Sort.
I'm very honoured to be here to share a lot of what we've done over the last decade with you and kind of my ideas and thoughts about the path forward.
And so I think we have about an hour. I'll try to.
I put quite an ambitious amount of information in this talk and hopefully we'll be able to end relatively early.
If I do breeze through a little bit,
it's because I want to leave time for questions and discussions because I'd really love to learn from you through your enquiries.
So here's some standard disclosures around research, funding and salary support.
So communication. We hear about it all the time.
You know, it's hammered home constantly during medical training, surgical training, et cetera.
So what we're the what's the current state of communication and surgery, and we'll touch a little bit on then kind of my views.
And some of this will just be very clinical vignette based where you'll you'll recognise
these situations and know or understand that you've been in these situations before.
Failure to rescue, as Peter described, is really something I have worked on for the last decade,
but I describe it as my straw man for understanding, communication and quality in health care and surgery in particular.
And then we'll talk a little bit about kind of where we can go toward the future. So it's an excellent quote from George Bernard Shaw.
The single biggest problem in communication is the illusion that it has taken place, and we recognise this on a day in and day out basis.
Think about the the sheer volume of information that you're communicating across providers, clinicians, et cetera, within the hospital.
We say something and we assume everybody has understands it.
We write something in the electronic medical record or the paper chart, and we assume everybody who needs to know knows.
And so truly, the goal here is to close that loop and understand that communication is a lot more than just written or verbal,
that there's a patient in ICU in Michigan who I'll tell you a little vignette about this patient,
and we'll come back to this patient toward the end of the talk.
The 71 year old patient, who underwent a subtotal gastrectomy for cancer with a runway reconstruction patient,
ended up developing a leak, was in the ICU, doing fairly OK, but required a procedure in our interventional radiology suite.
And because of his tenuous state, was going to require an anaesthesia transport.
It's how we describe it. So it was going to require some higher level of transport.
And the anaesthesiologist came up to the surgical intensive care unit.
Oftentimes intubate the patient, take them back down for the procedure and then bring it back up.
And debate sounds very routine, right? We'll get to a lot of the flaws in this case that actually led to this patient dying as we move forward.
But just remember something as simple as we're going to go up to the ICU into the very routine, take him down to the to demonstrate upswing.
Come back. Remember this patient? So I found this a very interesting.
Now I study communication mostly in the post-operative setting,
but I've taken on a new role in the last year kind of understanding and improving quality and culture and efficiency,
et cetera, within within the operating rooms. And this is an eye opening study about communication within the operating room.
You all do timeouts in the operating room right now.
Those checklists have been rammed down our throats for a while now, and they seem like they would make sense that they would do good.
But part of the problem is they become rote and people don't pay as much attention to the quality or content of the timeout.
And one of the pieces, if yours is similar to ours, are the very first thing you do is introduce everybody in the operating room, right?
This was a very interesting study where they polled everybody in the E.R. at the end of the case to see who knew other people's names.
And I would draw your attention if for nothing else to this box right here,
you would think the surgical attending assay would know his or her surgical resident their name.
They got it right only sixty eight percent of the time. That's I mean pathetic is maybe a little overstatement, but that's pretty sad.
But this is the current state of communication health care.
We don't we don't pay as much attention as we need to and in some places have really led this effort with scrub caps,
with people's names on the front. I don't know if you do that here. We are actually doing that at Michigan now because of this.
I really do think that a lot of communication, subtle or otherwise is is withheld,
is held back because I'm embarrassed because I don't remember your name.
I don't want to call you, Hey, you. I don't want to say, Hey, anaesthesia. So if it's not super important, I'll let it slide.
But you can imagine death by a thousand cuts in the operating room if that is continuing to happen.
We're going to have balls dropped. So here's the ideal situation, right?
We have nurses, doctors, physios, everybody coming together, talking to each other.
And this is really the ideal state and health care. I would describe this as a unicorn. You don't see this anywhere.
Multi-disciplinary kind of conferences don't count. I'm talking about day to day management of patients.
I challenge you to find a ward anywhere where everybody comes together, sits down,
really kind of puts their heads together as they're trying to come up with a diagnosis or treat their patients.
So I really feel like this is a unicorn.
What's really happening is usually this nowadays you've got a care team in the background trying to figure out as a doctor back,
they're trying to figure what's going on. And then you've got.
Other people distracted by their smartphones or hair to enter the vital signed data, they can figure it out.
I mean, this is really kind of this idea of the separation of powers on the units.
The hierarchy were trying to flatten is fine for the communication isn't necessarily occurring the way it should because again,
a lot of what we do now, they're holding a paper charts pretty archaic. I shouldn't say that you guys have paper charts.
