I haven’t posted in quite awhile. Why? Because for the last 6 months I have devoted over 125 hours to creating a course that will provide you with the tools to fix our healthcare delivery system. Every system is designed to produce the results it achieves, and unfortunately at this time our healthcare systems are inadvertently designed to harm patients. You will learn how to apply the principles that high performing manufacturing systems to continually improve quality, you will learn how to apply the lessons you learned in team sports to becoming an integral member of your healthcare team. When patients become part of the healthcare team they are far more likely to receive higher quality, safer and more efficient care. You will learn how to recognize impending errors and dangerous conditions so that you can avoid harm. One of the most important lessons I will be teaching is how you can become an adaptive leader, a leader who can bring about change, and goodness knows our health systems need to undergo dramatic changes. And finally I will teach you how to organize others to achieve the goal of continually improving healthcare delivery. The course is free and it is offered through the University of Florida and Coursera. The Institute of Healthcare Improvement with the help of Michael Briddon has generously offered a number of teaching modules that have been incorporated into our course. Upon completing the course you can become part of the solutions. If everyone makes one or two small improvements every week or month our systems of healthcare delivery will steadily improve. WE ALL CAN MAKE A DIFFERENCE.
As compared to Samuel Adams where are we in our campaign? Individuals have created service organizations that have provided support and contributing solutions. These organizations have been created by single individuals and then expanded. They have taken effective steps to support patients and families injured by medical errors. They have documented the types of medical errors, provided counseling, as well as advice on how to avoid being injured. They have created programs that allow patients and patient families to educate caregivers on how to improve the safety and quality of their care. Members of these organizations have attended the meetings of national healthcare safety and quality organizations and discussed their personal experiences in medical centers throughout the country. These efforts continue to bare fruit; however as the many comments of the over 1600 patients on the Probpublica patient harm facebook site reveal, patients continue to be injured, and the majority are angry and distrustful of our health care systems. How can we advance our campaign to reduce medical harm and improve how patients injured in our health systems are treated? A group of very involved patients and families who have suffered the consequences of medical harm now propose a national organization created by and for injured patients and patient families. We are working together as the outreach initiative within the Empowered Patient Coalition. The goals of our organization are in evolution; however, one of our first actions will be to hold a national meeting exclusively about and for those who have been injured in our health care systems. As our campaign progress diagram shows we have a long way to go, but thanks to the work of those who have gone before us we have an excellent foundation.
The founding father most responsible for encouraging the colonist to seek independence from Great Britain is Samuel Adams. While he was in college at Harvard his father, a brewer and successful businessman, was driven to bankruptcy by a capricious ruling by the British Parliament. From that day on Samuel Adams dedicated his every hour to convincing his fellow colonists that our country needed to seek independence from the intrusive governance of the British.
As he began his efforts the Massachusetts Bay colonists were complacent. They were prospering and did no have to expend money for military protection. Their trade with the British was lucrative. All was well, why change? It took 17 years for Samuel to convince his fellow countrymen to act. How did he convert them from complacency to urgency? He used 5 approaches:
- One-on-one meetings – He met individually with his countrymen to discuss British rule and to share his vision for an independent America. Using personal narrative and sharing the misfortune of his father he recruited those with a shared vision to join his campaign for American independence.
- Assembled a leadership group – Through his one-on-one meetings and through his membership in the Caucus club he identified young and influential members of the community to form a leadership team to create strategies and tactics for the campaign for independence. He also helped to create the “Sons of Liberty”. Among his recruits were his younger cousin John Adams, and a highly successful merchant John Hancock.
- Editorials in the Boston Gazette and Public Advertiser. These anonymous editorials warned of the danger of taxation without representation. When British soldiers shot 5 colonist for throwing snowballs, he labeled the event the “Boston Massacre” and had Paul Revere create an engraving and distributed the posters depicting the massacre throughout the Massachusetts Bay Colony
- Organized large gatherings beneath the Liberty Tree, Faneuil Hall and the Boston Harbor. It was here that his fiery oratory aroused his audience and created an urgency to act.
- Created effective strategies and tactics that countered the British Government’s every move to manipulate the colonists. When the Stamp Act taxed colonists’ commercial activities Adams convinced his fellow countrymen to institute the “nonimportation” of British goods (100 years later this tactic received the name “boycott”). The refusal of American merchants to buy British products led British merchants to complain to their Parliament and encouraged the Parliament to rescind the tax.
The ultimate event and culmination of Samuel Adams campaign for independence came I773 when he organized the gathering of over 7,000 people (over half of the population of the Massachusetts Bay Colony) at the Boston Harbor to protest the unloading of tea by the British ship the Dartmouth. He had previously orchestrated a unanimous ruling by the colonial North End Caucus forbidding the unloading of British tea in Boston Harbor. This act was in response to a ruling by the British Parliament allowing the East India Tea Company to import their tea directly to the colonist, bypassing the American Merchants. The captain of the Dartmouth came to this large gathering and requested that he be allowed to unload his tea because the British Parliament had mandated that all cargo must be unloaded in American ports within 20 days and the 20th day had arrived. Samuel Adams instructed the Captain to go to the governor and request an exception to leave the port without unloading his tea. The captain beseeched the governor to make an exception, but he refused.
