Shooting for "Sensemaking" in Health Care

Despite my lackluster sports careers in tennis and Ultimate Frisbee, I am a huge sports enthusiast. In college, I was introduced to basketball. My hometown team, the Miami Heat had just fought their way to the 2006 NBA Finals. Like any good fan, my eyes were glued to the TV every game against the Dallas Mavericks. I gasped at every missed shot, held my breath during every free throw shot, and cheered for every point scored. The Miami Heat's journey to the championship was epic and I have been enamored with them ever since.

However, since winning the NBA Championship in 2006, the Miami Heat have really tried my devotion to them. In the 2006-2007 season, my team was riddled with injuries and inopportune player absences. Shaq had promised us a repeat championship, but the end result was far from that. The Miami Heat instead became the first defending champion since 1957 to get swept out of the playoffs in the first round following a championship season. Disaster only continued in the next season with major roster shake-ups. The Heat made history again by ending the season with the worst record in NBA history: 15 wins and 67 losses. When the Miami Heat came to Boston that year, they set another new record: the fewest made baskets in a game (17). I left the game with the feeling that I should have worn green and that it was time for me to switch my allegiance to the Boston Celtics, the team of my new home.

But, things began to turn around in the next year. The Miami Heat began rebuilding the team around superstar Dwyane Wade and the new talent joining the Heat gave them new energy. This year, they are seeded 5 in the Eastern Conference and face the Boston Celtics in the first round of the NBA Playoffs. However, their tumultuous journey to Game 5 (today) serves as a reminder of how unstable my beloved Miami Heat are. While watching Game 4 last Saturday, I could not help but think of the work of Karl Weick, Rensis Likert Distinguished University Professor of Organizational Behavior at the University of Michigan Business School. Thankfully, on Saturday, the Miami Heat, down 3-0 in the best of seven series against the Celtics, beat the Celtics 101-92 to force a Game 5 (today).

As much as I love the Miami Heat and have faith in Wade's athletic prowress, I am not hopeful about tonight's game. Using Weick's own words, the Miami Heat are not a high-reliability organization, an organization that operates under very trying conditions all the time and still manages to have fewer than their fair share of accidents, but should be.

The conventional way of thinking paints organizations as stable and secure structures or institutions. Referencing and extrapolating from the intelligent design movement and the watchmaker's analogy, the conventional organization is one that was carefully designed and left to operate and survive against all subtle and radical changes. However, Weick believes that organizations are alive and dynamic. At all times, they "chat, dissemble, disguise, mobilize, and galumph." In an ever-changing reality, these dynamic organizations possess the ability to change, anticipate, react and adapt to the unpredictable and unexpected.

It's not difficult to see the Miami Heat as such a dynamic organization. Each player is a member of the organization and in the game, they are acting, communicating, and reacting to whatever play the opponent team throws their way. So, why is the error rate or number of losses so great? How did the Miami Heat slump so low after winning the NBA Championship? Looking back at my abridged account of the Miami Heat's recent past, you will notice significant unpredictable changes made to the organization: injuries, roster changes, coaching changes...and those are just changes within the organization itself. Every opposing team experiences such changes and brings those with them to the game. These are external changes. For organizations like the Miami Heat, as Weick describes, "when the unpredictable happens, and the world as we know it unravels, we are all the more likely to become so paralyzed that we cannot survive the experience."

In my own unqualified opinion, the Miami Heat have been operating as a flawed and rigid organization. Its world-view relies heavily on Dwyane Wade and his ability to carry the entire team to victory. When the Miami Heat won the NBA championship in 2006, it was Wade who scored a series of clutch points to edge the Miami Heat past the Dallas Mavericks. The writing was on the wall, so to speak, in regards to Miami's rigid reliance on Wade. In the following season, Wade briefly injured his wrist and then seriously injured his shoulder. In the season where the Miami Heat dropped to its lowest point, Wade was obviously rusty from his injuries. Who charged the Miami Heat forward to win Game 4 and stay in the playoffs this season? Dwyane Wade. He scored 46 points alone. Of course, Wade has had the help and support of his teammates, but not enough since the NBA championship line-up to really call the Miami Heat a team. The Miami Heat since the 2006 championship has been a one man show. Taking a look at tonight's game, what do the Celtics have to do to overcome the Heat? Study and adapt to one man and according to news reports, they did just that. The Celtics spent three times more time than usual watching film to prep for tonight's game. If I was a betting woman, my money would not be on the Miami Heat to win tonight.

