When I was a sophomore in high school, I handed in my musical instrument (I played the violin in junior high school and switched to cello my freshman year of high school), quit the orchestra, and signed up for weight training 101 (much to my orchestra teacher's displeasure). It ended up being a really great class for me, as it started my interest in sports science and sports medicine, which had a significant influence on my desire to become a physician (as I have posted many times, my lifelong dream all through college was to be the team physician for the Chicago Cubs!). One of the first things that I learned in weight training 101 was the "principle of progressive overload." Simply stated, if you want to get stronger or faster, you have to push yourself just a little harder every time you work out. For example, if you want to build up your muscle strength so that you can increase your maximum bench press, add 5-10 pounds to your bench press work-out every few days. Alternatively, if your goal is to run a marathon, start out with running one long run every Saturday and add 1 mile every week. Slowly but surely, over time, you will build up your muscle strength (so you can bench press a couple of hundred pounds) or increase your stamina to the point where you can run that marathon.
Later, in one of my exercise science classes in college, I learned about Milo of Croton. Milo was a great wrestler from ancient Greece (Croton was a city at the base of the toe on the Italian peninsula) - basically he was the LeBron James of his day. Milo won just about every sports competition that was held in his day. He was a six-time wrestling champion at the Olympic Games, a seven-time champion at the Pythian Games, ten-time champion at the Isthmian Games, and nine-time champion at the Nemean Games - you get the picture, he was really good. In fact, Milo won Ancient Greece's version of the Grand Slam (winning the Olympic, Pythian, Isthmian, and Nemean Games during the same year) five times (the Grand Slam title was called the Periodonikes). Legend has it that Milo was walking to the gym one day when he saw a newborn calf at a farm near his home. He convinced the farmer to let him carry the calf from the farm to the gym. Milo repeated the feat every day for the next four years. Of course, the calf grew larger (and heavier) every day, and eventually Milo was carrying a four-year-old bull all the way to the gym - in other words, the principle of progressive overload!
As it turns out, the science of improvement has its own version of the principle of progressive overload. Whenever you are trying to improve a process, you should start out with small, incremental improvements. Plan-Do-Study-Act (PDSA) cycles start with so-called "small tests of change." After you carefully study a process, you will probably come up with a number of possible interventions that will make the process more efficient or better in some way. Rather than implementing all of the process changes all at once, start with only one. Test your hypothesis by implementing the process change and studying whether the change results in an improvement. Then move on to the next process change. As each successful change is adopted, the overall process becomes more efficient - continuous improvement through the principle of progressive overload!
And just imagine, I learned all of this by giving up playing the violin so that I could take a weight training class!
Sunday, April 29, 2018
Wednesday, April 25, 2018
"All politics is local"
The late Thomas Phillip "Tip" O'Neill, Jr, 47th Speaker of the U.S. House of Representatives is often credited with saying, "All politics is local." You can either agree or disagree with Speaker O'Neill's statement, but I think that the statement would apply to health care as well. Jeff Goldsmith and Lawton Burns posted an article on the Health Affairs Blog that provides a number of examples of highly innovative, and in some cases, disruptive and transformational changes implemented by health care systems around the country that subsequently failed to take hold in other areas of the country. Goldsmith and Burns referred to a concept in the winemaking world called "terroir" (I had to look it up). The term is defined by Webster's dictionary as the natural environment (soil, climate, topography) in which a particular wine is produced (more technically, where the particular grape is grown). "Terroir" explains why some of the finest champagne grapes come from a specific district in northeastern France and nowhere else. The two authors then go on to list several examples of transformative health delivery systems that have failed to scale to other parts of the country, including the Kaiser Permanente system (a model of health care delivery that has been incredibly successful in Oregon and California, but not so much in other markets, including Colorado, Hawaii, and the District of Columbia). In fact, attempts at replicating the Kaiser Permanente model in areas of the country outside of California and Oregon have been costly failures in the majority of cases. They go on to say that, "Very little about the health system is actually national." In other words, just as in politics, "all health care is local."
There is no question when it comes to transformational change, leaders who fail to take account of things like institutional culture and local attitudes and behavior do so at their own peril. We, as a health care industry (and perhaps physicians most of all), have greatly contributed or even created the conditions that have led to the fragmentation and regionalization of care delivery practices - indeed, the way things are done in New Jersey don't look too much like the way things are done in Ohio. We have to do better. We, as a health care industry, need to be open to change, and now is the time to do so. If we wait too much longer, these changes will be forced upon us.
Every time I hear a physician complain about some regulatory requirement, I can't help but wonder if we allowed this to happen simply because we refused to change. Just the other day, I heard from a physician who wanted to know why the hospital leadership was suddenly becoming the "quality police" and requiring all of these things (medication reconciliation, closing open charts, signing verbal orders, etc, etc, etc) that made her life more difficult and contributed to professional dissatisfaction and burn-out. I responded by saying that these were regulatory requirements (many of which do actually improve the quality of care, but admittedly some that don't really do so) that were being forced upon the hospital by regulatory bodies, such as the Joint Commission and the federal government. It always, always goes back to a graph showing the dramatic (almost logarithmic) increase in the number of health care administrators compared to physicians over the last decade. Again, we created this situation when we, as physicians, failed to change. We failed to lead, and as a result, someone else took over.
Health care is not easy. It's complex, and it's probably all local. But we have to recognize that the time for change is now. We have great issues that need to be addressed, and if we fail to do so, someone else is going to take over and try to address them in ways that we don't like (ways that don't necessarily place quality of care and value at the forefront). If we accept change, and if we learn to adapt best practices from other health delivery systems to our own local environments, health care delivery will improve. For the better.
