Archivi del mese: maggio 2013

AHRQ Identifies Top 10 Patient Safety Strategies @Medici_Manager @WRicciardi

Laurie Barclay, MD

The Agency for Healthcare Research and Quality (AHRQ) has identified the top 10 patient safety strategies (PSSs) ready for immediate use. Paul G. Shekelle, MD, PhD, from the RAND Corporation, Santa Monica, California, and colleagues present the list in a special supplement to the Annals of Internal Medicine published online March 4. These interventions, if widely implemented, could dramatically enhance patient safety and save lives by reducing medication errors, bed sores, and healthcare-associated infections.

“Wide-scale reductions in patient harm have been modest despite over a decade of research, improvement, and effort since the Institute of Medicine’s ‘To Err is Human’ report,” Patrick W. Brady, MD, told Medscape Medical News in an email interview. “Since that report, the evidence base for safety strategies has continued to grow, but great challenges exist in taking these strategies to scale throughout health systems,” said Dr. Brady, an assistant professor in the Division of Hospital Medicine and the James M. Anderson Center for Health Systems Excellence, Department of Pediatrics, University of Cincinnati, Ohio, who was not involved in the AHRQ project.

According to a journal news release, diagnostic errors result in between 44,000 and 80,000 annual deaths in the United States alone, and bed sores lead to another 68,000 deaths. Thousands more patients die each year as a result of communication errors or failure to receive evidence-based interventions.

During the last 4 years, Dr. Shekelle and colleagues conducted an evidence based assessment of PSSs, including 79 strategies identified in the 2001 AHRQ report, Making Health Care Safer: A Critical Analysis of Patient Safety Practices. On the basis of that assessment and subsequent input from clinicians, researchers, and policymakers regarding the epidemiology of errors and preventable harms, the investigators identified the top 10 PSSs, as well as 31 additional PSSs.

“The team of patient safety experts who put this list together are among the most respected safety experts in the world,” Nancy Foster, vice president of quality and patient safety policy at the American Hospital Association, told Medscape Medical News in an email interview. “The strategies they have identified are effective, important, and should be on the top of every healthcare leader’s list for consideration.”

AHRQ’s Top 10 Patient Safety Strategies

  • preoperative and anesthesia checklists to reduce operative and postoperative events;
  • bundles including checklists to reduce septicemia associated with central lines;
  • catheter reminders, stop orders, nurse-initiated removal protocols, and other interventions to limit urinary catheter use;
  • bundles to prevent ventilator-associated pneumonia, including head-of-bed elevation, sedation vacations, oral care with chlorhexidine, and subglottic suctioning endotracheal tubes;
  • hand hygiene;
  • do-not-use list for hazardous abbreviations;
  • multicomponent interventions to help prevent pressure ulcers;
  • barrier precautions to reduce healthcare-associated infections;
  • central line placement guided by real-time ultrasonography; and
  • strategies to improve venous thromboembolism prophylaxis.

“It is as important for hospital and health system leaders to know why some strategies are not on the list as to know what is on the list,” Foster said, wondering about the absence from the list of adoption of electronic health records despite robust decision support. “Is the evidence still emerging? Were they concerned about emerging evidence of some of the risks from use of [electronic health records]?”

Dr. Brady largely agreed with the list but noted that it could be the “source of some spirited debate.” He commended AHRQ for recommending strategies supported by excellent systematic review and/or research designs including randomized trials and comparative effectiveness studies.

“The considerations used by the authors [regarding] scope of problem addressed, strength of evidence of strategy effectiveness, potential for unintended consequences, cost, and difficulty of implementation are logical and will advance the field of patient safety science,” Dr. Brady said.

Implications for Patient Safety

Foster identified 3 challenges to finding the underlying causes of medical errors and strategies for reducing them: budget cuts affecting AHRQ research, rarity of some errors hindering determination of causes and solutions, and multiple causes underlying some errors, which necessitate use of bundled strategies.

“Medical errors are a worldwide problem that can affect many, many patients and their families, and the AHRQ has safety research as one of its missions, but its entire budget is miniscule compared to that of [the National Institutes of Health], and within AHRQ, patient safety is…only one of the important components,” Foster said. “If we want to resolve the problem, we need a sustained and significant investment in patient safety research, which would mean increasing AHRQ’s budget even in this era of federal budget cuts.”

The payoff could be dramatic. The American Hospital Association recently reported that their Hospital Engagement Network of nearly 1600 hospitals had a 40% reduction in central line bloodstream infections using the bundle recommended by AHRQ, and preliminary results on the implementation of the catheter-associated bloodstream prevention bundle appear to be equally promising.

“Wide implementation of [AHRQ’s] strategies would save tens of thousands of lives each year,” Dr. Brady said.

Barriers to improving patient safety may include failure of health systems to implement complex, behavior-based interventions, as influenced by organizational leadership and culture. Dr. Brady recommends additional research in this area.

“An additional challenge to the successful implementation of safety strategies at individual hospitals may be the increasingly long list of ideas to improve patient safety,” Dr. Brady noted. “As this field has no shortage of good ideas, it may be challenging for hospital boards and patient safety leaders to determine where to focus. This rigorously developed, evidence-based top 10 is an important step to help healthcare administrators, clinicians, and researchers best target their efforts to improve patient safety now.”

“Fundamentally, we need to know more about what causes harm to patients and which strategies are effective in preventing them,” Foster concluded.

The AHRQ supported development of their report. Dr. Brady and Foster have disclosed no relevant financial relationships. Some of the report and editorial authors have disclosures involving the National Institutes of Health Research Collaborations for Leadership in Applied Health Research and Care for Birmingham and the Black Country; ECRI Institute; Veterans Affairs; AHRQ; Centers for Medicare & Medicaid Services; National Institute of Nursing Research, Office of the National Coordinator; UpToDate; Cantel Medical Group; Association for Professionals in Infection Control and Epidemiology, Hospitals and Health Care Systems; National Institutes of Health; Leigh Bureau; Penguin Group; American Board of Internal Medicine, Salem Hospital; Lippincott, Williams & Wilkins, McGraw-Hill; QuantiaMD; PatientSafe Solutions, CRISI, EarlySense; John Wiley and Sons; Marc and Lynne Benioff; United States–United Kingdom Fulbright Commission; RAND Corporation; and/or more than 100 other healthcare organizations including hospitals, healthcare systems, and state medical and hospital associations. Full conflict-of-interest information is available on the journal’s Web site.

