This so-called "care continuum"

Hospitals are so much like farms...silos, silos everywhere.

How's about an update on that project i spoke of previously, something about a "huddle"?? So for the last 4 months of 2013, I designed and implemented a daily anticipatory huddle to review patient risks in anticipation of patient needs, aiming to prevent eventual unplanned readmissions and adverse events. With so many different health specialists required to delivery care in a hospital (as i quickly realized), connecting everyone in a timely and effective manner initially seemed like such a daunting task. What is a huddle? Just like in football, it's all about talking through your team's plan. In this case, each morning we review all patients on the unit (floor), notably his/her progress, risks for adverse events such as a fall or infection as well as anything that may cause them to be readmitted, and also the transition process, or simply how/where they will go next (home, rehab) and the care plan.

Now, of course that doesn't seem like a novel idea, but imagine trying to transform the culture from one of reactive care (treating only after the fact) to one of mindfulness, or planning ahead. To complicate matters, we're talking about a staff that ranges from new to 40+ years experience. And oh by the way, there are nearly 400 different IT systems to document this so-called "care process". Yea, that's no typo. And in IT, you have what are called "interfaces", which allow these systems to communicate, only that many of these systems don't even remotely speak the same language.

So what'd we find? Well, the endeavor has only begun; however, prelim. findings show that identifying patient risks and reviewing all patient cases multiple times per day dramatically improves outcomes. In fact, we've cut unplanned readmissions in half! Why does this matter? Our hospital is $100 million in the red for FY'14. The volume of patients that return to the hospital unplanned is equivalent to $65 million. MILLION! And while the penalty for these unplanned readmissions is merely 1-2% of the total reimbursement rate (incrementally increased), it's inevitable that it'll soon be $0 paid for patients returning to the hospital as unplanned. Yea, it's called planning ahead. Not that we're breaking records or reinventing medicine... we're simply putting together the puzzle pieces of a one-billion piece puzzle.

So what i'm now doing is expanding my focus beyond just the patients' stay after surgery. How'd they get here? Was it an elective or non-elective (car accident, sports injury)? How do we communicate before and after care? Do we educate the patient? Who contacts who? Where is it documented? As a patient, I find it absolutely incredible that this health system has never connected the dots from the various care components-- maybe educate the patient, identify risks, how about discussing care needs and logistics for after the surgery? Clearly this isn't some life-changing tool or invention (though some management thinks otherwise); we're merely connecting the disparate dots relative to patient care needs from the moment they identify the need to well beyond evaluation and surgery. That's a true care continuum and we SUCK at it. More later...

On the next Jerry Springer: Trauma observations

Ever been through the trauma dept. of a hospital? WHOA. I've done quite a few observations over the last few months, and i've seen/experienced most anything. From deaths and nervous breakdowns, to parents fighting over child rights and even no one showing up to make life decisions for patients. It's no surprise, but many of the patients that come through have either a history of visits (deemed "frequent flyers") or they have social issues. The latter is what actually makes the trauma unit so chaotic, not the actual injuries. Dude, people FREAK OUT when someone they care for is not well. More than anything, you begin to understand why exactly these patients came to the hospital to begin with. Mental instability, comorbidities, non-compliance with meds, family history of drug abuse, no father, jobless for 8 months, etc etc. It makes me wonder how much of this could really be fixed with education and realistically how much is unpreventable. I'll expand more later (relating these two sections in this issue), but i can say that there's massive opportunity to trim up the fat in hospitals, what we like to call the "low-hanging fruit" or quick wins.

Crack is whack, son.

Let's huddle and regroup
 
When executive leadership tasked me with transforming the care delivery approach at our health system, I knew that it'd take quite the rapport in order to land successfully. Knowing the importance of face time, I spent the first 2-3 months (summer) getting to know the unit staff members. From the unit manager to the nurses and the care partners (medical assistants), connecting with everyone was important. What they didn't know is that with these "passer-by" check-ins, we were using them for different purposes. They were casually getting to know fellow staff members while I was building rapport, namely trust and respect. This approach has worked wonders in our progress to improve our clinical communication, leveraging a soft power approach with an assertive mindset. At any point we shy from our objective, I steer us back on target right immediately through positive reinforcement. So what exactly are we doing? Changing the way clinicians communicate in the hospital. Instead of taking a reactive approach, or waiting until it's too late, we are communicating about patient risks before something bad happens. Genius, right? Not really. I actually am completely dumb-founded that no one has ever done this before. So I've now established certain times of the day where all care providers update one another on their patients' progress. You could say opening the communication lines. I've also leveraged an iterative change model, what's called "hyper-change". Given the tight turnaround time that our board is expecting results, I knew that we couldn't use your traditional single dependent variable approach when evaluating patient outcomes. So we implement small changes to our model every Monday morning. They are expected, yet realistic, and staffers are surprisingly okay with this. More on provider communication later...

