Drinks, Pizza, and a Little Basketball

Nostalgic for the hours I used to spend in college dining halls debriefing a long organic chemistry lab session, planning the next Chinese Students Association event or discussing the misuse of Murphy's Law when describing catastrophic global events, I take great comfort in studying in cafes or catching a casual drink at low-key bars. Food and drinks are within reach and conversations are aplenty. However, it seemed just too perfect that I would find myself at a Wolverine friendly bar and pizza joint called the Brown Dog in the middle of Telluride to catch Game 3 of the NBA finals with my new patient safety friends.

In between sips (true sips because alcohol and high altitude could turn into a physiologic disaster), we would seamlessly transition from discussing the patient harm that results from unstandardized hand-offs to watching the Miami Heat claw their way towards a lead in the series against the Thunder. The true cherry on top was the mouth-watering smells of Detroit deep dish pizza that surrounded us. Because the University of Michigan atmosphere mixed with good pizza and beer seemed to be a winning combination for stimulating patient safety conversations and Miami Heat success, we recreated the magic for the rest of Miami's journey to become the 2012 NBA Champions. As I wistfully look back on my week in Telluride, especially as I suffer in the inhumane heat wave that has metaphorically encircled Southeast Michigan in an inescapable head-lock, I can’t help but intertwine patient safety and health care quality improvement with basketball.

Since becoming a basketball fan when the Miami Heat won the NBA Championship in 2006, my home team has really tried my patience. Like any health care quality nerd, I began to see health care connections in sports. The Miami Heat represented all of the negative characteristics of a poor performing health care system, primarily an organization that had seemingly lost its way (click here to read more about the Miami Heat and its failures as an HRO).

2010 represented a turning point. In a politically unwise and arrogantly publicized event, LeBron James was recruited to join Dwyane Wade and play for the Miami Heat. Chris Bosh of the Toronto Raptors also decided to move to warmer climates. Before I knew it, amidst the global antagonism directed towards Miami, a new sense of purpose had been injected into my home team: The Big Three had promised to fill their fingers with championship rings. While the rest of the world derided the team for its bombastic promises, I bought into the dream. With three superstars on the same team, as the Boston Celtics had proven in 2007, how could the Miami Heat fail?

Did the Miami Heat succeed in the 2011 NBA Finals? No. The Big Three was simply that, three basketball superstars who all happened to play on the same team. An optimist would say that The Big Three’s first season together was a string of small experiments (PDSA cycles) on how LeBron James, Dwyane Wade, and Chris Bosh would share the court together. But, what this looked like on TV was confusion and a total lack of coordination. The Big Three had their moments when they would each individually live up to their All-Star reputations, but these occurred in unpredictable and unreliable spurts. The Miami Heat haphazardly played its way into the 2011 NBA Finals and an entire season’s worth of bewilderment became obvious to the world as it was blown out by the Dallas Mavericks. I distinctly remember watching the team disintegrate into a group of headless chickens that did not seem to know what to do even when it possessed the ball.

In retrospect, the 2010-2011 season should not have come as a surprise to me. In assembling The Big Three, the Miami Heat committed the same mistake that many health care organizations make: attempting to achieve greatness through cultivating great parts. In a thought experiment to build the world’s greatest car by assembling the world’s greatest car parts, Dr. Don Berwick, former CMS Administrator and CEO of IHI, describes:

“Anyone who understands systems will know immediately that optimizing parts is not a good route to system excellence”… We’d connect the engine of a Ferrari, the brakes of a Porsche, the suspension of a BMW, the body of a Volvo. “What we get, of course, is nothing close to a great car; we get a pile of very expensive junk.”

The basketball teams that want success to become an intrinsic characteristic of the team, invest and develop not just individual talent, but also create a reliable system of teamwork.

Examining the Miami Heat’s run for the 2012 NBA Championship, the Miami Heat has done just that: built on the talents of The Big Three and transformed into a high-functioning team. For those that continue to carry Miami Heat antagonism (I realize I am in the great minority being a Miami Heat fan), I’m not claiming perfection, but improvement. Although an abbreviated season, the Miami Heat discovered a rhythm of teamwork that allowed The Big Three to play together as a more unified front. The Miami Heat faced one of its first great tests in the second round of the playoffs against the Pacers. Chris Bosh was injured and out of the picture and the Miami Heat was shut out of Game 3, falling behind in the series 1-2. The Miami Heat of 2011 probably would have been knocked out of the NBA Finals running. But, the Miami Heat of 2012 readjusted and Udonis Haslem stepped up to the plate to fill in the gap that Chris Bosh left. The Miami Heat beat the Pacers 4-2.

Improved teamwork was even seen off of the court. In the wake of the Miami Heat taking the lead in Game 3 against the Thunder, the drama that erupted in the media was when Kevin Durant of the Thunder was caught telling Dwyane Wade, "You're too small." Although the statistics of the team do back-up Kevin Durant's statement, LeBron James' response that the actual size of the players doesn't matter as long as they're fundamentally sound and play with the effort that helps that makes up that difference, rang true of the 2012 Miami Heat teamwork mantra. Just looking at the media coverage of the Miami Heat's journey to the championships, the words "we" and "team" are being used more frequently and coverage of the last game sings the praises of not just the Big Three, but also Mike Miller, Shane Battier, and Mario Chalmers--critical teammates who all contributed to the win.

So, what does this all mean for health care? The theme of the week at the Telluride Roundtable was communication. While we spent the day discussing the importance of communication facilitating successful teamwork, what we had in front of us in our after hours was an example of the incredible transformation of a basketball team that truly took teamwork to heart. So, as many of us are getting ready to apply for residency and are looking for residency programs and institutions that value patient safety, don't fall into the trap of optimizing health care by just optimizing individual parts, also consider what programs and institutions do to facilitate excellent interdisciplinary teamwork.