There is no question when it comes to transformational change, leaders who fail to take account of things like institutional culture and local attitudes and behavior do so at their own peril. We, as a health care industry (and perhaps physicians most of all), have greatly contributed or even created the conditions that have led to the fragmentation and regionalization of care delivery practices - indeed, the way things are done in New Jersey don't look too much like the way things are done in Ohio. We have to do better. We, as a health care industry, need to be open to change, and now is the time to do so. If we wait too much longer, these changes will be forced upon us.
Every time I hear a physician complain about some regulatory requirement, I can't help but wonder if we allowed this to happen simply because we refused to change. Just the other day, I heard from a physician who wanted to know why the hospital leadership was suddenly becoming the "quality police" and requiring all of these things (medication reconciliation, closing open charts, signing verbal orders, etc, etc, etc) that made her life more difficult and contributed to professional dissatisfaction and burn-out. I responded by saying that these were regulatory requirements (many of which do actually improve the quality of care, but admittedly some that don't really do so) that were being forced upon the hospital by regulatory bodies, such as the Joint Commission and the federal government. It always, always goes back to a graph showing the dramatic (almost logarithmic) increase in the number of health care administrators compared to physicians over the last decade. Again, we created this situation when we, as physicians, failed to change. We failed to lead, and as a result, someone else took over.
Health care is not easy. It's complex, and it's probably all local. But we have to recognize that the time for change is now. We have great issues that need to be addressed, and if we fail to do so, someone else is going to take over and try to address them in ways that we don't like (ways that don't necessarily place quality of care and value at the forefront). If we accept change, and if we learn to adapt best practices from other health delivery systems to our own local environments, health care delivery will improve. For the better.
Tuesday, April 24, 2018
"The price of money is what you have to give up to get it..."
One of the concepts that I learned in business school was something called the "price of money," which is often defined as "what money can buy" (i.e., if a banana sells for one dollar, then the price of one unit of money is 1 banana). Merriam-Webster's online dictionary defines "the price of money" as "the net rate of interest paid for borrowed money." In other words, the "price of money" is the interest that you could have earned if you had taken the money that you invested in a business or stock and put it in the bank. Conceptually, this particular definition is not technically correct - we would be more accurate if we called this concept the "time value of money," but regardless, this is how "the price of money" is often defined. Most economists would define the price, or cost of money as "what you have to give up to get it."
I guess I had the "price of money" concept in the back of my mind when I read that the New York Yankees called up their top minor league prospect, second baseman Gleyber Torres to the major leagues (he had his first major league hit in the game last night). Why do I care about a baseball player for the New York Yankees? At one point, he was in the Chicago Cubs organization (and I am a die-hard Chicago Cubs fan). The Cubs basically traded him (and a few other players, who haven't made as big of an impact) to the Yankees for All-Star closer Aroldis Chapman. Chapman played an instrumental role in the Cubs' World Series victory and then became a free agent at the end of the season. He signed again with the New York Yankees. Theo Epstein, President of Baseball Operations for the Chicago Cubs organization realized the importance (and the consequence) of this move. He also understood the risks. If the Cubs hadn't won the World Series, especially if Torres turned into a superstar for the Yankees, Epstein would have become the laughing stock of professional baseball. It ended up turning out just fine - the Cubs ended up winning the 2016 World Series after 108 years!
What Theo Epstein recognized was simply the "price of money." He decided that the short-term win was worth the potential of the long-term loss (we still don't know if Gleyber Torres will turn out to be a superstar or a bust). In other words, he understood that he had to give up a potential superstar to win the World Series now. Do you agree with his choice?
How many times are we, as leaders, faced with a similar choice. I would bet that all the experts would tell us to make the investment for the long-term instead of the short-term win, and in probably 999 times out of one thousand, I would say that they were absolutely, positively correct. I would also say that Theo Epstein built another World Series winning franchise (the Boston Red Sox) exactly by focusing on the long-term as opposed to the short-term. Moreover, he built the Cubs from a perennial bottom-dweller to one of the most successful teams in the last few years by exactly focusing on the long-term (building up the minor league system, avoiding signing large, expensive free agent contracts, etc). I think (and many casual baseball fans, sportswriters, and pundits would agree) that the decision to trade a potential superstar to win a team's first World Series in over 100 years was exactly worth it.
Again, in almost every case, and as a general rule, when faced with a decision about winning now versus winning later, the best decision is to win later. However, there are always exceptions to the rule. You just have to be sure that what you have to give up for the short-term is worth it. Fly the W.
I guess I had the "price of money" concept in the back of my mind when I read that the New York Yankees called up their top minor league prospect, second baseman Gleyber Torres to the major leagues (he had his first major league hit in the game last night). Why do I care about a baseball player for the New York Yankees? At one point, he was in the Chicago Cubs organization (and I am a die-hard Chicago Cubs fan). The Cubs basically traded him (and a few other players, who haven't made as big of an impact) to the Yankees for All-Star closer Aroldis Chapman. Chapman played an instrumental role in the Cubs' World Series victory and then became a free agent at the end of the season. He signed again with the New York Yankees. Theo Epstein, President of Baseball Operations for the Chicago Cubs organization realized the importance (and the consequence) of this move. He also understood the risks. If the Cubs hadn't won the World Series, especially if Torres turned into a superstar for the Yankees, Epstein would have become the laughing stock of professional baseball. It ended up turning out just fine - the Cubs ended up winning the 2016 World Series after 108 years!
What Theo Epstein recognized was simply the "price of money." He decided that the short-term win was worth the potential of the long-term loss (we still don't know if Gleyber Torres will turn out to be a superstar or a bust). In other words, he understood that he had to give up a potential superstar to win the World Series now. Do you agree with his choice?
