Practicing Like A Rock Star: The Need for a Culture Change in Medicine

Consider this definition:

prima donna: (noun) 1. a first or principal female singer of an opera company. 2. a temperamental person; a person who takes adulation and privileged treatment as a right and reacts with petulance to criticism or inconvenience.

www.dictionary.com

We've all interacted with these types of people before. They hog the basketball on the courts and refuse to pass the ball. They must be placed front and center in every dance formation if not given a solo. They are the rock stars that never show up for rehearsals, claim all of the glory, and blame others when their voice is shot from partying all night long. In several industries such as sports, dance, opera, aviation, and medicine these rock stars usually have amazing talent and have worked hard to reach their top position. But, what they fail to recognize is that their trade goes beyond their individual bubble--it's a team effort.

Dance and performance have been very important parts of my life from as early as I can remember. How many hours have I spent in rehearsal? How many people have I performed before? Those questions are just impossible to answer. Throughout college, I was involved with a dance troupe called the Asian American Dance Troupe. Every spring we would host a dance show on campus highlighting a wide range of Asian dance styles. The show, Eastbound, was always a huge, almost all-consuming, undertaking not only because of the 40 plus dancers in the troupe, but also because of the tremendous amount of coordination that was required to deliver a successful show.

Just to give you a flavor of what goes through the minds of the troupe's captains and board:

• Show shouldn't be more than 1.5 hours long. Absolute max 2 hours. Don't want people to be bored
  
• 14-16 pieces
  
• Need entertaining MCs
  
• Adequate spacing between pieces to allow for quick changes. Enough spacing for pieces with very complicated costumes
  
• Coordinate and space dancers in multiple pieces. Avoid back-to-back pieces and if unavoidable, veterans can better cope than newbies. Make sure we have enough guest groups to fill in between pieces
  
• Need stage managers and runners who are authoritative, are familiar with pieces, and know almost everyone's names
  
• Each dance needs costumes with strong stage presence. Coordinate costumes with choreographers and okay with costume manager
  
• All dances must be ready! Ask choreographers to be responsible for own dancers
  
• Block off lots of studio hours for last minute rehearsals
  
• Each dance needs proper lighting cues that match costumes and mood of pieces well. Coordinate with lighting director
  
• Lighting director and sound manager need to attend formal training sessions with performance space manager
  
• Ask sound manager to compile all music for show together on one CD, including guest group music
  
• Water and snacks in dressing rooms to keep dancers hydrated and happy
  
• Separate rooms for boys and girls, make sure not too many dancers in one room
  
• Need at least three cameras for filming. Hopefully, they are of comparable quality. Volunteer camera crew?
  
• Coordinate selling of bubble tea refreshments during intermission
  
• Coordinate police detail
  
• Cash box! Tickets! Lowell Lecture Hall seats 300 people!
  
• Tape the performance space. Mark center center, center front, center back
  
• All costumes need to be ironed

And that's just a subset of what feels like a million processes that must be executed for a successful show. How many people did I mention? 40+ dancers, a costume manager, a lighting director, a sound manager, performance hall manager, choreographers, guest groups, stage manager, film crew, audience members, and the list continues. A successful Eastbound requires full participation from all of these individuals--the performance team, and interactive communication among all. When something goes wrong, in the spirit of "the show must go on", the performance team steps up and takes care of the situation quickly and appropriately. As the audience claps at the end of the show, we all take the stage as a team and celebrate. WE did it!

I've performed with several different groups and must confess that a culture of teamwork is often the exception and not the norm. If we all don't pitch in to iron all of the costumes or go over the last eight counts of the first piece to make sure the circle formation does look like a circle, the audience's experience is diminished and our reputation is damaged. Everyone is a star dancer, but to truly make an memorable impression we need to be a stellar troupe.