OK, sorry, I had a picture. I also teach a class how to put your foot in your mouth one on one.
So, so, so. But you know, we think about even the electronic medical record as being the panacea of communication in health care.
And as we know in our experience, it's a lot of cutting and pasting and very minimal important content.
Not to mention, it doesn't really, you know, you would you wouldn't text the things you write in the medical record.
There's a bit of formality in the medical record that loses some of the nuance of communication.
So then we have some communication occurs and we have physicians fighting and yelling and we see this mostly between departments.
We've got consultants and consulting for me is something different.
So if you got a consulting physician,
so if I'm a surgical attending and I've got infectious disease gastroenterology and we all have different views on how the patient should be managed.
Unfortunately, some of this has devolved into conflict.
It's become even more difficult in the communication occurs through passive aggressive notes in the electronic
medical record as opposed to I think this is actually probably somewhat therapeutic to just get it all out there.
But again, this can contribute to even worse communication.
So I'm painting kind of a relatively negative picture because I really do think that communication health care is is not where it should be.
And these are just some, some concepts that many of you apply that resonate with you.
So let's get some data out there. So the Joint Commission is basically the accrediting body for hospitals in the United States,
and here are all seminal events need to report to the Joint Commission, and they undergo a root cause analysis.
And you see here that communication is in the top three every year as a root cause of sentinel events in health care.
So, you know other things up there that you all have heard from Peters Group and others around human factors, leadership, et cetera are up there.
But you know, we know that communication is really the linchpin to improving a lot or preventing a lot of these events.
So what are the solutions we have come up with? Well, that's easy, right?
We've got checklists so that, you know, of course, that's like the gold standard for communication in nursing.
We use in the United States with something called ESPA. It's basically a structured communication tool.
I now have these daily goal sheets that have they're supposed to have clear communication, so standardisation makes some sense.
For team behaviours, many of you heard of team steps,
the Agency for Healthcare Research and Quality put together this comprehensive plan for how you can improve culture and team building.
And so, you know, that's a decent solution. Technology, you know, we talked about the EMR.
What about smartphones, right? So do you all carry one way pagers or do you how do you guys communicate to paging paging system or anything that sort?
Or does it go to your? Does it go to your smartphones? No. So we still have one way pagers that it's pretty funny because some of our patients
who are of the new generation see us with those they they thought those were extinct.
Because what? Why would you want just unit directional communication?
There is no way of closing a loop in a lot of adverse events or widening at get the page.
And then that's it, I'm off the hook. We have technology out there.
I mean, there's a lot of hospitals in the US now.
They're using proprietary software that is privacy compliant, that allows for two way communication using smartphones.
So so what's the problem with these approaches, though?
I mean, if these are the solutions they all sound reasonable, we would have perfect communication is that they take a one size fits all approach.
They don't take into consideration the context within which we are delivering care, and it's supposed to be the same for the medical physicians,
as well as the surgeons supposed to be the same on the ward as it is on the ICU, supposedly on the same inpatient outpatient.
So clearly, this one size fits all approach is not going to work.
And so to better understand these nuances of communication, we need a case study and that's where failure to rescue comes in.
I think it's something that you can describe to your grandmother or your grandfather. It totally makes sense patient as a complication.
I'll get into description in a second, but you know, we fail to rescue them. Why?
You know, so here's here's an overly simplistic view of a surgical episode, right?
Patient as an operation they may develop a seminal complication could be something as simple as a urinary tract infection DVT.
If it's not detected, it can lead to domino complications.
We've all seen those patients right starts with one little thing and then just the dominoes continue to fall and then they may succumb to that.
And so for probably the latter part of the 90s and early 2000s,
the goal was if we were going to reduce mortality after surgery, we had to prevent complications.
A lot of initiatives around making sure antibiotics were given on time. DVT prophylaxis was administered appropriately, et cetera, et cetera.
And we did a good job of that. I think we got compliance rates in the United States upwards of 90 percent for a lot of these processed measures,
but we weren't realising the benefits fully for mortality reduction.
So rescue kind of flips it on its head a little bit and says, OK, you know, things are going to happen.
The adverse outcomes are going to happen. You have the 70 year old obese diabetic male who comes in for an operation,
and they're going to have a really high likelihood of developing a superficial surgical site infection.
Right? The question is, do you detect it and treat it? Or do you allow it to become an organ space infection?
And because you haven't treated it? And so this idea of rescuing is really preventing these seminal complications from leading to a domino effect.
So. How do we get this on the map?
This was actually initially described in 1992 by a paediatric anaesthesiologist,
but was kind of a term and a quality measure those obscure in the literature and a lot of people did not know about it, especially in surgery.
Part of the critique around it was that it was using administrative data so that the complications were not fully.
