Calling all Enzymes in Healthcare

The bread rises to its fluffy deliciousness due to a leavening agent- yeast. The Greeks, as you would expect, had a word for it- Enzumos. Enzymes are the original change agents in biological systems that increase the rate of chemical reactions. They help convert substrates into products. 

If you are a leader in your microsystem, or on a larger scale in your organization or community, welcome to the Enzyme Club ! If your role and your goal is process improvement, you have a lot in common with the enzymes. Alan Ferscht's book on enzymes outlines how enzymes (and change agents) work.

1. They lower the activation energy- the energy that must be overcome before the chemical reaction can happen. The change agents build momentum by reshaping the people and culture to overcome the inertia.

2. They provide an alternative pathway.

3. They bring substrates together in correct alignment and orientation.

The enzymes and change agents work better and faster as the temperature or the urgency of the process gets higher, but only up to a point. If heated too much, the enzyme is denatured. Enzyme rates depend on the solution condition (the culture, policy, governance) and the substrate concentration (human resources). 

Enzymes can catalyze millions of reactions every second. Orotidine 5-monophosphate decarboxylation that could take up to 78 million years without catalyst, is done by the enzyme within 25 milliseconds ! Such is the power of the change agent. However, even the superheroes need a helper, a sidekick. Enzymes need cofactors and coenzymes that are vital for the functioning and efficiency of the process. 

Change agents in healthcare and other industries are very specific and tend to work best in the environment where they evolved. It is very desirable for enzymes and change agents to be able to function in hostile environment or in the midst of inhibiting factors. There are emerging strategies to make the enzymes more robust. We need to find such strategies to make our change agents resilient and more effective.

Healthcare as seen from the patient/family side

This past Friday, grandpa V had a cardiac arrest. He was a very vibrant 89-year-old with many medical conditions. He was resuscitated, intubated and transferred to the hospital emergency department. We drove down friday night to be at his bedside in a Delaware ICU. We take care of such patients all the time. This was one more chance for me to be on the other side and see how the healthcare system works or does not work. I saw from a family's perspective what drives outcomes and patient/family experience. I hope the wonderful treatment we got was not because I was a physician. There were many things that worked well.

Communication: The emergency department physician and the attending cardiologist both got on the phone to update me as I was driving down I-95. They were open to ideas, and they started hypothermia protocol at my suggestion. The interventional cardiologist also called me before the procedure to explain the rationale and the risks.
Access: The nurse and the ICU allowed family visiting, and gave frequent updates. Doctors and nurses were available a phone call away.
Caring: The hospital sent a comfort cart with coffee, juices, muffins while we were at the bedside vigil. small touch, goes a long way. It showed that they cared.

So, inspite of a bad outcome--death, the family was pleased with the care provided at the ICU in Delaware and will always be grateful to the wonderful nurses, physicians, and the hospital staff for taking such good care of grandpa and us.

I relearnt my lessons.

Serious Reportable Events

The National Quality Forum updated and added four new conditions to the list of serious reportable events on June 13, 2011. Some of the estblished serious reportable events include patient fall resulting in serious injury or death, wrong site surgery, air embolism, serious medication error, among others.
The updated list can be found here at NQF site.
The four new reportable events include:
1. Patient death or serious injury resulting from the irretrievable loss of an irreplaceable biological specimen

2. Patient death or serious injury resulting from failure to follow up or communicate laboratory, pathology, or radiology test results
3. Death or serious injury of a neonate associated with labor or delivery in a low-risk pregnancy
4. Death or serious injury of a patient or staff associated with the introduction of a metallic object into the MRI area

For Health And Happiness

As the United States moves towards healthcare reform, there is concern even amongst liberals who support the need to reform about the creation of an even bigger government bureaucracy.
Even the National Health Services -NHS of the Great Britain is going through a major shake up with removal of midlle managers and putting physicians in charge. This happened soon after Dr. Don Berwick, self-professed admirer of NHS, is appointed as the head of the CMS by President Obama.

The key question is- What works better?
Centralized planning or free market medicine?
Evidence-based medicine or artisanal clinician autonomy?

I believe the answer, as it relates to healthcare, is somewhere in the middle.
Our society and our government can set up the ground rules that encourage competition and innovation of healthcare, based on value. Now, the real question is-what do we, as Americans, value when it comes to healthcare?

I think that just as the greatest advances in human health and condition were made not by the pharmaceutical laboratories or shiny operating rooms, but by the improvement of socioeconomic standards, sanitation, clean drinking water, and such basic needs; the greatest advance in bending the cost-curve of our healthcare spending will require a Manhattan project that aims at prevention.

Legislative action at local, state, and national levels that promotes cheaper health foods, home cooking, exercise, family and social networks that improve mental health will prepare our future generations to make the right choices for a healthy life.
The biggest requirement for all this to happen at each home is Time, and time is in short supply right now for families. The increased need for multiple incomes to sustain a lifestyle rich in consumption of material stuff that do not actually improve our well-being is our downfall. But when spending and consumer demand is considered the lifeblood of the economy, these fantasies of simple, healthy living are possibly against human nature itself.

