Raising expectations in healthcare: Scotland NHS central line infections bottom out

All truth passes through three stages. First, it is ridiculed. Second, it is violently opposed. Third, it is accepted as being self-evident.

     - Arthur Schopenhauer

My son and I were browsing through the electronics store yesterday.

He picked up an Amazon Kindle e-reader and tried to make the text scroll by touching the screen.  He was puzzled when it didn't work.  We discovered that this model had button controls.  That is so 5 minutes ago!

He's used to touch-screens through playing with his brother's iPod Touch and Grandma's iPad, so he's come to expect that every electronic device works that way.  It's like the classic scene in Star Trek IV, when the crew goes back in time and Scotty tries to use an early-model computer:

As Schopenhauer predicted, Scotty is ridiculed for having expectations (his "truth") beyond what was thought possible in that era.

Last week, at the IHI National Forum, I had my expectations raised by someone else's truth.

Jason Leitch, NHS Scotland's National Clinical Lead for Quality, gave an energetic presentation about Scotland's healthcare quality strategy and results.  One slide stood out.  It showed the drop in central line infection rates since 2008.  The March 2011 data point was annotated "zero central line infections in whole country".

Entire country of Scotland.  Central line infections. None.

It's like getting rid of polio or smallpox.

I was imagining what it must be like to be a physician inserting a central line, or a nurse caring for one, in Scotland.  The motivation to follow standardized protocol meticulously must be tremendous.  The country's reputation is on the line!  Expectations are sky-high.

What if patients and families in other countries found out that central line infections can be avoided?  If they got hold of Scotland's data and the care bundle they use, expectations everywhere would be sky-high.  Then, after the ridicule and opposition (from healthcare professionals), it would become self-evident that these infections are a defect in care, and not inevitable.

Central line infections - how quaint!

Give the people what they want! I'm experimenting with social media

I had the privilege to act as host for some of the Saskatchewan participants at last week's IHI National Forum.  As the organizers planned the trip, we discussed ways to communicate with each other while at the conference.  It's a huge venue with over 5000 attendees, so keeping in touch can be challenging.

We decided to try Twitter.  I was a little nervous as I had never tweeted before.  As you can see by the newly-added Twitter feed in the right column of this blog, I've become a convert.

Not everyone signed up for Twitter, but those who did found it very useful.  We were able to arrange impromptu meetings and share pearls from the sessions we attended.  We also made a fortuitous contact with Paul Levy.

You may be familiar with Paul Levy through his blog "Not Running a Hospital" (formerly "Running a Hospital").  As CEO (now retired) of Beth Israel Deaconess Hospital in Boston, Levy pioneered transparency by blogging about his hospital's complication rates.  He noticed that Sask IHI attendees were actively tweeting (hashtag #saskihi11) and tweeted his way to joining us for dinner.

It was a terrific opportunity to meet someone who has been a leader in using social media in health care.  As it turned out, Levy was IHI's social media guru-at-large, and conducted several well-attended sessions on using Twitter, Facebook and blogs.

His recommendations for bloggers got my attention: 300 words 3 times a week.  Levy suggested that frequent, shorter blog posts were more palatable for readers than infrequent, longer pieces (my usual style...).

Here's my next social media experiment: I would like you to tell me which form you prefer.  In the right hand column, I'll post a survey that will stay up for the next few days.  If there seems to be interest in more frequent posts, I'll do my best to change things up for several weeks, then repeat the survey.

Thanks for your help, and thanks for taking time to read this blog!

Surgical checklist - Trying some changes I learned at IHI National Forum

"What can we do by Tuesday?"


You'll hear this phrase a lot when you're at the IHI National Forum, or similar QI events.  It's shorthand for:

 "We're all really excited about the possibilities for improvement that we've talked about.  We have the will to change and we've come up with some great ideas.  But, now comes the hard part: execution.  Once we all get back into our regular work lives, the enthusiasm we're feeling right now can be swept away by the relentless current of clinical tasks.  So, let's deliberately think about execution right now, before we're distracted by our "real work".  What can we try out first thing next week?  Let's make a commitment to a test of change, but make it a small one.  Try it one time, with one patient or colleague."