We're not reliable. So in 2009, with two of my colleagues, Drs. Brookmeyer and Dimmock,
we gained access to the Inskip data in the US and this was early on in an experience where it was only about 100 hospitals.
Now there's over five six hundred hospitals that participate. And the beauty of this data was that it was near clinical nurse abstracted data.
So the complications, everything was very reliable. So there was no argument anymore that, you know, your data is unreliable,
so you can't make judgement judgements or you can't make any conclusions about how failure to rescue mortality and complications are related.
So when we use this high quality data, we took hospitals, we divided them into quintiles five equal groups rated by their risk adjusted mortality.
And you could see, even in this kind of select cohort of large academic medical centres in the United States,
there was a two fold variation in mortality following major surgery. So this is interesting in of itself, but we know variation exists everywhere.
But the key was understanding the relationship between failure to rescue and complications.
This had been described again by Jeff Silber and others in administrative data.
But this is the first time we were using a clinical data to describe this,
and what we found was the same quintiles of mortality had very similar rates of both all complications or a major or significant complications.
And what really distinguished their differences between them as far as their mortality was,
this concept of rescue and rescue is really mathematically as the case fatality rate of major complications.
And so this seems very kind of obvious now,
but at the time in 2009 really caught the attention of people in the United States and
especially surgical departments that then suddenly began to pay attention to this measure.
Now again, it had been around the Agency for Healthcare Research and Quality in two thousand three,
adopted it as a quality measure and reported it after our study.
The AHA or National Medicare programme began to report this on their website, and you can actually log on now and look up any hospital and see.
Here's University of Michigan health system. Kind of see where do they?
Are they above below or at the national rate for rescue in the national quality?
Former truly drives a lot of the agendas in the United States had endorsed this from twenty thousand seventeen and recently withdrew endorsement,
mainly because people like Medicare were using administrative data to report this, and they felt that there was a reliability issue.
They endorsed the the concept, but not the way it was being measured.
But nonetheless, there are a lot of people who have begun to pay attention to this, and it has sparked some interest in how do we reduce it?
So whenever you measure it on something and it's reported, how do you improve it?
Well, this is where some interesting organisational systems and design really took off.
So as a so I was a research fellow, I forgot to mention that in 2009, when I wrote that paper, and in the ensuing four to five years, basically,
we tried to understand every macro system level characteristic that was associated with food rescue,
trying to unpack it and understand it using secondary data or large datasets.
And we looked at things like hospital volume, you know, teaching status, hospital technology levels, nurse to patient ratios, et cetera.
And we found some interesting solutions or excuse me, associations, but there were no solutions there.
Many of the things I just described to you are fixed.
I'm a nurse. The patient ratios maybe a little bit movable, but you ask any hospital leader.
It's not like there's an infinite amount of money to keep hiring more and more nurses.
So yes, it'd be great if every patient had one to one nursing, and that's just not going to happen.
So one of my friends at the time and she still my friend, but she didn't tell me that she's a trauma surgeon in Houston.
She can tell me she was going to write this. So, you know, we were, you know, this is one of my research fellows.
Yeah, there's the and Brookmeyer. And we wrote this paper, you know, thinking about he was he's now a vascular surgeon,
was interested in cardiovascular surgery and nobody had really described failure rescue.
And that's okay. Great. All right. This on paper, for him, it was a chance for him to learn how to write and analyse data.
But Lillian called me out nationally publicly on this and said, Look, enough is enough.
You've written umpteen papers about this. What are you going to do about it?
Thank you. So, you know, you try to take inspiration from that.
And so we did and we decided to take this kind of very simplistic view and begin to kind of add some pieces around and start
building a conceptual model around what are some things that we can study some aspects and so we can study in a rigorous way.
So we apply for funding through the National Institute for Ageing and receive funding to really understand too big
two pieces micro system level resources that may affect the ability to recognise and respond to complications,
as well as this concept of kind of teamwork or safety attitudes within health systems.
So here's what we did.
We went to thirty two hospitals in the state of Michigan that participate in a large quality collaborative there that has clinically abstracted data.
And so that's where we garnered this data and mortality data.
You could see within these 32 hospitals. Again, it's very similar to the national population.
But a two fold difference in failure to rescue this was we picked a kind of higher risk operations, you know, twofold risk.
So so this is very consistent from the worst of the best performers.
But we then did was we began to look at these micro system level factors, right?
So ICU staffing is is the one that I'll talk about.
We at the time knew and Peter Pronovost had really kind of pioneered a lot of this in writing about closed ICUs, which in the US are closed.
ICU essentially means you have a board certified intensivists who manages the day
to day events for patients and writes the orders and takes care of all that.