What can the Miami Heat do to become a high-reliability organization? It needs to develop its, as Karl Weick calls it, sensemaking abilities. Sensemaking is the process through which the complex and unpredictable world is given order, within which people can orient themselves, find purpose, and take effective action. This sensemaking is achieved through two other Weick concepts called mindfulness: the ability to react to even very weak signs that some kind of change or danger is approaching and the ability to take strong, decisive action based on these signals, and galumph: purposeful playfulness and innovation that provides organizations the opportunity to test different possibilities and scenarios. For the Miami Heat, the team's reliance on Wade immediately following the championship season was a weak signal that should have been corrected immediately, rather than seen as a sure-fire formula for success. New players and innovative starting line combinations were tried. Miami just needs to be even more creative. With this unflinching commitment to reliability coupled with increased innovation, the Miami Heat will see improvement. I am confident in my team.

Stepping back from my NBA playoffs fervor of excitement, what do basketball and sensemaking have to do with health care? Like the Miami Heat, health care is an organization that has yet to achieve the status of being a high-reliability organization. Health care has similar rigid organizational flaws. There is an over reliance on individual performance, weak signals of variation and danger are not taken seriously, and there is great need for innovation and system redesign. If health care can make improvements in sensemaking, it too can reach the season playoffs and become champions. Basketball fans hold their heads up high when their team becomes a high-reliability organization and performs well. But in health care, the stakes are higher. Our patients depend on us to make health care more reliable because it means they can live another day. The health care playoffs are happening right now, and it’s about time we all pitch in and start shooting for sensemaking in health care.

For a more eloquent explanation of sensemaking and its application to health care, read Don Berwick's IHI National Forum Speech, "Escape Fire".

An Evening of Thanks

I have a little over a month left of my first of year of medical school...an unbelievable fact. One of the highlights of my year has been the Family Centered Experience program. I have written about the program in previous posts here and here. Closing up our year, all first year med students were asked to work in small groups and create an interpretive project using untraditional media to express our understanding of what we have learned from our patient volunteers. Tonight, all of our interpretive projects were on display and we spent the evening with our classmates and patient volunteers experiencing the reinterpretation of the struggles and triumphs of a life with illness.

Interpretive projects included poems, works of art, mixed media art pieces, cookbooks, original pieces of music, interpretive dance pieces, a children's book, and much more. Since pictures are worth a thousand words....enjoy!












To our patient volunteers, thank you so much for a memorable year!

If you had the opportunity to creatively express the patient experience with illness, what would you create?

Join Us On April 5th!

IHI Open School hosts a call with the Picker Institute/Gold Foundation Grant Program

Join us on April 5, 2010 from 12 - 1 PM EST. The Picker Institute/Gold Foundation Challenge Grant Program provides annual grants for integrating innovative patient-centered care projects into resident physician training. Three recipients from the 2009 – 2010 Challenge Grant Program cycle will present their projects on this free call facilitated by David Leach, MD, former executive director of the Accreditation Council for Graduate Medical Education (ACGME). Learn more about their projects. Participating sites include Beth Israel Deaconess Medical Center, William Beaumont Hospital, and Children’s Mercy Hospital. Register now for the call!

This is the Clinic that Will and Charlie Built...

I have officially become a groupie of the quality improvement in health care movement. Books sitting on my nightstand include: Pauline Chen's Final Exam, Super Crunchers by Ian Ayres, and How to Change the World by David Bornstein. I squealed like I had just sighted Brad Pitt when Atul Gawande's latest book, The Checklist Manifesto arrived at my door. Instead of simply saying that I need to clean my apartment, I specifically think that I need to "5S" my kitchen and desk. In order to stay fit and get rid of the belly fat I've grown since starting medical school, I am now in PDSA cycle 3 for a 30 minute exercise routine that I can reliably perform every day. The latest sign that I am a quality improvement junkie is my weekend pilgrimage to Mayo Clinic in Rochester, Minnesota.

