His focus on a “human factors” approach looks for sources of safety and risk everywhere in the healthcare system. His book “Patient Safety – A Human Factors Approach” examines: the designs of devices, the teamwork and co-ordination between different providers, communication across hierachical and gender barriers, cognitive processes involved in diagnosis and treatment decisions, the constraints and goals of the organization, the financial and human resources provided, the technology that is available and the politics and culture of the organization. He is exhaustive in his review of Patient Safety.

There are a number of competence assumptions in both aviation and healthcare. However, the incidence of adverse events in aviation is 10 to the minus 6 and in healthcare it is 10 to minus 4. A big difference if you are the patient.

These differences can be explained by the varied assumptions about competence: continuity, assurance and maintenance. Other aspects of competence related to ability to collaborate on a complex task in a team and use of standard communication for problem solving.  Aviation has limits on the amount of work to avoid fatigue. Sleep deprivation and the absence of fatigue management decreases the accuracy of judgement.

Aviation has standard format briefings for each new operational phase, division of labour for tasks and the extensive use of checklists. In aviation, skills, competence and safety levels demonstrated in one situation are not considered transferable to another. Pilots are checked out at least twice per year in the simulator. Healthcare has none of these safety measures. Healthcare’s motto used to be: see one, do one, teach one. Unfortunately, this motto is out of date.

Another source of adverse events is the complexity of the healthcare system. Errors seem to be systematically connected to features of people’s tools, tasks and operating environment. The doctor’s work space is filled with ambiguity, uncertainty and moral choices. This work space is not guided by the healthcare organization’s rules and regulations. It is guided by the local rationality of the work space.

According to Dekker, the system is not safe.  The logical targets for intervention are the error-producing conditions present in the working environment. A complex system with conflicting goals and outcomes that are better, faster and cheaper is “drifting towards failure”. The  system is more prone to adverse events, as economic constraints and production needs increase.

The healthcare working environment is characterized by complexities, uncertainties, pressures, unlimited variability, shortcomings and contradictions between multiple goals that workers have to reconcile, decode and pursue at the same time.

The irony is that bad outcomes can arise even when everyone is doing good work and is following the rules. In complex situations, adverse events can arise without really bad assessments or bad decisions.

Because of the complexity of the system and of the patient’s context, a common error is cognitive lock-up or fixation. There is an expectation by patients and by other doctors that problems require immediate answers. Medicine strives for causal simplicity and will hold on to it even if there is contradictory data.

Unfortunately, the expectations of immediate problem solving, no matter how complex the patient’s problem, biases doctors in a certain direction. From the mass of uncertain, incomplete and contradictory data, doctors develop a plausible explanation. Unfortunately, if they are not actively questioning their assumptions, they can fall into “cognitive lock-up”.

Multiple threads of activity, task and causes can disrupt the doctor’s attention. There is more certainty and comfort in continuing with prior conclusions. And escalation of the problem increases the need for co-ordination demands across people. Trouble can arise because the processes for informing, updating and working with others are not efficient.

Organizational risk is a characteristic of a complex system. Adverse events are the result of structural interactive complexity and tight coupling within the system. The only way to reduce risk to is to reduce complexity. System vulnerability arises from unintended and complex interactions between seemingly normal organizational, managerial and administrative features of the system.  There is steady progression of small steps toward greater risk. A mistake is embedded in everyday organizational life and worsened by scarcity and competition, unprecedented and uncertain technology, barriers in information flows, standardization and lack of communication and collaboration.

So instead of allowing our healthcare system to drift into failure, here are some productive strategies for improving patient safety: promoting adverse event investigations without the threat of punishment, systems for adverse event reporting, rapid response teams, narratives about near misses, improved soft skills such as communication and interaction for producing safe and successful outcomes, ensuring diversity in decision making by including persons with diverse skill sets and knowledge, checklists with check-off provisions, operational discretion at the level of the front line operations persons and promoting accountability by empowering people to change their work conditions.

Success in complex system does not result entirely from following best practices but from a diversity of responses that allows it to cope with a changing and dynamic environment. Ironically, making changes to some components within a complex system may lead to an exponential growth in relationships and associated transaction costs and therefore to more complexity with markedly increased system costs.