And the surgical team is really kind of the ones that are consulting on the patient
is providing input from a surgical perspective and pathophysiology as far as feeding,
et cetera. And so at the time in the state of Michigan, you could see, I mean, overall, those pie about a forty five percent rate of close use.
But it held true that hospitals that were better at rescue had more closed.
Ice use made sense, right? So this is actually a relatively easy thing to flip a switch on.
You hire an intensivist. It's not that difficult as opposed to other things like, you know,
trying to hire more nurses or trying to improve or increase your hospital technology, et cetera, et cetera.
So, so this sparked another interesting question in my era dawned on me the other day
was as a medical was a medical student here in the UK who was visiting us here,
right? Yeah. So who came to spent a year with us to do some research and was interested in unpacking
this idea of intensive staffing and how that affects mortality within hospitals?
And so there's a little bit of kind of nuance here as far as the the statistical methodology that we employed here.
There had been innumerable papers written about the benefits of ICU closed ICDS or intensivists,
but the floor there was there was a lot of pre post evaluations,
meaning it was they looked at before there was intensivists and after there was intensivists in aggregate.
And they saw, yeah, of course. But you know, places where there was intensivists did better.
I mean, that was undeniable. The question was, if you are as an individual hospital looking at your outcomes over time and you hire an intensivist,
do you see an improvement in your specific outcomes? Sure.
Some people had seen that, but in aggregate, was this true? And so what we found, we use this econometric technique called difference in differences.
And in this technique, we're able to remove what we describe as secular trends.
And what does that mean? We know health care in general is getting safer.
So we know in general mortality rates from 30 years ago after major surgery were higher than mortality rates currently.
If we just look at point zero thirty years ago and say there is no intensivists and look at now,
oh yeah, of course, the intensivist led to improved outcomes.
But when you remove that trend over time of improvement, you begin to unpack different changes.
And so in this difference, the difference is technique. You need a time zero.
That's typically a policy change. Right. So we we use this technique a lot in national policy evaluations.
But in this situation,
we were able to use it as the point at which intensities were hired at specific hospitals around the country and we were using Medicare data for this.
And you would expect and we looked at both medical and surgical patients.
If this hiring of an intensivist were to lead to improved outcomes, that the moment this is this is the trend of mortality,
you would expect there to be a sharp, inflexion or at least some inflexion that that hiring led to improvement.
We saw a trend where the opposite almost in surgical or really just no significant change.
This was kind of eye opening. And this really helped with my conceptual model around rescue.
There is no easy fix. There is no light switch. You can flip to improve quality.
And I applied my own experience to this data when I had arrived at Michigan as a trainee.
We had just closed the issues and as an intern, you are, you know,
very intimately involved with patient care patients going back and forth from the ICU.
And our chair had hired arguably the best intensivist in the country, Leanne Napolitano,
to come in and close the eyes and develop a much more structured critical care environment.
Well,
you can imagine she was met with a lot of resistance by many of the senior surgeons who had for many years managed their own patients in the ICU.
And so you can see in a maybe a slightly different environment or a different individual that just hiring that intensivists,
they could be overpowered or kind of just made irrelevant by the surgical services.
But in our hospital, our chair resolved any and all conflicts between Dr. Napolitano and the surgeons by saying, Surgeons, you're wrong.
The intensivist is right. And that was extremely powerful.
And that is an example of leadership of culture.
And so you can imagine a lot of places that are hiring intensivists to meet some sort of external
benchmark or measure may not be fully invested in providing that individual or individuals.
The recipe for success. So that's that was huge. So we then looked at safety attitudes more broadly in the state of Michigan,
we look the same 30 to hospitals and we apply the safety attitudes questionnaire to those hospitals.
And we did this in aggregate on surgical units and the Safety Attitudes Questionnaire,
if you're not familiar with it, has multiple domains that can be reported out off of this.
It's probably, I think it's like 50 or 60 questions, and we focus on the top two teamwork and safety climate and what we found.
Interestingly, and I was surprised by this, I thought there'd be a nice association between safety, culture and outcomes.
Those same three groups of hospitals low, middle and high food rescue.
We found no difference between them with their team or climate or safety climate.
But one thing that's interesting in this data is that the nurse is consistently rated.
The safety and tumour climate is worse than their surgeon counterparts,
so this is interesting, and this holds true if you look at any safety culture data.
This holds true consistently and this gets to the concept of kind of what is a
frontline provider actually experiencing versus what is the view from the top.
And you know, we slice, you know, we did the whole salami slicing. We looked at every different question.
And again, there was no difference across any of any and all of these questions.
It was very consistent across these groups. So I was frustrated at this point and I told Lillian I was like, Listen, I don't know what to do.
I tried. I failed. There's clearly no easy but an improved rescue.