Andre 6 months later...

Last I spoke of Andre, he and I had been going through some growing pains. A quick recap of the story-- after being matched for 7 months (at that time), he began stealing cash from my car (I had planted cash on 6 consecutive weeks). I gave him 2 options: confess and volunteer for a month or not confess and volunteer for 3 months straight. And so that's what we did, once per week, volunteer at the Nashville Rescue Mission serving either lunch or dinner. I made him work off, in hours, the equivalent of every dollar he stole, based on minimum wage. My observations were fascinating. When Andre is put into a situation where maturity and/or leadership is necessary, he steps up to the plate... nearly every time. To ensure that he learned a major life lesson here, I had him talk with some of the residents of the mission, and I don't mean sugar-coated, superficial small-talk. Nerp. This kid knows more at 13 than I did at 18, in so many ways. So I told these guys to share their stories, straight-talk. Tell him of the cocaine addiction that drained your bank account, the armed robbery that landed you in prison for 8 years, the gang affiliation that left you partially disabled. Yea, share those juicy stories. And so they did, along with the consequences of their actions. He learned so much from this that he asked if we could continue volunteering once per month. Ataboy. More than anything, I want him to know that we all make mistakes, but learning from your actions is what makes you a better person.

Keep calm, carry on...

The impact of nonverbals

Over the past few months I've taken note to how the c-suite presents themselves in meetings, particularly in public, patient-facing settings. It's absolutely incredible to experience this knowing the challenges we're going through ($100M shortfall this FY, $250M over next 2 years), yet to witness key leaders across the org present themselves in a confident and composed manner. More than anything, it's reiterated the importance of nonverbals. There are the more obvious cues of facial expressions and vocal tones, and the not-so-obvious such as posture, stature, breathing, body movements (fidgets/motions), head tilts, and eye contact. In passing the CEO and COO in the hall every other day or so, they are consistently alert, content, smiling, and well-groomed. Additionally, they not only acknowledge my presence but greet me and other colleagues (agnostic of position) majority of the time. And while this seems trivial, it sends a very strong message throughout the organization and publicly, to both employees and patients-- hey, we face challenges but we can do this, together. It reminds me a lot of a coach in a post-game news conference. The best coaches have a way of deflecting attention away from the hotspots and onto other focal points -- such as the giving younger players some game time, getting 3 players back from injury next week, or mastering new play schemes and being more "ready to launch" next week. Same thing with leaders in a major corporation, and I've definitely been learning a great deal on how to better my leadership skills and influence outcomes simply via my nonverbals.

Following the leader

In mid-June, I launched a new team huddle as part of a much broader multi-phase, incremental rollout that will adapt certain features of a standardized anticipatory care delivery model. The overarching goal is a paradigm shift from reactive to anticipatory care. And where a pilot leverages a "potentially shippable" product to test in the market/environment, we are using a proof of concept framework, which leverages a build/test-as-you-go methodology, similar to the agile methodology. It's been fascinating to see this initiative evolve over time, going from a basic huddle that aims to get everyone present and talking/listening to the present-day standard of actually mitigating patient risks. It's been 2 months since going live, and I've found quite a few best practices to be incorporated as part of our ongoing rollout. Most notably, I have identified 3 critical success factors: continuity, culture, and leadership. While this project is currently only used during the day shift on weekdays, it reiterates the need for consistency 24/7. I could implement the greatest model ever during the day, M-F, but if all other times fail to adapt, what have we accomplished? From a leadership standpoint (and related to the notes on nonverbals), a unit staff/team often turns to their manager/lead for initial reaction re: adoption. "Is this realistic? Should I do this? Why should I care? What do you think?" It's reiterated the criticality of not just having a manager agree to carry out the tasks/projects asked of them but to truly believe in and support an initiative and be willing to change him/herself. And as before, it reiterates the extreme importance of body language. And once a precedence has been set, the ride from there on out is much, MUCH easier. The third critical success factor that goes with the continuity and leadership is the culture. So let's say that my manager supports this model and everyone's all in all the time; this doesn't necessarily equate to improved outcomes. Why? 1 word -- goals. What are we trying to accomplish? The expectation set will gravitate towards awareness, yes, but what ultimately makes a team/staff improve outcomes is via goals. After inquiring about the unit goals 2 weeks ago, I found that current goals are to merely "get them out faster", turn and churn, not "keep them healthy". So i'm tweaking these as well. I find it amazing that a major unit at a level-1 trauma hospital does not have anticipatory, patient-first team goals anyways. The goals, instead, are how to shorten the length of stay and washing your hands more-- important but a drop in the bucket compared to actually improving patient outcomes. It totally misses the boat! The coming months will be very interesting to see this all play out.

