Knowledge Management and Healthcare

HealthCareCohenSaving Lives

In that moment when you realize that what you are experiencing is real and you have been shaken into the understanding that you are a human being; frail, fragile and living only for a short time this one moment can define or redefine your whole life.

Most of us live our day-to-day lives in a state of ignorance with regard to our health and our lives until we are faced with our mortality or impacted by someone close to us being sick.   People that work in the healthcare industry especially those on the front lines of medicine know all too well about human mortality.  That being said, it is still easy to get into routines and patterns of operation which create a narrow scope of perspective.  In other words,  being in a medical practice can create an intentional numbness.  Some studies show that doctors may suppress their emotions or their brains may automatically inhibit their ability to be empathetic in a short period of time.  The stress of being a person in an environment constantly being reminded that life is short and constantly fighting battles to save lives takes a lot out of people.  It also impacts their decision-making process.

My personal and professional experience has driven me to question why knowledge management is lacking in the healthcare industry.  This industry isn’t short of information but there are indicators that medical practitioners may not have the right information at the right time.

***Frame***

Chip and Dan Health wrote on KevinMD

The following is an exclusive excerpt adapted from #1 New York Times best-selling authors Chip and Dan Heath’s new book Decisive: How to Make Better Choices in Life and WorkHow a smart process helped Kaiser Permanente save lives, which was released on March 26, 2013.

One of the most fundamental problems of decision-making, according to psychologists, is that people get stuck in a “narrow frame”—they view their decision in an unduly limited way, often missing options that are available to them. To break out of a narrow frame, people need new options, and one of the most basic ways to generate those options is to find someone else who’s solved your problem.

For many health care leaders, this search for new options has become second nature. They’ve long since learned to “benchmark” competitors and absorb industry “best practices.” Sometimes, though, the practices that work for one organization may be incompatible with another, like an organ transplant that is rejected. (Imagine if McDonald’s, inspired by movie theaters, started trying to hawk $12 Cokes.)

That’s why we shouldn’t forget, when hunting for new options, to look inside our own organizations. Sometimes the people who have solved our problems are our own colleagues. That’s what was discovered by the leaders of Kaiser Permanente, one of the largest HMOs in the country with almost 9 million members.

In early 2008, Alan Whippy (her first name is pronounced uh-LANN), the medical director of quality and safety at The Permanente Medical Group in  Northern California, was staring at a set of data that astonished her. To continue pushing their hospitals to get better, Whippy and her team had asked the leaders of the 21 Kaiser Permanente Hospitals in Northern California to do detailed case studies of the last 50 patients who had died at each of their hospitals. One problem their hospitals had addressed aggressively—heart attacks—accounted for 3.5% of the deaths. But almost ten times as many deaths came from another cause that was barely on the radar screen at Kaiser Permanente or most of the other hospitals they knew: sepsis.

Dr. Whippy explained sepsis with an analogy: “If you have an infection on your skin, it gets inflamed–red and hot and swollen. The infection itself doesn’t turn the skin red, that’s the body reacting to the infection.” Sepsis is a similar reaction to an infection in the blood stream. The body’s inflammatory reaction spreads to the whole body, even to parts far away from the infection—a case of pneumonia, for instance, can trigger kidney failure or even brain damage.

What Dr. Whippy and her team realized was that physicians were paying careful attention to the infections, like pneumonia, but they weren’t aggressively treating the associated sepsis, which was often the true cause of a patient’s death.

Freeze there. Whippy had a problem on her hands: She needed options for improving Kaiser Permanente’s treatment of sepsis. Where could she find those options?

She located one critical connection within Kaiser: Dr. Diane Craig, a physician at Kaiser Permanente Santa Clara. Craig and her colleagues had spent several years working on sepsis and had already shown some reduction in their sepsis death rate. They were frustrated that progress was not quicker, though—especially since the “recipe” for managing sepsis was known. In 2002, a provocative article had appeared in the New England Journal of Medicine, showing that patients were substantially less likely to die from sepsis if they received quick and intensive treatment shortly after they were diagnosed.