There's nothing that I can, no toolkit that I can provide.
But at the same time, I began to look toward the future and had a fortuitous interaction with somebody at our at our institution.
I mean, this is bad timing. So if you want to put a joke and I just kind of chill the mood a little bit at the halfway point.
I love this cartoon. You may have seen it before in case you can't see it there in the back, you know, and that is why we lift on three.
They dropped the patient. They're holding it. So. All right.
Tough crowd. So. So this is this is where I describe in my mind as inflexion point of understanding rescue.
So Carl, why can Kathy Sutcliffe really kind of pioneered the concept of higher liability organisations?
And I'm sure many of you here are familiar with it.
It's become one of the buzzwords in health care, and I didn't realise that they were Michigan faculty.
And that Carl Wijk had retired,
but Kathy Sutcliffe was alive and well and still continuing to do this research over in the University Michigan Business School.
And so this really sparked a relationship between Kathy and I to understand and apply a lot
of the principles in higher liability to what we were trying to do in in Chile to rescue.
And you know, so so for those of you who aren't as familiar with higher liability organisations,
I mean, the concept is that the capacity for an organisation,
the capacity for organisational resilience is really kind of based on the understanding that the unexpected is going to happen.
This gets to that complication idea, right? We can't prevent all complications that are going to happen, that we know it's inevitable,
but we have to build in systems and plan and anticipate what we're going to do once those occur.
And you guys do a lot of this work here. So I'm kind of preaching to the choir.
So what are some examples of? I mean, everyone always uses nuclear power as one.
I think this is my favourite aircraft carriers.
The I've read a lot about aircraft carriers in the course of my work on understanding rows and what you're just what you're seeing here.
What's interesting you describe this is called unwrap, but it's basically replenishment of supplies.
It's occurring between the supply boat. And if you ever played Battleship that game, here's the supply bill.
And here's the battleship. So are the carrier there.
You can see these these cables attached between these two boats.
They're not standing still. As you can see, they're moving at about 12 knots.
Don't ask them what that means. I just know they're moving at 12 knots.
And what they have to do is this coordinated effort to move supplies across now seems easy enough.
OK? What if it's choppy water? What if this the captain of this ship falls asleep and starts veering off the left again?
This slight differences can result in catastrophic consequences, because if these cords, there's people you can see here on the other end of it,
if they snap because they move apart, you lose supplies in the water, but you lose people.
Those will snap back and kill sailors on both sides.
So this is a very coordinated effort that is practised quite a bit.
You can imagine. Imagine how this is an operation. Right.
And the complication is that this this aircraft carrier starts to slow down a little bit because of some incident, that some incident.
If this is not well communicated to the captain of this ship or catastrophic consequences to innumerable people.
Just think of that as surgery. Right?
Except these are your patient and the operation something comes veers off course if we don't communicate them to recognise it.
Catastrophic consequences can occur a patient's death. So here's a now here's a good description from a senior officer from aircraft carrier.
I'll just read this quickly. So you want to understand an aircraft carrier? Well, just imagine that it's a busy day in shrink San Francisco airport.
It's only one short runway and one ramp and one gate make planes take off and land at the same time.
At half the present time interval, rock the runway from side to side and require that everyone who leaves in the morning returns that same day.
Make sure the equipment is so close to the edge of the envelope that it's fragile,
then turn off the radar to avoid detection, impose strict controls on radios.
Fuel the aircraft in place with their engines running. Put an enemy in the air and scatter live bombs and rockets around.
Now what the whole thing down with seawater and oil and man it with 20 year olds, half of whom have never seen an aeroplane up close.
Oh, and by the way, try not to kill anyone. That's like surgical wards, right?
I mean, to some degree. So we think we have it tough because I mean, you know, we all suffer from the NIH syndrome not invented here, right?
So like the concept is or this wasn't invented in health care.
So we're different. We're special. Our environment is just completely.
We're not an aircraft carrier. We're dealing with human beings. These are human beings, too.
And I would argue this a much more complex environment with complex decision making that's occurring.
So we don't get to just throw our hands up in the air and say, we don't know what to do.
So. You've heard about higher reliability organisations.
But what Cathy taught me is that it's it should be more of a verb. It's high reliability organising.
It's not. You don't achieve because I hear this. People want to achieve high reliability.
You don't achieve higher in a higher level organisation. You continue high reliability organising.
And what does that mean? There's these five pillars of high reliability organising preoccupation with failure,
reluctance to simplify sensitivity, operations, deference to expertise and commitment to resilience.
I put these up here like this intentionally. The top row you can describe as being important problem detection, complication detection.
The bottom row is really problem management or complication management, right?
We have to build these principles into our every day, not just say that, you know, we achieved it once and now we're good.