Black box warnings

Black box warnings

When is the last time you actually read the label on your prescribed medication? Due to a growing number of meds prescribed with a black box warning, you should probably take notice.

So what is it? A medication labeled with a black box warning can cause serious side effects (such as a fatal, temporary or permanently disabling adverse reaction). A serious adverse reaction can be prevented, reduced in frequency, or reduced in severity by proper use of the drug. For example, a medication may be safe to use in adults, but not in children, non-birthing women but not pregnant women. So is this a new procedure for public awareness? Not really, and it still isn't all that well known. Even though the warning system serves a purpose, a relatively small population knows about it, much less knows its purpose. As of 2010, according to the NIH, there were about 350 black box warnings issued for various medications.

What Information does the FDA Require in the “Black Box”?

This FDA-mandated warning aims to provide a concise summary of the adverse side effects and risks associated with taking the medication. Understanding side effects will help you make a better informed decision. However, a major challenge today is that physicians sometimes prescribe such a medication without neither evaluating the common side effects nor evaluating the patient's overall health and history/risks.

Common examples

The most commonly prescribed meds with black box warnings include antibiotics (Cipro), diabetes (Avandia), and antidepressants (Zoloft, Lexapro, Paxil).

Regardless of these more common examples, ALWAYS review your medications prior to consumption. And even if your medication doesn't officially have a black box warning issued by the FDA, it's not to say that it does not come with serious side effects and/or risks. Doing background research always helps, and this is also why it is extremely important that your medical history be accurate!!! (especially current meds list)

Real-life example

In February 2012, friend of mine took Cipro for 2 days before his girlfriend, a pharmaceutical professional, found out and immediately had him flush his system; it was too late. In the 18 months since then, he has been permanently disabled and bound to a chair/bed. The risk? Rupturing your tendons, ultimately preventing/limiting mobility. For the first 6 months, my friend was on medical disability. In the months since, he swam in his pool daily to improve circulation while also trying a myriad of homeopathic medical procedures/treatments, and he has improved quite a bit. He is still bound to the bed during the day, with occasional movement to/from the kitchen and bathroom. Nonetheless, he's also since gone back to work full-time, working from his bed using a projector screen via his ceiling and using a dictation command software to complete his job duties. Pretty incredible stuff that puts life in perspective... and pushes my longing to improve health care all the greater.

Putting it all on paper

There's a map for that

How often do you work in auto-pilot mode at work OR do simply as you were taught? This is scarily common across major health systems, and after shadowing/observing various processes and staff, we are certainly no exception. In fact, we have never created any such process flow or diagram of sorts to visualize just exactly how/what care delivery is across the hospital, including variance by service and unit. So for the last 2+ months, I've lived in scrubs (getting up 10 min prior to bus arrival has been heavenly), with the primary intent being just that-- getting a baseline of how exactly we are delivering patient care. Most of the time a hospital's focus is how to increase the profit margin, speed up throughput, decrease waste, reduce infections, etc. My focus has been quite simply "what are we trying to accomplish and how are we currently doing that?" Aside from observing the actual process steps, I've evaluated the technology/communication means, owner(s), and issues, risks, and gaps. My findings in one sentence? Duplication, omission, delays, entry error, disconnects... to name just a few. It's been fascinating to observe what seem to be basic processes become complex and ineffective process steps for multiple reasons. My findings – in the form of detailed process maps – support a risk profile proof-of-concept release, which aims to essentially "catch the bad stuff before it happens." A solid first step is understand what you have. Only time will tell, but I'm thinking that these observations are going to do soooo much more than simply identifying patient risks. Stay tuned...

