Primum non nocere – First Do No Harm

It’s no secret that hospitals can be unsafe places. It is reported that every year in the U.S. 200,000 people die from hospital acquired medical errors or infections. That means that a patient is 33,000 times more likely to die from hospital acquired harm than in a plane crash.  This is unacceptable and Saint Francis is doing something about it.

At the core of our calling is to ‘First do no Harm.’ Every physician I’ve met over the past 20 years adheres to this professional mantra. We want to help, not harm, our patients. We carefully consider our treatment decisions. Sometimes ruminating about our choices, especially if the outcome for our patient was not what we had intended. We do inform our patients of the potential for harm as a result of our interventions, but all of us hope for and fully intend to avoid them.

We own these individual patient risks as physicians. But we are embedded in a system, and the system imposes its own challenges and risks upon us and our patients. Astute clinicians and administrative leaders recognize that system errors and inefficiencies lead to harm, not necessarily the decisions or actions of any one individual. Other industries have acknowledged this reality and have been working to find and fix these errors for decades. These include the aviation and nuclear energy industries as well as the U.S. military. The result has been a remarkable reduction in deathly errors and the emergence of high reliability science. What has been learned in these other industries can be translated into health care. The results will be safer care.

With the help of CHI, Saint Francis Medical Center is one year into a cultural transformation that is being fueled by high reliability science branded as “SafetyFirst.” All Saint Francis employees have undergone initial training and have begun to use numerous safety techniques to help create a culture of safety. We have already seen a reduction in common errors as a result. For example, the near elimination of mislabeled specimens and the elimination of orphan EKG’s. The newly created SafetyFirst infrastructure, data collection, and analysis has provided insights to our global care that we did not have access to before. After reviewing three years of incidences, a top ten list of common process challenges has been identified. Teams are actively working to fix these process weaknesses. We are learning and patient care is improving.

Physician awareness and participation is critical to the ultimate success of this cultural change. Without us, the transformation will be incomplete, and patients will suffer harm. With us, the organization will continue on its journey to truly exceptional care, and our patients will reap the reward.

This month there will be two opportunities for physicians and providers to obtain CME credit for learning more about high reliability science – SafetyFirst. Additionally, if unable to attend in person, a video recording is available for viewing.

In my opinion SafetyFirst is an excellent example of where the three major ‘tribes’ of health care – nursing, administration, and physicians – are drawn together by our passionately shared and common goal of taking exceptionally good care of patients. While we each come to the table from different and valuable perspectives, we unite together to first, do no harm.


At the most recent quarterly medical staff meeting I presented the results of the physician’s satisfaction survey, the focus group, and my responses to the information provided.  Part of my response was directed at SFMC’s past effectiveness at implementing change efforts. Most often, both in the focus group and from direct communication with physicians, this has been relayed to me in a simple statement: “Nothing ever changes.” Usually that comment comes with frustration, because the physicians want things to improve. That’s a good thing. It means physicians care.

My observation is that SFMC is eager to improve anything for the patient. Likewise, the organization, meaning staff and management, want to please the physicians. They care deeply about what they think and want to be responsive and helpful.  This is a good thing. It means the organization cares.

It’s a puzzling paradox. Physicians and the organization want things to improve for the patient.  Clearly, things stay the same (if they do stay the same) not for want of desire for change.

Another premise offered by some physicians is that there is an ability deficit. It’s not that there is a lack of desire by SFMC but a lack of management skill in pulling off change. I disagreed. If that were the case, then we wouldn’t see improved patient satisfaction scores (now exceeding the 94th percentile in the HealthStreams national database), or core measures (a 6% increase improvement in 12 months), or new technology, physician services, and any number of adaptations to the ever changing healthcare environment. These things did not occur by happenstance. It took leadership to pull it off.

I don’t think it’s about ability or willingness. Simply put, most change efforts fail. They fail for everyone, in every business, including healthcare and Saint Francis. Change management and leading change are topics of textbooks. But there are key sequential steps which must be achieved in order for change to be successful and be sustained. [1] The textbox shows eight steps which must be followed sequentially in order for change efforts to be successful and to stick.

Kotter’s 8 Steps of Change

1) Create urgency
2) Form a powerful coalition
3) Create a vision for change
4) Communicate the vision
5) Remove obstacles
6) Create short-term wins
7) Build on the change
8) Anchor the changes in Corporate Culture

Think about your past experiences with major change efforts in your clinic or at SFMC. If you think of a success story, you’ll see how these steps were applied. If you think about change efforts that didn’t stick, you’ll where steps were missed.