And so something that we did, you know, tried to apply this idea of high reliability organising to surgery.
And along with Kathy and my post-doc at the time and Peter front of us,
we wrote this paper really kind of more of an opinion piece that's that has some
data behind it in understanding the three waves of innovation in patient safety.
It was mostly in surgery was the was the was was really the venue with which I was writing this or the backdrop with which I was writing this.
And we all know that we had technical advancements, right?
So we've improved the technology around surgery and we've gained some significant improvements.
But I believe we reached kind of flatten the curve now. We're just kind of fiddling with robots, right?
So I point to the urologist. You know, so there's certain indications for it.
But now we're try push. And people are doing inguinal hernia repairs with robots.
I find that there's anybody who do that, OK? I find that crazy.
And then, you know, so we've reached kind of five standardising procedures. We talked about this.
We achieved great strides. I believe in standardisation with checklists and things of that sort process compliance.
But again, we used to flatten the curve in really the third wave. My believe,
my belief in the third wave is this concept of high reliability organising something that other industries have done for years and decades,
and that we are now just starting to understand and dive into.
So I put this up here. I would encourage you to read it. If you want a copy of it, I'm happy to send it to you.
Not because I wrote it, because I really believe in the principles we laid forth.
So I've got about 18 minutes or 20 minutes, the top of the hour, and I've got to try to cut it short.
I'm going to tell you a little bit about what we're doing now to improve rescue and really improve communication.
We develop this failure to rescue patient safety learning lab that has two big
components to IT technology and human behaviour used to say human factors on the right.
But I I appreciate I am not an expert in human factors,
so I would be a charlatan if I wrote human factors up there said behaviour is my
kind of you can tell me later if that's OK is my kind of compromise with this.
But what we've done here, I'll tell you a little bit about the technology piece and then a little bit about the human behaviour piece.
So we know that technology's all around us in the preoperative setting through visits, risk prediction, patient education.
We know in the operating room there's decision support going on and all the time within the hour for anaesthesiology colleagues,
for perfusion, et cetera, help us decision decide where to put patients after surgery and then in the patient room.
It's just becoming this smorgasbord of of wireless and Bluetooth devices that help us with surveillance that can help us with deterioration,
risk, escalation of care, et cetera. I'm going to hone in on just one piece that we've begun to think about and work on in the post-operative setting.
What's interesting? The way we collect vital signs?
I heard a lot about this yesterday from some of the folks in Peter's group about how we collect vitals.
We have highly trained nurses going around and this is just a schematic from this company, by the way.
I have no interest in this company, so I just they just have a really good figure.
You know where the nurse or tech or somebody has to go find a poll that has all the equipment on it for blood pressure,
so they go to the patient's room, they generally wake the patient up in the middle of the night.
They slap this stuff on them. They they write down.
You guys probably have the same government issued napkins that everybody writes the vital signs on, right?
That's they write it on a little napkin and then they have to leave the room.
In theory, clean that equipment. But if your hospitals like mine, they don't always do that.
And then they have to enter the data somewhere, either write it on a chart or enter.
And this is the way we've been doing it from the days of Florence Nightingale, right?
This has not changed for hundreds of years. This is the way we collect them.
Why do we not employ the most simple technology that's available like a little, you know,
like my my Apple Watch here is monitoring my heart rate this entire talk, right?
It's soon we'll be able to monitor my EKG. We have the technology out there to have this being captured in real time and then fed
into systems that can either present it to us in a more efficient manner or begin to
run certain algorithms on it so that we go from this linear traditional health care
model to this model where we have analytics and all different sorts of patient input.
Why not have the algorithm use the patient's Fitbit or Apple Watch that had been collecting vital signs
data before we operated on them and incorporate that into what should be happening to them afterwards?
These are not revolutionary or, you know, pie in the sky ideas.
Apple is doing this. There's not telling us about it yet.
So we need to be on the forefront of understanding this and incorporating it into our workflow.
And I put machine learning on. I can't talk about technology, health care anymore without talking about machine learning and AI.
And those are those are two again, buzzwords that I will not say that I know much about AI.
I collaborate with individuals who use this.
And one of the major limitations for us in health care is it's it's easy to build algorithms using one hospital's data,
but it's only helpful for that one hospital.
And the only way we're going to achieve nirvana, so to speak with machine learning, is when we have giant data repositories of vital signs,
data and whatnot coming in from people all over the country and all over the world.
And this is kind of the Big Brother piece that Apple is doing in the background because I know they're collecting,
they're probably wondering why is this heartbeat like five hundred pieces that minute right now,
you know, but they're collecting this data in the background, and hopefully we'll have some ability to apply that to clinical care in the future.