This past weekend the AMSA Chapter at Mayo Clinic hosted a Patient Safety and Quality Care Conference at Mayo Clinic. The Mayo Clinic has not only been one of President Obama's shining examples of high quality care at low costs since he began his health reform push early last year, but has also consistently popped up during my experience at IHI as a health system that has truly embraced the IOM aim of patient-centeredness. Even though I'm buried underneath the dorsal columns of my central nervous system sequence, this was an opportunity I could not miss!



When I stepped off the plane in Rochester, I was abruptly greeted by a chilling gust of wind. But, that didn't deter me and like any good quality improvement groupie, I pressed on. From the moment my shuttle dropped me off in front of the Gonda Building and the Mayo Clinic greeters helped me out of the van, I knew I had arrived at what many say is the mecca of patient-centered care. It was difficult not to spend the weekend with my mouth agape.

Every aspect of the Mayo Clinic from its architecture and design, to the doctor-patient relationship, to Mayo's treatment of patient safety strongly embodies and reflects its mission: Mayo will provide the best care to every patient every day through integrated clinical practice, education and research. As Dr. Tom Viggiano, Dean of Mayo Medical School explained during his talk about Mayo Clinic's History, Culture and Professionalism Covenant, Mayo Clinic's mission stems from a remarkable story. A story about the work of Dr. William Worrall Mayo and his two sons, Drs. William and Charles Mayo.



Dr. William Worrall Mayo, born in England and a student of physicist John Dalton, arrived in Rochester as the Union army's examining surgeon. As his sons were growing up, William and Charles were intimately involved in their father's practice. They drove their father on patient rounds, attended medical society meetings, and even assisted their father in surgical procedures. This early exposure laid the foundations of medicine and patient care for the two brothers. Both William and Charles through consistent encouragement from their father attended medical school and both returned to Rochester to join their father's practice.

The tornado of 1883 that hit Rochester was a catalyst that led to the creation of Rochester's first hospital built in collaboration with the Sisters of Saint Francis. The Mayo family then became the physicians of the hospital and it was the brotherhood bond between William and Charles that was the first "team" that set the tone for the teamwork we see at Mayo Clinic today. As the hospital expanded and the fame of the brothers grew, it became necessary for William and Charles to pick physician partners to join the practice, expanding the team. In Dr. William Mayo's words, here is how teamwork was defined:

"As we grow in learning, we more justly appreciate our dependence upon each other. The sum-total of medical knowledge is now so great and wide-spreading that it would be futile for one man to attempt to acquire, or for any one man to assume that he has, even a good working knowledge of any large part of the whole. The very necessities of the case are driving practitioners into cooperation. The best interest of the patient is the only interest to be considered, and in order that the sick may have the benefit of advancing knowledge, union of forces is necessary."

One such recruited partner in the team that proved to be influential in shaping Mayo Clinic, was Dr. Henry Plummer. Dr. Henry Plummer's ingenuity led him to design an easy, retrievable medical record system. This system gave each patient an ID number and the mode of transport for these records was a system of pipes. Dr. Plummer's innovation acknowledged the fundamental place that medical records had in research and advancing medical knowledge and the need for shared data between physicians to deliver the best care for patients. Dr. Plummer was also instrumental in bringing the Mayo vision of integrated care into reality with the construction of the first Mayo Clinic building (built in 1914), which housed clinical medicine departments, laboratories, and administration offices all under one roof.



As the years continue, additions and innovations to the Mayo Clinic all align with the traditions that Drs. William and Charles Mayo started. There is a Mother Goose rhyme called, "This is the house that Jack built..." Each successive stanza in the rhyme gets longer and longer as odd characteristics are added to the house that Jack built. The Mayo Clinic Model of Care we know and admire today is a result of a similar layering construction.

Though, from my weekend experience at Mayo Clinic, the foundations that Drs. William and Charles Mayo created are more than just a model of care, it's a tangible culture, or even a life force that allows the Mayo Clinic to thrive. The wholly understood value that the needs of the patient come first allow the Mayo Clinic to continually push the boundaries of improvement. The weekend was primarily focused on medical errors and the developed practices and systems at the Mayo Clinic to address patient safety and quality care. We heard from Dr. Stephen Swensen, Director of Quality at Mayo Clinic, Dr. Thor Sundt who is pioneering improvements in interprofessional teamwork in the surgical setting, Dr. Paula Santrach, Chair of Clinical Practice Quality Oversight Committee, Dr. Douglas Wood, Medical Director of the Quality Academy, Dr. Bob Cima on error analysis in surgery, and many many more who volunteered their time to not only share with us their approaches to medical error management, but true to the Mayo Clinic's culture of putting the patient's needs first were also frank about areas that needed improvement. If President Obama's shining beacon of clinical excellence continues to make improvements upon "the clinic that Will and Charlie built," then the rest of us certainly have lots to learn.