The captain returned to the huge gathering and informed Samuel Adams of the governor’s order. What should Samuel Adams do? Should he insight a riot, be labeled a traitor, and be immediately jailed? He implored the crowd “This meeting can do nothing more to save our country” and disbanded the crowd. As though on cue, 40 men dressed in Indian outfits yelled out “Boston Harbor a tea-pot tonight”, marched to the British ships unopposed, and with hatchets split open 342 chests of tea and dumped them into the harbor.
This act infuriated the British who blockaded the harbor, and sent 4 infantry regimens to Boston. These events precipitated the Battle of Lexington and Concord, the first Continental Congress, the Declaration of Independence, and the Revolutionary War.
Nothing is more American than organizing fellow countrymen to act. And those of us who have been injured by medical errors should follow the example of Samuel Adams to create a sense of urgency among our caregivers and our health systems. We should follow the example of this great founding father so that others will not suffer our fate, and to assure that those who have been injured by medical errors receive the care and compensation they so justly deserve.
For more about Samuel Adams read Chapter 6, “Culture is Nothing More than Group Habit” in Critically Ill, A 5-point plan to cure healthcare delivery.
This week I learned about the story of a family medicine resident who discovered a nearly fatal medical error and questioned the senior physicians about how to prevent future patients from suffering similar harm. As a consequence of his questioning of his superiors he was labeled as a trouble maker who did not respect authority. He has been suspended from his residency for the past 5 months, and as a consequence of reaching out to the press he has escalating a private disagreement into a public firestorm.
What went wrong? This resident is a member of the millennium generation, a generation that was raised differently than past generations. Parents of the millennium generation have treated their children more as colleagues and explained to them the reasoning behind each rule and family decision. These children have been closely supervised and encouraged to participate in formal activities such as sports teams, music lessons, dance lessons, acting lessons, and many other supervised activities. Their close supervision has encouraged an acceptance of authority and of institutions. As a consequence of the recommendations by the famous pediatrician Dr. Benjamin Spock, this generation has been nurtured, and rewarded for their every achievement. Everyone on the children’s soccer and baseball team received a trophy. Most people in this generation have been raised to think that they are special.
What does this mean for health care? These young people are not about simply following orders and deferring to those in authority. Rather, they want their work and the systems they work in to have meaning and purpose. They want to know the reasons behind every decision. The millennium generation asks “Why?”.
In my view this generation has the potential to transform health care. They promise to be the leaders of change. Because they have no stake in the status quo, they are far more likely to challenge it. They have altruistic goals and want to improve our society. Whenever someone tries to bring about a change in the way things are done, he or she is an adaptive leader. Health care badly needs adaptive leaders because the status quo (over 100,000 deaths and over 1 million life-altering injuries per year in the United States caused by preventable medical errors) is not and never should have been acceptable.
The dangers associated with adaptive leadership are well known. This quote by Noccolo Machiavelli, 1515 insightful describes the age old impediments to change:
There is nothing more difficult to carry out, nor more doubtful of success, nor more dangerous to handle, than to initiate a new order of things. For the reformer has enemies all who profit by the old order, and only lukewarm defenders in all those who would profit from the new order. This lukewarmness arises partly from fear of their adversaries who have the law in their favor; and partly from the incredulity of mankind, who do not truly believe in anything new until they have had actual experience of it.
Whenever a meaningful change in the way things are done is attempted disequilibrium occurs. Those in favor of the status quo feel a sense of loss. As shown in the figure above, they try to reduce the discomfort of change by attacking the leader who is trying to bring about the change, or by delaying the change. The key to effective adaptive leadership is to maintain the degree of disequilibrium in the productive zone. If there is no discomfort meaningful change is not being achieved. However, too much disequilibrium can lead to outright rebellion. If leadership can moderate the degree of disequilibrium eventually the change will become the new “way it is” and will be regarded as the status quo (far right of the figure). Those in charge should avoid punishing those who are leading change because punishment will serve to maintain the status quo. Adaptive leaders need to be protected and rewarded. Our patients are counting on them!
To read more about adaptive leadership please go to:
Critically Ill: A 5-point plan to cure healthcare delivery (Chapter 5) by Frederick Southwick also available in Kindle
We have a supermarket chain in Florida called Publix. George Jenkins founded this remarkable company in 1930 at Winter Park, Florida. The success of his company has always been based on customer service. As he told his employees at the end of each orientation, “If there is ever a customer you can’t handle, give them my phone number, because I will.”
Publix has a guarantee posted in every store that reads:
“Publix guarantees that we will never knowingly disappoint you. If for any reason your purchase does not give you complete satisfaction, the full purchase price will be cheerfully refunded immediately upon request. We have always believed that no sale is complete until the meal is eaten and enjoyed.”