Annals Intern Med. Published online March 4, 2013.

Cause e rimedi della crisi economica ambientale

Reducing medical errors: What we can learn from the Dreamliner @Medici_Manager @kevinmd

 | POLICY | MARCH 9, 2013

If you think that medical errors are a thing of the past, you are mistaken.

It has been 14 years since the Institute of Medicine’s report “To Err Is Human” shattered the myth that most, if not all, physicians are all-knowing practitioners with flawless skills and infallible judgment.

The story of what happened in the report’s wake was predictable:

  • Where the healthcare industry failed to act as it should have, the federal government and accrediting organizations stepped in to set the standards for healthcare quality and safety, establish quality measures, and assure that healthcare delivery entities complied by instituting financial and other penalties for poor performance.
  • Patients who previously felt safe began to question their healthcare providers.
  • We began to see some evidence of improvement in the quality and safety of healthcare services across the U.S.

In light of the foregoing, a recent “trip” to the website for American Medical News, the newspaper of the American Medical Association, left me feeling frustrated and sad.

story by Kevin B. O’Reilly referred to a recent well-referenced article in Surgery, noting that, at the close of last year, “never events” continue to occur in U.S. operating rooms 80 times per week.

In addition to causing temporary or permanent harm to patients, he extrapolated that these events carry a financial burden of almost $1.3 billion over 20 years.

Although surgical “never events” are rare (i.e., one in every ~12,000 procedures), their seriousness should not be diminished — especially when simple checklists and protocols have been shown to reduce the occurrence of such mistakes to near zero.

According to the article, published findings of a review of medical liability settlements and judgments collected in the National Practitioner Data Bank for 1990 to 2010 revealed that surgeons of all ages are involved in “never events” such as inadvertently leaving surgical items in the patient, performing either the wrong procedure or the right procedure on the wrong site, and — most egregious of all — operating on the wrong patient.

Startling as this is, previous studies have found that the 90% of injured patients who do not receive indemnity payments are not even included in the data bank.

Other studies have shown that “never events” can be eliminated — or at least minimized — by intensifying focus on identifying and correcting deficient processes, for example by addressing communication lapses with presurgery briefings and marking operative sites.

To its credit, the Joint Commission’s Center for Transforming Healthcare launched a project in 2010 to reduce wrong-site surgery risk at eight healthcare organizations and to provide tools to help others prevent these mistakes.

After these organizations reduced the proportion of cases in which there was a process-related problem that could have resulted in a wrong-site surgery from 52% to 19%, the commission made a wrong-site surgery prevention toolkit available to its accredited hospitals at no cost.

A national surgical safety project — NoThing Left Behind — introduced a slight change in the process for counting sponges at the end of procedures and some organizations have adopted new technologies (e.g., bar-coded sponges) to address the problem of retained foreign bodies.

Despite these and other evidence-based efforts, surgical “never events” continue to occur at the rate of 4,160 every year.

Because patient safety is part and parcel of my daily routine — whether in the hospital, the classroom, or at a national meeting — I ask myself why our industry is not mortified and why, as a nation, we are not appalled.

When I look to the airline industry for analogies, as I often do, the Boeing 787 “Dreamliner” comes to mind.

After only a couple of incidents, the federal government grounded this newest, most technically sophisticated airliner until the problem was fully understood, the deficiency corrected, and the risk to passengers and crew minimized.

Shouldn’t we address surgical “never events”, which affect 4,160 patients each year, with the same urgency and gravity that we address the potential risk to 210-270 passengers of travelling in the “Dreamliner”?

David B. Nash is Founding Dean of the Jefferson School of Population Health at Thomas Jefferson University and blogs at Nash on Health Policy.

Does Primary Care Need To Be Retooled? @Medici_Manager @HealthLeaders

Joe Cantlupe, for HealthLeaders Media, March 14, 2013

The president of Partners Healthcare and a Harvard University economist contend that primary care in the U.S. needs to be restructured to improve physician business practices and provide more value for patients.Under this “subgroup management,” primary care physicians would oversee improved coordination of care for greater efficiencies and clinical outcomes.

So say Thomas H. Lee, MD, network president of Partners Healthcare, and Michael E. Porter, PhD, the Bishop William Lawrence University Professor at the Harvard Business School, and director of The Institute for Strategy and Competitiveness, both in Boston, in a Health Affairsarticle this month. I spoke to both of them about their primary care challenge. (Erika Pabo, MD, MBA, a resident at Brigham and Women’s Hospital in Boston, was a co-author.)

“If we’re going to make primary care as effective as we want to, we have to start with a clear overreaching goal and try to restructure primary care,” Porter says. “It starts with value and that’s the true north compass. Primary care isn’t really one thing. It’s a lot of different things for a lot of different patients with very different needs.”

“If we can segment the needs and take patients and group them into fairly straightforward categories, such as healthy adults, or someone with one or two chronic conditions or very disabled people, we can understand the needs of a defined group of patients, and change the nature of primary care,” Porter adds.

The primary care framework isn’t working now, they say. As Lee sees it, too many physicians are “stumbling down a road, not sure where they are trying to go, as opposed to a bunch of people effectively moving down a road.” For doctors, it’s a vital question: their livelihoods are at stake.

“Market share is going to places that can meet patients’ needs and do it more effectively,” Lee says. He warns that physicians who “won’t be able to get their act together to adopt a strategic framework will be less successful and lose market share to organizations that can.”

Under their plan, a physician practice would divide patients into small groups reflective of differences of “core needs and circumstance,” Porter and Lee write. A practice may refer some patients to other providers better equipped to meet particular needs.

As it is now, an absence of a “robust overall strategy” is one of the causes of primary care’s problems, according to Porter and Lee.