I've certainly learned a lot this weekend both through the stated curriculum in the conference agenda, but also through the hidden curriculum of taking in the culture of the Mayo Clinic. I may not be able to take back to the University of Michigan Mayo's unique electronic physician and patient tracking system or redesign all of the exam rooms at Michigan so that physicians are never talking down to their patients, but I can take a plank of Mayo's culture and lay it down as my foundation so that wherever I am, I can do my best to extend the clinic that Will and Charlie built.



A big thanks to Crystal Pruitt and Crystal Shen of Mayo Medical School who organized this enlightening conference. I look forward to more great opportunities to learn about patient safety and quality improvement from the great leaders at the Mayo Clinic.

"What Do I Need to Know for My Clerkships?": A Look at the Lucian Leape Institute Report on Medical Education

In the world of medical school, spring is a time of transitions. First year medical students are returning from spring break and gearing up for the last stretch of class before summer. Second year medical students are getting ready to buckle down and study for the USMLE Step 1 board exam (good luck to all!). Third year students are on their last clerkship rotations before becoming fourth year medical students. And fourth year medical students are holding their breath as Match Day approaches (this Thursday!). Like any time of transition there are a lot of questions about the future floating around. One of the most honest and interesting questions I have heard recently was from a second year student to a resident, "What do I need to know for my third year clerkships?"

This may sound like a strange question to those outside of the world of medicine. The third year of medical school should be a logical progression from the second year, right? Not exactly. Most medical schools in the United States are structured so that the first two years are spent predominantly in lecture. The first year covers the normal physiology, anatomy, and biochemistry of the body systems and the second year delves into pathology and pathophysiology. These years are marked by long hours in class and little, if any, patient interaction. With at most a two week gap after the USMLE Step 1 exam, third year medical students are then thrown into the hospital wards to learn how to apply the basic sciences into the practice of patient care. Are these new third year medical students ready to care for patients?

The Lucian Leape Institute of the National Patient Safety Foundation says, "no." Just last week, the Lucian Leape Institute released its first of a series of reports on patient safety. The first report, titled: “Unmet Needs: Teaching Physicians to Provide Safe Patient Care,” finds that U.S. medical schools are not adequately teaching students how to provide safe patient care. Click here to read the report.

Although I have just 8 months of experience in the medical education system, I am not surprised by the conclusions of the report. A quick glance at the competencies tested in the USMLE Step 1 board exam that second year medical students ordinarily must pass before starting their third year clerkships will demonstrate the emphasis placed on the basic sciences of the body systems. While I don't disagree with the importance of understanding the basic sciences of the human body and disease processes, I agree with the Lucian Leape Institute report that there is a crucial dimension to patient care that is blatantly missing in an exam that signals that students are ready to be members of a patient care team.



The transition into a third year medical student is not easy: learning how the hospital operates, determining and establishing the medical student role on the care team, understanding and learning to anticipate the actions of the interns, residents, and attendings, and being prepared to answer any basic sciences question your attendings may ask you (a process called pimping). The third year is also an important learning opportunity. The more procedures and cases seen means a greater breadth of experience for future life-saving. Impressing your attendings is another facet to the third year of medical school. A good recommendation from attendings can go a long way in the residency application process. In the thick of all of that, medical students are probably too stressed to think about patient safety and definitely don't want to slow down the service just to ask "why?" when witnessing unsafe or needlessly complicated workflow processes. The chaos of third year makes asking questions about patient safety and quality improvement professional suicide.