Similarly, in health care, a patient's care does not lie heavily on the shoulders of one individual. A performance team of physicians, nurses, pharmacists, technicians, surgeons, administrators, receptionists, and many others all are part of the patient's experience. If Team Member A forgets to sterilize an instrument, Team Member B should speak up, and Team Member C can help find one that has been sterilized. Everyone on the performance team is a hero to the patient because they are providing them with much needed help--the performance team can save lives!

On January 15th, Paul Levy, President and CEO of Beth Israel Deaconess Medical Center in Boston, wrote in his blog, "Running a Hospital" about the resounding evidence of the use of a checklist to prevent surgical complications and what it takes to implement change in the health care system. Immediately following his provocative post is an even more thought-provoking dialogue bringing together patients, practicing physicians, nurses, and other care givers with some of the greatest leaders in the field studying the implementation and spread of best practices.

Are physicians prima donnas? Perhaps they are. But are they really to blame? Perhaps they are just a product of the current medical culture. A culture as Dr. Berwick shares in a comment that trains physicians to believe "a self-image of heroism, autonomy, and artistry...that the patient's fate is in their hands - that they personally and individually are responsible for excellence...They are not being dumb. They are pursuing the form of excellence and responsibility that they have been told to pursue."

In the dance world we excuse a prima donna attitude because of his/her talent. But, to achieve a fantastic show we need to stop making excuses. When we know that patient care could be better we need to stop allowing care givers to operate as lone individuals. The depth and breadth of skill necessary now to provide the best care to patients is too deep, too complex, and too wide to be a lone hero. As Gary Kaplan, CEO of Virginia Mason Medical Center said, "Our training to only trust ourselves to ensure our patient's well being is deeply rooted but ultimately maladaptive for today's complexities in diagnosis and treatment."

So what can we do to promote team work? As health professions students, I think we could start with better understanding of our patients and teammates. Spend a day with a patient and see how he/she sees the system. Spend a day with a nurse, spend a day with a physician, spend a day in the lab, spend a day with an administrator...and most importantly discuss your experiences with others. Any other ideas of how we can usher in a new culture of teamwork into health care?

I'll admit that I used to think that the tech crew helping with our shows were insensitive and incompetent. Didn't they know that red lighting flooded and overpowered pink costumes? Couldn't they hear the music and energy shift? That was until I went up to the tech pod and saw the large and complex switchboard that controlled all stage lights. Creating purple light didn't just require one button, but a pull here and a flick of this and a push on that. It was my impatience and lack of understanding that led to my frustrations with the tech crew. They were doing their best. After explaining what we wanted in advance and respecting their own artistic touches and expertise, I've never had difficulties with lighting. Since then, I've come to appreciate how lighting helps to set the tone of a piece and enhances our ability to express ourselves.

So, I guess the key to practicing like a rock star is to simply not practice like a rock star. Embrace the team and you'll see that practicing within a rock band is even cooler. If anything, you will always have your band mates with you to get through the bad and celebrate the good.

Click here to read an article in The New York Times titled "Arrogant, Abusive and Disruptive--and a Doctor" to see how teamwork breaks down.

Want to get into a great residency program?

If you're reading this, you probably think improving the quality of health care is pretty important. Here's someone who agrees with you:

Joel Katz is Assistant Professor of Medicine at Harvard Medical School and director of the Medicine Residency at Brigham & Women's Hospital -- one of the finest hospitals in the U.S.

When he's selecting residents, Dr. Katz looks for students who are interested in improving the quality of health care. In his own words:

The principal mission of the residency is to train great doctors -- "great" meaning doctors who can recognize who is and is not sick, act decisively in the absence of a complete data set, think critically about the 'big picture' of health and disease, and know their limits and feel comfortable seeking the advice and wisdom of their peers.

At the Brigham, Dr. Katz has recently launched a residency track in management leadership skills, including those directly relevant to patient safety and quality improvement.