I made one of those commitments, but I couldn't wait for Tuesday.

While at last week's IHI meeting, I had attended several sessions discussing the surgical safety checklist.  All the speakers emphasized that the real value of the checklist in promoting communication and team building among OR staff.   So, while checking on antibiotic administration and the correct side for the procedure are critical, the checklist holds potential for a deeper benefit. 

The speakers talked about creating a "psychologically safe" environment in which everyone in the OR theatre has permission - in fact, is invited (required?) - to raise any concerns about patient safety. One surgeon told the story of a medical student who called a stop to preparation for surgery because he thought the patient's wrong ear was being operated on.  The staff reviewed the patient's record and determined that they were operating on the correct side, and the medical student was mistaken.  However, the surgeon praised the student for his courage and commitment to patient safety, and asked staff to applaud the student!  Now that's dedication to psychological safety!

In Saskatoon Health Region's current checklist, there's no explicit invitation to speak up like this.  The first version of our checklist began with having all staff in the room introduce themselves to each other and to the patient, but that component was dropped.  I wanted to try reintroducing that element, and also adding a personal invitation to everyone in the room to raise patient safety concerns. I decided to try it Friday (yesterday) morning, with one case. I planned to collect the staff's impressions of the expanded checklist after the surgery was completed.

I started by telling everyone in the room (an anesthetist and 2 OR nurses) about the IHI meeting and what I wanted to test.  We discussed this before we brought the patient into the room.  They agreed to try it.  


Once the patient joined us in the room, I explained that we would do our usual surgical checklist, but that we were also going to add the 2 elements.  We introduced ourselves by name and role, and I invited everyone to use the phrase "I have a concern..." if they had any safety concerns.  


After the surgery was finished and the patient went to the recovery room, we discussed the trial.  (Coincidentally, the nurses had talked about this issue at morning report, so it was fresh on their minds.)  Everyone was keen to have the introductions, particularly as there are often students, residents or other trainees in the room, and this is a way to be sure that everyone know everyone else, as well as their role.  The idea of the safety phrase was also well-received.


Next week, I'll try this again in a new room.  I'll likely be working with a different team. As the idea was well-received yesterday, I don't anticipate having to "sell" it by giving the IHI story again.  What I'm really interested in is the day when someone uses the "I have a concern..." safety phrase.  How will I respond to that interruption?  Will I ensure psychological safety?


Also, I'll be vigilant for occasions where someone could have used the safety phrase, yet didn't.  I suspect that will be the more common situation.  That could happen because of differing views on what a "patient safety concern" is, or because staff don't yet trust that I will be receptive to them raising a concern.

IHI lightning strikes again!

Before I left home for this week's IHI National Forum, I wondered if I would have as dramatic an experience as I did at my first IHI visit.  I'm not sure if you're allowed more than one epiphany.

5 years ago, the National Forum changed my career.  Seeing better ways of providing care, and learning the tools to implement those changes led to the improvement work our practice has undertaken.  It led to the chance to meet QI enthusiasts across the country.  It led to this blog.  So, I had high expectations that something at this year's meeting would show me yet a new direction for my QI journey.  

Until yesterday afternoon, I had been disappointed.

I've heard some incredible stories from presenters at the Forum, but they are all variations on themes I've heard before.  I was hoping for something earth-shaking.  

Then, I started hearing stories from other Saskatchewan attendees.  We're over 30 Saskatchewan-strong at the Forum, and to a person, thrilled to be here.   First-time attendees are enthusing about their experiences, like I did at my first visit.  They're talking about testing change ideas at home next week.  They're also anticipating some of the barriers they'll face: lack of time, inadequate resources, no team support.

That's when it struck me: The next step for me is to support others' work.  Making connections. Smoothing paths.  

Working on improving one practice has been satisfying; playing a part in improving many practices... I can hardly wait!

 IHI - you did it again!