So, how are medical students to learn the skills needed to deliver health care safely? The Lucian Leape Institute recommends restructuring medical education to include topics like safety science, human factors engineering, systems thinking, and the science of improvement into the basic science years of medical school. The report also recommends that medical students be given opportunities to develop interpersonal skills that include effective communication strategies for future interdisciplinary teamwork. In order to include these elements to medical training, faculty trained in patient safety and quality improvement who can model good patient safety behavior is essential. Unfortunately, most medical schools have not reached a critical capacity of faculty for training in patient safety and quality improvement to occur. Yet, from the student perspective, we can't wait another 10 years after the publication of the IOM "To Err is Human" report to reach that critical capacity.



Here at the University of Michigan, the few faculty we do have trained in patient safety and quality improvement are working hard to provide students with patient safety skills. In our first year of medical school, we've had a mandatory nurse shadowing experience and a sociocultural discussion case on medical errors to provide the first exposure to patient safety and effective teamwork. The University of Michigan also offers a second year two week elective on patient safety and a fourth year elective led by our very own, Dr. John Gosbee. At best, the University of Michigan has opportunities for students who seek to learn patient safety and quality improvement skills. This is a good start, but as the Lucian Leape Institute report would indicate, not enough. Patient safety needs to be prioritized formally from medical school through residency in order to make health care safer for all.

At the very least, concepts of patient safety and quality improvement should naturally become part of the answer to the question, "What do I need to know for my clerkships?"

Is patient safety a part of your curriculum? What do you think the best strategies are for making patient safety and quality improvement a bigger component to your health professions education and training?

Being Honest: Ducking Out from Under the Table

My adorable dog, May, has her flaws. Her bark and temper are infamous in our neighborhood. If the toy is not made of rubber, it will become an unrecognizable ball of mush within days. However, when it comes to going out to do her business, May almost never has accidents. On those rare occasions she makes a mistake, she slowly greets us with her head ducked down rather than her normal energy-filled charge when we arrive home.

We understand why these accidents happen. Most medical errors, as discussed in the IOM report, To Err is Human, are a result of poorly designed systems that do not give providers the best chance possible to care for patients in the way that they would like. May's accidents are also systems error. We only find a pool of pee in the house when we leave for a long period of time without allowing her to go out before we leave. May was not being negligent or purposefully filthy; the system she lives in simply does not allow her to successfully avoid these accidents. With these system constraints in mind, we do not blame her, but continue to work on scheduling improvements to prevent future occurrences.



Clinicians never want to intentionally harm their patients and are often emotionally impacted by a mistake. Similarly, as far as we can tell, May deeply regrets her accidents. Since she cannot use words to express her regret, she hides under the dining table and avoids eye contact as we clean up the mess until we say, "It's okay, May." Sometimes, she will even circle the "biohazard" zone slowly, as if admonishing herself. May's actions demonstrate her acknowledgment of the accident and we accept her apology--a courteous exchange that occurs between people all the time.

Medical malpractice is one of the few bipartisan goals of the current health reform battle. However, how to reform this messy process that is hard on all participants (physicians, hospitals, patients and families, and insurers) emotionally and financially is not as clear. Focusing on how to minimize costly lawsuits through caps on financial damages awarded to patients further complicates the fundamental courtesies that should occur when a mistake happens: acknowledgment, understanding, acceptance, and forgiveness.

In a paper published in the NEJM in 2006, then Senators Hilary Clinton and Barack Obama discuss how to improve patient safety and the medical liability climate through open communication between physicians and patients. The paper cites that the most important factor in people's decisions to file lawsuits is not negligence, but ineffective communication between patients and providers: lawsuits occur when "unexpected adverse outcomes are met with a lack of empathy from physicians and a perceived or actual withholding of essential information."



For those of you who are Grey's Anatomy fans (click here to read a Grey's Anatomy Obsession confessional), episode 13 of season 6 titled, "State of Love and Trust," touches specifically on medical liability reform and being honest with patients. A patient, later discovered to have a form of cytochrome P450 that unexpectedly allows her to metabolize anesthesia faster than normal, wakes up from anesthesiology in the middle of her bowel surgery and is traumatized by the violence of surgery and the panicked yelling from the surgical team. Emotionally disturbed by the experience, the patient wishes to press charges against the hospital. Dr. Shepherd, interim Chief of Surgery, is deep in thought about the threat of a lawsuit on his first day as Chief, when Dr. Miranda Bailey talks to him about open communication between physicians and patients in situations of medical error (see clip above). By apologizing to the patient, Dr. Shepherd is acknowledging the mistake and the patient's concerns, is providing the patient with the opportunity to understand and accept the mistake, and is working with the patient to reach an agreement that allows both sides to accept the mistake and attempt to reach forgiveness.

