Tuesday, July 13, 2010

Loved to Death

There is currently a lot of debate around how or even if manufacturing processes such as LEAN and Six Sigma "have any place in health care." The question seems polarizing, with both opponents and proponents providing more heat than light. As if global warming isn't bad enough already.
The problem isn't so much a particular technique (or dare I say, fashion), it is the managerial propensity for falling in love. It's happened before.
Remember clinical paths (care maps, critical paths)? They were going to be the saviour of health care! For a while, they showed some promising results. Patients got better and more timely care. Outcomes improved. Across-the-board job satisfaction of health care workers improved. The costs of providing care decreased.
So what went wrong?
One of the truths about any tool is that it works well for a specific and proscribed number of tasks. This is as true for clinical paths as it is for screwdrivers. You might be able to adjust a Philips-headed screw with a flat-blade screwdriver, but using a Philips screwdriver would yield better results and be easier.
Similarly, clinical paths worked beautifully for some specific diagnostic or procedural group: open-heart surgery, joint replacement surgery, treatment of community acquired-pneumonia. Steps that improved patient outcomes were identified, and systems were put in place so they weren't missed. Activities that did not improve outcomes were minimized or deleted outright. Costs went down and patients got better faster and everyone was happier.
Then someone decided that if it worked for these groups, we should do it for everyone! My standard screwdriver drives standard screws so well, let's use it to drive other screws! And drive nails! And saw wood! And (this is critical) think of the money we'll save!
That the proposition made no sense whatsoever was somehow overlooked.

You can imagine what happened. Clinical paths work, and work well, for those patients who are likely to have a fairly standard hospital course. If the diagnosis, patient response, or complications make the course in any way non-standard, the patient "falls off the path." This isn't necessarily bad, but the tool is no longer useful, and all the improvisation or wishful thinking or watering down will make it so. When one hospital I worked at announced the goal of having 90% of the patients on clinical paths, I knew they were doomed. Some of the paths became so generic that it met the stated goal, but did nothing to improve patient care. Make that "less than nothing": it diluted the power of a once-useful tool, created a paperwork distraction from the real work of patient care, and created the false dichotomy of "it's either useful for everyone, or it's useless."
No tool is useful for everyone, in all circumstances, ever. So instead of using clinical paths only where they were designed to work, they were used everywhere, then abandoned in frustration when the earlier results weren't replicated.
I don't know much about LEAN or Six Sigma. I've heard accounts of it working well in some aspects of health care delivery, and disastrously in others. Even at Toyota, when LEAN was first popularized, the technique was over-applied with horrendous consequences.
I don't believe these techniques will save health care. I don't believe they will necessarily destroy it, either. They, like other tools, will have their appropriate place where they will produce remarkable improvements in quality, cost control, and value.
Then, if the pattern holds true, someone will fall in love, apply the principles where they don't work, and ruin everything. How do we keep that from happening again?
I'm not sure. I think a reasonable start is to learn these systems for ourselves, so that we fully understand their appropriate uses. We also need a healthy level of skepticism: no bullet is magic. Any approach in current favor should be critically appraised with at least this question: "What circumstances or processes do this technique's developers recommend it not be used for?" That question should have a meaningful answer, and that answer should be believed.
We all need to be willing to try new tools, as there may well be something better out there. We also need to understand those tools, understand their appropriate use, and use them correctly.
It's something we aren't particularly good at.

Tuesday, July 6, 2010

Defining "Safe"

As members of the Minnesota Nurses' Association file to their respective polling places to vote whether to ratify their new contract, they are faced with the reality that safe patient care in general and "safe" staffing levels in particular are going to be a complex and protracted endeavor.

However, before they even attempt to engage their respective hospital administrations in a discussion about patient safety, nurses need to arrive at their own, specific definition of "patient safety."
Of course, everyone wants patients to be "safe." Do all parties mean the same things by the word "safe"? Corporations, most recently Toyota and British Petroleum, are notorious for a more elastic definition of "safe." Classically, corporations will comply with the letter of the law, but no more. Any additional safety initiatives are closely monitored, and are considered a success if they save at least as much money (in the form of litigation fees, fines, settlements, and so on) as they cost. If they don't, no matter how much improved safety is realized from the program, it's "financially unsupportable."
Nurses have a more stringent definition...somewhere. It's difficult to define patient safety, and tease it out from such phenomena as optimal care or a busy patient assignment. Does it necessarily follow that not getting a meal break means patient safety was at risk? Some say yes, some say no, some simply aren't sure.
Moreover, is "safe patient care" enough? I would contend that safe patient care is a component, but not the totality of either effective patient care or optimal patient care, both of which beg their own definitions. When the best I can say about my shift is, "I gave really safe care," I'm trying to console myself, not congratulate myself.

In my evidence-based practice research around patient falls prevention, it occurred to me the interventions to prevent falls broke down into three categories:
  1. Decreasing the number and intensity of risk factors.
  2. Supporting, improving, and increasing the patient's adaptive behaviors to prevent falls.
  3. Interrupting behaviors that increase patient falls risk.

It occurs to me that safe patient care requires similar capacities from the caregiver. Specifically:

  1. Identification of risk factors, events, or processes that increase the exposure of the patient to harm.
  2. Intervention to decrease or eliminate these risk factors, events, or processes, thereby decreasing the risk of harm to the patient.
  3. "Rescuing" the patient from emergent harmful situations.
  4. Adequate resources (personnel, equipment, training) to carry out these safety activities.