How many times are we, as leaders, faced with a similar choice. I would bet that all the experts would tell us to make the investment for the long-term instead of the short-term win, and in probably 999 times out of one thousand, I would say that they were absolutely, positively correct. I would also say that Theo Epstein built another World Series winning franchise (the Boston Red Sox) exactly by focusing on the long-term as opposed to the short-term. Moreover, he built the Cubs from a perennial bottom-dweller to one of the most successful teams in the last few years by exactly focusing on the long-term (building up the minor league system, avoiding signing large, expensive free agent contracts, etc). I think (and many casual baseball fans, sportswriters, and pundits would agree) that the decision to trade a potential superstar to win a team's first World Series in over 100 years was exactly worth it.
Again, in almost every case, and as a general rule, when faced with a decision about winning now versus winning later, the best decision is to win later. However, there are always exceptions to the rule. You just have to be sure that what you have to give up for the short-term is worth it. Fly the W.
Sunday, April 22, 2018
A story of giving
There is a story in the New Testament that I have always liked - it is from Mark 12:41-44 and goes like this:
Jesus sat down opposite the place where the offerings were put and watched the crowd putting their money into the temple treasury. Many rich people threw in large amounts. But a poor widow came and put in two very small copper coins, worth only a few cents. Calling his disciples to him, Jesus said, "Truly I tell you, this poor widow has put more into the treasury than all the others. They gave out of their wealth; but she, out of her poverty, put in everything - all she had to live on."
It's usually referred to as the "Parable of the Poor Widow," and it has always been one of my favorites. The story reminds me of something I read a while ago, but it has always stuck with me to this very day. Shortly after the events of 9/11, government officials and citizens from around the world expressed their support of the United States - at times, foreign countries pledged their political and military support, while in other cases, countries offered their condolences, their thoughts, and their prayers. Apparently, a group of Kenyan Masai tribespeople offered their support in the form of the greatest gift that they could give - fourteen cows. William Brancick, a representative from the U.S. State Department actually attended a ceremony to accept the cows, stating, "I know that for the Masai people the cow is valued above all possessions and that the gift of a cow is the highest expression of regard and sympathy." He went on to say to the Masai tribespeople present at the ceremony, "When we count the value of these cows, and when we add the value of the great spirits that gave them, we can say without doubt that you seem richer still."
Incidentally, the cows were never brought back to America. A few years later, another U.S. official came back to Kenya to complete a deal for the tribe to take care of the "American cows" for America. The U.S. official also announced that a scholarship had been created for fourteen children to attend school, which has continued to this day. Also of note, the "American cows" now number more than thirty! These cows are marked as the "American cows" by a special "Twin Towers" marking on their ears. There is a children's book about this story which can be downloaded here. It is a beautiful story of service and giving.
I know what you are probably thinking - what in the world do these two stories have to do with leadership and health care. I would respond by saying, "Everything." Archbishop Desmond Tutu once said, "Real leaders are not blinded by the trappings of power but recognize their role as servants." Leadership starts and ends with service, and service starts with giving.
Jesus sat down opposite the place where the offerings were put and watched the crowd putting their money into the temple treasury. Many rich people threw in large amounts. But a poor widow came and put in two very small copper coins, worth only a few cents. Calling his disciples to him, Jesus said, "Truly I tell you, this poor widow has put more into the treasury than all the others. They gave out of their wealth; but she, out of her poverty, put in everything - all she had to live on."
It's usually referred to as the "Parable of the Poor Widow," and it has always been one of my favorites. The story reminds me of something I read a while ago, but it has always stuck with me to this very day. Shortly after the events of 9/11, government officials and citizens from around the world expressed their support of the United States - at times, foreign countries pledged their political and military support, while in other cases, countries offered their condolences, their thoughts, and their prayers. Apparently, a group of Kenyan Masai tribespeople offered their support in the form of the greatest gift that they could give - fourteen cows. William Brancick, a representative from the U.S. State Department actually attended a ceremony to accept the cows, stating, "I know that for the Masai people the cow is valued above all possessions and that the gift of a cow is the highest expression of regard and sympathy." He went on to say to the Masai tribespeople present at the ceremony, "When we count the value of these cows, and when we add the value of the great spirits that gave them, we can say without doubt that you seem richer still."
Incidentally, the cows were never brought back to America. A few years later, another U.S. official came back to Kenya to complete a deal for the tribe to take care of the "American cows" for America. The U.S. official also announced that a scholarship had been created for fourteen children to attend school, which has continued to this day. Also of note, the "American cows" now number more than thirty! These cows are marked as the "American cows" by a special "Twin Towers" marking on their ears. There is a children's book about this story which can be downloaded here. It is a beautiful story of service and giving.
I know what you are probably thinking - what in the world do these two stories have to do with leadership and health care. I would respond by saying, "Everything." Archbishop Desmond Tutu once said, "Real leaders are not blinded by the trappings of power but recognize their role as servants." Leadership starts and ends with service, and service starts with giving.
Wednesday, April 18, 2018
"Don’t ever take a fence down until you know the reason why it was put up."
Health care often looks to the aviation industry for best practices to improve patient and employee safety. Despite the recent "60 Minutes" CBS News report this past week on Allegiant Airlines that found more than 100 serious mechanical incidents, including mid-air engine failures and flight control malfunctions between January 1, 2016 and October 31, 2017 and yesterday's Southwest Airlines accident involving a mid-air engine failure resulting in 1 death, the safety record for commercial aviation has been exemplary. Just this past year, the current President of the United States accepted full responsibility for the fact that calendar year 2017 was the safest year on record for commercial air travel. The commercial aviation industry is certainly an exemplar when it comes to safety.