As then Senators Clinton and Obama explain in the paper, open communication allows for improvements in patient safety. The proposed National Medical Error Disclosure and Compensation (MEDiC) Bill was based on model disclosure programs such as those in place at the University of Michigan Health System (Go Blue!) and the Veterans Affairs system. These programs have given both patients and physicians protection while successfully reducing administrative and legal costs for providers, insurers, and hospitals. Surveys from these successful programs have also showed greater trust in and satisfaction with health care providers. On the cost side, the disclosure programs have resulted in the filing of fewer malpractice suits, a reduction in litigation costs, accelerated provision of compensation to patients, and increases in the numbers of patients who are compensated.

It is a remarkable feat that the University of Michigan Health System has reduced litigation costs from $3 million to $1 million in four years with its disclosure program. Though isn't it ironic that at the heart of the solution to such a complex problem are the basic principles of being honest and communicating openly with patients?

Telling patients the truth at times may be harder, but it is the most respectful thing to do. My dog, May, would bark in agreement.

Understanding the Incomplete Medical Diagnosis

*names and some details have been changed to maintain and protect privacy*

If multiple sclerosis was an anatomy review item, I can just imagine Dr. Zeller pointing at the spinal cord and asking me, “Eva, what is the clinical presentation of multiple sclerosis?” After overcoming the anxiety of being “pimped,” my response would probably include symptoms such as: muscle weakness, difficulty in moving, difficulty with balance, visual problems, fatigue, and pain. Before meeting my patient volunteer, Casey, that’s how I characterized multiple sclerosis. The mental image in my head also included a wheelchair. This snapshot of multiple sclerosis is the medical mold that physicians give to their patients upon diagnosis, which I used to think was complete and scientifically correct.

After almost six months with Casey, I now understand that this sort of medical mold is incomplete. This medical mold is analogous to giving an unknowing sculptor a headless cast of Michaelangelo’s David and telling him that this represented Michaelangelo’s complete masterpiece. What was missing in the medical mold of multiple sclerosis (MS)?

What was missing was Casey. Her empowering and encouraging relationship with Dr. Osuco, the optometrist who made her initial diagnosis; the negative recommendations she received from physicians that told her to quit nursing school because she had MS; her steady and rapid inability to walk up flights of stairs; the finality and fear she felt when researching more information about her condition; the shame of losing the ability to spell simple words; the unbearable embarrassment of urinary incontinence; the feeling of helplessness as her right side got weaker; the difficulties of maintaining a treatment regimen that seemed to fundamentally change her personality; starting every date with “I have MS”; shopping for life insurance plans along with her elderly mother; the loss of friends because they just couldn’t handle it; designing a plan for “when things get to that point”; doctor shopping and coming across the kind and comprehensive care that Dr. Richardson provides; temporarily losing hearing in her right ear and worrying about its implications on her MS; letting go of managing the disease on her own and instead working with Dr. Richardson's team; navigating how others view her given her very normal appearance but serious condition, trying not to mention her occupation as a nurse unless it means better care for her and her family; meeting other MS patients at varying degrees of disease progression who are all fighting and living quality lives; negotiating the risks and benefits of a high-risk drug that drastically improves quality of life but can cause a deadly brain infection; being the primary caretaker for her elderly mother who is surviving on an oxygen tank and two developmentally challenged foster children; working as a nurse nearly full time; her strong beliefs to advocate for quality and patient-centered care; and lighting up the room with her warm smile. That is the complete picture of MS.

How can we as future physicians learn how to see the complete picture of a disease? We need to be aware that our list of symptoms is only a subset of factors that can instigate tremendous challenges and change on another life, learn how to talk to patients about their values and greatest concerns, and integrate those values and concerns with the treatment plan. By laying a foundation of trust and building a strong partnership with patients, we can begin to cross the gap between the stigma that we create and the reality of illness in an individual. My experience with Casey has taught me these important lessons and I hope to never forget them as I continue in my training.

Many thanks.