“Thinking about primary care as a single service not only undermines value but also creates a trap that makes value improvement difficult, if not impossible. We will never solve the problem by trying to do primary care better,” they write. “Instead, primary care must be redefined, deconstructing the work that goes on within those practices and rethinking how it is performed.”

Examples of the team focus: integrated cancer teams that increasingly include both palliative care specialists and a psychiatrist to measure patient outcomes. Or, patients with end-stage renal disease may be referred to a dialysis team that provides primary as well as nephrology care.

As Porter and Lee envision a new primary care structure, they say care teams and delivery processes can be designed for each patient subgroup, with measurable outcomes. Such data measurement is woefully lacking under current primary care, they say.

The possible changes would touch not only on clinical care, but also go into the day-to-day function of existing primary care practices, which includes scheduling or patient visits. Patients with common chronic diseases can be “preferentially” scheduled to facilitate more efficient visits that may include group educational programs, they write.

Diabetes sessions could include an expansive team of specialists such as endocrinologists, podiatrists, and nephrologists. Especially complex case sessions with patients could involve mental health specialists, palliative care consultants, and social workers.

It’s no surprise, they say, that some of the best work in primary care is now focused on specialty care, especially the complex needs of elderly and disabled patients. “Various organizations have built a whole care model for those people,” Porter says.

He pointed out some examples, including the Commonwealth Care Alliance , which includes multidisciplinary teams and home visits. Others having integrated delivery care, where primary care and specialists work hand-in-hand, include CareMore, Intermountain Healthcare, Cherokee Health System, and the Department of Veterans Affairs.

To finance all of these primary care changes, Porter and Lee endorse the bundled payment model for a “total package of services for a defined primary care subgroup during a specific period of time, the approach most aligned with patients.”

While some healthcare organizations are moving in the right direction to improve primary care, much is lacking. Lee was even tough on his own health system. “We’ve got 65,000 employees, and the number of people whose job it is to improve the value of our care for healthy people, which is most people out there? The number is zero,” Lee says of Partners. “It’s not anyone’s job right now. Therefore, no one does it in a systematic way.”

Indeed, there is much discussion about population health, medical homes and Accountable Care Organizations with primary care physicians playing important roles. That’s nice, Porter and Lee say, but those models still fall short of the multidisciplinary, collaborative teams needed to augment primary care.

“We’re saying ‘let’s take it one step further,'” Porter says. “What are the primary care needs of different individuals?”

Porter and Lee acknowledge that their model certainly poses difficulties for small practices, but they insist small physician groups should not be excluded.

“There are a whole bunch of forces challenging the one and two doctor practice going forward,” Lee admits. “I don’t think anyone will look back and say this paper by Mike Porter and Tom Lee put them over the edge. There are ways to get physicians spread out, even in rural settings, to work together. They have to be ready to want to work together and collaborate with colleagues to improve the value of care for patients over time.”

Change must be in the offing for primary care, Lee insists. “I don’t think anyone feels like things are stable and that all (physicians) need to do is just show up for work and work as they currently are working and be OK,” Lee says. “We want to provide this strategic framework to make something happen, as opposed to fretting about it.”

Joe Cantlupe is a senior editor with HealthLeaders Media Online.

Patient Safety Programs Ineffective, Most Nurses Say @Medici_Manager

Alexandra Wilson Pecci, for HealthLeaders Media, March 12, 2013

Nurses see themselves as the gate-keepers of patient safety, but many believe that the culture inside their hospitals actually keeps them from achieving patient safety goals.

They say poor communication, ineffective programs, and punitive environments are hampering patient safety efforts.

Those are some of the findings from a survey of 900 practicing registered nurses by the ANA and GE Healthcare. The survey, which queried 500 nurses in the United States, 200 in the United Kingdom, and 200 in China, finds that few nurses would call their hospitals “safe.”

One of the most striking findings is the apparent chasm between the existence of hospital patient safety programs and their perceived effectiveness. For example, 94% of nurses surveyed say that their hospitals have programs in place that promote patient safety, which on the surface is great news; these programs are probably something that the execs at these institutions brag about.

However, nurses—90% of whom consider themselves most responsible for patient safety, over physicians (69%) and patient safety officers (60%)—don’t seem enthusiastic about the effectiveness of their hospital’s patient safety programs.

Only 41% of nurses describe the hospital they work in as “safe.” Just over half of nurses (57%) believe that the patient safety programs in their hospital are effective.

Whether these programs exist doesn’t seem to affect nurses’ perceptions of patient safety as much as the factors that affect how the programs are actually put in to practice. For example, in theory, patient safety programs might rely on error reporting and discussing these errors as a team.

In practice, however, error reporting often doesn’t occur because nurses are afraid they’ll be penalized for making mistakes. The survey found that although 90% of nurses say it’s important to have a culture where nurses are not penalized for reporting errors or near misses, 59% agree that nurses often hold back reporting patient errors in fear of punishment. Most nurses (62%) say the same about reporting near-misses.

Another key component of patient safety is open communication between nurses and their peers (and their leaders); nurses and physicians; and hospitals and patients.

But again, nurses identify a gap between theory and practice. Despite the prevalence of patient safety programs—and the communication that those programs presumably encourage—just 37% of nurses rated their hospital as excellent at communication with the patient. Even fewer nurses (31%) say their hospital is excellent at communication between staff.

For example, 33% of nurses said that that “poor communication among nurses at handoff” is something that has increased the risk of patient safety incidences in their hospital in the past 12 months, and 31% said “poor communication with doctors” has also increased the risk of patient safety incidents.

Another area where nurses crave more communication is technology. The survey finds that 74% of nurses say that technology/software patient safety initiatives exist in their hospitals. Although 59% of nurses say that patient safety data is collected and reported, they also say that there’s no follow-up or feedback given to the nurses.