Important changes to a complex system will involve improving the quality and efficiency of the relationships between the independent agents that work within the complex system. The following diagram depicts the complex system as a network of independent agents.

The problem with healthcare budgets, according to Kaplan and Porter as reported in the New York times, seems to be that no one knows what it costs to deliver healthcare and no one knows how these costs relate to outcomes achieved.

When agencies try to cut costs, they will often make across-the-board cuts that are unsustainable because they have no connection to the true costs of care.  No one measures the costs based on the actual resources that are used. Without understanding resources used and outcomes achieved, costs will keep rising.

Kaplan and Porter’s research shows that many healthcare organizations are improving their measurements of outcomes. But they  have done little to measure the actual costs of achieving those outcomes.

To accurately measure costs, teams of clinicians and administrators must identify all the processes involved in care. The teams then identify the quantity and unit cost of each resource- doctors, nurses, equipment, supplies, devices and admin support – used in each process. Together these form the true cost of care.

This process helps healthcare organizations to discover immediate and realizable opportunities for improvements in outcomes and decreases in cost.

For example, the head and neck division at MD Anderson used specialized nurses instead of doctors in the evaluations of new patients, moved to standardized processes and improved IT. This resulted in a 36% reduction in cost without any adverse effects on patient outcomes.

According to Kaplan and Porter, with accurate information on costs and outcomes, providers can improve care, save money by eliminating wasted steps, and reduce waiting times.

Understanding costs could be the most important tool in transforming the value delivered in healthcare. This will help to improve patient care and stop arbitrary cuts and counterproductive cost shifting.

A patient advocate has to have the tenacity of a bull dog, a sharp and creative mind and the quick and practical resolve of our pilot-hero Captain “Sully” Sullenberger.

Here’s a case showing you what I mean:

Carrie is a 52 year old business owner living in Northern B.C. She developed severe headaches. The CT done in the local hospital showed fluid collections inside her head. She went to Vancouver to see a neuro-surgeon. He did a MRI which showed the fluid collections. He decided to wait and see.

Carrie was concerned and retained Rupert Case Management (RCM) for a second opinion. She couriered her imaging studies to us. We sent them to one of the top neuro-radiologists in Canada. He was intrigued by the studies and had a case conference with several neuro-surgeons. They concluded that she likely had an active CSF/fluid leak in her spine.

When I tried to speak to Carrie’s neuro-surgeon, he was evasive. He did not respond to emails or calls. He had booked Carrie for a brain operation on Monday.

When I finally got him on the phone on Friday, he was dismissive and abrupt.  He had to agree to read the email from the neuro-radiologist which suggested a spinal MRI.  He admitted Carrie to the hospital on Sunday for the spinal MRI and the operation on Monday morning.

When we got the news that the Vancouver MRI showed the spinal cord leak and that the brain operation had been cancelled we were thrilled for Carrie and her family. She had the leak patched through a lumbar puncture and flew back home.

So that is what a patient advocate should do. Unfortunately, doctors do not know how to react to an advocate. They will rarely talk to an advocate. Often the response is adversarial.

If the doctors would agree to listen and to at least consider the information provided especially if the second opinion is from a credible authority, then everyone including the doctors will benefit from this collaboration.

When a family is paying for care for a client with special needs delivered at home or in a residence , they may not understand if they are getting value for their money.

RCM responds to this need by providing CARE AUDITS which involve a review of the quality, relevance and timeliness of care with a determination of the client’s Quality Of Care Score.  This score ranges from 1 to 100 ( 7o is good, 80 is better, 90+ is excellent) and helps families understand if they are getting value for their money.

Case study:

C.J. was an 81 year old male with dementia. His two closest friends ( ages 83 and 85) were the administrators of his estate and responsible for his financial affairs. They had chosen a care provider who staffed his condo with two full time care providers 24*7. They also provided meals and other necessities. The problem was that this care was too expensive for C.J.

We were asked to provide a CARE AUDIT by C.J’s lawyer.

