems into the open that normally just “flow on by.”  Each layer of management below you will be very threatened if you are not actively generating positive energy around the problems “surfacing” and modeling the energetic engagement with Lean principles to get the problems solved, permanently.

6. Own it.  Obviously, there is a lot of “doing” that others will lead, but no staff person should have cause to think you have “delegated” Lean to anyone, including lean experts.  This is a critical mistake most hospital CEOs make.  Paul O’Neill, our chairman, says “show me a company that brags about its equal opportunity office, and I will show you a company without equal opportunity.”  The same is true for Lean — it needs to be “the way we are learning to run our business, starting with me.”

7.  Coach, encourage and support — especially your direct reports (all of them need to be deeply involved).   The feel in the executive suite should be of you putting your arm around each member of your team, saying “this is the way we are going.  It’s not going to be easy, but we’re going to get there together.  Now let’s have at it.”

8. Establish an incentive system.  Start with recognition (which always needs to be maintained) and add shared financial incentives once you can confidently base them on true value creation vs. gaming and sub-optimization.

9. Regular communication (of course), usually with a concrete teaching and support focus.  Show real work.  Tell what it’s teaching the people involved and what the organization can learn from it.

10. Constantly draw more people and areas into the doing.  Everyone in the organization needs to know it’s about them.

Una vita di qualità, fino all’ultimo

Martedì 13 Marzo 2012

In che modo ci si prende cura delle persone negli ultimi giorni di vita?

Lindqvist et al. hanno chiesto agli staff che assistono le persone negli ultimi giorni di vita di descrivere gli interventi non farmacologici. Nello studio sono stati coinvolti 16 gruppi impegnati nell’assistenza palliativa di persone malate terminali di cancro provenienti da 9 paesi, tra cui l’Italia.

I gruppi di lavoro hanno creato un elenco di 914 interventi (statements), che possono essere raggruppati in tre categorie:
• Assistenza all’individuo che comporta contatto con il corpo: molti interventi riguardavano la cura della bocca, la comodità della posizione; un argomento molto sentito anche la capacità di sapersi astenere dal “fare comunque qualcosa”,.
• Ascolto e dialogo, soprattutto con i familiari: “osare stare in silenzio con la persona in punto di morte”, “trovare un equilibrio tra il non nascondere informazioni e il creare un’atmosfera tranquilla“.
• Creazione di un ambiente gradevole e sicuro: molta attenzione a fornire stimoli sensoriali piacevoli, sia a casa sia in ospedale. Si va dalla musica alle foto di persone care, a un’illuminazione appropriata. In questa categoria sono stati inclusi anche interventi di cura della persona come dare lo smalto alle unghie, curare la capigliatura, fare la barba.

L’80% delle dichiarazioni sugli interventi proveniva da personale infermieristico, il 15% da personale medico e il 5% da altre figure professionali.

Lo studio è stato condotto nell’ambito del progetto europeo OPCARE9, nato con l’obiettivo di ottimizzare l’assistenza delle persone malate di cancro negli ultimi giorni di vita. L’assistenza nelle ultime fasi dell’esistenza può essere molto migliorata: l’Italia infatti appartiene a un gruppo di paesi ricchi molto lontani dalle prime posizioni, in una classifica stilata nel rapporto The quality of death. Ranking end-of-life care across the world sulla qualità della morte. E invece prendersi cura di una persona comporta anche fare in modo che gli ultimi giorni siano vissuti nel modo migliore possibile.

The PLoS Medicine Editors (2012). Beyond the numbers: Describing care at the end of life. PLoS Med 9(2): e1001181. doi:10.1371/journal.pmed.1001181
Lindqvist O, Tichelman C, Lundh Hagelin C, Clark JB, Daud ML, et al. (2012) Complexity in non-pharmacological caregiving activities at the end of life: An international qualitative study. PLoS Med 9(2): e1001173.

Per approfondire:
Waller S, Finn H (2011) Environments for care at end of life. London: The King’s Fund.

@FLAHAULT: Alcuni dati utili per gli HPH

Tre tweet interessanti di Antoine Flahaut, Directeur de l’Ecole des hautes études en santé publique francese.

In inglese!

Culture and Health. The NL has the highest rate (41%) of physical activity in adults among European countries: bike is a cultural habit in the NL!

France has 7th lowest rate of obesity in EU. Its tasty cuisine is the fatiest. But we keep our 3 meals per day and nothing in between habit!

Sweden has 4 times less lung cancers than EU countries. Only 17% of the population is smoking, thanks to their cultural use of snus (12% of Swedish pop) !

