Communicaton and Implementation

I have been focusing on Health Care lately with good reason. Both personal and in the larger sense.

A consistent theme through my work is to understand how communication has changed in the work place. Seems odd to even suggest that a category as fundamental as communication can change.

What changes is our need. And, the technology or manner that we use to communicate.

When I was a young stage manager, I had a profound experience. I had prepared an Opera House stage for one of the greatest legends in jazz. A great artist and person.

Following rehearsal, I asked the crew to rearrange some lighting, believing that I was helping this virtuoso musician . The crew responded with equal respect and gladly made the changes, even though they were not easy to complete.

Minutes before curtain, as the audience waited, I brought the pianist to the wings, ready to go on.

He looked at me and said "Sal, you moved the piano further to the center of the stage". Yes, I replied, eager to tell him of my decision to change the lights.

Sadly, he looked at me and said: "I can't walk that far without a cane and I did not want the audience to know that".

It was a lesson immediately placed in my heart, as he bravely made the journey to play the piano.

Communication and implementation are often a simultaneous event in today's work world. It is something that the customer has taught us. It simply is necessary in the kind of environment we live and work in.

The lesson I learned that night is one I am still trying to understand. Intentions can be good and implementation complete. But somewhere, in fact always, lies that fundamental need to communicate. Often, it's about critical issues that we just don't see.

Sal

While We Were Watching the Florida Primary

California Senate Panel Rejects Health Coverage Proposal

by JESSE McKINLEY and KEVIN SACK

Published: January 29, 2008 NY Times

SAN FRANCISCO — In a blow to universal health care coverage in California and possibly to its prospects nationwide, a State Senate committee on Monday rejected a sweeping plan by Gov. Arnold Schwarzenegger that would have offered insurance to millions of uninsured residents.

The Senate Health Committee defeated the plan 7 to 1, with three abstentions, as Democrats and Republicans alike said they found it too nebulous and potentially too costly for a state facing a $14.5 billion deficit.

“This bill is not only not perfect, it is flawed,” said State Senator Sheila James Kuehl, Democrat of Los Angeles and chairwoman of the committee, who voted against it.

Mr. Schwarzenegger, who had seemed resigned to the plan’s defeat in recent days, sounded a determined note on what he had viewed as a major policy initiative of his second term.

“I am someone who does not give up, especially when there is a problem as big and as serious as health care that needs to be fixed,” Mr. Schwarzenegger, a Republican, said. “One setback is just that — a setback.”

The loss in California, the nation’s most populous state and often its most influential, bodes poorly for universal health coverage, an issue that just a year ago appeared to have found its moment. Besides Mr. Schwarzenegger, the governors of two other populous states, Pennsylvania and Illinois, proposed ambitious health care plans in 2007. But in the end, nothing of national significance was passed.

Drew E. Altman, president of the Kaiser Family Foundation, which studies health policy, said the vote in California reinforced the need for action in Washington.

“California’s failure, after coming so close, underscores the lesson that too many states don’t have the political will or resources to reform health care on their own,” Mr. Altman said. “Thus the need for a national solution.”

Mr. Schwarzenegger’s proposal was modeled largely on a Massachusetts plan, which requires individuals to have insurance, prohibits insurers from denying coverage on the basis of age or health, and uses government subsidies to make insurance affordable for low-income workers.

But last Wednesday, as the California Senate committee heard testimony on the bill, Massachusetts announced that spending on its health care plan would increase by $400 million in 2008, a cost expected to be borne largely by taxpayers.

Shortly after the vote, Assemblyman Michael N. Villines of Fresno, the chamber’s Republican leader, praised it as a rejection of “a massive government-run health care scheme.”

On the Democratic side, there were concerns about the so-called “individual mandate,” which would have required all Californians to carry and pay for insurance, except those in economic hardship.

The vote comes as Mr. Schwarzenegger faces a dire financial situation and has proposed a spending cut of 10 percent for most state agencies.

Jonathan Gruber, a health economist at the Massachusetts Institute of Technology who was commissioned to advise Mr. Schwarzenegger and the Legislature on the health proposal, said it “was pretty clearly doomed by the larger fiscal deficit.”

How the California vote affects the issue’s national profile remains to be seen. A New York Times/CBS News poll taken this month showed that 7 percent of those questioned thought health care was the country’s most pressing problem. Over all, it ranked third after the economy and the war in Iraq.

The California bill looked to have a chance when it passed the Assembly in December. But it faltered badly in the Senate, particularly after a report from the state legislative analyst last Tuesday raised questions about its long-term financing.

Senator Darrell Steinberg, Democrat of Sacramento, was one of several to express frustration that the Legislature had failed to draft a passable bill.