We reviewed the type(s) of services provided, the qualifications of the staff providing the care, the consistency, appropriateness and relevance of the care provided. We also calculated the client’s QUALITY OF CARE SCORE out of 100.

In addition, the CARE AUDIT included a review the total costs for the services being delivered.

And because the client’s needs were dynamic and changed over time, a CARE AUDIT was  required twice per year.

Once we had reviewed the care, it was clear that the care provider organization was “double teaming” the case and driving costs way up to their financial advantage.

We recommended a small, friendly and specialized nursing home with 22 beds that was able to take a dementia patient. The costs to C.J.’s estate were reduced by 75% with this move.

The CARE AUDIT is best done working with the investment managers and trustees who are responsible for the management of capital for the client with special needs.

A CARE AUDIT reviews and reports on the quality of the care and the costs of care. The investment managers job is to manage the capital in a prudent manner.  RCM works with the investment managers to ensure that the expenditures are appropriate.

In C.J.’s case, the friends who were trustees were not capable of either assessing the care or watching the dollars.

The CARE AUDIT is proving to be a very worthwhile service with RCM’s staff working hand in hand with investment managers and trustees from banks and from other financial institutions in order to protect their clients’ short and long term needs.

In the future, more families will be purchasing care. Some insurers are abandoning the long term care insurance market. The public sector is cutting back on services.  An awareness of these trends, will encourage families to allocate capital for the purposes of funding future needs for care.

There was a brief article about Jacalyn E.S. Bennett and her company Bennett & Company which has been in business since 1984 making lingerie. The most striking part of the article was Ms Bennett’s description of her company’s values. She describes Bennett & Company as a “company with a conscience”.

The company’s business model is based on teachings of Gandhi and principles of the Buddha. That means her 1,800 employees working in China and Sri Lanka and her team of 35 at her headquarters in Newburyport, Mass., treat everyone with the highest respect. They donate to more than 30 nonprofits, from Sarvodaya Suwasetha in Sri Lanka to the Insight Meditation Center of Newburyport.

Eastern philosophy also informs why Ms Bennett chose to specialize in lingerie. Lingerie is literally closest to a woman’s heart. Though no one may see it, lingerie has a lingering influence on how we feel about ourselves during the day — which she hopes is special and cared for. When a woman is kind to herself from the inside, she projects that kindness out to others, which then is returned to her. This “circle of kindness” is at the core of the Buddha’s teachings.

This description created an immediate connection for me to her and her company. It was, in fact, riveting in its impact.

Why not make values explicit for doctors, nurses and patients. Let’s go beyond ethics and a rational understanding of what is ethically appropriate. Let us design, articulate and communicate these actionable values to our doctors, our patients and their families.

So I  started to look for values that have been communicated by our hospitals. And I found very little. They do, however, list the patient’s rights along with the hospital’s departments and the phone numbers.

So I am proposing that we design and articulate our actionable values to ensure that new doctors and nurses share them and patients understand them.  Or they don’t have to become doctors or nurses, they can become accountants, actuaries or economists.

Here’s a case study that might explain what I am talking about:

Charles was a 30  year old alcoholic who had been drinking 26 ounces of vodka per day for 2 years. He looked terrible: his eyes were yellow, his belly was very swollen, his legs were swollen, he was confused and he was shaking.  I sent him to the ER. The next thing that I heard was that he had been admitted and designated DNR which means ” Do Not Resuscitate”.

We were stunned by that decision. So we called the hospital ethicist and held an ethical review of that decision. It was inappropriate. The treating team agreed to start an IV.

Next, it was clear that Charles was dying because of his liver failure. So we asked if he could be put on the liver transplant list. The answer was a loud NO!  The policy is that any alcoholic who has been drinking within the last six months is not elligible for the transplant. So we decided to go to court with the transplant agency and hospital. We lost. The policy is hard and fast and global.

So we waited for Charles to pass. He received last rites on a Friday night. I called the nurses station on Saturday morning to find out what time he had passed. The nurse told me that he had “woken up”.  He proceeded to get better and was discharged to a rehab programme within 2 months.

The rehab programme that we selected was a one year programme. He needed time to heal. When he was there, he started to take courses at the local university and eventually decided to become a drug and alcohol rehab worker. That is what Charles is doing today.