Health care has often copied best practices from other so-called High Reliability Organizations (organizations that maintain excellent safety records despite the fact that they operate in dangerous environments). Military aviation (at least, U.S. Navy aviation) is frequently cited as one example of a High Reliability Organization (HRO) - in fact, the U.S. Navy aircraft carrier, USS Carl Vinson was one of the three original organizations that was investigated in the original paper defining HROs by Tom Mercer, Todd LaPorte, Gene Rochline, and Karlene Roberts (the Federal Aviation Administration's Air Traffic Control system and Pacific Gas and Electric's nuclear power plant at Diablo Canyon were the other two organizations). So it is perhaps surprising (and somewhat concerning) that the U.S. Navy, Marine Corps, and Air Force have all reported an increase in the number of aviation accidents in the past couple of years.
What's going on here? The Navy has reported that Class C mishaps (defined by the military as an accident resulting in $50,000 - $500,000 in aircraft damage or lost work days due to injury) have increased by over 80 percent during the past five years. The Marine Corps has observed a similar increase in Class C mishaps over that same time period. Finally, the Air Force reported that Class C mishaps this past year hit a seven-year high. In all three cases, the frequency of more serious accidents (Class A and B mishaps, which result in more significant monetary damage or death) have either remained level or, in some cases, decreased over the same time period.
What is the common thread across these three branches of the military (side note: I could not find similar reports for the Army and one report actually suggested that the number of helicopter accidents has actually declined)? Notably, in all three cases, the increase in Class C mishaps traces back to the year 2013. What happened in 2013? One word. Sequestration. Historically, the military has been funded through continuing resolutions under the Budget Control Act - this stopped in 2013, the year that automatic budget cuts known as sequestration went into effect. In order to meet the budget targets, the military cut back on purchases of spare parts, released (through both early mandatory retirement and attrition) aircraft maintenance personnel and their supervisors, and decreased the flight time for pilots (flying a military aircraft is notoriously expensive). These budget cuts have occurred at a time when the military has been asked to do much more with less resources (while military operations in Afghanistan and Iraq have been scaled back significantly, they certainly have not ended completely). In other words, the military has scaled back, in some cases rather significantly, on normal operations in areas such as training and maintenance so that they can continue to fund combat operations around the world.
"Doing more with less" is a phrase that we hear a lot these days. However, in regards to military aviation, "doing more with less" is strongly associated (note that a cause-and-effect relationship has not been demonstrated) with an increase in the number of accidents (albeit, not the most serious type of accident). It would appear that "doing more with less" is not necessarily something that health care should copy from this HRO!
We have significant problems in health care today. U.S. health care is way too expensive, and the amount of money spent in health care doesn't necessarily translate to better outcomes and better value for our patients. Hospitals are going to be forced to cut costs - truthfully, the vast majority of hospitals have already been forced to do so. The key here, I think, is to be very careful about what expenses get cut. Perhaps that is the lesson we should take from the Navy, the Marine Corps, and the Air Force. Trying to find savings through cuts in maintenance expenditures or by decreasing the number of experienced personnel (senior, experienced personnel cost more and often get replaced with younger, less experienced, but less expensive personnel) in operational positions is likely a fool's errand that will cost more in the long run.
I am reminded of a quote by the author G.K. Chesterton from 1929, which was actually used once by President John F. Kennedy in one of his speeches. "Don't ever take a fence down until you know the reason why it was put up." In other words, be careful how you try to find cost savings in military aviation operations and health care.
Health care has often copied best practices from other so-called High Reliability Organizations (organizations that maintain excellent safety records despite the fact that they operate in dangerous environments). Military aviation (at least, U.S. Navy aviation) is frequently cited as one example of a High Reliability Organization (HRO) - in fact, the U.S. Navy aircraft carrier, USS Carl Vinson was one of the three original organizations that was investigated in the original paper defining HROs by Tom Mercer, Todd LaPorte, Gene Rochline, and Karlene Roberts (the Federal Aviation Administration's Air Traffic Control system and Pacific Gas and Electric's nuclear power plant at Diablo Canyon were the other two organizations). So it is perhaps surprising (and somewhat concerning) that the U.S. Navy, Marine Corps, and Air Force have all reported an increase in the number of aviation accidents in the past couple of years.
What's going on here? The Navy has reported that Class C mishaps (defined by the military as an accident resulting in $50,000 - $500,000 in aircraft damage or lost work days due to injury) have increased by over 80 percent during the past five years. The Marine Corps has observed a similar increase in Class C mishaps over that same time period. Finally, the Air Force reported that Class C mishaps this past year hit a seven-year high. In all three cases, the frequency of more serious accidents (Class A and B mishaps, which result in more significant monetary damage or death) have either remained level or, in some cases, decreased over the same time period.
What is the common thread across these three branches of the military (side note: I could not find similar reports for the Army and one report actually suggested that the number of helicopter accidents has actually declined)? Notably, in all three cases, the increase in Class C mishaps traces back to the year 2013. What happened in 2013? One word. Sequestration. Historically, the military has been funded through continuing resolutions under the Budget Control Act - this stopped in 2013, the year that automatic budget cuts known as sequestration went into effect. In order to meet the budget targets, the military cut back on purchases of spare parts, released (through both early mandatory retirement and attrition) aircraft maintenance personnel and their supervisors, and decreased the flight time for pilots (flying a military aircraft is notoriously expensive). These budget cuts have occurred at a time when the military has been asked to do much more with less resources (while military operations in Afghanistan and Iraq have been scaled back significantly, they certainly have not ended completely). In other words, the military has scaled back, in some cases rather significantly, on normal operations in areas such as training and maintenance so that they can continue to fund combat operations around the world.
"Doing more with less" is a phrase that we hear a lot these days. However, in regards to military aviation, "doing more with less" is strongly associated (note that a cause-and-effect relationship has not been demonstrated) with an increase in the number of accidents (albeit, not the most serious type of accident). It would appear that "doing more with less" is not necessarily something that health care should copy from this HRO!
