Skills decline – a problem on the rise

In the 2-year course of our Osler journey, my business partner Jeff has said to many time who in the hospital he’d want looking after him if he needed a procedure performed : the senior registrar.

 

As Jeff sees it, senior registrars are about as sharp skills-wise as they are ever going to get.  They do the most procedures, they learned the most recently and they are yet to be cloaked by an air of invincibility.

 

And he’s not far off the mark.

 

But what it highlights is an increasingly recognised phenomenon – skills attrition in consultants.

 

In many procedural specialties, there is an almost precipitous drop off in exposure to invasive procedures from the day you pass your fellowship exam.  There is a changing of the guard, where those who once did, now supervise.  Add to that the competition for access to increasingly rare opportunities and there is little doubt that emergency physicians, retrievalists, rural generalists and intensivists are starved of exposure.

 

It’s more likely that the problem has been quietly suspected for some time, but as an industry we’ve been more inclined to turn a blind eye to it, for the solution presents an even bigger problem – if we’re all diminishing in our skills capacity, what on earth are we going to do about it?

 

But the problem is now becoming too big to ignore.  Andrew Tagg, an emergency physician from Melbourne, wrote about this recently.  Access to opportunities to perform procedures are becoming so rare that inevitably we are all deskilling.

 

So what to do?

 

The first step in any quality assurance process is to measure.  Any textbook on clinical audit will tell you the three key areas that we can measure – activity, process and outcome.

 

The first should be easy.  Documenting our activity is an important first step in detecting gaps in our experience.  There is a fairly clear relationship between recency of performance and ability to execute, so it makes sense to track the volume and timing of our activity.

 

The second examines our method.  Is it really too much to ask to submit ourselves to periodic review of our performance by our peers? Is there a better way to validate that my practice is consistent with modern standards?  While inevitably there are logistical challenges with this style of approach, the potential benefit in safety terms more than justifies applying it.

 

Finally, and most problematic, is to measure outcomes.  It’s difficult for many reasons, not the least of which are standardising definitions, accurate data collection (particularly of delayed outcomes) and the relatively low incidence of complications for most things we do.

 

We should not refuse to measure ourselves because we are afraid of what it might tell us.  The more mature response is to find out where our limitations lie, and find a solution.

 

We owe that much to our patients.

 

The old adage is that “Not all that is important can be measured, and not all that can be measured is important.” However, there is plenty that can be measured and is of value to us.

 

We owed it to our patients to try.

Hospital Safety Report Provides Opportunity for Innovation

A new report into managing critical safety risks in the hospital system makes important recommendations and highlights the need to prevent patient injury and death in the first place, says a high-tech medical start up.

 

The just-released Duckett review into DHHS management of incidents, such as a spate of perinatal deaths in Victoria in 2013-4, underlines the ongoing national tragedy of 1800 Australians who die each year and another 6800 who are impacted by such adverse events.

 

Osler Technology, the brain child of intensive care and retrieval medicine specialist Dr Todd Fraser, provides real time, meaningful data on patient outcomes within the clinical workspace, and enables clinician leaders to respond rapidly and creatively to prevent future events.

 

By tracking individual training and activity data, it ensures all staff practice within their scope.

 

“The recommendations of the Duckett review create a better environment for patient safety across the wider health system but this is only half the battle. Left unanswered is how health systems prevent patient injury in the first place,” said Dr Fraser.

 

“If meaningful change is to be made, clinical staff will be the ones to make it, and they can only do so with the right tools and information at their disposal. This is where a system like Osler plays a role by taking the high level principles identified in the Duckett review and applying them at individual patient, clinical manager and clinician levels.”

 

Read the full media release here:

20161020-osler-media-release-take-2

Stephen Duckett’s report highlights need for new thinking on clinical governance

Background

The recently released Duckett Report was commissioned in response to a review of the role of DHHS in detecting and managing critical safety risks and clinical governance across the system following a cluster of perinatal deaths at Djerriwarrh Health Service in 2013-14.

 

The report highlights that while Victorians have a right to assume that healthcare is generally of a high quality across the system, there continue to be significant deficiencies in the system’s defenses against avoidable patient injury.

 

The report cites a 2014-15 review of hospital acquired diagnoses in Victorian Healthcare System, which concluded that “complications of care are far from rare in our hospitals”.  In fact, more than 300,000 patients per year suffer a complication in Victorian hospitals, at least 70,000 of which are potentially preventable such as malnutrition or pressure ulcers. Many of these result in fatalities.

 

This issue, to say the least, is huge.

 

The Duckett report was commissioned to review the role of the DHHS in preventing these events.

 

Essentially, the report calls for the department to better support Victorian Health Services in providing a high level of local clinical governance on safety and quality, to monitor outcome data more closely, and to respond more effectively when things go wrong.