Dr. Katz will be checking this blog between now and February 24. Leave a comment or a question for him here, and he'll see it. Ask anything you want. Curious about why most professional training programs don't emphasize the improvement of care? Want to know how you can make patients safer? Hoping for some tips on how to stand out in your field?

To ask a question, click the "Comments" link at the bottom of this post.

Interested in Improvement Work in Developing Countries? On Call with Dr. Patrick Lee

Image linked from www.elpasotexas.gov

Interested in improving the quality of care in a developing country but not sure how to get started?

Curious about how effective, lasting improvements are made in rural, resource-poor settings?

Then join us for the next On Call and hear the story of how Dr. Patrick Lee and his teammates helped make dramatic improvements at a hospital in Kirehe, Rwanda. Dr. Lee, a volunteer clinical mentor for Partners in Health, recently finished a residency in internal medicine and primary care at Massachusetts General Hospital.

You’ll learn how Dr. Lee and his team prioritized their improvement goals, overcame the lack of resources and infrastructure, and built staff consensus and trust. You’ll also discover how you can apply the team’s learnings to your own work in a developing country or right here in the US – whether you are in a clinical or non-clinical setting.

Featured Speaker: Patrick Lee, MD
Event Date: Tuesday, January 27, 2009
Event Time: 4:00 - 5:00 PM Eastern Time
3:00 - 4:00 PM Central Time
2:00 - 3:00 PM Mountain Time
1:00 - 2:00 PM Pacific Time

Click here to register!

This free call is part of a monthly audio conference series that brings experts in health care improvement together with students from medicine, nursing, dentistry, pharmacy, health care management, public health, and other allied health professions. Each hour-long call is moderated by a student, ends with a question-and-answer period, and focuses on an issue that affects you. Visit our website to download audio files or written transcripts of past On Call audio conferences.

Hope to see you all on the call!

Health Care Reform Reading List

This past Saturday, I attended a health care conference hosted by the Harvard Business School Healthcare Club. In the Public Policy panel, John McDonough, Senior Advisor to Senator Ted Kennedy on Health Reform, and others shared with us their thoughts on the current atmosphere for health reform. They all agreed that we have the potential for change and that all the players are in place, but it won't be easy. This is the fifth time we've had a national debate on health care and it probably won't be our last. John McDonough shared with us an essential reading list to understand health care reform. This includes:

• The System: The American Way of Politics at the Breaking Point by Haynes Johnson and David Broder


• Critical: What We Can Do About the Health-Care Crisis by Senator Tom Daschle


• Senate Finance Committee White Paper "Call to Action: Health Reform 2009" by Senator Baucus


• Congressional Budget Office Reports on Health Reform

Have any of you read these papers or books? I myself have just picked up The System, which details the health reform efforts during the Clinton Administration. Thoughts? Comments?

Getting Lean at MIT, Part 2

I just learned about an idea so phenomenally, immediately useful that I felt the need to share it. The idea is called value stream mapping and analysis, and typically it reduces production time (for anything – a paper for Literature 1A, a Rolls-Royce, a successfully administered medication) by 75 percent.

Essentially, what you do is write down every single step in a given process, using a flowchart-style diagram. Then you identify the steps that add value to the customer. Here’s how you know if a step adds value:

1. The customer cares about it.
2. The item being produced changes in some way.
2. The step is done right the first time.

When you do this, the time-wasters pop out at you in Technicolor. Bells sound, lights flash, etc. And you now have a better picture of what’s taking so darn long.