We have significant problems in health care today. U.S. health care is way too expensive, and the amount of money spent in health care doesn't necessarily translate to better outcomes and better value for our patients. Hospitals are going to be forced to cut costs - truthfully, the vast majority of hospitals have already been forced to do so. The key here, I think, is to be very careful about what expenses get cut. Perhaps that is the lesson we should take from the Navy, the Marine Corps, and the Air Force. Trying to find savings through cuts in maintenance expenditures or by decreasing the number of experienced personnel (senior, experienced personnel cost more and often get replaced with younger, less experienced, but less expensive personnel) in operational positions is likely a fool's errand that will cost more in the long run.
I am reminded of a quote by the author G.K. Chesterton from 1929, which was actually used once by President John F. Kennedy in one of his speeches. "Don't ever take a fence down until you know the reason why it was put up." In other words, be careful how you try to find cost savings in military aviation operations and health care.
Tuesday, April 17, 2018
Standing Watch and Duty Hour Restrictions
I came across yet another interesting article today while searching on the Internet for something else that was completely unrelated (funny how that happens quite a lot!). According to an article published in September, 2017 (okay, it's a little old, but still relevant) in the Navy Times, the United States Navy has issued new rules and guidelines dictating the amount of time that sailors can stand watch, as well as the amount of time that sailors are required to rest between watches. The new rules and guidelines are designed to better align watch schedules and shipboard routines while at sea with sailors' circadian rhythms and sleep-wake cycles. The new rules were issued following an investigation into the fatal collisions of the USS John S. McCain and USS Fitzgerald in the summer of 2017, which cited fatigue as one of the contributing factors to both accidents.
Perhaps I should step back and explain a little more about what it means to "stand watch" in the Navy. There is a long tradition, going back to the Golden Age of Sail, that proscribed how the work of sailing a ship was distributed among the officers and crew. Every member of the crew was assigned to a "watch" - typically, the crew was divided into two (e.g., Port and Starboard watches) or three (e.g., Red, White, and Blue watches) watches. The 24 hour day was then divided into the following watches (this time referring to a period of time, typically a 4 hour period):
First watch: 2000 to 0000 (military time is used here, but this refers to 8 PM to midnight)
Middle watch: 0000 to 0400
Morning watch: 0400 to 0800
Forenoon watch: 0800 to 1200
Afternoon watch: 1200 to 1600
First dog watch: 1600 to 1800
Last dog watch: 1800 to 2000
Note that all but two of the watches lasted 4 hours - the two exceptions, the first and last dog watch, were shortened to two hours so that there were an odd number of watches in the day. In this manner, the crew could rotate through all the watches, rather than one half of the crew always having to be on duty for the Middle watch every night, as an example. In addition, the crew would eat their evening meal during the two dog watches. There are a number of reasons why the two shortened watch periods are called "dog watches," which I won't get in to here (but if you are interested, see here).
While there have been a number of variations on the watch system used over the years, they are all essentially the same from a conceptual standpoint. All of the different watch schedules did have one thing in common - they resulted in a significant number of hours of work in a given week. Government studies found that, in some cases, sailors on ships were working more than 100 hours a week. Notably, the Navy already limited the number of hours that aviation crews and submarine crews could work in a given 24 hour period or over the course of a week.
The new watch standards are in direct response to these two very high profile accidents. When asked about the accident investigations, Admiral John Richardson, the Chief Naval Officer, said, "Both of these accidents were preventable and the respective investigations found multiple failures by watch standers that contributed to the incidents. We must do better."
Rather than dictating the exact schedule, commanding officers of each ship will be allowed some discretion to choose from several watch schedules in order to accommodate for a ship's crew level, deployment status, and operational mission. The point, however, is that they will have to abide by certain requirements. Naval Surface Warfare spokesman, Cmdr. John Perkins said, "You're going to have to form some level of watch bill that protects sailors' sleep. The ships still have some flexibility, but sailors are going to have to get a certain amount of protected sleep."
The preceding discussion sounds very familiar to those of us in health care. Several years ago, the Accreditation Council for Graduate Medical Education, which oversees and dictates how resident physicians are trained in the United States, issued restrictions on how long interns and residents could work in the hospital, largely in response to concerns that physician fatigue was impacting patient safety. All of this makes perfect sense - we don't want physicians and nurses making mistakes because they are so tired that they "can't think straight." Unfortunately, there is not a lot of evidence to support that duty hour restrictions translate to significant improvements in patient outcomes (for example, see the systematic review here and here and here). In fact, several authors have expressed concern that duty hour restrictions can lead to worse outcomes by virtue of the fact that the number of hand-offs in care from one physician to another is increased. Important information pertinent to patient care is frequently lost during these hand-offs of care.
Let me be clear. I do support duty hour restrictions - tired physicians and nurses do make mistakes, and we should not ask them to work the kinds of hours that we used to require in the past. However, there are two points that I would like to make. First, simple fixes often do not result in significant improvements, especially in complex systems like health care and shipboard duty. Any system-level change needs to be done very carefully and only after trying to identify and mitigate the unintended consequences of such a chance (for example, increasing the number of hand-offs in care). Second, something that has become quite obvious to me over time is that health care is not that much different from other industries. We have a lot to learn from one another. For example, perhaps the Navy could learn about the impact of duty hour restrictions from the health care industry? We need to share our experiences and our best practices. That is the only way that we will get better.