Higher on the food chain... or redesigning the food chain?

As with any large organization, working at a major health system has drawbacks to go with the numerous perks such as flex time, tuition reimbursement, and telework. One challenge I've found in working at a large AMC is that, in addition to it being very bureaucratic, many people are placed in positions based on tenure or simply because they are "next in line". But take a step back and look at today's most successful organizations, and you see something completely different – a structure based on meritocracy. I experience this on a daily basis and in all forms, from the wretched, death-by-PowerPoint presentations with small essays on every slide to even the most basic time management skills or perhaps an unwillingness to stretch and learn a new skill. I find it interesting that calendars are always so full for senior management yet frequently so little actually gets done. On a daily basis, I see (or experience) inefficient meeting facilitation, presentations that totally miss the boat, or worse yet, people who simply don't effectively manage daily operations or even have no clue what the underlying objective is of their project. A large part of being a leader is breaking down barriers and empowering your team; it's not a secret sauce, but it's surely absent for many. If you look today across all job markets, yes you will see a considerable gap in the 'on-the-job experience', from college grads to seasoned, tenured professionals. However, I've frequently asked myself what happens when the younger employee is significantly more talented and/or capable of doing a job  than a more tenured or senior employee, and all that separates the two is time? As is the case at our hospital, the younger "new guy" typically gets that pass to "wait your turn". The result? An organization misses out on tremendous potential to capitalize on raw talents and disruptive innovation. 

Work at a rescue mission

Andre has encountered some hiccups over the last few months, and it all came to a head two weeks ago. After stealing money from me on numerous occasions, I confronted him and he denied ever stealing anything. Knowing that he was definitely the culprit (after marking the bills), I decided that volunteer hours would be the best way to teach him a lesson. Coming from a double-incarcerated family, he is at a pivotal age (13) for learning right from wrong, before it's too late. So I asked him-- at 18 do you want to be sitting next to your parents in prison or walking across the stage graduating from high school? Because I want the latter. Ending on a positive note, I said that we can do this together, but he's got to want to change and learn from his mistakes. This past Thursday, we volunteered at a men's rescue mission for the first of many weeks to come. We served food in the cafeteria for 2 hours; more than 400 meals served! He got to see first-hand that no matter how bad you think life is there are always 2 things constant... someone is worse off than you, and you can learn from your mistakes. He actually said this to me when driving him home, a sign that I think we're headed in the right direction. I plan to have Andre sit with some of the participants there at the mission to hear their story-- how they got there and what they have learned.

Role play

The last 6 weeks have been incredible. At the first of April, I began observing various services and units across our hospital in an effort to baseline current care delivery. I have been documenting things such as AM/PM rounds, rounds and action items by position, orders, issues, risks, bottlenecks, confusions, patient flow, technology, communication methods, culture, and duplicative process/entry. Thus far, I've completed assessments for 5 areas/services, 2 of which support our project in the short-term. The long-term impact will be HUGE, as this is the first time the med center has ever documented its care delivery processes, by owner and communication means. It's also uncovering much of the 'so what's causing this problem' factor-- for instance, the managers (nurse practitioners) in trauma spend an avg. of 4-5 hours of their total 12-hour shift simply updating and handing over between shifts (both outgoing shift and incoming shift). That means that approx. 40% of the manager's time is simply updating someone else!!! When I used this as a concrete example during a briefing to our vice-chancellor, he was completely floored and is very eager to see where this goes. Observations will continue for the next month or so... and it's sure to provide many more shockers. I'll update you on specific findings and provide more context (why are we doing this?) in my next post, once i've identified more themes and connected more dots.

