Ac-Cent-Tchu-Ate the Negative...

I'm sitting in the physician's lounge eavesdropping on two surgeon colleagues, who I both admire and respect, while they talk shop. But it's all about what's not working. With a heavy focus on "dumb" patients, referring physicians, admitting clerks, charge nurses.....

What's up with all the negative talk? Why don't we sit around sharing stories about all the good that surrounds us? What about the patient who asks her doctor "how are you doing?" on a day that has been visibly rough on her surgeon? The housekeeper who sees his job as making the patient environment as safe as possible for all who spend time in the hospital. The lady that works the cafeteria till that knows your name and your favourite afternoon treat. Or the charge nurse who takes the extra time to sit with his patient and her daughter to actually explore why it's difficult to take all the different pills we order without ever thinking about the complexity of compliance. And the referring physician, with limited access to diagnostics and support, who uses her clinical knowledge and expertise to make a really hard diagnosis and an appropriate, fully investigated referral.

Things are by no means perfect. But when all you can see and talk about is "what's wrong" maybe you should pause, take a look at yourself, then ask yourself the same question.

MRSA vs Lice

YUCK!  Harmless (but still yuck!)

I sat at one of my ICU’s work stations last week.  I planned on spending my time going through charts, writing notes and rechecking lab results.  Instead I sat watching the comings and goings, fascinated by our staff and our patients’ families adherence to basic infection control procedures.  Across from my work station were two adjacent patient rooms.  One patient was on isolation because he had head lice at the time of admission.  The other patient was on isolation because she was colonized with one of the “super-bugs,” methicillin-resistant staphylococcus aureus, aka MRSA. This is one of the multi-drug resistant bacteria that have emerged over the last few decades, in part to antibiotic overuse.  

Head lice elicit a visceral reaction in most of us. You are probably subconsciously scratching your head right now.  They are common in situations where people live or interact in close proximity. And while they may be gross, head lice are harmless.  

MRSA: not nearly as disgusting, but way more harmful!

MRSA is becoming increasingly common both in the community and within healthcare facilities.  But MRSA is not harmless. Patients who get a hospital-acquired MRSA infections suffer: their length of stay and death rate increase. And the cost to the healthcare system also increases. 

Unfortunately, we do not get the same visceral response when we think about MRSA.  And I think that is one of the underlying reasons I saw what I saw.

Adherence to infection control practices by families and staff for the patient with lice were universally executed with perfection.  

For the patient with MRSA: not so much.  

It is well known that MRSA transmission is primarily a healthcare worker vigilance problem.  We can prevent the transmission of the potentially deadly MRSA bacteria from one patient to another.  How?  Washing our hands before and after any contact with our patient or our patient’s environment. Gowning and gloving. Attention to cleaning the patient-care environment. It requires a level of fastidiousness that borders on OCD.  But we can do it.  

Three or four years ago we had a significant Norovirus  (aka Norwalk) outbreak in our hospitals. No one wants to catch an   infectious diarrhea: it, too, elicits (both figuratively and literally) a strong visceral reaction in all who come in contact with the virus. Our adherence to best practices was so good during the Norovirus outbreak that our Medical Director of Infection Prevention and Control was able to report to the Quality Committee that no in-hospital transmission of MRSA occurred during this time period where we are so focused on infection prevention.  She attributed this success to our staff’s strong desire to not contract such a horrible case of the runs.  

Viral diarrhea and head lice - YUCK!   

Too bad we don’t feel the same way about MRSA transmission.  

Let's Get Physical

Recently my friend Peter told me about a workout he completed at our Field House.   

Peter is crazy fit.  Right now he is on the other side of the world on a five-week hiking holiday.  He runs, skis (alpine, backcountry, cross-country, heli...), hikes, portages, canoes...  This workout wasn’t really for his benefit.  One of his friends had a heart attack.  Once the crisis was managed, Peter’s friend was referred to Saskatoon Health Region’s Livewell Cardiac Rehabilitation Program.   One of the program requirements is that you need to bring a workout partner with you.  And that’s how Peter got to the Fieldhouse the other day. 

The Saskatoon Health Region Livewell Cardiac Rehabilitation program has a long history (over forty years!) of offering supervised graduated exercise to people with active coronary artery disease.  If you live within our health region, have angina or have had a heart attack, heart surgery, or heart stents, you will be referred to the Cardiac Rehab program which is supervised by doctors, nurses and kinesiologists.  Dieticians, pharmacists, physiotherapists, social workers, physicians and, probably most importantly, other people living with heart disease will support you.  You will learn how to safely increase your activity and exercise endurance all while working out at a world class facility. 