Perhaps I should step back and explain a little more about what it means to "stand watch" in the Navy. There is a long tradition, going back to the Golden Age of Sail, that proscribed how the work of sailing a ship was distributed among the officers and crew. Every member of the crew was assigned to a "watch" - typically, the crew was divided into two (e.g., Port and Starboard watches) or three (e.g., Red, White, and Blue watches) watches. The 24 hour day was then divided into the following watches (this time referring to a period of time, typically a 4 hour period):
First watch: 2000 to 0000 (military time is used here, but this refers to 8 PM to midnight)
Middle watch: 0000 to 0400
Morning watch: 0400 to 0800
Forenoon watch: 0800 to 1200
Afternoon watch: 1200 to 1600
First dog watch: 1600 to 1800
Last dog watch: 1800 to 2000
Note that all but two of the watches lasted 4 hours - the two exceptions, the first and last dog watch, were shortened to two hours so that there were an odd number of watches in the day. In this manner, the crew could rotate through all the watches, rather than one half of the crew always having to be on duty for the Middle watch every night, as an example. In addition, the crew would eat their evening meal during the two dog watches. There are a number of reasons why the two shortened watch periods are called "dog watches," which I won't get in to here (but if you are interested, see here).
While there have been a number of variations on the watch system used over the years, they are all essentially the same from a conceptual standpoint. All of the different watch schedules did have one thing in common - they resulted in a significant number of hours of work in a given week. Government studies found that, in some cases, sailors on ships were working more than 100 hours a week. Notably, the Navy already limited the number of hours that aviation crews and submarine crews could work in a given 24 hour period or over the course of a week.
The new watch standards are in direct response to these two very high profile accidents. When asked about the accident investigations, Admiral John Richardson, the Chief Naval Officer, said, "Both of these accidents were preventable and the respective investigations found multiple failures by watch standers that contributed to the incidents. We must do better."
Rather than dictating the exact schedule, commanding officers of each ship will be allowed some discretion to choose from several watch schedules in order to accommodate for a ship's crew level, deployment status, and operational mission. The point, however, is that they will have to abide by certain requirements. Naval Surface Warfare spokesman, Cmdr. John Perkins said, "You're going to have to form some level of watch bill that protects sailors' sleep. The ships still have some flexibility, but sailors are going to have to get a certain amount of protected sleep."
The preceding discussion sounds very familiar to those of us in health care. Several years ago, the Accreditation Council for Graduate Medical Education, which oversees and dictates how resident physicians are trained in the United States, issued restrictions on how long interns and residents could work in the hospital, largely in response to concerns that physician fatigue was impacting patient safety. All of this makes perfect sense - we don't want physicians and nurses making mistakes because they are so tired that they "can't think straight." Unfortunately, there is not a lot of evidence to support that duty hour restrictions translate to significant improvements in patient outcomes (for example, see the systematic review here and here and here). In fact, several authors have expressed concern that duty hour restrictions can lead to worse outcomes by virtue of the fact that the number of hand-offs in care from one physician to another is increased. Important information pertinent to patient care is frequently lost during these hand-offs of care.
Let me be clear. I do support duty hour restrictions - tired physicians and nurses do make mistakes, and we should not ask them to work the kinds of hours that we used to require in the past. However, there are two points that I would like to make. First, simple fixes often do not result in significant improvements, especially in complex systems like health care and shipboard duty. Any system-level change needs to be done very carefully and only after trying to identify and mitigate the unintended consequences of such a chance (for example, increasing the number of hand-offs in care). Second, something that has become quite obvious to me over time is that health care is not that much different from other industries. We have a lot to learn from one another. For example, perhaps the Navy could learn about the impact of duty hour restrictions from the health care industry? We need to share our experiences and our best practices. That is the only way that we will get better.
Sunday, April 15, 2018
"Addition over subtraction, multiplication over division" every time...
I wanted to write a little more about former President Clinton's recent speech to the 2018 Becker's Hospital Review 9th Annual Meeting in Chicago this past week (I also talked about this speech in my most recent blog post). I don't like to get too political, and I will start off to say that there were a lot of things that President Clinton did when he was President that I didn't necessarily agree with, even if I thought he was (and still is) a gifted speaker. To be perfectly honest though, I agree whole-heartedly with many of the things that he said in his speech last week, and there was one statement that he made that particularly struck home. I actually looked on the Internet this morning to see if he had said something similar before - he did during an interview with Trevor Noah on The Daily Show on September 15, 2016. In his interview then (and he basically said the same thing last week), President Clinton stated:
"America's come so far. We're less racist, sexist, homophobic, and anti-specific religions than we used to be, but we have one remaining bigotry - we don't want to be around anybody that disagrees with us."
Wow. I had to look up the first part of his statement, just to be sure he was correct. If anything, it seemed that we have slid back a little during the last couple of years (corresponding, more or less, to the start of the 2016 Presidential Campaign and the subsequent start of the current Administration's term in the White House) compared to where we were a few short years ago. Not too long ago, I read an article in The Economist that provided some statistics to back up this claim (which surprised me at the time, and still does given the rhetoric we hear today on a daily basis). For example, only 4% of Americans supported inter-racial marriage in 1958 - compare that to the fact that 50% of Americans supported inter-racial marriage in 1997 and today, almost 90% of Americans do. According to the FBI, hate crimes declined by over 48% from 1994 to 2015. Today, more Americans support gay rights and gay marriage than ever before. The gender gap in pay is shrinking, and more women are in leadership positions than ever before. Please don't misunderstand me - we have a lot of work left to do, but at least in regards to the first half of his statement that we as a nation are "less racist, sexist, homophobic, and anti-specific religions than we used to be", the facts support President Clinton.
The second half of President Clinton's statement struck me the most, as I am perhaps just as guilty as anyone and everyone else. It is true - "we don't want to be around anybody that disagrees with us." Why do you think neighborhoods and communities are becoming more and more polarized? Why do you think community groups, clubs, organizations, and in some cases, schools and colleges are becoming more and more polarized? All politics is personal, and in our case, as a nation, we are much less tolerant of each others' political views than ever before. President George W. Bush was speaking at the same conference later in the week (I had to leave the conference early, so I did not get to hear President Bush speak). President Clinton said of Bush, "When it comes to politics, we sometimes fight like cats and dogs, but we respect each other immensely. And I am proud to say that we are good friends." In 2016, former Speaker of the House John Boehner and former Vice President Joe Biden accepted the Laetare Medal from the University of Notre Dame. Both Boehner and Biden each stated that while they often disagreed with one another on a number of issues, they both shared immense respect and the deepest admiration and appreciation for all that the other had accomplished. We need more of this kind of attitude in our political leaders. But that attitude has to start with us - all of us.