Here’s an example. I recently set up internet service for my home (I’m not going to name the company, but it rhymes with Berizon). What’s the company’s process? In my case, it was something like this:

Step 1: I place the order by phone on a Friday. (10 min)
Step 2: Customer service rep (Jackie) receives and files order. (3 days)
Step 3: Jackie calls and schedules a time when Ray, the technician, can come to my house. (10 days)
Step 4: Does Ray go to the right house at the right time? If no, back to step three.
Step 5: Ray examines the wiring at my house. (30 min)
Step 6: Is Ray properly skilled and equipped with the right tools for the job? If no, back to step 3.
Step 7: Ray notifies Jackie, in the home office, of the need for a new work order. (15 min)
Step 8: Is Jackie in today? If no, back to step 3.
Step 9: Jackie approves work order. (2 hours)
Step 10: Ray sets up internet. (15 min)

In this process, which steps actually added value for me? I’d say Step 1 and Step 10 – a total of 25 minutes’ worth of work. In between, there were examples of pure waste (for instance, Ray went to the wrong house) and steps that didn’t add value but were necessary (Step 3).

I’ve charitably made this process only ten steps long. It actually took me about a month and a skillion, jillion phone calls before I could watch “Star Wars: Retold” in the comfort of my own home. If Berizon made a process map of all the steps required to install internet at my house, do you think they’d quickly find ways to reduce their cycle time (the time that elapsed between the order and the delivery of the product)? I think yes.

The applications of process mapping for health care are obvious. Instead of a customer requesting internet service, think of a man who shows up at a crowded emergency department with chest pains. Or a woman with poorly-controlled diabetes who doesn’t have a car to get to her appointments. Or a patient whose insurance company promises to pay out a claim but takes months to do it – giving the patient a choice between paying the enormous bill or watching his credit rating drop into the toilet.

To learn more about process mapping and related ideas for system improvement, check out the Lean Enterprise Institute's website – full of good ideas and resources.

(Many thanks to Dick Lewis, Earll Murman, and Annalisa Weigel, who allowed the IHI Open School team to observe their class on Lean at MIT today.)

Getting Lean at MIT

I spend most every weekday morning in a panic. I shower, throw on clothes, shovel in some breakfast, and frantically gather my wallet, keys and phone before running out onto an icy sidewalk -- and even then I'm generally at least five minutes late.

Today, a few members of the IHI Open School team went to MIT to learn about "Lean" - a production practice that seeks relentlessly to eliminate waste. Lean came out of Japan's post-WWII auto industry, but it has broad applications for practically any sort of production (including the elaborate production that is my morning routine).

Lets take a look at a Lean practice called 5S: Sort, Straighten, Scrub, Standardize, Sustain.

SORT: My alarm goes off and I knock over two glasses of water and a couple of books trying to hit the snooze button. I end up throwing out a sodden issue of Wired Magazine. I ought to SORT through the items on that tabletop and get rid of what's not needed.

STRAIGHTEN: My clothes aren't organized in any systematic way, and I spend a lot of time visually searching for what I need. When I STRAIGHTEN out my closet by putting things in bins, I save time.

SCRUB: I didn't do the dishes last night, and now I have to spend precious time rinsing out a cereal bowl. Last night I could have SCRUBBED the dishes and made them ready.

STANDARDIZE: I lose five minutes running from room to room, looking for my keys. I could create a STANDARD place for them - say, on the hook by the door -- so I'll never search again.

SUSTAIN: Here's the challenge. Once I decide on these changes, I need to SUSTAIN them over time.

Okay, so that solves my morning mess. But Lean is a lot more than a way to get yourself to work on time. It's a way to cut waste from any process - defined as a set of actions that transforms an input into an output. Whether the output is a chem problem set, a healthy patient, or a Toyota Prius, lean production requires you to sit down and understand key processes, noting which steps add value and DON'T add value for the customer.

So how to apply these principles to a system as big and complex as health care? Start by checking out "Going Lean in Health Care," a free white paper from IHI.

Third Grade Poster

Today is Inauguration Day. I have never seen so much excitement from everyone on Inauguration Day before. Words like "renewal", "hope", and "change" are on everyone's lips. Barack Obama's Inauguration is openly being compared to JFK's Inauguration and FDR's Inauguration. But, because I wasn't alive then and don't have the privilege of time travel, Obama's Inauguration reminds me of a very special day when I was in third grade.