I can't even guess if this is a workable definition, or even the foundation for someone else to develop one. I do know, however, that if we can't clearly define what we consider "safe patient care," we can't measure it and we can't effectively advocate for it. It requires profound limberness of logic to insist that because you can pay for whatever damage you've caused and no one was hurt (much), you're a safe driver. Unless we have a definition with more veracity, this may well end up stuck with this one.

Safe patient care is not excellent patient care, but excellent patient care is safe patient care. Until we have a standard to which we can compare the caregiving circumstances we face, we will be unable to truly know what is required to provide safe and excellent patient care. And odds are, we'll end up providing neither.

Saturday, July 3, 2010

The Slippery Slope to a Holy War

I am seeing a few scatter signs that the quest for safe staffing is becoming a "holy war." This concerns me, and it concerns me a lot.

The conditions needed for a holy war is that each side believes something very strongly, and just as strongly believes the position held by the other party is antithetical to their own position. Accepting, at least for now, each side's position is sincere as presented:

  • Nurses believe safe patient care requires mandated staffing ratios, and Management has more than adequate resources to cover the additional cost.
  • Management believes safe patient care requires solvent and financially stable institutions, with a high degree of flexibility to exactly meet demands for nursing services, and mandated ratios are financially unsupportable.

As each side lacks the data to prove their position, they are operating from belief, from faith. Faith is impervious to debate, it is cannot be proved or disproved, and each side holds its "articles of faith" as sacred while holding their opponent's view as profane.
As I follow postings on the MNA Facebook page, I see other complementary and disturbing trends, also consistent with preparations for a "holy war":

  • Those outside the group (in this case, MNA) who do not share the articles of faith (the hospitals) are infidels; they must be vanquished.
  • Those inside the group who do not share the articles of faith are heretics; they must be found and cast out.

Herein lies my problem. As Robert Langdon put it in Angels and Demons, "Faith is a gift I have yet to receive." I occasionally envy the serene confidence that marks people of faith: a Christian with four aces is truly a wonder to behold. That envy is not compelling enough for me to desire this "gift." I claim as my gift the ability to see the grays and notice the nuances. The universe is complex, simple answers do not satisfy, and the search for the complex and nuanced answers is endlessly fascinating. I will not surrender my gift, no matter how inconvenient my vision is for myself or others.

This is unease is compounded by history. Crusades seldom work out well for the crusader: the infidels are well armed and have the home-field advantage. I fear that if MNA decides to embark on this crusade, we won't fare any better and likely will suffer greatly for our efforts.

The importance of patient safety is inarguable; it must be enhanced and assured. Nurses' professional integrity is an obligation of every professional nurse, and a demonstrated component of safe patient care. Required staffing ratios are one of many paths; true believers' assertions to the contrary. There are many others to be investigated and tested, with care and deliberation, lest our "cure" (like so many in our history) creates a new and more dangerous disease.

I profess no faith, only provisional trust. More generous provisions must be earned. Mandated staffing ratios have not earned that even my most provisional trust.

And I will not march into any conflict on the basis of faith.

Thursday, July 1, 2010

Into the Whitewater

As a nurses’ strike appears all but inevitable, I find myself in both unfamiliar, but also strangely familiar territory.

This is the first time I’ve worked at a unionized hospital, and the first time I’ll be participating in an open-ended strike. All this is new and unfamiliar. Yet what I feel as I approach the strike date feels oddly familiar.

Once again, I’m heading into the whitewater.

I’m hardly an expert whitewater rafter. I’ve been on a few two- to six-hour trips, on rivers that were wild and dangerous enough to be fun and keep me on my toes, but not so much as to be truly frightening. Unless something extraordinary happened, I had reasonable confidence I’d come out the other side soggy, but unscathed.
I don’t expect the strike to be fun. It will be turbulent, and I’ll need to pay attention, but I expect to come out the other side more-or-less unscathed. Still, some of the lessons from riding the real whitewater seems relevant to what we will likely be facing in the days and weeks that come:

  • Pay attention: There will be a lot going on, so pay attention. There will be things you need to do and instructions you’ll need to follow. I know I have a bad habit of retreating into my own head (hey, it’s an interesting place), but it’s unwise, and at least occasionally dangerous in situations like this. Stay alert, and be “present.”
  • Listen to your guide: Some people have been down this “river” before; they know how to read it and know what the hazards are. Listening to and following their instructions is the most reliable way to both get the boat down the river safely and keep from going for an unscheduled swim.
  • Row: You aren’t a tourist here, you’re a participant. Do your part and participate!
  • Don’t pass up any lines thrown to you: Should you end up taking that unscheduled swim, people will yell to you, “Swimmer (that’s your name now)! Throwing line!” A rope will land coming over your shoulder. Get a tight hold, hold it tight to your chest, and let yourself be pulled to the boat or shore. “No, thanks…I’ll be alright” is both unnecessary and inappropriate. Whitewater swimming can become whitewater drowning all too easily.

In the whitewater ahead, there will be a lot going on, so pay attention and stay informed. Many of our union leadership has been down this river before, so listen up and follow instructions. Walk the line and speak up when asked; we’re all spokespeople for our cause. Don’t pass up any assistance that comes your way. The links on the MNA web site and Facebook page list ropes that have already been thrown to you. It’s up to you to grab them.
Few people will find the river ahead to be an enjoyable adventure. That’s okay. Being paralyzed with fear isn’t an option, either. Be present and participate, and you may find the ride more fun than you expected. At the very least, once we reach the calm on the other side of the rapids, you will have the satisfaction of knowing you made it through.