We have big problems to solve, and we have to solve them now for future generations. President Clinton was exactly right. We do better when we work together. Study after study shows that groups composed of diverse opinions, backgrounds, and experiences are more successful at solving problems. We need that kind of diversity today. President Clinton emphasized that he would always support "addition over subtraction" and multiplication over division," which is what we need more of today. It was a great lesson for me personally, and one that I absolutely need to work on and improve in my own personal and professional life.
"Addition over subtraction, multiplication over division" every time...
"America's come so far. We're less racist, sexist, homophobic, and anti-specific religions than we used to be, but we have one remaining bigotry - we don't want to be around anybody that disagrees with us."
Wow. I had to look up the first part of his statement, just to be sure he was correct. If anything, it seemed that we have slid back a little during the last couple of years (corresponding, more or less, to the start of the 2016 Presidential Campaign and the subsequent start of the current Administration's term in the White House) compared to where we were a few short years ago. Not too long ago, I read an article in The Economist that provided some statistics to back up this claim (which surprised me at the time, and still does given the rhetoric we hear today on a daily basis). For example, only 4% of Americans supported inter-racial marriage in 1958 - compare that to the fact that 50% of Americans supported inter-racial marriage in 1997 and today, almost 90% of Americans do. According to the FBI, hate crimes declined by over 48% from 1994 to 2015. Today, more Americans support gay rights and gay marriage than ever before. The gender gap in pay is shrinking, and more women are in leadership positions than ever before. Please don't misunderstand me - we have a lot of work left to do, but at least in regards to the first half of his statement that we as a nation are "less racist, sexist, homophobic, and anti-specific religions than we used to be", the facts support President Clinton.
The second half of President Clinton's statement struck me the most, as I am perhaps just as guilty as anyone and everyone else. It is true - "we don't want to be around anybody that disagrees with us." Why do you think neighborhoods and communities are becoming more and more polarized? Why do you think community groups, clubs, organizations, and in some cases, schools and colleges are becoming more and more polarized? All politics is personal, and in our case, as a nation, we are much less tolerant of each others' political views than ever before. President George W. Bush was speaking at the same conference later in the week (I had to leave the conference early, so I did not get to hear President Bush speak). President Clinton said of Bush, "When it comes to politics, we sometimes fight like cats and dogs, but we respect each other immensely. And I am proud to say that we are good friends." In 2016, former Speaker of the House John Boehner and former Vice President Joe Biden accepted the Laetare Medal from the University of Notre Dame. Both Boehner and Biden each stated that while they often disagreed with one another on a number of issues, they both shared immense respect and the deepest admiration and appreciation for all that the other had accomplished. We need more of this kind of attitude in our political leaders. But that attitude has to start with us - all of us.
We have big problems to solve, and we have to solve them now for future generations. President Clinton was exactly right. We do better when we work together. Study after study shows that groups composed of diverse opinions, backgrounds, and experiences are more successful at solving problems. We need that kind of diversity today. President Clinton emphasized that he would always support "addition over subtraction" and multiplication over division," which is what we need more of today. It was a great lesson for me personally, and one that I absolutely need to work on and improve in my own personal and professional life.
"Addition over subtraction, multiplication over division" every time...
Thursday, April 12, 2018
"Give it all you got"
I had the opportunity to go listen to former President Bill Clinton speak in Chicago yesterday evening. He was one of the key speakers at a health care policy and administration conference that I was attending. While I didn't always agree with him when he was President, one thing that I always admired about him was that he was a gifted orator. He always seemed to know what exactly to say and how to say it. Well, he hasn't lost that one bit. It was an awesome, inspirational speech. He had a lot to say about the current political climate, world events, and of course, health care. He spoke for about 30 minutes or so, and then he was interviewed on stage for another 10-15 minutes or so. One of the questions that the interviewer was asked was "Why do you still do it? Why are you still so involved with your Foundation, with world events, what keeps driving you after all of these years as an ex-President?" He didn't stop to think one moment, but quickly answered, "The people of the United States elected me to serve as President, but it doesn't stop there. I continue to serve to give back to the American people."
Giving. It's a simple word, but it is packed with a lot of meaning. I once got to meet and talk to one of our local Cincinnati business leaders, Carl Satterwhite, at a United Way fundraiser a few months ago. Mr. Satterwhite's mantra (it's even on his personalized license plate and Twitter handle!) is "Give to Get to Give." In other words, the more you give, the better off you are so that you can give even more - it doesn't matter if it's money, time, or talent, you "give to get to give." When you think about it, it makes a lot of sense. And I suspect President Clinton would agree. He has lived his life as a public servant, which afforded him even more opportunities to serve.
Apparently, Mr. Satterwhite's mantra comes directly from the Bible. St. Paul wrote in his second letter to the people of the city of Corinth (2 Corinthians 9:6-14):
My point is this: The person who sows sparingly will also reap sparingly, and the person who sows generously will also reap generously...And God is able to make all grace overflow to you so that because you have enough of everything in every way at all times, you will overflow in every good work...You will be enriched in every way so that you may be generous on every occasion...
In other words, you "give to get to give"! But that's not all of it. The Bible teaches us more on this, this time in Luke 12:48:
To whom much is given, from him much is expected.