So what values were working or not working in Charles’ case. The first consideration with values is that you have to hit the pause button to get into the values’ space. This is important. If the doctor or nurse is in their usual clinical haze, then values will be of no significance. See Daniel Golman on Ted talks on compassion.

We were respectful of Charles and did not condemn him because of his severe addiction to alcohol.

We showed persistence in seeking a solution. We did not give up.

We were curious about whether a transplant was an option. Liver transplant patients can live for 20 or more years with their transplant.

We were empathetic. We felt the pain that his family felt. He fought for him in the ethical and legal courts.

We were hopeful and not defeatist.

We were authentic. We want to help no matter what.

We were kind but not wimpy in the fight for Charles and his rights as a patient.

So, we find that perhaps that team that labelled Charles as a DNR case, were not aware of what values that they should have been following in caring for Charles. Maybe they were in a clinical haze and did not hit the pause button.

Go figure!

Here is a case study:

Virginia had been in the intensive care unit for 9 weeks in respiratory (lung) failure. The care team had tried many antibiotics to treat her infection(s). None of the medications had worked. She went into heart failure. She was unconscious and supported on a ventilator.

Her father-in-law grew frustrated in not having access to the care team and not understanding what was being done. He wrote a very strong letter to the hospital CEO and the chief of the medical staff. He was very angry. His daughter was a lawyer. They were ready to litigate in court.

That is when Rupert Case Management (RCM) was retained by the family to help.

After reviewing the medical records, our first action was to organize a conference call with all of the ICU doctors and the chief of the medical staff.  This was not a trivial feat. We worked through the CEO’s office to accomplish this. There were seven doctors who rotated through the ICU on a one week on and seven weeks off schedule.  Many of them were unaware of the changes in the patient’s status.

Once we got their attention, we worked with the family to organize and prioritize their interpretation of core issues and critical decisions. This was presented to the care team. This brought further appropriate attention to the patient.

Unfortunately, she passed. The family asked for an autopsy. They wanted answers. We were asked to organize a second opinion. The first pathologist had been  selected by the hospital staff. They did not trust the first pathologist.

The second pathologist, who was a heart-lung pathology specialist, was selected by the family with our assistance.

The outcome was surprising to everyone. This patient had TB of her heart. This was confirmed by the two pathologists. During her hospital stay, she had been treated for TB.

The outcome was that the family felt satisfied with the answers. And costly and time consuming litigation was avoided.

This is an example of using design thinking to create a customer-facing process to help patients and families in extreme distress. In this process, a qualified third party such as Rupert Case Management (RCM), with experience in advocacy and in the management of complex cases, is introduced by the hospital to the patients and families as a value added service. This process provides the families with carefully managed “customer experience”, with seamless access to information that is made understandable to a lay person and with guided access to hospital staff.

If this process of increased transparency and responsiveness is employed pre-emptively, then many instances of litigation against hospitals might be avoided.

Virginia’s family was appreciative of the advocacy work that we undertook. There was also the realization that litigation against the hospital or the doctors was not warranted.

Design thinking can be used to develop and deliver a process of carefully managing the “customer experience” of angry and frustrated patients and their family members. This process provides increased transparency, improved comprehension of the core issues, empathic responsiveness and acknowledgement of the customer’s concerns.

RCM’s process is proving to be of marked value in preventing needless litigation and in maintaining and improving the long term relationship capital of hospitals in their communities.

Continuity of care is similar to a football team. If all the players do what they want, then there is chaos. If there is a plan, a quarterback providing leadership and co-ordination of the players, then there is a better chance of winning.

Continuity of care is the co-ordination of different types of providers, the recognition and management of active problems according to a shared plan and the management of transitions.

And continuity of care, when it is well managed, is important for achieving superior patient outcomes.

Here’s the case study of Ben, a previously active senior, who entered the hospital in lung failure. He was in the intensive care unit (ICU) on a ventilator for 4 weeks. During his 9 week hospital stay, he lost 60 pounds, could not drink fluids without choking and he could not stand unassisted. Ben had fallen through the cracks.