Major Findings

To this end, the report makes several important recommendations, among them :

 

  1. The department must set a clear example to the wider health service that this issue is its number one priority
  2. The system should focus less on “meeting accreditation standards”, and instead greater emphasis placed on outcome monitoring
  3. The department better supports the boards of health services by reviewing the appointment and training processes for board members, to ensure they can effectively oversee hospital governance
  4. Performance of the health service is more effectively monitored, by making better use of available data and filling in gaps as they exist
  5. Improvements are made in the utilization of data, so that the entire system can benefit, and learnings are better shared
  6. All hospitals should be open to periodic external review
  7. That hospitals are held to account in only providing care that falls within its scope of capability
  8. Consumers and front line clinicians must have a louder voice in the quality assurance process.

 

What does this all mean?

Promoting a culture of transparency and accountability, and most importantly trust, are an excellent start, and to this end, the department is to be congratulated for the example it has set.

 

As Dr Duckett himself points out, the department acted immediately to support Djerriwarrh protect its patients, investigate the cluster of deaths and engage in an open disclosure process.  It then sought prompt external review of its own role in the process and made those results public immediately.  It is a high level demonstration of the transparent accountability required at clinician level.

 

The recommendations of the Duckett review create a better environment for patient safety across the wider health system but this is only half the battle. Left unanswered is how health systems prevent patient injury in the first place.  Albeit beyond the scope of the review, here lies the rump of the improvement curve – what are the hospitals and health services, their clinical managers and individual clinicians supposed to do to improve patient care?  The report provides few answers.

 

If meaningful change is to be made, clinical staff will be the ones to make it, and they can only do so with the right tools and information at their disposal.

 

Without appropriate tools, processes and culture in place, no amount of oversight will achieve the department’s lofty goal of zero preventable patient injury.  This is where ready-made systems like Osler plays a role by taking the high level principles identified in the Duckett review and applying them at individual patient, clinical manager and clinician levels.

How can Osler contribute to improved clinical governance?

Osler provides an opportunity for hospitals to be proactive in their patient safety efforts.  As Dr Duckett points out, hospitals should be operating within their defined scope of practice.  The problem is, few clinical managers have sufficient granular visibility of their activity to enable this to occur.  Using Osler to ensure all staff are adequately trained to perform invasive procedures, non-technical skills and basic equipment familiarity helps manage this clear and apparent risk.

 

By providing real time, meaningful and comparative data on clinical proficiency, complication rates and currency or practice, Osler enables hospitals to identify and respond to limitations in service levels and patient care.

 

And by creating a collaborative environment for clinicians, Osler can distribute these essential learnings across the healthcare system so that Victorians, indeed all Australians can be treated in a safer manner.

 

 

“You have to be willing to acknowledge your problems before you can remedy them. If I were to characterise the state of public and private hospital care in the state of Victoria, I’d have to say that this first step is lacking. Both the public and private hospital systems and the government regulators who oversee them are in a state of denial with regard to the level of harm being caused to the public by inadequate attention to quality and safety deficiencies.”

Paul Levy

former president and CEO of Beth Israel Deaconess Medical Centre in Boston, Massachusetts

Deakin University, Thinker in Residence, 2016

“How many of these have you done?”

A recent opinion piece in the Journal of the American Medical Association drew attention to the issue of procedural experience in healthcare.

 

Titled “How many have you done?”, the piece described the experience of a doctor who required a procedure herself, in this case, an amniocentesis.

 

Of course, what the patient was really asking is, “How can I be reassured you know what you are doing?”

 

The thrust of the piece was that the training doctor who performed the procedure had felt compelled to misrepresent their experience with the technique, deftly deflecting questions by the patient and her partner that explored his competence.  The author calls for a more honest response to these types of questions, while acknowledging that this is often difficult to do.

 

But is it any wonder a young doctor has trouble answering this question?

 

Healthcare continues to battle with the issue of competency.  It is still rare for doctors to be formally certified to perform specific procedures.  In fact, the industry still does not have a shared understanding of what competency actually is!

 

Furthermore, because it is uncommon for doctors to assiduously record their activity and outcome data, and even more rare for them to benchmark against their peers, most clinicians are simply oblivious to performance level.

 

So when patients are searching for reassurance that they will be cared for as best they can be, most of us struggle to be clear and meaningful in our response.  Because most of the time, we just don’t know.

 

Wouldn’t it be much better for the junior doctor to answer with authority?

 

“Well, I’ve completed a recognized pathway and been certified to practice after a period of supervision by experts.  Furthermore, I continuously review my performance results and feel comfortable that I’m doing well.”