Live & Learn












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Programma Nazionale Esiti dell’AGENAS: l’Azienda Ospedaliero-Universitaria di Udine

Operazione trasparenza da parte di AGENAS: anche in Italia si comincia a pubblicare i dati sulle performance degli ospedali. Lotta alle variazioni! La stampa generalista ha ancora un approccio da “pagella” che, quando le cose vanno bene, fa piacere! La sfida, però, è che i dati vengano usati per ridurre le variazioni e quindi migliorare la qualità dei servizi e gli standard di assistenza.

Live & Learn

Personal Behavior Pattern Observed: 

Major deliverable assigned.  Have several weeks advance notice.  Weeks click down.  Put off preparation. Then half-heartedly start framing work. Set it aside.  Get distracted.  Deliverable constantly looming, hanging, distracting, irritating and making me irritable.  Sleepless nights.  Clock ticking down.  Tell myself I’ll get to it during the weekend. (Right)  Weekend comes and goes.  Monday arrives.  1.5 days to go.  Scrambling now. Can feel heart pumping.  Grinding teeth. Anxiety screaming.  Finish.  Deliver request.  Passed without giving blood…yet internal organs are still rattling.  

Post Game Review: C+ (Gracious self assessment.) 

Behavior of Colleague Observed:

Preparation commences weeks in advance.  Back to back meetings scheduled.  Full team engaged.  Countless hours of preparation.  Brainstorming.  Discussions. Planning.  Drafts.  Work.  Re-work.  Ideas and issues are socialized with key constituents and decision makers attending meeting.  Project rehearsed.  Project presentation flawless.  No surprises.  Senior management feedback: Rally Hats On!  “Wow.”

Post Game…

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Provocatorio, ma utile per una riflessione critica.


Consider these charts that show possible dose-response relationships of medicines.  Also of poisons.  Why has no similar research been done on the effects of accreditation?  Does that fact that is imposed by legislation and marketplace coercion imply that testing will show no benefit?

The cartel would like you to believe that accreditation produces the effect shown in B.

I don’t think so.  Accreditation may improve a poor lab that would not thrive in a competitive market anyway.  For most, it impairs performance.  It would also impair profitability if it weren’t for the coercive aspect of accreditation being enforced by several mechanisms including legislation and misrepresentation. EQA scheme organisers have noticed a decline in labs’ performance when they become accredited.

Let’s see the research to prove which of the dose-response relationships applies to the record-keeping obsession.  Otherwise, let’s see the end of the inspection cartel that was founded as a home for redundant…

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Live & Learn

“A few months after I started practicing law in a large law firm, I learned that the other lawyers who started with me were paid $8,000 a year. I was paid $6,000 a year (with wife and 3 kids).  I learned I was paid less because the others went to Harvard, Michigan, Yale, etc, and I went to West Point and the University of Illinois for law school. I was deemed not as smart, less worthy, than my colleagues. Today, of course, young lawyers who learned of this disparate treatment would be crushed. My reaction? Use this as positive motivation to pursue a
new personal philosophy which I invented, that day,
which, since then , I have called: ‘win by winning.’ This means win by doing better, working harder, rather than by complaining that you have been ‘unfairly treated´ It worked.”
– Fred H. Bartlit, Jr.

“Fred Bartlit is a…

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L’Azienda Ospedaliero-Universitaria S. Maria della Misericordia di Udine rilancia la sua partecipazione alla rete regionale HPH del Friuli Venezia Giulia.

Nominato il nuovo coordinatore: Raffaele Zoratti, internista e endocrinologo. Un nuovo adepto, molto motivato e molto preparato che coordina anche un gruppo di lavoro multidisciplinare

Nominato il nuovo comitato HPH ospedaliero, presieduto da Giovanni Guarrera, direttore medico di presidio.

A sostegno di questo rilancio è stato programmato un corso di una giornata, in due edizioni consecutive il 28 e 29 marzo 2012, che sarà svolto da Paolo De Pieri.

Il programma è il seguente:

Principi e concetti a sostegno della promozione della salute


Il programma HPH

Iniziative concrete


Strumenti per lo sviluppo della promozione della salute in ospedale


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Ingaggiare i giovani medici nella leadership del sistema sanitario nazionale

Brown, Ahmed-Little e Stanton hanno pubblicato, sull’ultimo numero del Journal of the Royal Society of Medicine, un lavoro dal titolo “Why we cannot afford not to engage junior doctors in NHS leadership”.