Who was the doctor most responsible for Ben’s management?  What was care team’s focus? How much did the team know about Ben’s changing problems? How much did Ben know about his issues?

With doctors on duty for only one week out of a seven week rotation, they lost touch with the details of the case. There was poor co-ordination and continuity of care.

Once Rupert Case Management (RCM) was retained, our job was to ” ring the bell”.

Here is what happened. RCM brought awareness of Ben’s core issues and critical decisions to all members of the treating team (doctors, nurses, physios and OTs) on a daily basis. This is very important.

Our nurse case managers were tenacious in discovering the core issues and persistent in communicating core issues and critical decisions to the treating team each day.

In fact, we have designed a matrix to communicate this information visually. To get the care team’s attention, we know that we have to communicate to their visual cortex and engage them emotionally.  This is necessary to get the right actions initiated for Ben.

By improving continuity of care and co-ordination of all the different care disciplines,  Ben got the attention that he needed. Ben started to gain weight. He ate more. He drank his  thickened fluids. He walked with assistance. He perked up and in fact, he got married while still in the hospital. We sent flowers.

We really enjoy helping complex patients by ringing the bell! And here is why we are often needed.

At times, patients’ concerns are not addressed in a systematic manner. Most care is delivered ad hoc.  Patients do not understand their management options. Patients frequently fail to recall basic elements of their care plan. All this is occurring as care becomes increasingly complex.

To manage this complexity, RCM communicated Ben’s core issues and critical decisions to all members of the treating team each day. This provided a dynamic continuity of care management process that shifted the focus to meet new and evolving needs on a real time basis. The result of introducing this process has been consistently higher quality outcomes with fewer errors.

Transitions can be sources of error. The nurse case managers and doctors at RCM act as the “coaches” to ensure that transitions are “seamless”.

We are making a commitment to talk about continuity of care as the 11th commandment.

And isn’t that what healthcare should be about?

Clara is a 62 year old patient with a complex past history. About 20 years ago, she had an early stage cervical cancer removed. Now she presents with masses in her peritoneum/abdomen from the original cervical cancer.

Her oncologist had limited experience with the treatment of this type of cancer. He welcomed a second opinion.  The team at Rupert Case Management (RCM) provided two second opinions from world class gynecological oncologists. One of the experts suggested that we consider molecular profiling. That is when this scientific advance became very important for Clara.

Molecular profiling is a new diagnostic technology. Each cancer has a unique signature. The signature can be de-coded using biomarker testing. Then the patient’s biomarker signature is used to search the world’s medical literature for treatment options  based on world wide biomarker research. This search generates an evidence-based treatment protocol . This is revolutionary for cancer patients.

Molecular profiling begins with an immuno-histochemistry (IHC) analysis. An IHC test measures the level of important proteins in cancer cells providing clues about which therapies are likely to have clinical benefit and then what additional tests should be run.

With a sample of patient tissue, then a gene expression analysis can be done using a microarray. The microarray test looks for genes in the tumor that are associated with specific treatment options.

As deemed appropriate, additional tests such as Fluorescent In-Situ Hybridization (FISH) is used to examine gene copy number variation in the tumor. Polymerase Chain Reaction (PCR) or DNA sequencing is used to determine gene mutations in the tumor DNA.

The results from each of these tests are matched with the published findings from thousands of the world’s leading cancer researchers. Based on this analysis, the process identifies potential therapies for patients and their treating physicians to discuss.

This is an important starting point for Clara and her team of doctors.

Molecular profiling is available for patients requiring chemotherapy. The process of selecting medications is very complex. At times, the process is subjective and is based on a doctor’s personal experience and his/her interpretation of the medical literature.

The team at RCM will be pleased to assist clients in ordering molecular profiling and co-ordinating all aspects of the process from start to resolution.

To start the conversation, call at any time. 1- 800 620 7551.

What is needed is a new way of thinking about health system service delivery. This starts with a blank sheet of paper and a team of creative and curious individuals from diverse backgrounds and with deep expertise in various disciplines. Their job will be to make the best decisions possible in order for healthcare services to be better, faster and cheaper.