Even if your not familiar with the Bible, you have probably heard at least a version of this admonition, which basically says, "Whatever you are doing, give it all you got." Even if you didn't vote for him or agree with him, I think that you would agree that President Clinton has done a lot for the people who elected him President, both during the time he lived in the White House as well as the time afterwards.
So I leave it with this. Give so that you can give more. And give it all you got.
Giving. It's a simple word, but it is packed with a lot of meaning. I once got to meet and talk to one of our local Cincinnati business leaders, Carl Satterwhite, at a United Way fundraiser a few months ago. Mr. Satterwhite's mantra (it's even on his personalized license plate and Twitter handle!) is "Give to Get to Give." In other words, the more you give, the better off you are so that you can give even more - it doesn't matter if it's money, time, or talent, you "give to get to give." When you think about it, it makes a lot of sense. And I suspect President Clinton would agree. He has lived his life as a public servant, which afforded him even more opportunities to serve.
Apparently, Mr. Satterwhite's mantra comes directly from the Bible. St. Paul wrote in his second letter to the people of the city of Corinth (2 Corinthians 9:6-14):
My point is this: The person who sows sparingly will also reap sparingly, and the person who sows generously will also reap generously...And God is able to make all grace overflow to you so that because you have enough of everything in every way at all times, you will overflow in every good work...You will be enriched in every way so that you may be generous on every occasion...
In other words, you "give to get to give"! But that's not all of it. The Bible teaches us more on this, this time in Luke 12:48:
To whom much is given, from him much is expected.
Even if your not familiar with the Bible, you have probably heard at least a version of this admonition, which basically says, "Whatever you are doing, give it all you got." Even if you didn't vote for him or agree with him, I think that you would agree that President Clinton has done a lot for the people who elected him President, both during the time he lived in the White House as well as the time afterwards.
So I leave it with this. Give so that you can give more. And give it all you got.
Monday, April 9, 2018
"Absence makes the heart grow fonder?"
I came across an interesting article published in today's Wall Street Journal ("Necco wafers, taste of childhood and chalk, face the final crunch"). Apparently, the New England Confectionery Co., maker of Necco wafers (do a Google search - trust me, you've heard of them), Clark Bars, and those little heart-shaped Sweethearts with the romantic messages that get passed around every year on Valentine's Day, is apparently closing shop if it can't find a new owner by the end of May. The company has been around since 1847, making it the oldest continually operated candy manufacturer in the United States. Apparently, candy aficionados are so worried about the pending end of the Necco wafer that they are stocking up and hoarding whatever supplies are left. Personally, I am more worried about Clark Bars and the heart-shaped Sweetheart candies than I am Necco wafers, as I have never been a huge fan! The story is reminiscent of what happened when Hostess Foods announced they were going to stop making Twinkies ("The end of the Twinkie") - Twinkie lovers everywhere pleaded with the company to continue making their beloved snack, while consumers started stockpiling Twinkies, Ho Ho's, and Ding Dongs off supermarket shelves.
What's going on here? Apparently, the old saying ("Absence makes the heart grow fonder") really is true, at least when it comes to Twinkies and Necco wafers. But what about humans? A quick Google search suggests that, at least when it comes to personal relationships, there is at least some evidence that couples who are separated by distance do better in some cases (though there are several studies that suggest the opposite is true). Maybe the more appropriate cliché is the statement, "You never know what you have until it's gone" (or a better version, courtesy of the 1980's hair band Cinderella , "Don't know what you got, till it's gone").
What's the lesson here for today? If you didn't figure it out yet, it's pretty basic. Appreciate what you have today, because it may not be there tomorrow. We all have a lot to be thankful for - don't ever forget that fact. There's always a reason to be happy, optimistic, and thankful. Things can always be worse. Just think of a life without Necco wafers and Twinkies!
What's going on here? Apparently, the old saying ("Absence makes the heart grow fonder") really is true, at least when it comes to Twinkies and Necco wafers. But what about humans? A quick Google search suggests that, at least when it comes to personal relationships, there is at least some evidence that couples who are separated by distance do better in some cases (though there are several studies that suggest the opposite is true). Maybe the more appropriate cliché is the statement, "You never know what you have until it's gone" (or a better version, courtesy of the 1980's hair band Cinderella , "Don't know what you got, till it's gone").
What's the lesson here for today? If you didn't figure it out yet, it's pretty basic. Appreciate what you have today, because it may not be there tomorrow. We all have a lot to be thankful for - don't ever forget that fact. There's always a reason to be happy, optimistic, and thankful. Things can always be worse. Just think of a life without Necco wafers and Twinkies!
Sunday, April 8, 2018
"Be kind whenever possible"
I just got back this afternoon from a nice, relaxing vacation at the beach with my wife. One of the things that really impressed me occurred on the very first morning after we had arrived. We were out running, and we both noticed the number of individuals who looked up and said, "Good morning" as we passed each other by. I stopped counting after about 20 "Good mornings." It was a really nice touch that made us both feel welcome. What impressed me even more was the fact that a number of these individuals were people like us - just there for a nice beach vacation!
It made me stop and ask myself, "How much better would the world be if people started looking up from their cell phones, newspapers, or quiet thoughts, smiled, and said 'Good morning' to everyone who they passed by?" Can you imagine it? That level of kindness is contagious.
The Dalai Lama (who has authored a couple of books on kindness), once said, "Be kind whenever possible. It is always possible." Kindness starts with saying, "Good morning."
It made me stop and ask myself, "How much better would the world be if people started looking up from their cell phones, newspapers, or quiet thoughts, smiled, and said 'Good morning' to everyone who they passed by?" Can you imagine it? That level of kindness is contagious.
The Dalai Lama (who has authored a couple of books on kindness), once said, "Be kind whenever possible. It is always possible." Kindness starts with saying, "Good morning."
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