Taken as a whole, these results seem to indicate that nurse leaders need to make a greater effort to really engage bedside nurses in patient safety initiatives, from development to implementation. Nurse leaders and executives should remember what Carolyn C. Scott, RN, M.Ed, MHA, vice president of performance improvement/quality for the Premier Healthcare Alliance, told me recently:

“There’re some incredibly creative and innovative bedside nurses in each and every organization. I’m always amazed at the ideas and the strategies that they’re even able to bring forward themselves; how to make something better.”

Alexandra Wilson Pecci is a managing editor for HealthLeaders Media.

How to survive a bad manager @Medici_Manager @timkastelle @berkun

Is your manager:

  • Inconsistent: Says one thing, does something else.
  • Arrogant. Always believes they are right, and makes sure you know it.
  • Egocentric. Makes every issue and decision about them.
  • Doesn’t listen: is offered advice but ignores it before even considering it.
  • Self-centered: Doesn’t support, encourage or look out for their team.
  • Mean/Abusive: Makes people feel bad for no reason.
  • Micro-manager: Refuses to delegate anything, despite what they say.
  • Coward: Backs down whenever challenged.
  • Isolated: doesn’t involve others in decisions, and rarely looks for ways to support/encourage the work of their team.
  • Incompetent: Lacks basic communication, intellectual, or emotional skills needed to for their role.
  • Checked out: Isn’t committed to their work or their team?

Read this Scott Berkun’s post!

A Crisis is a Terrible Thing to Waste @Medici_Manager @LDRLB @MaxMckeown

A crisis is not the same as a disaster (although a disaster may prompt a crisis). A crisis is a ‘crucial situation’ or a ’turning point’. Such turning points force a choice between inertia and innovation.

Waiting for a real crisis to drive innovation may not allow enough time or resources for new ideas to save the company. By the time anyone recognizes a real crisis, it may be too late to do anything about it.

Even if the organisation survives, external crisis may not happen often enough to motivate continuous improvement, progress, or growth.

  • You can look into the future. What may endanger your company? What products could competitors launch? What new laws may challenge how you do business? How will customer needs develop? What do you have to do better to thrive in the future?
  • You can look into the past. What has threatened your company in previous years? What has killed similar companies? What threats have there been to your country or industry?
  • You can look at the present. What events encourage a sense of urgency? How will political victories or losses impact your plans? How do new discoveries challenge your markets? What can you learn from successes and failures of others?

Samsung preaches the gospel of perpetual crisis. That’s why forty percent of employees work in research and development looking for the next breakthrough. It’s also why it has overtaken Nokia in many markets, because it notices and responds to market trends fastest – before crisis turns to disaster.

That’s why deadlines are never changed. It’s why design teams volunteer to live and work 24 hours a day in their Innovation Center. They pursue perfection against the clock until they deliver. The result? Over 1600 patents each year, the industry’s lowest costs, highest profits, and weekly announcements of “world’s first” or “world’s best”.

Most people need some reason to make tough choices. An organisation finds it even harder to make progress without knowing that it “has to”, and will usually wait until a real crisis comes along before getting on with the hard stuff that is essential to moving forward.

Intel also believes in using crisis to drive innovation. They decided that the only way of innovating fast enough is to use fear of future events to motivate urgent focus. It did this by encouraging what it calls a ‘culture of paranoia’. Everyone worried about real and imagined threats.

Everyone practiced ‘constructive confrontation’ to express opinions bluntly to subject proposals to aggressive, desk thumping, red-faced criticism. All in the hope that it would force tough action before a real crisis wiped out the company.

There are limitations to such a culture. Being paranoid may mean that you recognise threats but it does not mean you understand what adaptation is required. Nor does it mean that you can act and adapt as necessary.

Paranoid Intel has known for decades that success in chips for personal computers was getting in the way of developing new chips for mobile gadgets. It has failed many times to do much about impending disaster.

Yelling is not the same as open discussion. Vitriol is not an effective replacement for reasoned argument. Is it likely that people with the most valuable opinions will also be those with the loudest voices? Won’t senior managers be most likely to win?

The strength of the Samsung approach to ‘crisis culture’ is it builds in urgency and focus at the start of the project. This is where it has the greatest impact.

First, it seeks to avoid the main reasons innovations fail – because they are late or incomplete. Second, simplifying and improving design at the start helps each stage of production. Third, it only demands paranoia from small groups over a short period. This is crisis culture that is attempting to be effective, flexible, and sustainable.

Asking “crisis, what crisis?” is a denial based on either ignorance or self-interest. The problem with such denial is lessons are not learned. The danger to the leader doing the denying is they end up looking out of touch. Events move quicker than they do leaving them far behind the adaptability curve.

Max McKeown

Max McKeown is an English writer, consultant, guru and researcher specialising in innovation, strategy, leadership, and culture. He is the author of six books, including The Strategy Book and Adaptability.

Incidentalomas: The real cost of ordering tests @Medici_Manager @SIHTA_Italia @kevinmd


I recently read a very good article in the New York Times about a patient found to have the classic incidentaloma, a small mass in the adrenal gland.  This is estimated to be seen in 4% of abdominal CT scans, and is rarely serious but typically leads to recommendations for additional testing and follow up CT scans to assure that it is not either a metastatic cancer from another area or a hormone secreting tumor of the adrenal gland itself. It is so common that the NIH has a formal recommendation article to guide physicians on how to manage a small adrenal mass found on imaging modalities, what they refer to as adrenal incidentaloma, and even have an acronym “AI.”

The term incidentaloma is a tongue-in-cheek to denote an incidental finding on an imaging test.  –oma is the suffix used in the name of any tumor or enlargement.  Examples are lipoma, condyloma, meningioma, teratoma, and dozens of others. The root of the term obviously refers to the fact that it was an incidental finding on a test looking for something else altogether.