While the IHI Open School facilitates interdisciplinary communication by bringing health professions students of all disciplines out of their isolated silos together to discuss quality improvement and patient safety, what else can be done to improve interdisciplinary communication and hence create a reliable system of teamwork? I'd love to hear what you are doing at your institutions, so comment below and share your successes and challenges--perhaps some drinks and pizza will spark some health care quality improvement magic.

Why Hospitals Should Fly...

Isn't it appropriate that after 7hrs of flying and a 1.5hr windy car ride I find myself in Telluride, CO at an elevation of over 10,000ft to spend a week participating in the 8th Annual Telluride Interdisciplinary Patient Safety Roundtable?

My third year of medical school has been nothing short of transformative. While my classmates and I have grown tremendously in translating our theoretical knowledge into clinical skills, what has also grown is an increasing awareness of the plight of our patients. Many of our patients are already in a vulnerable position given their medical conditions. What does the health care system do to help them regain their health? We force them to navigate the rough seas of a fragmented health care system.

Out of frustration for one of my patient's experiences while on my Family Medicine clerkship, I wrote this welcome message that satirizes the typical patient experience in our current system:

Welcome aboard the US Health Care Cruise Line! Please take your time to explore all of the great features we have to offer on our entertainment Decks to take care of all of your medical needs, whether you need them or not! Here, our motto is “more is better,” so take this opportunity now to indulge away!

First, a brief message to our VIP guests: As the group of people with multiple health and social needs that are the true drivers of high health care costs, welcome! As you navigate this beautiful vessel outfitted with the latest most expensive technology and drugs, please keep the following in mind:

Primary care services are conveniently located on Decks 1 and 5. Deck 1 is only accessible via our exclusive Jet Ski coverage program. If you are not a Jet Ski member, we recommend you seek services at Deck 5. Deck 5 is only open three days a week in the afternoons. Both Decks have the friendliest of staff, but are only trained to address clinical questions.

Housing, childcare, utilities, legal, financial assistance and food services are available. With constantly evolving entertaining activities being offered through these agencies, we unfortunately do not have updated directions to reach them. But, if you wander around the ship long enough, you will surely find your way! These are some of our busiest services with the greatest demand, so please don’t be discouraged if we cannot address your needs. None of our passengers have suffered too greatly due to inaccessibility to these agencies.

24 Hr Care is available on Deck 9. You can access Deck 9 by any means. But, in exchange for this convenience, you will likely need to wait several hours before being seen. A 24 Hr All-You-Can-Eat Pizza Bar is also located on the same Deck to make waiting more tolerable.

Getting around the ship is most efficiently completed on foot as there are long staircases that connect most Decks. However, if this is difficult for you, please call the main office to arrange for transportation. We have a limited number of staff who can carry you to your desired destination. But, your height and weight may prevent you from taking advantage of this great service.

Specialty care services for diabetes, cancer, asthma, mental health, and hypertension are located in a gilded section of the ship. We are practicing cutting edge techniques that are so advanced that there is little literature available about them! Please don’t hesitate to let us know if you are having difficulties finding our specialty services. We would be happy to escort you there. Just be sure to bring your boarding passes, credit card statement that documents the purchase of this cruise, and any records of all of the experiences you have had here onboard. We do not have an electronic system connecting all of our services.

Lastly, drug and nutritional supplements must be purchased off of the ship, so you are encouraged to step off and explore our various stops. These islands are not very well-equipped, so please be flexible with the inconsistencies of what they have to offer.

Only the Captain is completely familiar with the ship and its services, but given how busy he is, he is unlikely to be able to help you navigate your stay. We are confident that you all are capable of coordinating your own cruise activities!

With these simple rules, I can guarantee that you will feel so overwhelmed by our top notch services that you will be wondering, “was it all really worth it?” Again, welcome aboard and enjoy your stay!

Despite sporadic episodes of safe, effective, patient-centered, efficient, timely, and equal care throughout my third year, our inconsistent ability to deliver high quality care has left me almost hopeless for the future of health care. But, what has reenergized my spirits was reading the book Why Hospitals Should Fly written by John Nance, a professional pilot and lawyer with a distinguished career in leading the patient safety movement. The book is a fictional narrative that follows a former CEO of a hospital, Dr. Will Jenkins, as he travels to a suburb of Denver, CO to visit the fictional St. Michael's Memorial Hospital. St. Michael's is THE ideal hospital that exudes quality not only in its basic processes and operations, but also in its culture. As Dr. Jenkins visits various departments in the hospital, the reader not only learns about the effectiveness of specific interventions to improve safety (i.e. multidisciplinary rounds, team huddles, checklists, etc.), but also indirectly gains insight to the process of implementation (probably the most difficult part of patient safety work).

When I finished reading the book, I felt like my head had been lifted up from the chaos of our current broken system. My head is now 10,000ft above sea level, the same elevation where aircraft passengers can safely use their electronic devices. While I'm forced to drink liters of water a day to ward off acute mountain sickness, perhaps it is necessary for me to be at the level where airplanes fly in order to better understand how to redesign our health care system to achieve high quality care. That is probably the reason why we are all here at Telluride, CO.

Stay tuned throughout this week as we dissect some of our health care system's greatest challenges. You can follow our thoughts here and on Twitter (#TPSER8). You can also take a look at Paul Levy's experience here at Telluride on his blog. Here's to a strong take-off tomorrow!