Enough is enough

The June 2016 edition of Clinical Communique (a periodic report released by the Victorian Institute of Forensic Medicine) once again highlights the issues facing procedural healthcare.  The report highlights three recent coronial inquests into patients who succumbed to complications from central access devices, including a fatal myonecrosis, a pericardial tamponade and a carotid placement resulting in a stroke.  Multiple issues are highlighted in the insertion and subsequent management of these devices.

 

My problem with this is that we’ve heard it all before.  There is nothing new in these recommendations, yet the incidents keep happening.  And it’s far too simplistic to think of the clinical staff involved as “bad apples”.  Simple fact is, they are not.  They are hard working, intelligent, dedicated, diligent and well intentioned.  In fact, they’ll no doubt be completely traumatised by the experience.  So why does this keep happening?

 

Off the top of my head, let’s start with the following :
a) a lack of agreement on best approach (but there ARE existing guidelines)
b) failure to communicate guidelines effectively to those at the coalface
c) resistance by clinicians to embrace best available evidence
d) total lack of structured accreditation process for insertion of lines (and most other invasive procedures)
e) systemic failure to share learnings just like this on a wide enough scale

 

Surely its time our industry got its act together and did something meaningful to overcome these barriers.

 

If you’re interested, here’s the report

 

About the author

Dr Todd Fraser is an intensivist and retrieval physician, and the co-founder of the Osler Clinical Performance Platform, dedicated to improving certification and training in acute healthcare.

Everyday heroes. Saving lives, one at a time…

I’m the COO here at Osler Technology.  I’ve had decades of experiences building businesses, developing software and helping clients achieve benefits through the use of that software.   But until I got involved at Osler, I was a complete novice in the inner workings of our health care system (still am!).  A recent event reminded me about why we are building Osler.

 

Earlier this week, one of our content editors (and a practicing nurse) witnessed a woman collapse on the steps to a supermarket across the road from our HQ in Noosa Heads, Queensland.  She immediately swung into action and commenced CPR and basic life support activities and called Todd, our founder (and a practicing intensivist), who was up the road having a coffee.   Between the two of them,  they kept this woman alive until transported to Noosa Hospital. 48 hours later, with a new stent in place, she was sitting up in bed, calling Jo & Todd her guardian angels.   Without the lucky coincidence of the timing and location, this woman probably would not have survived.

 

As our CEO remarked,  “Truly amazing to be involved in a software company where our team members actually go on to the street and resuscitate people who have had a heart attack.”

 

We’re building tools to help clinicians acquire new clinical skills and improve their clinical performance,   and to help providers be more efficient in developing and maintaining those skills among their workforce.  We know that these everyday heroes get it right 99% of the time.   But if Osler can help improve clinical governance, patient safety, and help those heroes get it right 99.1% of the time,  then it will be a huge win for public health,  patient safety,  and of course, our amazing team.

Osler Community Survey – Give us your views

We’re interested in your opinions about professional and clinical skills development, clinical governance and transparency in healthcare, and your feedback on our product ideas. Osler is developing a revolutionary new approach to professional development.

This survey shouldn’t take more than 8 minutes to complete & your feedback is incredibly valuable. We will distribute a summary of the aggregated results to all respondents at the conclusion of the research.

The best 3 answers to a question in the survey will also receive a free one-year subscription to Osler Community when it launches later this year.

LAUNCH SURVEY

 

Clinical Skills Development

The 3rd leading cause of patient death might well be the hospital system itself

Another week, another report illustrating the harm that the healthcare industry inadvertently causes to its patients.

 

This week the British Medical Journal published a report by renowned patient safety champion Marty Makary which examines the role of healthcare error on mortality.

 

Healthcare error take many forms, including :

  • Unintended acts (either commission or omission)
  • Execution errors
  • Interpretation and synthesis errors
  • Planning errors, and
  • Deviations from processes of care

 

The report highlights the lack of visibility surrounding healthcare error. Annual causation mortality data is often compiled from death certificates and coding, based on classifications such as the International Classification of Diseases (ICD) code.   Such systems do not routinely account for healthcare error, and so do not feature on such annual lists.

 

The fact that healthcare error results in patient deaths comes as no surprise to most practicing clinicians, many of whom have either witnessed patient deaths related to management errors, or even been a part of the process themselves. And it’s not a pleasant experience.

 

What should be startling is that the issue has been recognized for so long, yet little progress seems to have been made. It’s now over 15 years since the seminal work of Lucian Leape and colleagues (1) highlighted as many as 98 000 American lives are lost each year related to iatrogenic factors in hospitals, with countless more injured. Many of these deaths are thought to be potentially preventable.

 

Despite the furore that Leape’s To Err is Human report generated, little seems to have changed. Subsequent reviews (2-6) have since estimated that between 200 000 and 400 000 US deaths can be connected to patient error annually.

 

Extrapolating the published literature, Makary and colleagues suggest that, if true, iatrogenic causes of death would rank third on the all-cause mortality table in the US (behind heart disease and cancer).