It was easier said than done, though. As Craig knew from personal experience, the quick and intensive treatment was difficult to implement for two reasons. First, sepsis is hard to detect. A patient might look fine in the morning but plunge into crisis by lunchtime, and by then it was often more difficult to correct the cascade of internal damage.  Second, the protocol recommended by the article for treating sepsis—which involves administering large quantities of antibiotics and fluids to the patient—carries its own risks.

As Craig said, “It takes a while for people to get comfortable saying, ‘This patient looks good but I’m going to put a large central IV catheter in their neck and put them in the ICU and pump them full of liters and liters of fluids. And we’ll do all this even though they look perfectly fine at the moment.’” The research supports this early intervention. The risks are worth it. But it was difficult for doctors, with their “Do No Harm” ethos, to move as quickly and forcefully as the research said they should.

Craig and Whippy realized that, to fight sepsis, they had to overcome these two problems by making sepsis easier to detect and by demonstrating to staff the risk ofinaction.

With Whippy’s support, Craig and her team began to incubate new approaches to the problem at Santa Clara. One idea was simple but powerful: Whenever physicians ordered a blood culture—a sign they were worried about a blood-borne infection—a test for lactic acid was automatically added to their orders. (Lactic acid is a critical indicator of sepsis.) This allowed them to detect sepsis well before it began to influence the patient’s vital signs.

Other changes were intended to make the Santa Clara staff more aware of sepsis. Posters and pocket cards were printed up that highlighted the symptoms of sepsis. A grid on the printed materials showed the mortality risk for different patient circumstances. “People could see that this patient, right in front of me, even though they look good—they have a 20% chance of mortality. It was very powerful,” said Craig.

If the doctors and nurses spotted the symptoms of sepsis, they were asked to call a “sepsis alert,” the equivalent in urgency of the “code blue” called when someone is experiencing a cardiac arrest. The sepsis alert summoned a team that could assess the patient and, if appropriate, begin the intensive sepsis protocol.

These innovative solutions began to work. Sepsis deaths began to decline. Whippy, who’d been following the work, knew that the Santa Clara team was assembling a package of cultural interventions that she could spread to other hospitals.  Meanwhile, other hospitals, who’d been pursuing their own solutions, added other critical pieces of the puzzle, like a “pressure bag” that fit around an IV like a balloon, ensuring that sepsis patients would receive fluids quickly enough.

Within a matter of months, under Whippy’s direction, the sepsis protocol was being actively implemented in other hospitals. By summer 2012, Kaiser Permanente Northern California, composed of 21 hospitals serving 3.3 million people, had driven down risk-adjusted mortality from sepsis to 28 percent below the national average.

This solution has astonishing potential. If all hospitals could match Kaiser Permanente’s 28 percent reduction, it would be the annual equivalent, in lives saved, of saving every single man who dies from prostate cancer and every single woman who dies from breast cancer.

* * *

The leaders of Kaiser make it a priority to study their own internal “bright spots”—the most positive points in a distribution of data. For the treatment of sepsis, for instance, Dr. Craig’s team represented a bright spot, because of its lower death rate.

Bright spots can be much more mundane, though. If you’re trying to stick to a new exercise regimen, then your bright spots might be the four times last month that you made it to the gym. If you take the time to study and understand your bright spots—how exactly did you manage to get yourself to the gym on those four days?—then you can often discover unexpected solutions. Maybe you’d notice that three of the four occasions were during lunch, which tends to be the least complicated time for you. So you might make a point to avoid scheduling things at lunch time, keeping that time free for future workouts.

The wonderful thing about bright spots is that they can’t suffer from the rejected-transplant problem, because they’re native to your situation. It’s your own success you’re seeking to reproduce.

Both bright spots and best practices, then, act as sources of inspiration. If you’ve got a dilemma, and you need new options, you can look for new ideas externally, as with benchmarking and best practices, or internally, like Kaiser’s leaders. What’s critical is that we refuse to get caught in a narrow frame, considering only one or two options, and instead widen our perspective so we can see the full spectrum of options that are available to us.