So let's go to the human behaviour piece, and this is actually my favourite part,
and of course, I didn't leave myself a ton of time to talk about it, but. I told you about a lot of secondary data analysis that we had done.
And one of the things that we tried to understand was these the relative contribution of all of these different factors to understanding rescue.
And what we found was if you take into consideration all eight of these fact or seven of these factors,
it only accounts for about 30 percent of the variation favourite rescue.
So that means are 70 percent unobserved variation, and we're not sure why that 70 percent is occurring.
And I believe it has to do, at least in part to human behaviour is the stuff that you can't really measure in a secondary data analysis.
So what we employed and I would love your insights on this is swim lane analysis, right?
So have you seen these before? Yeah, there this is literally just on one unit,
the interactions between all of these different individuals who provide care for the patient and how they all interact.
You know, all the different individuals they interact with, how do they monitor how they detect complications?
How do they assess patients? This is when I when we did this, I was like, Oh my gosh, I'm never going to figure this out, right?
This is how complicated health care is, but we know that there are ways for us to begin to hone in on at least a little nuggets
of of these interactions to improve how we rescue patients and ergo the perfect study.
Right. It's not perfect. My project manager tells me that I chose this acronym because I'm a surgeon and surgeons think they're perfect.
But I said, no, there's a little improvement, except it's the perfect ideal is the perfect care.
And this was our goal in or our goal was to really enhance these three areas where we felt were going to be important engagement,
communication and teamwork in improving the rescue process and to better understand whether these are the right constructs.
We visited five different hospitals in the state of Michigan, two that were low.
Failure to rescue outliers are high quality hospitals and three other high field rescue hospitals.
There were high outliers, and we conducted semi-structured interviews with about 50 stakeholders,
anywhere from surgeons to nurses to netstat those to rest for a therapist.
Hospital administrators, et cetera. And conducted a kind of a thematic analysis using consensus coding and came up with seven
themes or areas where we feel that we that our interviewees felt mattered the most in rescue.
And here they are. By the way, this type of research, like all those other things like my my fellows could do on their laptops.
This took two and a half years to do this, which was exhausting.
And then all I get is this one stinkin slide out of it. Mm hmm.
So so what matters most? The the factors on the left,
we actually found were positive across hospitals that there has been some sort of cultural and societal
shift where there was there is really no fear in speaking up because of a psychological safety.
Teamwork, actually, to a certain degree, happens fairly well once the crisis has been identified and action taking people rally.
We found that people providers felt that if there's a patient crashing, everybody rallies to that patient's care.
Nobody's really going to turn a blind eye to that and swift action really was taken.
The stuff on the left is these are sure for communication processes, access tools and recognition.
Rapport kind of goes without saying, but we'll talk a little bit about each of these in a second.
So here's some representative quotations from people. You know, I think this is this was interesting.
I'm very comfortable asking. I've never thought about twice about calling. And what we found was this was this was a nurse.
A lot of young nurses. I mean, this is like the new generation.
Like, I'll call you. I'll wake you up. I don't care.
I had those patients not doing well. That fear factor has dissipated a little bit.
And I think again, that's a cultural and societal shift that we're benefiting from the negatives.
So areas that really did need some improvement, communication recognition. So this is this really resonating?
He kind of blew you off when I think, no, there's really something going on now that makes it sound like people aren't listening to them.
But the question here is, are they blowing you off? Because maybe you didn't communicate the right information and we'll get to that in a second here.
You know, identification could be better. Consistently, people said, once we knew the problem was kind of obvious, right?
Like, OK, so the patient is septic shock. We know what to do. Question was, can you do?
Could you identify that sepsis before it led to shock? And that's where identification could be better.
And so we revised this a little bit and we recognise that it's it's about recognition and
effectively communicating early signs of deterioration that are going to lead to stress.
Again, some of this seems like almost like common sense, but it's.
Critical to hear this from the horse's mouth, so to speak.
And so what this led us to to begin to talk about is how do you know when escalating how to escalate?
We don't want people to be the boy who cried wolf right to constantly escalate, care unnecessarily.
And at the end of the day, no one's going to listen to you.
And in talking to our frontline providers, what we learnt is that the majority are novices, right?
So I see a lot of young faces on this side.
Are you all house officers training students? Yeah, great.
So, so, so you.
I think we heard this yesterday. Well, one day, wake up the night before you were a student.
The next day you're a full fledged doctor who can prescribe whatever you want.
Nothing changes when you're asleep, you're the same person with the same inexperience.
But yet one day you wake up and you're managing some of the most critically ill patients in our hospital.
Kind of scary, right? Engineers cringe at that. So what can we do to improve or shore up your experience?