One day, Ms. Kozak, my third grade teacher handed out large sheets of poster board and placed boxes of markers on our desks. She asked us to create a poster to celebrate Martin Luther King Jr. Day for the Palm Beach County Martin Luther King Jr. Day Poster Contest.

We all diligently went to work on our posters. Now, I had and still have little artistic skill. My sister is actually the artist of the family. She could draw Disney's The Lion King characters before she knew how to describe them in words! Most of my classmates drew remarkable portraits of Dr. King. After about an hour of doodling, here's what I managed to put on paper (a shoddy electronic 2 minute remake- not the actual poster):



A few weeks after Ms. Kozak collected our posters, she announced that the winner of the poster contest was in our class! I knew it had to be Sean because his portrait of Dr. King looked just like a photograph. But, I was wrong. Ms. Kozak said my name! I was to go to Pine Grove Elementary School on Martin Luther King Jr. Day to attend a celebration and accept a certificate!

I was so proud. As I walked out of the classroom at the end of the day, Ms. Kozak handed me a letter to give to my parents. She said in it included more information about the Martin Luther King Jr. Day celebration. When my parents opened the letter that night, my mom told me that maybe it would be too dangerous to go to the celebration.

Dangerous? Third grade for me, was 15 years ago. And 15 years ago, Pine Grove Elementary School was an impoverished public elementary school located in the heart of an economically depressed community. The area was frequently on the news making headlines in crime. Generally, it was an area that most people tried to avoid. But, after some thought, my parents decided that it was important for us to go.

On Martin Luther King Jr. Day, I put on my favorite moon sweater and wore my brand new white cowboy boots (fashion is also not one of my strong suits). I was ready for this big day. We drove to Pine Grove Elementary School and my parents were visibly nervous. We checked to make sure our car doors were locked twice before leaving the car and took out anything valuable. The mood, however, changed drastically as soon as we stepped into the gym for the celebration. The gym was brimming with people. My memories of the ceremony are a bit fuzzy now. But there is one moment that I will never forget.

When I was called up to the podium to stand next to my poster, I was greeted with a standing ovation. The audience was at least 70% African American and everyone was wearing their Sunday best. I will never forget the feeling of standing in front of such a large audience of strangers of all different races and backgrounds cheering. For those few seconds we stood together not to celebrate a poster, but to celebrate the message of peace, equality, and a shared humanity-- Dr. King's message. For those few moments, Pine Grove Elementary School was not a place to be feared, but an oasis to be envied.

An Obama Cookie!

Barack Obama is now the 44th President of the United States. It may have taken us 46 years since Dr. King shared his dream, and 15 years since my third grade poster, but our new President has accomplished the dream. In his inaugural address, President Obama said:

For we know that our patchwork heritage is a strength, not a weakness. We are a nation of Christians and Muslims, Jews and Hindus - and non-believers. We are shaped by every language and culture, drawn from every end of this Earth; and because we have tasted the bitter swill of civil war and segregation, and emerged from that dark chapter stronger and more united, we cannot help but believe that the old hatreds shall someday pass; that the lines of tribe shall soon dissolve; that as the world grows smaller, our common humanity shall reveal itself; and that America must play its role in ushering in a new era of peace.

Today is not just a momentous day for the minorities in America, but for everyone.

If I could draw a poster (this still comes with great difficulty) that embraced my dream for health care, here's what it would look like. It would take place in my dad's doctor's examining room. My dad would be facing the doctor. My mom, my sister, and I would be standing off to left of my dad. A nurse would be standing right next to the doctor. The nurse would be holding a few pamphlets ready to give them to my dad. The doctor would be pointing to a diagram of a foot displayed on a computer screen with his right hand. In his left hand, the doctor would be clutching a clipboard detailing a health regimen my dad should follow. A clock would be noticeably absent from the poster. And most importantly, we would all be smiling.

Hopefully, that's what we will be celebrating in 15 years. What would your posters look like? Happy Inauguration Day!