Saskatoon Health Region also offers similar programs for people with COPD, heart failure, diabetes, and strokes. And it’s affordable: $25 a month and for that you get to go three times a week. These programs have helped hundreds, if not thousands, of patients improve their activity levels, their health, and their quality of life.  What Peter pointed out to me that we don’t offer any similar preventative programs for all those people who don’t yet have a chronic disease.  You have to develop complications of a chronic disease before we encourage and support you.  A single drop-in rate for unsupervised use of the same Field House is $8.30.  A month pass is $67.  (BTW Clopidogrel (aka Plavix) is $100 a month in Canada.  Most patients with active coronary artery disease are on clopidogrel along with at least three or four other drugs). 

What if we prescribed exercise to our patients? This approach has been proven to be effective at increasing activity levels and quality of life.  Several communities in Alberta are starting to look at this approach also.  What if we chose to pay for access to a trainer, a dietician, a yoga class?  As they say, an ounce of prevention is worth a pound of cure.  It seems like we are coming at the problem of chronic disease management more than a little too late.  

12 years after his death, a mentor's lessons still live on.

Dr Anita Chakravarti is a colleague and friend of mine who provides leadership and energy to the Saskatchewan Living Well Physician Wellness Initiative.  This worthy endeavour is a partnership between the Saskatchewan Medical Association, the University of Saskatchewan College of Medicine  , and the Student Medical Society of Saskatchewan  . Anita is cataloguing work in this area; she recently asked me to write a few words about the Barrie Reynolds Memorial Lecture which is held in memory of one of my mentors, Dr Barrie Reynolds.  Barrie was my program director for most of the five years of my Anesthesiology residency.  Sadly, he killed himself in January 2000, shocking his family, colleagues and friends. Here’s what I had to say:

Dr Barrie Reynolds worked for over 25 years in the operating rooms, intensive care unit and delivery suites at Royal University Hospital.  He was an expert clinician and teacher.  He also had an unbelievably large and giving heart, always finding time for anyone in need.  Residents in particular would flock to Barrie if they needed advice, someone to listen to their story, or someone to go on the offense on their behalf.  Barrie also had a knack for seeking out those in need.  

Barrie made himself so available to all of us we thought we knew him as well as we let him know us.  Ultimately we all learned too late we didn't know Barrie as well as we thought. In spite of all his accomplishments and the love and respect of his family, friends and colleagues, Barrie had a silent struggle with depression. He committed suicide on January 4, 2000.

The Barrie Reynolds Memorial Lecture was created through the combined generosity of Barrie’s family and his colleagues at Royal University Hospital.  The lecture is held annually in January.  A guest speaker is invited to Saskatoon to talk about the art of medicine.  Past topics have included physician wellbeing, bioethics, professionalism, and diagnostic failure.  

Barrie died over 12 years ago but he left an indelible mark on hundreds of healthcare professionals who are working in Saskatoon and beyond.  He taught us to practice medicine to a high standard, to give back to our profession, family, and community, and that we are all vulnerable to mental illness.   

Flying the (Safe and) Friendly Skies

Last month I flew down to Regina on our local charter airline.  We buckled up, listened to the safety instructions, taxied to the runway....then taxied back towards the hangar.  Over the intercom the pilot explained he was unable to complete all parts of the preflight checklist so he needed to have his mechanics review the situation.   We all agreed this was a very good idea and got off the plane.  We were assured by the ground crew  that we would be either be back on the plane within short order or we would be moved to the next hour’s flight. 

Five minutes later we were back on our plane.  We again fastened our seatbelts and prepared for takeoff.  But what surprised and delighted me was the pilot’s next step.  He got out of the cockpit, faced us, and explained in plain language that he, his co-pilot, and mechanic had identified the problem (a switch needed resetting), executed the solution, and successfully completed the preflight checklist.  “Full disclosure!” popped out of my mouth before I could catch myself.  My traveling companions, both who also work within the health system, laughed at me.  

Why did this experience strike me as being extraordinary? I’ve experienced multiple similar delays with other airlines.  But I have never been so well informed about the presence of a problem, the proposed solution (including a Plan A and Plan B), and the complete resolution of the problem as I did this time.  I felt completely comfortable that all steps had been taken to ensure my safety.  I thought about how confident I was that all the right things were being done by this pilot, the mechanics, and the airline. 

Can we be confident our patients can say the same when they experience any delay, a complication, or a change in plans?   Sadly, I know the answer to that question is no.  We must keep working on creating an open, transparent space where our patients can feel the same way I did while flying with my team.  

You 5S'd Our Fridge

You 5S’d our fridge!

By now you may have heard Saskatchewan’s healthcare system is starting on an exciting Lean journey.  