Sure-- my observations as project manager for the above project have been valuable, but it's actually the role-play that has been the most fascinating experience. Ever seen the show Undercover Boss? Well, it's sorta like that. So over the last 2-3 months, I've played different roles in meetings and introduced myself in different formats, intentionally hiding my badge. My hope was to experience what it's like to be in various positions of an organization, from a surgeon to nurse, to admin asst. and intern. Think your job is bad? Do you feel like everyone hates you? Well, go role-play for a day. I can only speak from a hospital perspective, but I am absolutely floored from my experiences. The respect and overall demeanor of/from people when wearing scrubs and/or introducing as a physician and/or position of authority was not even on the same timescale as when introducing from the perspective of a traditionally unrespected position (secretary, intern, housekeeping). What's most interesting about the whole situation is that we typically view equality within the realm of ethnicity, but there's so many other aspects to equality, as I experienced first-hand. The sheer lack of respect, trivializing of input or roles, and even the frequent 'who the hell are you' or 'do you know who i am' look/phrase numbed me to the bone. Eye-openers like this are good for everyone, and I'm encouraging more senior leaders to do the same. On the flip-side, a quasi-role-play has worked magically for some departments, allowing "back-office" staffers (such as our call center, who schedule appts) interface with actual patients to accent their laborious job duties with realization of medicine, letting them all know that, even though they don't see patients' faces daily, they ARE making a difference. These staffers walk the halls and waiting rooms to meet patients and see first-hand that they are all indeed making a difference, one appointment at a time. So powerful....

Curriculum 2.0 -- a new medical school curriculum

For the last 80 years or so, medicine as we know it today has been delivered to patients in the same fashion. You become sick or have abnormal health condition(s), you get treated, you get well (hopefully). Why? Look no further than the training itself. Why do you fold your shirts into thirds or wash your veggies before you consume them? Why that's how you were taught, so of course that's how you do it. And the same goes for physicians.

The old approach: For the last ~80 years, "traditional" medicine has been practiced in the same manner-- year 1 of core prereq's (bio, chem, anatomy), followed by year 2 of foundations, and a disease focus, namely pharmacology, immunology, microbiology. You want more bazaar? Some schools teach one subject at a time! Everyday, the same subject for 8-week blocks. It's your standard turn and churn routine. But how does that make any sense, given that all of the systems and functions of the human body are inter-related in every aspect possible? At the end of year 2, students take the USMLE to test medical competency. In years 3 and 4, students begin rotations in various units and specialties, with year 4 seeing greater responsibility. Toward the end of year 4, each student must choose a focus area for their residency, which more or less means "hey choose what you want to channel all of your attention on". Subspecialties (e.g., anesthesiology) require additional years of training (called fellowships).

The new approach: Vanderbilt UMC and a few other med schools launched a new curriculum in the last 18 months, aimed at changing how students learn about medicine. Dubbed Curriculum 2.0, this new medical school model provides a deeper comprehension of the many scholarly fields essential to our understanding and practice of medicine. It more or less aims to instill a life-long learning model for all students, adapting to the every-changing shift in care practices and methods (based on research and outcomes data over time). After learning the core medical concepts (biochem, anatomy, etc), a personalized learning model shores up tailored course material as the student progresses. This aims to not only eliminate today's cookie cutter MD issue but also maximize the fit of clinician interest with both opportunity and curriculum. On top of it all, a longitudinal macro course ties is all together, helping to explicitly addresses the strengths and limitations of various diagnostic/therapeutic approaches and explain clinical reasoning as the student moves along on the journey called med school. This curriculum overlays onto the previous time span req't.

The gap: This new approach is eons better than the old approach. Doctors of old-- okay, let's be frank...all doctors in practice today-- learned on the archaic and ineffective legacy model or health care delivery, whereby students more or less are required to memorize the concepts and terminology in 40-50 2-inch text books, cram for exams/comps, followed up shortly thereafter with no recollection of what just happened. What did i just learn?! And if you are having a hard time relating to this, speak for 5 minutes in the foreign language you took in high school-- hell, even in college. Having issues? Yea, use it or lose it... that simple.

Although Curriculum 2.0 is a major advancement in the format of the curriculum, it's the curriculum itself that needs to be totally revisited. What do i mean? Today's medical field is littered with amazingly brilliant individuals, making immense strides in treatment and patient outcomes. But we have become so specialized in our care delivery that we have pigeon-holed ourselves when it comes to delivering a consistent and effective macro-patient care continuum. To address the pain in our chest, we now have to see 17 different specialists, of which 9 order separate MRIs with contrast. Brilliant. I'm not saying specialists aren't necessary; in fact, they are essential to our continued advancements in medicine. However, doctors are trained to focus on one specific area and no more. It reminds me of the days in school where we put up dividers during tests-- no cheating. Who am i fooling, cheating?! Every hospital/provider claims they provide the best care, but when is that ever possible without working together and/or sharing information? Bottom line-- no one provider has all the answers... impossible, in terms of both human retention AND time. But knowing who to turn to and what to look for/ask is within reach. That's more like it, eh?