When I hear about problems that “never change” at SFMC, it tells me that what needs to be changed is difficult and complex. These are issues that will require substantial contribution from all involved, persistence, and attention to the realities of change. Most often, as clinicians, we are tempted to shoot from the hip, give an order, or tell someone to fix something, and move on. We are trained to think this way and act this way. But that doesn’t serve us well when we are attempting to deal with complex, large problems. Then it becomes more like internal medicine than surgery; requires a rigorous scientific method-based methodology, involving teams made up of multiple disciplines, and leadership attentive to the realities of the 8 steps of change.

This reality is part of the reason why I continue to appeal to physicians to roll up their sleeves and participate in major change efforts. Without exception, physicians are part of the “powerful guiding coalition” step. Without you, change efforts will fail. With you, we have hope and opportunity for moving forward and addressing those things that have ‘never changed’ before. Join us in the journey to exceptional patient care.

[1] Kotter, JP Leading Change: Why Transformation Efforts Fail, Harvard Business Review, Jan, 2007 #R0701J-PDF-ENG

How the Accountable Care Act Changes Everything

 The idea of bundled payments – paying a set dollar amount for an episode of care – is not new. In the early 1990′s, CMS sponsored a demonstration project. It was successful at reducing costs. Since then several other projects have demonstrated the same results.

The accounting is pretty straight-forward. CMS calculates an expected cost for an episode of care, around a specific condition or surgery. They negotiate a specified time period that defines the episode, and then agree to a payment amount that is a few percentage points below the expected cost for that episode. If the actual cost for an episode is less than the negotiated price, the provider pockets the difference; if the cost exceeds the negotiated price, the provider eats the loss. Providers assume the risk, not CMS. In this scenario, CMS wins because they realize a cost savings, and, if the provider is sophisticated, understands the drivers of cost, and works to reduce them, they can do well. Patient’s win because costs are reduced, quality is maintained, and providers stay in business. 

While these demonstration projects have been win-wins, before they could be spread nation-wide, CMS had to seek congressional approval. This is where things became difficult and lobbyists realized their opportunities.

In healthcare, every dollar of cost reduction is someone’s paycheck. I don’t think that’s absolutely true, but the beneficiaries of an inefficient, high cost system definitely know a threat when they see one. They made certain that these demonstration projects never received congressional approval. For the most part these projects have sat gathering dust on a shelf for the past twenty years.

The Patient Portability and Accountable Care Act changed this situation. CMS was granted permission to establish an innovation center and to spread changes from pilot programs to a national level without congressional approval. Therefore, when projects show success, we can expect rapid and nationwide implementation.

 Many experts believe that bundled payments, now in the early stages of piloting, will be successful. Some expect rapid, nationwide implementation of this payment model as early as 2015.

 If that happens, everything changes.

Related Reading:  The founder of LeapFrog’s perspective on payment reform.  


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When leaders listen, they learn.

I want to thank John Wagoner. He spoke. I listened. And I learned something important about organizational communication.

Soon after my arrival at SFMC I observed an opportunity for improved communication to physicians. Information is the lifeblood of effectiveness. We are relying on mailboxes and quarterly staff meetings to share our most vital information. Like coarctation, relying on these two channels alone severely restricts the free flow of information and subsequently hampers our ability to adroitly adapt to our changing environment. This concerned me, but John expanded my understanding of why we should be concerned.

 He shared that one consequence may be the unintentional creation of an ‘in the know’ group and a ‘not in the know’ group. One group more involved and the other less so. One group is more aware, the other unaware. Therefore, one more amenable and adaptable to, and the other surprised by, change.

Because some see surprise as equivalent to resistance, over time, some individual physicians or physician groups are labeled as “trouble-makers” or “resistant.” Preconceived perceptions of participatory unwillingness hamper communication – people are more reluctant to interact with them – creating the proverbial negative feedback loop.

We need to be careful. Incredulity is not equivalent to resistance, especially if the response is due to a lack of information. And if the lack of information is because there are structural deficiencies, such as a department that no longer meets, then we need to take ownership of those deficiencies and correct them.

Divisions are critical communication distribution channels, and provide fertile ground for peer-to-peer education, accountability, communication, and leadership development. Without them, we create an organization that favors false labels and significantly hampered adaptability.

We continue to expand communication channels to physicians. This blog is one example. But we also need to make certain that the formal organizational structures support the adequate exchange of information.

Thank you to John Wagoner for the illumination.