Its all about creating value for the customer.  In healthcare, that means relooking at everything we do through the eyes of our patients.  The foundation of lean is eliminating anything and everything that does not add value to the customer/patient. If any step in a process does not add value for the patient, you are creating waste.  

We are in early days here, learning a completely different way to approach our work, whether it be as healthcare workers, administrators, system leaders or architects. We are also learning new words (want to poka-yoke a process, anyone?) concepts, tools, and approaches. If you walk around hospitals, clinics, and offices in Saskatchewan right now you might overhear conversations being held using this new language.  Sometimes this new language makes it home.

The other day I came home from the gym and headed straight to our fridge, expecting the usual shuffling of OJ, cranberry juice, costco-sized sweet chili garlic sauce, yogurt and a collection of stacked containers of leftovers to get to the milk I was craving.  I was amazed to find a clean, organized, spacious fridge.  “You 5S’d our fridge!” I blurted out, before realizing the right thing to say to my husband was a HUGE thank you! 

5S is a workplace organization tool that creates an efficient environment or process. Most often 5S is used to talk about transforming a cluttered workspace into a clean and organized place to work.   5S entails five disciplines all which start with S that together are used to transform a messy process or workspace into one that is streamlined. 

So without knowing it (he’s a natural at this), the five steps my husband used to create the beautiful fridge you see here were: 

Sort: Frequently used items (defined as at least one use every 2 days) were separated from those items used less frequently.  Anything not needed was tossed. 

Store: Standard locations for everything were defined with everyday staples kept in the upstairs fridge while everything else was moved to our underutilized basement fridge (which also underwent a thorough 5S).

Shine: Everything was cleaned, and all family members agreed to keep shining on a daily basis. (It is so much easier to do this when the sort and store steps have been completed for you!)

Standardize: Everyone needs to follow the new principles the same way. 

Sustain: Develop a system to make sure the gains of the first four S’s aren’t lost.  This is the hard part, but so far, we have sustained the gains!

5S is one of the key activities used across our province as part of Saskatchewan’s Releasing Time to Care Program that aims to improve the patient’s experience by focusing on the processes used by the care team. 

These two pictures clearly demonstrate the potential gains from applying 5S to a nursing unit storage room: 

So just as it is now easier and faster to find what I need in my kitchen (along with a whole host of other benefits such as inventory reduction combined with less food spoilage since we can see what we have and don’t have), nursing units across our province have reduced waste in their daily work by reorganizing their workspace and process using 5S.  

What other lean principles have traveled home with you? I wonder what a sensei’s house looks like! 

Need another reason to do the surgical checklist?

Today I bumped into the mom of one of my son’s friends.  She had recently had surgery, knew I worked in some of our city’s operating rooms, and had a question for me about her experience: “Are things always like that?”  My heart sank as I asked, “like what?” anticipating a complaint about the amount she spent at the hospital that day, or perhaps the confusion of the process.  

Instead, she said “Do the workers in the Operating Room always introduce themselves?  Do they always check so thoroughly that I’m the right person having the right surgery? I never knew how many people were on my team!”

Oh, you cannot imagine my relief when I realized she was asking about the Checklist!  I happily explained we have been working on implementing the surgical checklist for over 18 months.  And that it is “mandatory” in all operating rooms in Saskatchewan since March, 2011.  And that I’m VERY proud to say that our current performance is 96.2% across Operating Rooms in Saskatoon Health Region.  Not just the main ORs but also our Labour and Delivery operating theatres, our Women's Health Centre, and our surgical suites in our rural regional hospital.   And just to brag a little more, we strive for perfect care with our checklists: to be compliant in our health region means we do all of the three components (checklist, which is done 99.4% of the time, timeout (99.4%), and debrief (97.2%)) with the attending surgeon, anesthesiologist, an operating room RN, and, most importantly, the patient.

She shared with me she had been in an operating room once before and remembered feeling overwhelmed by the process, the number of strangers in the room, and the feeling of not knowing what was going to happen.  But this time, she said, was completely different.  She felt calm, safe, and confident.  She really liked knowing why each person was in the room, and that they, too, had a first name.  She felt she was part of the team, and was in fact the most important person in the room.  

This person underwent what we in the medical profession would call “minor surgery” (ask the patient, there is no such thing as “minor” surgery). Very simple, not a lot of steps, no need for preoperative antibiotics, VTE prophylaxis or special instruments.  The sort of case where you might wonder whether the implementation of a surgical checklist would have a large impact.  But for this patient, using the checklist made the difference between feeling overwhelmed and scared, and feeling calm and in control.  

That’s reason enough for us to make sure we really, truly, with heart and commitment, do the surgical checklist.  For every patient, every procedure, every time.