“When this bill fails,” said Mr. Steinberg, who abstained, “what’s next?”

Jesse McKinley reported from San Francisco, and Kevin Sack from Atlanta.

http://www.nytimes.com/2008/01/29/us/29health.html?ref=health

Thinking About Health Care Workers - This is an older blog

Now & Then

"Our Industrial Credo was the precursor to what is known today as the Johnson & Johnson Credo. Written by General Robert Wood Johnson in 1943, the year in which the Company announced its intention to become publicly traded, Our Industrial Credo was based on Johnson's first documented statement of a company's social responsibilities, Try Reality" - J&J, Our Credo History http://www.jnj.com/our_company/our_credo_history/index.htm
.
I find it fascinating, that in1935, in a pamphlet titled TRY REALITY, Johnson asked his contemporary industrialists to accept what he called "a new industrial philosophy". He believed this "to be a corporation's responsibility to customers, employees, the community and stockholders".

What Do You Suppose That Pamphlet Might Suggest for Today's Reality?

In today's dynamic and often virtual workplace, how do we assure people what the original Credo required and intended for employees in our contemporary workplace?

And, who would be the "industrialists" that Johnson would speak to now?

A 1948 version of the Credo promised workers that:

"They must have a sense of security in their jobs. Wages must be fair and adequate, management just, hours reasonable, and working conditions clean and orderly. Employees should have an organized system for suggestions and complaints. Supervisors and department heads must be qualified and fair minded. There must be opportunity for advancement — for those qualified and each person must be considered an individual standing on his own dignity and merit".

I am writing this at 2 AM. Where's the Credo when I need it?

Back to the Hospital

I am looking to health care institutions that have a bias for change.

My wife had to return to the hospital a second and third time since December 23rd. A different hospital than the first visit.

Bottom line:

Once again, expert and dedicated emergency room staff. However, they suffer from staffing issues, payer requirements and slow to evolve - EMR (electronic medical records).

The patients suffer as well.

1. My wife's medication in the ER was delayed by what seemed at least 2 hours. Reason: The nurse in charge had left. The nurse attending my wife had been recruited from the cardiac floor because of the ER being understaffed. The cardiac floor is not on the same computer platform as the ER. The attending nurse could not work the program. There may be legal reasons for the cardiac to be separated. However, this arrangement did not work when we needed it to work.

2. After waiting 12 hours or more to be admitted, my wife went to a room after midnight. The ER nurse (who had volunteered to stay for extra hours), simply took her to the room herself. There was no one available to transport her. Having been sleep deprived for days, part of the reason for admitting Maggie was to help her to get rest. She wound up in a room with a woman in a state of dementia who yelled and talked, rarely stopping, and had been doing so for days.

3. Medications that were ordered and confirmed 4 times in the ER were not ready or indicated when she was admitted twelve hours later. Not one meal served to her in all her stay reflected the "lactose intolerant" indication that was critical to maintaining her much needed calorie intake.

This is a very good hospital in NYC. Their medical staff is outstanding. Information flow and the the need for a business model change are clear.

ERs are businesses. This particular hospital has been mandated by its Board of Directors to break even this year. They see the need for a business model change - ( I think they do).

"They spent 3 million dollars on software upgrades this year. Why can't I connect on the same platform. I don't even know how to access the vitals from the ER triage which is down the hall" - My memory of what the cardiac nurse told me during her frustration working in the ER. "I can't do my work".

Some hospitals are innovating with EMR and integrating patient information across the board. From patient management, the doctor and the payer to create a more efficient and successful hospital stay. These hospitals are trying to do something that is not conventional in health care today. To share information, accountability and be more inclusive in an effort to work differently and achieve better results. Look for those hospitals. It will pay off when you need them.

In business, we have learned the hard way, to understand usability testing, tool development based on what communities of practice need, and when to challenge the best advice of consultant applications.

Emergency care is a business.

Here's an interesting article on businesses and health care. It's not necessarily on point directly for what I have been discussing. However, it's obvious, that hospitals cannot do this alone. That re-engineering is a concept that must be dynamic in this arena. Without communication and stuck in silo and specialty practice behaviors, the incentive to communicate is not always there.

http://www.fastcompany.com/magazine/117/next-can-ceos-cure-cancer.html

Health care and communication. The continuing issue.

Useful Information on Health Care

It's important that I not seem naive or negative about my comments on health care today. We are all in this together and the health care workplace is in need of not only change, but support.

One long time nurse and teacher (while she was describing her own health crisis and how her students became her help) said to me:

"Health care workers need to know that they are cared for too".