Classic incidentalomas include:

  • Tiny solitary pulmonary nodules. Commonly on chest x-ray or chest CT scan a small pulmonary nodule is seen.  Most times these are the result of a prior fungal infection or previous inflammation, but often require follow up imaging.
  • Small ovarian cysts seen on pelvic ultrasound.  The ovaries of women of child bearing age form an ovulatory cyst each month, and commonly these normal cysts, or other small cysts of questionable importance are noted on pelvic ultrasounds done for evaluation of uterine fibroids, evaluation of abnormal bleeding, or other concerns where ovarian cyst or cancer is not the primary concern.  Follow up ultrasounds, occasional surgery, and lots of emotional angst are the most common outcomes.
  • Renal cysts. Abdominal CT scans often show “lesions” in the kidney that require further evaluation to determine if they are simple renal cysts or possibly solid tumors.  They usually are cysts, but are common incidental findings on CT scans done to look for kidney stones, diverticulitis, or other problems. Again additional evaluation with ultrasound and sometimes monitoring over time or even biopsy are done to further evaluate these incidentalomas.
  • Lab test abnormalities, though not referred to as incidentalomas are other common incidental findings that often lead to a cascade of follow up testing.  The most common example in my practice is minor elevation of liver enzymes called transaminases, or liver function tests.  When abnormal these are usually repeated along with testing for viral hepatitis C and B.  If they remain abnormal liver imaging, sometimes liver biopsy are often done.  The usual outcome is a diagnosis of fatty liver, with advice to stop drinking alcohol, and lose weight.  This is advice that could have been given without even knowing the liver enzymes were elevated.

The whole incidentaloma problem is just one example of the real cost of ordering tests, especially tests like CT scans and MRIs that are so sensitive that they often find insignificant minor abnormalities or normal variants that lead to yet more expensive and sometimes invasive evaluation.

Edward Pullen is a family physician who blogs at

Sette domande che ti farai alla fine della tua vita @Medici_Manager @silviogulizia

E se prendessimo un attimo per rispondere ora a queste domande? Giusto per cercare di arrivare in fondo con le risposte pronte, che in fondo per prepararsi a morire ci vuole una vita, ma a volte non hai a disposizione tutta la vita per prepararti.

  1. Sono orgoglioso di come ho vissuto?
  2. Cosa ho scoperto?
  3. Come ho sfruttato le opportunità che si sono presentate?
  4. Mi sono preso abbastanza responsabilità od ho lasciato correre troppo spesso?
  5. Che battaglie ho vinto per raggiungere i miei obiettivi?
  6. Quanto ho amato davvero?
  7. Quanta parte della mia storia l’ho scritta di mia mano?

John Seddon on the #Francis report: “It’s the system stupid” @Medici_Manager @David_ukan

Osservazioni sul controverso Rapporto Francis da parte di uno studioso dei sistemi complessi, avversario dell’impostazione “comando-controllo”.

The 1,782 page Francis report into the Mid Staffs tragedy is a mass of detail. Hugely disturbing detail, you can’t fail to be moved by the evidence. But Francis, perhaps because he has a legal mind, doesn’t get behind the facts; he doesn’t question assumptions, he doesn’t even open the door to matters of theory.

As a consequence his recommendations represent what we would call single-loop thinking. The NHS is subject to massive amounts of regulation, but Francis recommends more, wrong thing righter. He recommends a ‘zero tolerance’ approach to breaches of fundamental standards but doesn’t question why the system as currently managed, might produce such neglect. He calls for a culture that puts patients first, but doesn’t consider why the current system fails in this regard.

If it is true that we have reached a level of dystopia that requires us to articulate a ‘structure of clearly understood fundamental standards’ – his top recommendation – we should despair. He thinks inspection for compliance will drive sufficient fear amongst healthcare professionals, yet he points to the fear culture that is already pervasive and dysfunctional. He argues for openness and transparency but fails to understand that the current use of gagging clauses (which he says should be banned) and shocking treatment of treatment of whistle-blowers is, too, symptomatic of the culture of fear. He does nothing to explain the reasons we have a culture of fear.

Francis thinks the answer is training, failing to appreciate how the current system drives peoples’ behaviour. He thinks that better leadership will instil a better culture, without understanding what currently drives leaders’ behaviour. Like Ed Balls did with social care, he recommends the creation of a leadership college, as though we can train that too. He thinks better information and benchmarking will act as a stimulus to improvement, showing no understanding of how benchmarking will lead to mediocrity, not innovation. It is perhaps ironic that the Francis recommendations on health improvement treat the symptoms, not the causes.

When Francis gets close to the causes: acknowledging a form-filling, target- and cost-driven culture, he fails to question them. He cannot see that form-filling bears no relation to and will detract from quality, he doesn’t know what targets do to systems and why, he wouldn’t believe that a focus on costs is driving costs up. Francis has a legal mind. He gave us the facts. You should read his report; you will be moved. 

Politicians move in

The minister for health, Jeremy Hunt, takes up the Francis theme on excessive box-ticking, bureaucracy and burdensome regulation by announcing a talking-shop whose purpose is to reduce the regulatory burden by a third. I can hear Deming in my head: ‘why a third? Is it the right third? Why is it not two thirds? What benefit ensues against the cost of compliance? The best we can expect is less of the wrong thing; that’s still the wrong thing.

The right way to have gone would have been to order all leaders in the NHS to review their box-ticking and form-filling to ask: what of any of this is important to us in understanding and improving healthcare? And thus NHS leaders would make their own decisions about changing the nature of control and, as a necessary and urgent consequence, the nature of regulation.

The minister says we need a culture that puts the patient first, not knowing how the current system obviates any attempt to do that and announced a review of complaints procedures. You couldn’t make it up really; it is as though he read the Beano guide to management.

The prime minister, David Cameron, strides in with announcements about handing the Francis report to the police in order to find people to blame, giving performance-related-pay to nurses, sacking the bad ‘uns and making nurses fill in forms to prove they have spoken to every patient every hour. Clueless, wrong and damaging.

In short, while the minister promises to remove the dead hand of micro-management from crushing people, the hand is, in fact, warming up for BOHICA (bend over, here it comes again).

Closing one of his presentations with a literary flourish, the minister said: “Let me finish with words from TS Eliot we should not forget, when he said, “It is impossible to design a system so perfect that no one needs to be good.”

I’m no literary expert, but when I read Eliot’s ‘Choruses from the Rock’, I experience a man regretting society’s alienation from God; in the NHS, alienation from a worthy purpose:

‘What have we to do but stand with empty hands and palms turned upwards in an age which advances progressively backwards?’