Publix has been rated by Fortune Magazine as one of the top ten best companies to work for (2005–2008) and is one of Forbes Magazine’s top ten largest private companies (2009). Publix consistently scores higher than any other supermarket for customer satisfaction based on the national American Customer Satisfaction Index survey (1995–2010). (See Critically Ill: A 5-point plan to cure health care delivery)
Publix attributes its success to a continual focus on its customers. The key question arises, if Publix supermarkets can guarantee their food after it leaves the store shouldn’t our health care systems be willing to guarantee the care they provide to their patients after they leave the hospital or clinic? Stories like those of Jess, Carla, Marty, Veronica, and Georjean, would never have to be told. Imagine if each time a medical error occurred, the caregiver and health system immediately informed the patient, deeply and sincerely apologized, explained how the health system was taking steps to prevent the same error from harming others, and then fairly compensated the patient. Patients injured by medical errors would no longer feel as though they were being ostracized. They would no longer lose their trust in our medical system. They would no longer be suffering the financial hardship brought on by their injuries. After all, these injuries were not the fault of the patient. Why have the very institutions whose charge is to help those in need turned their backs on the patients who morally and ethically most deserve their help? When our health systems and caregivers make mistakes, shouldn’t they do everything in their power to help those they have injured?
Meet Marty and Gwen
Marty is a master carpenter who for years molded wood into the most magnificent heirloom furniture imaginable. He had a thriving architectural woodworking business and was always in demand. Gwen worked as a fund raiser and health policy advocate for a university health system.
In 2001, as Marty was turning 50, he was examined because he had some blood in his stool. During his colonoscopy a polyp was found near the rectum and was removed. In retrospect the polyp base had not been completely removed. He was told the polyp had cancer cells, but he was never scheduled for a follow-up colonoscopy. In the following seven years no one in whose care he was under ever recommended that he be seen every year.
In September 2005 Marty complained to his primary care physician that he had noticed blood in the rectal area. He was examined and told this was due to a hemorrhoid. Again in 2006 he noted blood on the toilet paper, and again he was told it was caused by a hemorrhoid. He trusted his physician, after all it was “not his place to question or quibble”. In mid-2007 he called the physician’s office complaining of globs of blood from the rectum and again was told it was just his hemorrhoid.
In July 2008 he was diagnosed with a malignant neoplasm of the rectum, stage IV cancer, meaning the cancer had spread to his lymph nodes. Marty was devastated. He had trusted his physicians. But he soon learned that he had not received the standard of care he deserved. Rectal bleeding should have been taken more seriously. An entire academic health center had failed him.
He was told by the first surgeon he saw that he had the worst colon cancer she had ever seen, and that he would be required to wear a colostomy bag for the remainder of his life. She demonstrated no empathy for his situation. Discouraged Marty thought about giving up, but Gwen would have not part of surrender. Through her connections they identified an outstanding surgeon, oncologist and radiation therapist. After extensive surgery, high dose chemotherapy that resulted in the loss of sensation in Marty’s hands and feet, as well as extensive radiation that resulted in delayed wound healing requiring 14 months of dressing changes, Marty recovered. He is now cancer free.
Marty could have sat at home angry and depressed over what had happened to him. However, having grown up in the 60’s he remembered the words of Bob Dylan’s song The Times They Are-A Changing: “Shake your windows. And rattle your walls”. And that is exactly what Marty has done. He met the the Chancellor of the Medical Center that had failed him in the hopes of preventing similar events from happening to others. He has spoken to healthcare providers (strike on this link to watch his eloquent presentation) describing in vivid detail both the worst and the best that our health systems have to offer.
Marty wants to be a force for change, and I hope that you will join Marty and me in our quest to reduce errors in our health care systems. The sharing of our stories can and will make a difference.
Lessons learned from Marty’s and Gwen’s experience:
- Problem – Marty was not provided with proper follow up instructions after his 2001 colonoscopy.
Solution – All colonoscopy reports should include recommendations for follow up. In Marty’s case a colonoscopy should have been recommended within 3 years or earlier if he experienced rectal area pain, bleeding or anemia.
- Problem – His primary care physician ignored his complaints about rectal bleeding. She attributed blood on his toilet paper to a hemorrhoid, which she misdiagnosed. She made a common reasoning mistake. Her diagnosis became anchored and she was unwilling to change her diagnosis despite additional input from Marty. She failed to listen to the concerns of her patient.
Solution – All physicians must be aware and guard against anchoring their diagnoses. An expert diagnostician keeps an open mind, takes in new information, and changes his or her leading diagnosis accordingly. All clinicians should also consider the worst case scenario, and exclude the most dangerous diseases that could harm their patients.
- Problem – When Marty presented his complaints to the Chancellor of the Medical Center, the administration and physicians circled the wagons. They never apologized and claimed Marty’s illness was a complication that could not have been prevented. This forced Marty to take legal action increasing the settlement costs to the medical center and causing great emotional stress to Marty and Gwen.
Solution – When an error occurs the caregiver and medical center administration should immediately acknowledge their error and sincerely apologize, describe the ways they will prevent similar errors from hurting patients in the future, and offer a fair monetary settlement for the harm they have caused.