Chip Heath and Dan Heath are the authors of the new book Decisive: How to Make Better Choices in Life and Work, as well as the previous bestsellers Switch and Made to Stick

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The Basics

In the book Decisive, the authors pointed out something that I found compelling but they glossed over.   The time it took from when the article from  New England Journal of Medicine was published until  Dr. Whippy could get the model into best practice was somewhere between 8-10 years.    Authors: Stephen Boone, MD; Christian Coletti, MD; John Powell, MD state in their quick reference guide on sepsis that:

Severe sepsis affects approximately one million patients and claims more than 250,000 lives each year in the U.S. It is the second leading cause of death in non-cardiac ICU patients. Early and aggressive therapy influences outcomes. Utilizing the Surviving Sepsis Campaign Guidelines improves morbidity and can decrease mortality by 25%.

If I am doing my math correctly, in the US alone healthcare professionals had an opportunity to attack 2.5 million cases of sepsis over the past 10 years and the indication is that most haven’t.   Regardless, this is a best practice that should be addressed.

This is about the right information at the right time.   I have written in the past about how in one hospital the leadership turned to a race team to learn how to perform an effective and efficient shift turn over.   I can’t think of any organization that needs to leverage knowledge management more than healthcare.  This is more than just money, this is about saving lives and wellness.onlinelogomaker-102613-2009

When I walk into the doctor’s office today, he is carrying his iPhone or iPad with him, he is managing his personal knowledge but how is his personal knowledge moving from his device to his team or his colleagues?

How many people do you know that have died or have had complications due to sepsis or septic shock?

This is one area of discussion, how many other opportunities are we missing out on?

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Do you know any healthcare professionals?  If so, forward the sepsis guidelines and best practice guides to them please, you never know you may save a life!

21 Days to something better.. It ain’t easy being you.

Be Positive, Work Hard, Success Will Follow

CardonFridge

http://sharetheadvantage.org/

There is a lot of talk about helping people but most of it is bullshit.   Today I want to pass on to you something that was given to me this year.  My friend Frank approached me after one of my blog posts and said.. “Howie, I am here for you to talk.”   Giving someone your time from my perspective is one of the most precious gifts someone can give especially with the busy schedules we have.

At work we don’t have counselors, mental health professionals or people who have time to really sit down and talk with.   We have to be productive citizens that work towards the goals of the job.  For a lot of people who is the reality, there really is no time for depression, anxiety or any other challenge.  There are a lot of people who come to work sick.   Staying home or being sick doesn’t seem to really be an option.   A lot of companies got rid of sick day allowances.  The point is that mental health seems to get lip service but that is about it.

There are two points here:

  1. Happiness is tied to success 
  2. Unhappiness presents cascading challenges which can produce undesired results.

Shawn Achor: The happy secret to better work

http://www.youtube.com/watch?v=fLJsdqxnZb0

What can I do?

Be like Frank.   People don’t want to admit when something is wrong.   A lot of times we don’t even know that something is wrong.  You don’t need a degree and 20 years of psychology to know when someone you are close to is acting different.   The question is what are you going to do about it and how will they react if you do something?  Here is what Frank did.

  • Asked me what was wrong
  • Offered to help
  • Gave me a card (the top picture) now is on my refrigerator.
  • Told me he cared about me and that if I need him that I should call him with no question.

With a small kind act he effectively impacted my life in a very positive way.   I have shared these concepts with my children and we talk about being grateful on a regular basis.  I am reminded everyday as I pass the refrigerator that I should be grateful and health is tied to meditation, exercise, expression and acts of kindness.   I am also reminded that Frank cares about people and he cared about me to share this.  I care about you to share this too.

We can petition the white house for help https://petitions.whitehouse.gov/ but just as the Death Star was turned down because of cost, the government can’t afford to fix mental health.  The money isn’t there.   It is up to us as individuals to help each other one person at a time from person to person.