Eliot (writing in 1934) describes how man is facing a tremendous flood of meaninglessness because context has been removed. Man has created an artificial world based on the new gods of reason, money and power. This is what has happened in health, the minister and his predecessors are responsible for a system that worships false gods. 

It’s the system, stupid

I went to be a ‘witness’ on the Moral Maze (Radio 4) to try my best to make this point. We have a choice: to run our organisations in ways that encourage bad behavior, or in ways that encourage good; behaviour is a product of the system. I say ‘try’ because, for those of you who don’t know, the Moral Maze is something of a bear-pit. Ex minister Michael Portillo was my ‘opponent’ – an intelligent man who, nevertheless, thinks a bit of fear is a good thing. Having roughed me up he was at least decent enough to acknowledge my arguments in the summing up.

You can ‘listen again’ here:


When is an Innovation? @Medici_Manager @timkastelle

by  on 3 March 2013 in innovation

Greg and I have been talking about whether or not innovation needs a purpose.  While we agree on many points, we can see two differing views on the question.  I will argue that within an organisation, innovation does need a purpose, and here is Greg’s post arguing the other side.

Let’s start by looking at a case study.  When Watson and Crick published their paper revealing the structure of DNA in 1953, they close the paper by saying:

It has not escaped our notice that the specific pairing we have postulated immediately suggests a possible copying mechanism for the genetic material.

In their annotated version of the paper, the fantastic Exploratorium in San Francisco says this about Watson and Crick’s statement:

This phrase and the sentence it begins may be one of the biggest understatements in biology. Watson and Crick realized at the time that their work had important scientific implications beyond a “pretty structure.” In this statement, the authors are saying that the base pairing in DNA (adenine links to thymine and guanine to cytosine) provides the mechanism by which genetic information carried in the double helix can be precisely copied. Knowledge of this copying mechanism started a scientific revolution that would lead to, among other advances in molecular biology, the ability to manipulate DNA for genetic engineering and medical research, and to decode the human genome, along with those of the mouse, yeast, fruit fly, and other research organisms.

In many respects, even though these applications were noticeable in 1953, it’s really only been in the past 10-15 years that we’ve started to see a significant economic impact from the discovery of the structure of DNA.

So, was the discovery of the structure of DNA an innovation?

DNA double helix horizontalDNA double helix horizontal (Photo credit: Wikipedia)

There are two ways to look at this.  Some say that it’s not an innovation if there isn’t an economic payoff.  Or even more strictly, that without a new product, it’s not innovation.  Others say that innovation is driven by discoveries like this – that we must engage in search and discovery activities even though we have no idea what practical applications will arise.

Even though these seem like opposites, you must do both –  This is another innovation paradox.

On the one hand, if you want to stay in business, the ideas that you execute need to create value.  Then you have to convert that value into something that helps you pay the bills. If you’re not innovating around your core, you are vulnerable to competition from people that are.

So while it’s not true that you’re not innovating if it doesn’t create a new product, it is true that you need to create value with your innovations so that you can generate some sort of return.

When we think about corporate groups that have engaged in pure search and discovery, the two big examples are probably Bell Labs and Xerox PARC.  It’s no coincidence that both parent firms effectively had monopolies when they made these investments – they didn’t have to care as much about returns.

The answer to the question: was the discovery of the structure of DNA an innovation? depends a lot on timing.  And it raises three important points about managing innovation.

  1. Innovation is a process.  I’ve said before that innovation is actually the process of idea management.  Lukas Fittl tackles this issue nicely by talking about the distinction between ideation and execution – what he refers to as the flipping the ideation switch:the_ideation_switch1For our purposes here, ideation is the period when you are doing the searching, which may not have much of a market focus, and execution is when you zero in on building a profitable business model for your idea. Fittl talks about this as a very directed process even in the exploratory state.
  2. You face uncertainty throughout this entire process.  There are a couple of persistent, damaging ideas that pop up here. One is that when you get to the execution phase of an idea, there isn’t any uncertainty anymore.  Unfortunately, this is not true.  Any time we are working with new ideas, we can never be certain that they will work.Roger Martin addresses this in a great post about strategy and uncertainty:

    Contrary to popular opinion, strategy is not about turning uncertainty into certainty. Lots of bureaucratically inclined board members and corporate executives want and expect this to be the case. When reviewing strategies, you can hear them asking for proof that the strategy will be successful.
    The reality is that strategy is about making choices under competition and uncertainty. No choice made today can make future uncertainty go away. The best that great strategy can do is shorten the odds of success.

    Greg has made the point that strategy and innovation are often conflated. In this case, Martin’s comments on strategy do apply to innovation as well.

  3. The business problem with exploration is that the gap between the discovery and the economic payoff is usually very long.  This gap is almost always longer than we expect.  Look at the DNA example.  Watson and Crick published in 1953, and at the time, they noticed that the idea had commercial potential.  But the first biotech firm, Genentech, wasn’t founded until 1976, and their first product didn’t come out until 1982 – nearly 30 years after Watson and Crick’s article!Sketch-DiffusionIf Watson and Crick had been working for a company in 1953 when they made their discovery, how would it have managed to stay in business until 1982? You’d need a lot of venture capital to support that…

One way to address this is to manage your innovation activities as a portfolio using a 70/20/10 split in your innovation effort.  70% goes to improving your core business with incremental innovations, so that you can continue to stay in business.  20% goes to finding adjacent markets that you can extend into.  And 10% goes to blue sky ideas that might change the world, but we just don’t quite know how yet.

Once again, it’s not an either/or question – it’s both/and.  We need to be both evolutionary and revolutionary.

However, in practical terms this means that innovation does need to have a purpose.  You can do all the discovery that you want, but if you don’t use it to create value, you won’t be in business for long.

About Tim Kastelle

Idea Connector – Studies innovation networks – author, speaker & consultant on innovation – University of Queensland Business School – links to academic papers, twitter, and so on can be found here.