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Sideways Corduroys and Disruptive Innovation

 I read those back-of-the-airplane-seat magazines. I never used to, but then the Kindle happened, followed by the IPad. You can’t use electronics during takeoff, so I pull the magazines out. I’m now a back-seat magazine connoisseur. If the Kindle and IPad hadn’t happened, I would be less educated. Trust me, you can learn some stuff. Like, who’s the world’s best Sushi chef .

Another example. What do you know about sideways corduroys? They reportedly reduce drag by an amazing 16.24%. And the company, Betabrand, created a market out of people who were never interested in shopping for clothes. Like many other disruptors, it started in a basement, on a laptop, by someone who had no experience in and knew nothing about the clothing industry. He had no idea that you were supposed to create clothes seasonally, to own warehouses stocked with inventory, to replicate fashion designers.

The company doesn’t use models to show their clothes, they use real customers. They communicate via FaceBook, Twitter and other internet-based solutions, and not mass media. They rapidly respond to ideas their customers offer. They individualize. They are decoupled from the established industry.

They don’t think outside of the box, they are outside of the box. So far out that they seem careless about what was supposed to be. The established industry is irrelevant. They saw a need and met it.

There’s a lesson for us in healthcare. It’s not a matter of if, but when. Because we are expensive, are frequently inaccessible to patients when they want and need us (Report Card), aren’t really patient-centered, have not moved into the 21st century, someone will begin building a new way of doing healthcare. It will be cheaper, more accessible, and will support and improve health. Patients will prefer it.

When this happens, it will not look like anything we’ve known for 100 years. It will be consumer-driven and not provider-centric, far less institutional and more home-based. There will be substantial non-professional self-care (read: less professionals), digital, mobile and increasingly virtual.

General Eric Shinzeki is reported to have once said, “If you don’t like change, you will like irrelevance even less.”

I can see some of the smirks and hear the guffaws. Like us, that’s just what the aristocracy was doing at a dinner party the night before July 14, 1789.  It’s just about as funny as sideways corduroys.

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Serendipity, Sushi, and Sitki

I happened to bump into Sitki Copur in the Grand Island airport. He was flying to Dallas, I was on my way to Boston. The meeting was pleasurable serendipity. Sitki is the consummate physician-scholar. We shake hands, he flashes his distinctive unassuming smile, and I feel welcome and appreciated. If it hadn’t been for an article about Sushi the greeting would have remained nothing more than notably nice. Sitki and the story highlighted for me a critical element of effective physician leadership

Jiro Ono owns and serves Sushi at Sukiyabashi Jiro in Tokyo. He is world renown. His ‘restaurant’ seats 10. To get a seat you have to make reservations more than a month in advance. You pay a minimum $390 for 20 pieces of sushi. That’s at least $19.50 per small piece of cold fish. This begs the obvious question: Why? The answer: Perseverant Passion.

Jiro Ono is 85 and he dreams about how to make sushi better. He’s done that for 60 years. He says, “While I’m making sushi, I feel victorious.” He has found his True North.   Hopefully the Saint Francis Cancer Treatment Center team, like Jiro Ono, feels victorious. They have a perseverant passion, Sitki has found hisTrue North, and our patients have reaped the reward.

Passion makes all the difference. The oncology team received yet another highly prestigious recognition: certification by the Quality Oncology Practice Initiative (QOPI®), an affiliate of the American Society of Clinical Oncology (ASCO). Cooperative, effective, team-based leadership and a relentless focus on continuously improving patient and family-centered care is what led to this accolade. A physician leader in partnership with other healthcare leaders is a powerful amalgam. It almost always results in just the sort of high quality healthcare patients deserve. And this, in of all places, happened in Grand Island, Nebraska, where sushi is rare, less expensive than Sukiyabashi Jiro, and really good at Wasabi.

There are many days I wonder, “What kind of care would patients receive from us if we all embraced our True North our own perseverant passion?”

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Welcome to something new. Not new in the sense that others haven’t already made this part of their daily life, but new to Saint Francis, and new to me.

On occasion, hopefully several times a month, I plan to post some thoughts regarding health care, broadly speaking, and how these thoughts may play out within the context of a rural midwest community, its medium-sized hospital, and the broader healthcare infrastructure. The  audience is my colleagues and peers;  very bright, hardworking physicians and other clinicians, who are caught up in a rapidly changing contextual environment that is at the same time disruptively challenging and also full of eye-popping opportunity.

I suspect there will be a wider spectator audience, which is fine. My hope is that you all find something interesting; sort of Saturday-morning-with-coffee interesting. Perhaps we’ll have a brief dialogue through your comments on the blog, or you’ll be motivated to click on the hyperlinks and learn more. Enjoy.