In the December 2010 issue of The Hospitalist (p. 43), I started the discussion of “The Story of Us” by outlining three threats that could limit our effectiveness in realizing our vision of quality and patient safety. The story continues here, with four additional threats to the culture of quality that is our mutual dream.
Threat 4: Strategy Trumps Tactics and Execution
There is no shortage of “strategery” in the context of healthcare reform, and it is tempting to succumb to the idea that the correct strategy automatically translates into intended results. But anyone who has suffered through a high-school rendition of Hamlet knows that while Shakespeare’s words might be the same, it is hardly a Broadway performance. Put another way, what is written in the coach’s playbook is the first step; execution of the playbook is what wins or loses the game.
Chan et al’s article “Delayed Time to Defibrillation after In-Hospital Cardiac Arrest” makes this point.1 I doubt there is any physician who does not know that defibrillation is indicated in a cardiac arrest, but as the article illustrates, it took more than two minutes for 30% of patients with in-hospital cardiac arrest to be defibrillated. The upshot: If you have a cardiac arrest, you might be safer in a casino than you are in a hospital.
Healthcare reform and the expanding literature in patient safety and quality bring us closer to having the strategy we need, but what lags is execution of that strategy. Tactics, not strategy, is our greatest deficiency now. And while strategy can be designed for virtually all hospitals, tactics rest with each individual hospital, as each individual hospital system is unique.
Enter again the importance of the hospitalist: the physician intimately aware of the intricacies of their hospital system. There are reasons that defibrillation might be delayed in an individual hospital; perhaps it’s the location of the code cart, perhaps it is how patients are determined to need telemetry monitoring, perhaps it is the line of communication between telemetry and the responsible physician. But whatever the reason, it is not likely to be the same for all hospitals.
And here is the new challenge for the hospitalist: Discover the unique systems deficits in your hospital that prevent the perfect strategy from translating into perfect results.
Threat 5: Focus on One Component at a Time
The essence of systems-level change is simple: In a system, changing one component has effects (good or bad) on other components of the system. Unfortunately, our healthcare systems continue to exist in silos, with few people in leadership positions who are empowered with a perspective of the system as a whole.
Case in point: the yin-yang of length of stay (LOS) and hospital readmissions. I doubt there is a hospitalist who has not heard the words “discharge by 11 a.m.,” in large part because of the hospital truism “every medicine bed is a wasted ortho bed.” Patients who leave by 11 a.m. open up more beds for patients coming out of the operating rooms, and that translates into more surgical procedures. But discharge by 11 a.m. is not as simple as it appears. A sound discharge decision that does not result in readmissions is predicated upon multiple components of the system: results from diagnostic testing have to be obtainable early, the physician must not be dual-tasked during the early hours (e.g. receiving patients from the ED or ICU, performing procedures, etc.), and communication with the family and PCP has to be established early.
The hospitalist thus finds herself stuck between the proverbial rock and a hard place: Discharge early (i.e. before you are ready to do so safely) but ensure that patients don’t come back. There is no easy answer to this potential dilemma, except to say that the solution rests with people who do have a systemwide perspective. To this end, it will be the hospitalist “on the ground,” familiar with the need to prevent readmissions but sensitive to the need to discharge early, who will have the unique insight to design solutions, for all elements of the hospital system, that ensure meeting both ends.
Threat 6: Ignoring the Adaptive Unconscious
Think about whether this has ever happened to you: You finish a busy day at work, with many thoughts still on your mind as you begin your car drive home. Thirty minutes later, you find yourself sitting in your car in your driveway, wondering, “Wow, how did I get home? I don’t remember that drive at all.” Such is the benefit of what Timothy Wilson in his book Strangers to Ourselves calls the “adaptive unconscious.” See it as the mind’s ability to go on “autopilot” to accomplish repetitive tasks without requiring conscious thought, freeing up the mind to devote mental energy to something else. It’s adaptive, of course, because without it, it would be impossible to do any physical activity (i.e. collecting your wallet and keys as you leave the house) while simultaneously doing another activity (i.e. talking on the cell phone as you leave the house). The danger, however, is that tasks that are performed by the adaptive unconscious autopilot are quite inaccessible to the conscious mind for inspection and improvement.
Now consider this example. Have you ever seen a patient in the ED, sat down at the nurses’ station with the chart (contemplating all that needs to happen for the patient’s care), only to look down a few minutes later to see a fully completed set of admission orders? And you say, “Wow, how did these orders get done? I don’t remember writing these at all. Well, thanks for that.”
The focus of the quality- and patient-safety movements has been on changing the physician’s “conscious mind” decisions. But the reality is that the vast majority of what we do in our daily lives is performed without conscious thought. You can’t begrudge it, because again, without it, you would be paralyzed. But it has profound implications for the goal of advancing quality and patient safety in our practice of medicine.
There are two points to make in the context of this discussion. First, the adaptive unconscious is not a magical gift; it develops as a product of our repetitive tasks. You can make that drive home, or write those admission orders, without conscious thought only because you have done it hundreds of times before. And here’s the implication: Much of the behavior that is not conducive to optimal patient safety is a product of what we have done for the past five years. And what we do now in changing physician behavior has implications not only for today, but also for what we will do five years from now.