What Don Berwick said five years ago @Medici_Manager @giovanimedici @specializzandi

Reposted from

Don Berwick is a world authority on patient safety. For two decades he led the US Institute for Health Improvement and he led the US president’s “Obamacare” reforms. In 2011 was forced to resign that post, partly for referring to the NHS as an example for the US to follow.

In 2008 he was quietly commissioned to report on the culture of the NHS by the then Chief Medical Officer Liam Donaldson. He reported a climate of “fear” but this did not become public until the Francis Inquiry into the Mid Staffordshire scandal.

Last month David Cameron announced Don Berwick had been asked to become NHS Patient Safety Tsar to lead a panel “to make zero harm a reality in our NHS”. Don’t be surprised if their recommendations run counter to the government’s ‘reform’ agenda.

In July 2008 Don Berwick wrote a 60th birthday message to the NHS in the British Medical Journal. In it he made ten suggestions for improving the NHS. His advice was so good, and so prefigures the Francis Report, that I thought I’d share it.

“First, put the patient at the center – at the absolute center of your system of care”. Berwick argues for “the active presence of patients, families, and communities in the design, management, assessment, and improvement of care, itself” rather than any reliance on focus groups or surveys.

“Second, stop restructuring.” In an echo of Francis he warns that it is destructive of time and confidence and leads to risk averse healthcare. Stability, he says, helps change “become easier and faster, as the good, smart, committed people of the NHS – the one million wonderful people who can carry you into the future – find the confidence to try improvements without fearing the next earthquake.”

“Third, strengthen the local health care systems – community care systems – as a whole.” Health economies, not the fragmentation into individual elements like hospitals, clinics, surgeries, should become the “core of design”.

“Fourth, to help do that, reinvest in general practice and primary care”. Berwick describes general practice, not the hospital, as “the jewel in the crown of the NHS”.

Fifth, please don’t put your faith in market forces.” I’m not sure David Cameron read this bit before appointing him. Berwick scathingly says: “It’s a popular idea: that Adam Smith’s invisible hand would do a better job of designing care than leaders with plans can. I do not agree. I find little evidence anywhere that market forces, bluntly used, that is, consumer choice among an array of products with competitors’ fighting it out, leads to the health care system you want and need. In the US, competition has become toxic; it is a major reason for our duplicative, supply-driven, fragmented care system. “

Sixth, avoid supply-driven care like the plague.” He warns, rightly, that the pursuit of institutional self-interest has helped make healthcare unaffordable in the USA

“Seventh, develop an integrated approach to the assessment, assurance, and improvement of quality.” He warned we needed a coherent system of “aim-setting, oversight, and assistance.” As Francis also discovered.

“Eighth, heal the divide among the professions, the managers, and the government.” This was another theme of the Mid Staffs report, made much worse by the rise of “general management” after the Griffiths Report of 1983. Berwick warned, again echoed by Francis, that “the NHS and the people it serves can ill afford another decade of misunderstanding and suspicion between the professions, on the one hand, and the managers and public servants, on the other hand.”

“Ninth, train your health care workforce for the future, not the past.” The new skills we need are those in “patient safety, continual improvement, teamwork, measurement, and patient-centered care”.

“Tenth, and finally, aim for health.” He warns that “great health care, technically delimited, cannot alone produce great health”, and goes on: “Developed nations that forget that suffer the embarrassment of growing investments in health care with declining indices of health. The charismatic epidemics of SARS, mad cow, and influenza cannot hold a candle to the damage of the durable ones of obesity, violence, depression, substance abuse, and physical inactivity.”

Don Berwick concluded the article by writing: “The only sentiment that exceeds my admiration for the NHS is my hope for the NHS. I hope that you will never, never give up on what you have begun. I hope that you realize and reaffirm how badly you need, how badly the world needs, an example at scale of a health system that is universal, accessible, excellent, and free at the point of care – a health system that is, at its core, like the world we wish we had: generous, hopeful, confident, joyous, and just. Happy birthday!”

Don Berwick’s own publications are a joy to read. You can also hear him in these two short videos. The first, ironically, was posted by an American free market think tank aiming to discredit him as being too left wing: it is indeed a brilliant two-minute defence of the NHS. The second summarises some key themes for good healthcare.

Lessons Learned from Aviation Can Bring Remedies to Patient Safety @Medici_Manager @pash22

In commercial aviation, the last passenger fatality on a large U.S. jet was more than a decade ago. In health care, there may be as many as 200,000 preventable deaths each year in this country alone. We must stop thinking of these as unavoidable, and instead think of them as unimaginable.

By Chesley “Sully” Sullenberger III

Sully Sullenberger

Long before I became known for the Hudson River landing of US Airways Flight 1549, I had spent my professional life becoming expert at the science of safety. Decades in the cockpit, combined with years of airline safety work as an accident investigator and an airline crew instructor, taught me that good outcomes are the result of reliable systems, good leadership, consistent use of best practices, clear communication – and years of preparation. It doesn’t matter if your domain is the cockpit or the operating room: safety requires a system and a culture that must be learned and practiced by every member of the team. And that is why I so strongly believe that there is much our health care system can learn from the impressive system and culture of safety that have been  developed in the airline industry.

How can two seemingly disparate worlds be connected? Consider that aviation and health care are both high-risk, complex, evidence-based domains that require high-level human performance. Now contrast the safety records of these two fields.  In commercial aviation, the last passenger fatality on a large U.S. jet was in November 2001, more than a decade ago. Not so in health care. As we know from the Institute of Medicine reports and others, there may be as many as 200,000 preventable deaths each year in this country alone, including deaths resulting from what are considered to be medical errors – but are really system failures – and health-care-associated conditions. That’s the equivalent of 20 large jetliners crashing a week with no survivors, nearly 3 a day. After about the second day, we would see what we had after September 11, 2001 – a nationwide ground stop. There would be a Presidential commission, Congressional hearings; the National Transportation Safety Board (NTSB) would search out causes. No one would fly until we had solved the problems. Because airline accidents are very rare, they involve many people at once, they are noteworthy and newsworthy, we have achieved in aviation the public awareness and the political will to act. And that’s what’s lacking currently in medicine, along with leadership and direction, and a real sense of urgency, to address a problem that is systemic, huge and immediate.  There are many who still think of these deaths as an unavoidable consequence of providing care.  We must stop thinking of them as unavoidable, and instead think of them as unimaginable.