I am not a qualified mental health professional, I don’t want to get involved

Right…  So what?  It doesn’t matter.   Doing nothing is doing something and with the way people are acting today we need more people to be caring and mindful not just to help others but to help themselves.  It reminds me of the first Spiderman movie where Peter Parker let the criminal go and the after actions of that criminal resulted in a direct blow to Peter.   If you see something is wrong and you do nothing, it may be you that ultimately is the one to pay the price.

If nothing else.. share the image of the card Be Positive, Work Hard, Success Will Follow.

Mental health is a “big rock” issue and the complexities of mental health issues are astronomical in nature.  I am not suggesting that we are going to solve all of the problems with mental health by working harder.   The point here is that as a friend, co-worker, good citizen, neighbor, good person, when you see something that isn’t right there may be something you can do.  In this case Frank shared ideas with me that resonated and I am sharing them with you.   Relating to work and success was his choice and vehicle for communicating his care and concern.

Every conversation will be different and your approach to helping someone will be different.  I am simply saying to do something and not wait until the government or others to help.  If the challenge is too big for you to help with, you will know that right away and you can seek further help and guidance.

Cloud SLA (Government / Defense)

I teach a cloud computing course for Thomas Erl @ Arcitura from time to time and the question that always comes up is the one about service level agreements.   It is a complicated subject that does not get enough attention in our industry.  I am presenting some of the discussions that we have had in class and some of the questions asked all relative to cloud computing and mostly aligned to the defense industry.    This is part of an SLA series of blogs to get people thinking about their requirements and to understand what an SLA can do or not do for a business.

Today I will share a short story .

It was 5:00 PM on a monday afternoon,  a routine procedure on a patient in London turned into a catastrophic challenge requiring expertise from across the pond.    Dr.  Jack Ash is a leading Gastroenterologist living in Ontario, Canada.   Dr. Ash received a call asking if he could help the patient in London.   Dr. Ash has extensive experience with remote surgery a relatively new practice taking shape using cloud oriented services.   Dr. Ash is using IT services provided by the hospital in Ontario.  The services in London are with a different hospital and a different IT service provider.   The configuration of the services look very similar to this (see figure 2) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1356984/

The SLA looks something like this IT_Service_Level_Agreement_Publish_To_Customers.   Dr. Ash didn’t have much time, he needed to act fast.   He ran down to the office and coordinated all of the requirements with the remote team in London.   This situation had been discussed before and the staff had practice with dummies and cadavers.  Fortunately for Dr. Ash he routinely performs procedures like this in Ontario between hospitals often.

The stage was set, the anesthesiologist had the patient stable and all of the supporting staff acted as planned.   Due to the situation and set backs some time had gone by and the procedure took place closer to 8:00 PM .

Dr. Ash started the robotic services and invoked various commands over the network.  At first the procedure was going well, there were some minor fluctuations with bandwidth but nothing major.  In order to make sure that the network connectivity was consistent Dr. Ash asked a staff member to call over to his local IT and make sure QoS was turned on.   The helpdesk reported back quickly that all available resources and network traffic managing the robotic services had priority on the network.   The procedure continued and Dr. Ash was noticing severe latency through his video stream.   He had to act fast to finish the procedure and just as he was finishing the final maneuvers, the robotic arms lost connection.  Luckily the original staff working on patient x were in the room for Dr. Ash to talk through the final moments.

What happened?  Why did the arm lose connectivity?  How did the SLA help?  How could the SLA have helped?

Although this story was not real, the technology is real and the fact is that medical practitioners are doing something like this today.   Why did the arm lose connectivity?  I’ll give you a hint, there was a soccer game at Chelsea http://www.chelseafc.com/ and there were a lot of people in London very interested in that game.

There are various reasons for the potential failure of service.   The problem is that most people focus on what technology can do as opposed to understanding where it make sense to use services like this and where it makes sense not to use these services.   There are plenty of business cases that could have created a more stable environment but more often than not businesses choose to go head first into situations like this.   It seems like a great idea and they even had an SLA!  I wonder what that would have done for patient x had this person died.

These are some of the concepts that we will need to explore further.  I will put together some defense oriented generic scenarios for thought.