With this in mind, the bad decisions that result in adverse events do not concern me as much as the bad decisions that do not result in adverse events. The adverse outcome has enough drama to immediately bring the decision into the realm of the conscious, making it accessible for the physician to change behavior. But a bad decision (call it a “near miss”) that does not result in an adverse outcome remains inaccessible to the conscious mind. And should the bad decision be repeated again and again, it would insidiously become integrated into the adaptive unconscious, forever coloring the physician’s delivery of care.
The scary part of the adaptive unconscious is that it is inaccessible to the conscious mind because it is unconscious. But there is a way to modify the adaptive unconscious: reflection. I am not advocating candles, incense, and Kenny G. But reflection on physician behavior has to occur, and it must be much more than just focusing upon the adverse events (which, by virtue of being adverse, are fully in the conscious mind). Reflection that meaningfully changes unconscious behavior has to be focused upon what seemingly didn’t happen. It is a step-by-step analysis of a physician’s performance in ordinary time.
Put another way, every quarterback in the NFL leaves the football game thinking about the interceptions thrown (the dramatic mistakes), but only by virtue of reviewing the game film does he become aware of the interceptions he almost threw. Unlike the NFL quarterback, the hospitalist does not have the luxury of reviewing game film, but the need for reflection on the “near miss” events is no less important.
This takes time, and it likely takes an element of external discipline that the ordinary physician cannot provide for himself. Time is addressed in the next threat, but see the summary of this discussion as simply this: In the face of the prevailing culture of peer review and RCAs, there has to be equal attention paid to finding time and structure to reviewing a physician’s performance in the absence of adverse events. Perhaps this is structured alone time; perhaps its structured time with other hospitalists as a group discussion—I don’t know. But some element of reflection in the absence of “what went wrong” has to occur, lest we find ourselves in 2020 repetitively responding to adverse events, wondering why in 10 years’ time, the number of adverse events has not appreciably diminished.
Threat 7: Failure to Optimize Efficiency
Our story began in 1999 with a focus on hospitalists improving efficiency. The second chapter of our story, of course, has been on improving quality and patient safety. Interesting, isn’t it, that we find ourselves where we began? For Chapter 3 begins again with a focus on improving efficiency, not for financial ends, but for the meaningful enactment of quality and patient safety. Two points make the case.
If I were reading the discussion above, and not writing it, I am sure I would have your same response: “Great, more things (reflection time) to do with a fixed amount of time, and no additional money. Thanks for another unfunded mandate.” The reality is that until we get to an ultimately inspired healthcare system, there is unlikely to be financial support, or a discounting of RVU expectations, to support reflection. So with a fixed amount of time, and increasing activities to fit into that time, there is only one answer: We must become more efficient.
Taiichi Ohno, Toyota’s chief engineer, described what are essentially the bones of “LEAN” in optimizing efficiency. The challenge before us, despite what we have already done, is to further eliminate the “Muda”: activity that does not add value. Not only will this save money, but it will also create the additional time necessary for reflection, which is in turn requisite for a meaningful culture of patient safety and quality.
But there is another reason, one that makes improved efficiency essential in advancing patient safety. In the early part of the century, Yerkes and Dodson published the performance vs. stress curve.2 Like preload to the heart, the authors postulated that performance (on the Y axis) was related to stress (on the X axis) in a rainbow curve. With very little stress, there was very little performance. As stress increased, so did performance, at least to the inflection point on the rainbow curve, after which too much stress led to decreased performance. If you have ever stared blankly at a computer screen trying to formulate a response to the simplest of e-mails, you have experienced both tails of the Yerkes-Dodson curve.
I suspect that there are few hospitalists faced with the problem of “not enough to do,” but I equally suspect that more and more hospitalists are finding themselves farther and farther to the right side of the Yerkes-Dodson curve. After the inflection point, with more and more stress comes less and less performance, a phenomenon felt in every performance-based career.
The bottom line is this: We have created more and more things for the hospitalist to consciously think about in ensuring patient safety and quality. If you had an index card for every guideline/core indicator/standard the hospitalist was supposed to remember, the stack would be 6 inches thick. And this list will only grow with time.
However, these admonishments “to the conscious mind” only improve performance if the physician has enough time to consciously think about each of them. If there is not enough time, then the physician’s mind reverts to the adaptive unconscious, which, because these QI measures have not been a part of his practice for the past several years, is unable to enact them. It’s captured by the simple sentiment when your patient has a DVT: “Wow, I knew to do that, but it just slipped my mind.” Moving too far to the right on the Yerkes-Dodson curve is more than just a risk for burnout; it has serious implications to ensuring that we design a strategy in quality and patient safety that actually comes to fruition.
And that’s Chapter 2 in the story of us: the need to ensure that our tactics and execution remain as important as our strategy, that one element of the system is never treated in isolation, that reflection on ordinary practice becomes a habit, and that efficiency remains a priority. TH
Dr. Wiese is president of SHM.
- Chan PS, Krumholz HM, Nichol G, Nallamothu BK; American Heart Association National Registry of Cardiopulmonary Resuscitation Investigators. Delayed time to defibrillation after in-hospital cardiac arrest. N Engl J Med. 2008;358(1):9-17.
- Yerkes RM, Dodson JD. The relation of strength of stimulus to rapidity of habit-formation. J Comparative Neuro Psych. 1908;18:459-482.