One remedy would be the establishment of an entity like the NTSB to investigate select, representative medical failures. (See An NTSB for Health Care — Learning From Innovation: Debate and Innovate or Capitulate).  This, I believe, would help move medicine from the current blame-based system to a learning-based system in which accountability and learning are fairly and accurately balanced, and people feel free to report not only their own mistakes but system deficiencies that might lead to an accident. Through the NTSB the aviation industry has a formal lessons learned process. It comes up with probable causes and contributing factors. It makes recommendations to the rule makers and the industry about how to prevent a recurrence. This information is globally disseminated, but locally actionable.

Another remedy is to change the culture involving what I call human skills. In the old days of aviation, captains could be gods and cowboys. They often ruled their cockpits by whim, according to idiosyncrasies and preferences, with little consideration of best practices. If someone spoke to a captain about an unsafe practice, they put their jobs on the line. Thankfully, those days are long gone. We have achieved much better standardization; we have taught captains that they have to be the builders and leaders of teams; we set the tone, we create an environment of psychological safety, where there are no stupid questions, where we create a shared sense of responsibility for the outcome. It’s not about who’s right, it’s about what’s right. And paradoxically, it’s this reliability, this standardization of processes that becomes the firm base on which we can innovate when we face the unexpected. That’s what my crew and I did on Flight 1549. This was something we never trained for, it was something we had never envisioned, and we had 208 seconds to solve this life-threatening problem we had never seen before.

For more than a hundred years now, we have been learning important lessons at great cost, many of them literally bought in blood. Almost everything we know in aviation, every procedure, every rule, we have because people have died. All these lessons that have finally made aviation so ultra-safe, we are now offering up to medicine for the taking.

What would it take for health care systems to adopt some of the practices of aviation? If there were a national reporting agency for medical errors and near misses, would you be more likely to report? Tell us what you think in the Comment box below.

Best known as the hero pilot from the “Miracle on the Hudson,” Chesley B. “Sully” Sullenberger III has been dedicated to the pursuit of safety for his entire adult life. An aviation safety expert and accident investigator, Mr. Sullenberger serves as a CBS News Aviation and Safety Expert, as well as founder and chief executive officer of Safety Reliability Methods, Inc.,  a company dedicated to management, safety, performance, and reliability consulting. He is also on the editorial board of the Journal of Patient Safety and a member of the Greenlight Group, a team of world class experts supporting a number of global health care research and development initiatives.


Andrea Silenzi, MD, MPH, PhD

ROMA, Martedì 7 maggio
Hotel Nazionale, Piazza Montecitorio
ORE 11.00
Otto società scientifiche, tra le maggiori nel campo della Sanità Pubblica e dell’Organizzazione Sanitaria, danno vita alla Fispeos, la più grande Federazione di Sanità e Salute pubblica in Italia con il fermo proposito di promuovere, sviluppare e consolidare un Servizio sanitario nazionale pubblico, equo, solidale, efficiente, produttivo e uniforme sul territorio.
La Federazione, che attraverso le società scientifiche aderenti porterà la voce e le istanze di decine di migliaia di operatori e professionisti sanitari, interverrà nel dibattito pubblico e si proporrà ai decisori istituzionali con proposte evidence-based ed iniziative scientificamente fondate. 
Domani, 7 maggio, alle ore 11.00, presso l’Hotel Nazionale di Piazza Montecitorio il Presidente della FISPEOS, Walter Ricciardi (Medici Manager SIMM) e il Consiglio direttivo presenteranno obiettivi e mission nel corso di…

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Readmissions and mortality @Medici_Manager @IncidentalEcon


Much has been made about the relationship between hospital readmission rates and mortality. Dead people can’t be readmitted, suggesting a negative correlation. On the other hand, decreases in both seem to be measures of quality, suggesting a positive correlation.

Harlan Krumholz and colleagues published a JAMA article last month that examines the correlation between risk-adjusted, 30-day readmission rates and mortality rates, both calculated on a fee-for-service Medicare cohort using CMS’s methodology. In particular, they examined patients discharged with a diagnosis of heart failure (HF), acute myocardial infarction (AMI), or pneumonia (PN). Correlations were not statistically significantly different from zero between mortality and readmission rates for the AMI and PN disease cohorts. For the HF cohort, the correlation point estimate was -0.17. Wanna see it?

readmit mort HF

(Dashed lines are medians. The blue line is a cubic spline smooth regression. The shaded area designates the 95% confidence interval.)

The authors conclude that mortality and readmission rates measure different, nearly orthogonal aspects of quality.

From a policy perspective, the independence of the measures is important. A strong inverse relationship might have implied that institutions would need to choose which measure to address. Our findings indicate that many institutions do well on mortality and readmission and that performance on one does not dictate performance on the other.

Ashish Jha has another perspective. A quote doesn’t do justice to his argument, but here’s the key passage:

So if one measure of quality is external validity – being at least somewhat correlated with the gold standard (mortality rates) — how does the readmission measure do? In a paper published recently in JAMA, we see that readmission rates don’t do so well at all. Readmission rates are un-correlated with mortality rates. In fact, for one of the three conditions, the readmission rate seems to go the wrong way: the best hospitals for heart failure (i.e. those with the lowest mortality rates) have readmission rates that are actually higher. Not perfect. Readmissions seem to have little external validity as a quality measure. Readmissions are, however, correlated with two things: how sick your patients are, and how poor your patients are. We now have good data that the Hospital Readmission Reduction Program disproportionately penalizes big academic teaching hospitals (that care for the sickest patients) and safety-net hospitals (that care for the poorest).

Ashish goes on to suggest readmission rates can still play a helpful role in motivating hospitals and health systems to improve. Maybe! I worry that they can also be gamed. Since they’re hardly correlated with mortality, we may not easily detect when they are.