One methodology that has proven effective with wicked problems is decision support modelling with general morphological analysis or GMA. The key proponent of this approach is Dr Tom Ritchey of Ritchey Consulting in Sweden. See his excellent book “Wicked Problems- Social Messes” published by Springer 2011.

There is an urgent call to action to be innovative. A continuous stream of innovations are needed from many sources.

Lean engineering, design thinking, customer development, agile development and the use of applied economics must form the basis for these innovations. With lean engineering, value is defined as providing benefit to the customer. This focus provides the opportunity to enhance efficiency and productivity.

Some innovations are already surfacing: patient focused hospital funding in British Columbia, the growth of ambulatory surgery centers in British Columbia, the North tele-health network in Ontario and the virtual ward at St Mikes hospital in Toronto.

That is why we are introducing the Dr Bill Waters’ Virtual Awards for innovations in health system service delivery.  Dr Waters is a very accomplished individual.  During his career, he was very successful in both the academic and real world of business. Dr Waters is a highly intelligent and charming individual who taught my MBA class micro-economics. That is why we have named these important awards for him.

The jury for these awards includes: Jonathan Guss, former CEO of the OMA, Harvey Botting, former publications manager at Rogers Publications, Dick Clark CA  and Andrew Shaw CEO of the Toronto Symphony.

We are seeking nominations for the Dr Bill Waters’ awards from recipients of our e-newsletters and from others.

Once the gold, silver and bronze finalists are selected, we will send out an e-announcement and press release.We will also be interviewing the winners and producing a video describing these innovations. The video will be on our web site and on You Tube.

So here’s to improvements in health services this coming year. Please email us with your nominations including an explanation of why the innovations should win the Dr Bill Waters’ award.

Stay tuned for the announcement of the finalists and for the video highlighting their innovations.

This new method of funding for hospitals is called “patient focused funding”. This is activity and performance based funding with clearly articulated service level targets.

The economic basis of this approach is described by the eminent management leaders and academics Robert Kaplan and Michael Porter in “How To Solve The Cost Crisis In Health Care” in the Harvard Business Review ( September 2011).

In most provinces, hospitals receive an annual global budget. This is known as block funding. All expenses come out of this bucket of money. When a patient goes to the emergency department, it costs the hospital money for each patient. This money comes from the global budget.

If you extend the logic, the hospital will do best financially by discouraging patients from coming to the E.R.  or being operated on in the O.R. The new change in funding has removed this “perverse incentive” which is an unintended consequence of the old system of block funding of hospitals.

With the new system of patient-focused funding, the hospital receives revenues from the province when the patient is helped in the E.R. The E.R. becomes a revenue center. The operating room and other parts of the hospital also become revenue centers- not profit centers.

This has helped in dramatically improving healthcare services for B.C. residents.

According to the Globe and Mail page A 9 Dec 10 2011, waiting times in E.R’s have been reduced by 50% fuelled by incentives as high as $600 for each extra patient admitted to an acute care bed within 10 hours.

The new money rolling into the hospitals is being reinvested in infrastructure and capacity. One hospital’s E.R. now has its own lab technician and a five bed unit for patients needing more treatment but not needing admission.

In one hospital in Nanaimo, the number of shoulder operations will double bringing to the hospital $3000 for each additional procedure.

In the first year of the patient-focused funding pilot, only $53M in new money from the province resulted in 67,000 more patients being treated on time in the E.R.’s of the 14 hospitals involved and an additional 36,000 procedures in B.C.’s 23 largest hospitals.

Waiting lists for ambulatory surgeries were cut by 25% in the first year of the programme.

Hospitals receive more funding for complex cases and for surgical quality care systems

This is a revolution in how hospitals are funded. The change is based on solid business management economics. The results for patients have been dramatic. The new model that can be scaled will likely be a mix of global budgeting plus patient-focused funding.

Good for B.C. They are getting it right. In fact, we are nominating the B.C. Ministry of Health for the Dr. Bill Water’s virtual award in applied economics for innovation in health system management.

Other provinces, such as Ontario, are starting to build momentum by introducing pay for performance. We hope that they will soon introduce B.C.’s model of  ”patient focused funding” for hospitals.