Il titolo si rifà a una frase del Primo Ministro Cameron (peraltro piuttosto contestato in questo momento per la sua proposta di riforma sanitaria): “It’s not that we can’t afford to modernize; it’s that we can’t afford not to modernize”.

Anche se oggi, pure in Italia, le preoccupazioni più urgenti riguardano la sostenibilità economica del sistema sanitario, la vera sfida che abbiamo davanti è la necessità di aumentare il valore dell’assistenza sanitaria: mantenere e migliorare la qualità, controllando i costi. Per questo obiettivo l’impegno dei clinici è essenziale! Ma è essenziale, soprattutto, ingaggiare i giovani medici.

Sir Bruce Keogh, nel 2009, ha affermato : i giovani medici che lavorano sulle 24 ore a stretto contatto con i pazienti, insieme con gli altri professionisti sanitari, hanno la capacità di comprendere a fondo come le cose funzionano veramente, dove stanno le frustrazioni e le inefficienze, dove si annidano i rischi per la sicurezza e come si può migliorare la qualità dell’assistenza clinica .

Gli Autori analizzano i motivi del disimpegno dei giovani medici. Da una parte, osservano che la “managerializzazione” della medicina ha demoralizzato i medici, li ha disincentivati ad impegnarsi nel management dell’assistenza sanitaria e ha creato uno spartiacque tra clinici e manager. Sembra di sentire qualcuno in casa nostra! Dall’altra ritengono che i carichi di lavoro, il basso morale e la mancanza di senso dell’istituzione siano di ostacolo al loro ingaggio.

Segue poi un’interessante analisi dei programmi inglesi per lo sviluppo della leadership clinica, fondati sulla formazione, sullo sviluppo e il supporto, sulla strutturazione delle carriere, su appropriati incentivi e sui sistemi informativi.

La conclusione è che ingaggiare i giovani medici nella leadership clinica è obbligatorio!

Non farlo, sarebbe come tentare di migliorare lo sport dello sci cambiando le regole di gara, il colore delle medaglie e la geografia delle montagne, senza badare a cambiare il modo di sciare.

Molti gli spunti per i nostri decisori nazionali e regionali, ma anche per il mondo universitario e per gli ordini professionali.

Raccomandazioni su “non fare”: un database del NICE

NICE ‘do not do’ recommendations

What are the NICE ‘do not do’ recommendations?

During the process of guidance development NICE’s independent advisory bodies often identify NHS clinical practices that they recommend should be discontinued completely or should not be used routinely. This may be due to evidence that the practice is not on balance beneficial or a lack of evidence to support its continued use. It is these recommendations that have been pulled together into the ‘do not do’ recommendations database.

The NICE ‘do not do’ recommendations database was created, and is maintained, by NICE’s Research and Development team. Read further information about the team´s work.

What is in the NICE ‘do not do’ recommendations database?

The NICE ‘do not do’ recommendations database contains all the ‘do not do’ recommendations that have been made since 2007. These have been abstracted from NICE cancer service guidance, clinical guidelines, interventional procedures and technology appraisals guidance. They will be updated or replaced as new guidance is published.

Each record contains the ‘do not do’ recommendation and includes additional information including the intervention, health topic, the guidance it comes from (with a link to the relevant paragraph in the guidance) and the other ‘do not do’ recommendations from the same guidance. Each recommendation also includes the health care setting that describes the main clinical environments in which the intervention or investigation may be initiated. The health care setting is subject to vary according to local arrangements.

Search the NICE ´do not do´ recommendations database.

What about ‘do not do’ recommendations before 2007?

NICE introduced optimal practice review ‘recommendation reminders’ from December 2006, as part of a set of products to help the NHS make better use of its resources. The reminders aimed to help the NHS reduce ineffective practice by highlighting selective ‘do not do’ recommendations from NICE guidance issued between 2000 and 2006.

The optimal practice reminders are still available, along with electronic templates for estimating the local cost implications.

See all NICE optimal practice review recommendation reminders.

This page was last updated: 02 February 2011

Live & Learn

“…70% of American workers believe the key ingredient to being lucky in their careers is having a strong work ethic…

…Of 7,000 respondents in 15 countries…84% said they believed that luck – good or bad – plays some role in their professional lives.

…But they aren’t relying on kismet: participants consider luck to be something people create for themselves…

…Respondents said the most important factors in generating good fortune are solid communication skills, flexibility, strong work ethic, acting on opportunities and having a robust network, in that order…”

Source: Wall Street Journal, Luck is Hard Work

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Bruciare, bruciare, bruciare!

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