This information was sent by a colleague.

http://www.hschange.com/

The mission of the Center for Studying Health System Change (HSC) is

to inform policy makers and private decision makers about how local

and national changes in the financing and delivery of health care

affect people. HSC strives to provide high-quality, timely and

objective research and analysis that leads to sound policy decisions,

with the ultimate goal of improving the health of the American public.

For example:

http://www.hschange.com/CONTENT/913/#ib2

Sal

I Am on the Side of the Health Care Professional

Just wanted to be clear about a previous post and troubling hospital experience that I described.

I firmly believe that we have a nation of health care professionals whose skills and intentions are not fully understood or implemented in our current system.

Ask a doctor how deeply the current payer system inhibits their use of knowledge and experience. And, take a closer look at why dedicated workers' morale is at issue.

There are great areas of innovation in our system however, and this is encouraging. Mass General's Benson-Henry Institute for Mind Body Medicine for example. http://www.mbmi.org/about/whoweare_staff.asp

I am no expert. That is the point. Let's work to allow the experts to practice, support younger minds to develop and patients to become more articulate and accountable.

This week's New England Journal of Medicine announcement that one is safer to have a heart attack in an airport or hotel rather than a hospital is an example of speed to react. Communication within hospitals is a major issue.

We cannot pretend that our system is "the best in the world" when it is not. The study focuses on equipment. Tools, whether they are technology based or mechanical are meant to carry out our intentions.

Communication and ease of transferring knowledge and information is fundamental. Electronic Medical Records require a significant cultural change and business transformation. While there is all this discussion regarding privacy, it was difficult to transfer the records of my wife's emergency stay in one hospital to her doctors and the hospital where the surgery occurred. Turns out to be a fax permission form that had no security really and a burdonsome process for action.

"Most hospitals rely on traditional defibrillators, which can be more cumbersome and time-consuming, and usually require a doctor. But newer defibrillators, which cost about $500 each and can be found in many airports and hotels, are much faster and easier to use. Because they are fully automated, the machine decides whether a shock is needed, and quickly administers it — so that anyone can use it quickly."

One article I read about this study suggests that Casinos are safer places to have a heart attack than a hospital. Casinos always communicate. They literally and figuratively almost always know where their money is at any time. It is no surprise that they can respond to a heart attack faster than a hospital can.

PS: The hospital where my wife had the surgery that seems to have resulted in a pneumonia called today to see how she is doing. Today is January 5th. The surgery was December 21st. They had no idea of what had occurred and how she needed to be treated at another hospital in emergency. In spite of having visited the surgeon several days ago and informing him on December 26th. Normally, this hospital calls one day after the surgery.

When I asked the surgeon if this kind of pneumonia was common during surgery he said "it is very common, well not very common".

My question to him is: How are you measuring what is common? You have not reported this to your hospital. Where is the data to support your response. What seems common to me, is lack of communication and consistent reporting of incidents.

New England Journal of Medicine heart attacks in hospitals

http://www.abcnews.go.com/WN/story?id=4080507&page=1

Why Hospitals Are Dangerous Places for Heart Attacks - Jan 3, 2008

Sal

It Always Hits Home

I have avoided this blog recently. The recent holiday season was difficult. With all the reading, research and personal experience regarding today's health care -- things hit hard over the last few weeks.

My wife, after having a fairly routine outpatient knee surgery on Dec. 21st, found herself on Dec. 23rd in an ambulance.

There is still confusion but the consensus seems to be that during the surgery she suffered pneumonia from what is called an aspiration.

The staff effort in the emergency room was diligent. There were other complications and they were able to sort out what was going on with expertise and understanding. However, I also had to work with them to make certain that they did not make quick assumptions to what might be a more complicated scenario.

Interesting, that when I apologized to the nurse for my assertiveness on arrival when I noticed a certain dismissive summary too quickly from two staff members, the nurse actually thanked me.

"I was proud of what you said to the admitting team. They needed to hear it and they will treat her differently now".

The short of it is that communication from this strong ER effort to other staff members was awful. Some verbatim that I heard.

"When I go to get the labs, sometimes I take the pictures myself because they are asleep up there" - Resident Doctor

"This used to be a really good hospital. It's not anymore" - Nurse

"That's not the right dosage. I am supposed to write that prescription" - Doctor upon discharge who had participated in the ER.

"We will keep her in the ER for as long as possible, because she will not get the same care once she goes upstairs (admitted)" - Nurse and long time employee

These are only a few of the morale, implementation and work routine hazards we experienced.

It goes deeper. Guarantees to connect and exchange information with my wife's primary doctors was never done.

I did find staff sleeping when they were on specific assignment to caring for the patient. Yet, there was never a question about the motivation or commitment of the health care workers. Something more dense is affecting their ability to perform.

We are all needing to help this situation.

Sal