So, to truly improve our health, we require an extreme makeover of our societal culture. Often a change of such magnitude requires dramatic event- "creative destruction." A vibrant forest emerges after a forest fire. We saw the beginnings of such shift after the Great Recession, when people learned to live with less, and eat in, grow vegetables, and have more family game nights and staycations- and many realized that it is actually not bad.

We lead the world in productivity, with higest GDP per hour worked, but we also need to look at per capita Gross Happiness Product, and learn from the leaders.

According to Abraham Maslow's heirarchy of human needs, besides absolute physiological needs, safety and security of health and employment is a major need for human wellbeing. In our profession, the two are linked inextricably. A lot of changes are coming our way in the healthcare industry of the Great USA.

source: wikipedia

According to a study by Hans Bosma, an epidemiologist from the University College London Medical School, men and women who feel that they have little control over their jobs are 50% and 100%  more likely to develop heart disease respectively  than those who feel that they are in control of their jobs.

Isaac Getz, author of Freedom, Inc, gives his prescription for librating an organization from top-down bureaucracy in his piece in the Wall Street Journal:
1. Stop telling your frontline people how to do their work and start listening to their solutions.
2. Start openly and actively sharing your vision of the organization so people will "own" it;
3. Stop trying to motivate people. Instead, build an environment that allows people to grow and self-direct
4. Stay alert. To keep your employees free, become the culture-keeper.

Prepare for change, for change is inevitable.

3 Questions for Better Communication

"How often did doctors treat you with courtesy and respect?"
"How often did doctors listen carefully to you?"
"How often did doctors explain things in a way you could understand?"

These three questions are included in the Consumer Assessment of Health Providers and Systems (CAHPS) survey that all patients receive after being discharged from a hospital or a nursing home, or a dialysis center. These same questions are also asked of our outpatients as a part of the Clinician and Group CAHPS survey.

Centers for Medicare and Medicaid Services (CMS) publicly reports Health Plan Medicare and the Hospital CAHPS data. The American Board of Medical Specialties (ABMS) uses Clinician and Group CAHPS data for the maintenance of certification program.
Many other payors and quality organizations also use CAHPS data for payment for performance.
In the near future, when your practice applies for medical home designation, your communication score on the CAHPS will be used in the evaluation process.

According to the Ask Me 3 campaign by the national patient safety foundation, providers should encourage their patients to ask three basic questions-

1.What is my main problem?

2.What do I need to do?

3.Why is it important for me to do this?

Simple techniques can improve communication.
•Create a safe environment where patients feel comfortable talking openly with you
•Use plain language instead of medical jargon
•Sit down to achieve eye level with your patient
•Use visual models to explain a procedure or condition
•Ask patients to "teach back" the care instructions you give to them

Good communication leads to improved patient satisfaction, better outcomes, better business, and increased reimbursement.

Poor communication is often cited as the leading cause of medical malpractice lawsuits.

Good Communication is simply, Good Medicine.

Practical Tips for Better Communication

Studies show that poor communication leads to poor patient satisfaction, more complaints, a higher risk of malpractice claims, and poorer health outcomes. While some healthcare providers are natural, gifted communicators, these skills can also be learnt by the vast majority of us. A 2007 Journal of American Medical Association study confirmed that scores achieved in patient-physician communication and clinical decision making on a national licensing examination predicted complaints to medical regulatory authorities.

The FIVE A of patient counseling are steps toward ensuring effective patient-doctor communication.

Assess: patient's key concerns, perspective, goals, and readiness
Advise: with empathy and clarity of recommendations
Agree: on a shared plan of action
Assist: in obtaining care and resources
Arrange: for follow-up and next steps

PEARLS communication technique is a great tool for a busy clinician:
Partner with the patient to define the problem and creat a treatment plan
Empathize by remarks such as,"it must be hard"
Acknowledge the problem- 'I am sorry to keep you waiting"
Respect the patient's opinion, efforts, and time
Legitimize patient's feelings when appropriate
Support the patient

Good communication also involves active listening, time, attention, appropriate body language and tone.

Time for a Revolution

According to Thomas H. Lee, the network president of Partners HealthCare System, in Boston, and a professor of medicine at the Harvard Medical School, most hospitals are designed for the nineteenth century. Most doctors don't know how to share power. Most patients with complicated problems don't receive coordinated care.
He calls for a revolution led from within in his article on fixing health care in the Harvard Business Review.
He shares his recipe for turning doctors into leaders.
A physician leader understands that-
1. Performance matters
2. "Value" is not a bad word
3. Performance improvement requires teamwork
4. Articulating Vision and Values is crucial
4. Organizing for performance is vital
5. Developing a measurement system allows valid, reliable, actionable data sharing
6. Improving processes leads to better outcomes
7. Dismantling cultural barriers builds a high performance organization
8. Defining strategy around patient's needs will transform delivery of healthcare

We may question what he means by fixing healthcare, in light of the Department of Justice antitrust inquiry into Partners' high-cost contracting with the insurance companies. That is the difference between value and value.
Truly high-performance organizations deliver patient-centered, value-oriented care effectively and efficiently, but they do not lose sight of the true values.