 

It’s hard to imagine that if healthcare error was viewed as a disease, widespread public awareness campaigns, fundraisers and dedicated research would be inevitable.

 

No one who works in healthcare could possibly suggest that a zero patient death rate due to iatrogenesis is possible. The healthcare system is almost as complex as the humans it cares for. It’s clear that the vast majority of patients who traverse the system are well cared for by highly motivated and caring individuals, and the results are usually positive.

 

That notwithstanding, healthcare needs to re-evaluate its approach to safety. The external perception of the acute care industry is that of a High-Reliability Organization, where safety is prioritised against all other factors. Industries such as oil and gas exploration, aviation, and nuclear power have demonstrated that this approach can reduce injury to almost zero.

 

The serial failure of our industry to embrace standard, risk averse behaviours contributes greatly to the harm it generates :

 

  • Failure of orientation
  • Failure to validate procedural competence
  • Failure to ensure equipment familiarization
  • Failure to embed policy and procedural change
  • Failure to embrace literature and national standards
  • Failure to embrace technology that can improve and enhance safety standards
  • Safe working hours
  • Failure of process documentation and audit
  • Communication failure
  • Failure to measure and report outcomes transparently
  • Failure to ensure critical incident learnings are widely distributed
  • Failure to report and investigate “near miss events”
  • Failure to create a no-blame culture

 

Applying these principles to the healthcare sector will inevitably create tensions and encounter barriers to implementation, but the first step is an acceptance that we can do better.

 

“I think doctors and nurses and other medical professionals are the heroes of the patient safety movement and come up with creative innovations to fix the problems,” he said. “But they need the support from the system to solve these problems and to help us help improve the quality of care.” Marty Makary (source CNN)

 

 

References

  1. Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a safer health system.National Academies Press, 1999.
  2. Leape LL, Lawthers AG, Brennan TA, Johnson WG. Preventing medical injury. Qual Rev Bull1993;19:144-9.pmid:8332330.
  3. HealthGrades quality study: patient safety in American hospitals. 2004. http://www.providersedge.com/ehdocs/ehr_articles/Patient_Safety_in_American_Hospitals-2004.pdf.
  4. Department of Health and Human Services. Adverse events in hospitals: national incidence among Medicare beneficiaries. 2010. http://oig.hhs.gov/oei/reports/oei-06-09-00090.pdf.
  5. Classen D, Resar R, Griffin F, et al. Global “trigger tool” shows that adverse events in hospitals may be ten times greater than previously measured. Health Aff2011;30:581-9doi:10.1377/hlthaff.2011.0190.

American Hospital Association. Fast facts on US hospitals. 2015.http://www.aha.org/research/rc/stat-studies/fast-facts.shtml

 

About the author

Dr Todd Fraser is a passionate campaigner for patient safety through better process.  He is an Intensivist and Retrieval Physician, and co-founder of Osler Technology.

Why I record all my outcomes, good and bad

Recently I led a crisis team that was required to intubate a patient with severe pneumonitis.

 

Ultimately the process went well enough – the patient was established on mechanical ventilation and we set about implementing the strategies required to treat his underlying condition.

 

Later that day, I took the time to record the procedures I’d performed in my logbook on Osler.  Intubation, induction of anaesthesia, arterial line, central line, bronchoscopy, transportation of a ventilated patient.  It’s what happened then that is the reason I’m telling this story.

 

I was forced to acknowledge that things hadn’t gone as smoothly as I would have liked.  The patient had desaturated below a level I was comfortable with.  An IV was accidentally dislodged as we moved the patient onto the CT scanner.  There was nothing catastrophic, but to me, it was a trigger to examine what had occurred.

 

Importantly, it gave me the opportunity to review all my intubations and see if there was a signal – was this a once off event?  Or do I have a bigger problem?

 

But it left me wondering whether this was just me or does everyone have these issues?  In reality, I have no way of knowing because I can’t benchmark myself against anyone else.  Perhaps I’m great at this, perhaps I suck.  Or perhaps I’m doing as well as anyone.  But it would be nice to know, because it changes how I see my performance.

 

Recording my complications doesn’t mean I’ve failed or am negligent.  It might not even by my fault.  But it did happen, and that’s the point.  If there is a way of stopping it happening again, then I need to find it.

 

With this in mind, I can now set my attention to figuring out why things had not gone as well as they could.  I found a few issues, both personal and team based, and have set about fixing them so I can reduce the chances of this happening next time.

 

And while I would love for things to have gone better the last time, it’s the next time I can do something about – and I feel good about that.

 

About the Author

Dr Todd Fraser is an intensive care and retrieval medicine specialist, podcast editor of the Society of Critical Care Medicine, and founder of Osler Technology, a clinical performance management platform for acute healthcare providers.