And I think it gets to this. I call the three CS of communication here. So competence is key, and that doesn't mean you're incompetent.
It just means that your confidence level isn't up to the level of someone who's been in practise
for 20 years and cared for thousands of patients and had this kind of immersive experience.
And so how do we improve and speed that process up?
Competence leads to confidence, right? You know, here's a here's a great quote from Jim Rohn effective communication is 20 percent what you know,
and 80 80 percent how you feel about what you know, right? So that quotation earlier where they said, I call and they kind of blew me off.
Well, it depends how I don't want to say forceful, but how convincing you were that there's a problem.
If it was just a hunch, then that that may that may not have resulted in the response that you want.
All right. I saw you look at your watch, I'm going to speed up in a second or so.
So what we did is we went to the against our frontline providers. We held this rescue innovation event.
I would encourage you to try one of these. If you haven't, I think you guys may have done stuff like this where we got all the stakeholders together.
We presented them with a lot of the data I just showed you and we let them come up with the solutions.
And here's what's insane. They came up with this early communication system.
This four pronged approach that actually fits into human factors kind of thinking without them even being human factors,
experts and the four pronged approach as these clinical pathways try and recognition video based competition, training and simulation based practise.
And the idea here is these are build on one another clinical pathways establishing an understanding of normal.
You, when you hit the wards, may have seen a couple of patients who had a Whipple operation, right?
Whipple patients are not normal post-op. You just like this is major physiologic insult.
A normal Whipple patient is not a patient. The same as a patient with pneumonia.
For you to understand what normal looks like, you need to have some guidance, some sort of expected post-op course.
And we've developed these for multiple operations now with the input of our surgeons and nurses to kind of say, what are some general milestones?
This is not an order set. This is not something that you just kind of checkboxes on.
What this does and what our trainees are using this now and our nurses find it helpful is it
allows them to have a more meaningful conversation with the attending surgeon or the care team.
Hey, you know what? It's Day three and they're still got an energy tube in what's going on.
It's just a simple question, Oh, well, you know, they've got gastroparesis and we're doing that.
Oh, is there anything I should be worried about? Yeah, you should definitely make sure head of bed is up because their aspiration risk and you know,
it sparks a conversation that would have not happened otherwise. So again, now these are the expected post-op courses trend recognition.
This is my favourite right now. This is the one we're working on is to begin to understand what is abnormal look like and what can you do about it?
And what we've done to teach this is this concept rescue improvement conferences.
We do this once a month. There are a modification of our typical Eminem conference, which I think is really an untapped resource.
Do you guys have weekly or monthly Eminem's here? Yeah, I think it's we do it the same way we did it a hundred years ago today.
And what we've done is try to flip it on its head. And this is the patient I was describing to you earlier the very beginning of the talk.
This is what happened. So the patient, they come in to intubate the patient to give their normal induction doses.
Patient goes into cardiac arrest and they do two hours of chest compressions to get the patient back.
But he ultimately succumbed the day after again, they were going in to do a routine procedure.
But what went wrong? So in a typical Eminem, we would talk about, oh, you know, frail old man and had a complication,
and they ask the attending, Would you do anything differently? They always say, No, no, we're done the same thing, right?
Sound familiar? Yeah. So you're not allowed to say that in this conference,
you can never say I would do the same thing because then I say that every patient going to die if you keep doing the same thing.
So so we have this case analysis checklist that we've modified from the Ottawa model.
And what we do is, ah,
we have our house officers are the ones who are present and they basically go through and identify all the different issues with that case,
thinking about it from a more systems and cognitive perspective. And what do they do with this?
They then have to come up with key concepts of rescue improvement. How what were the what were the critical fails in each of these arenas?
And in this case, there was an overconfidence on the part of the anaesthetic team that came up intubate.
There's a skill set error, and this led to an institutional change from this conference about resuscitating before you into they,
even in an elective setting in the afternoon in the hospital.
And there was critical teamwork failure when the anaesthesia team came up to intubate and tell you this,
the critical care team was rounding on the opposite end of the intensive care unit.
There was zero discussion between those two sets of providers on this very critically ill patient.
Had they asked that team the corroborating, there's an Oh, he's been kind of dwindling,
you know, he's a lot sicker than he looks like on paper, which is what what we talked about.
And so I'm going to skip over that. This became policy.
We this became a new policy in our hospital and how we effectively intubate patients in hospital.
This came out of a simple Eminem performance was the last time an Eminem changed policy in the hospital, at least in an hour.
Eminem never easily could say never. And here are the systems issue I'm going to skip over.
The last couple of pieces will go quickly because we only have four minutes left. Video based complication training.
This is an early stage of development. I liken this to kind of your choose your own adventure.
It's going to be fun. You guys are going to love it.
It's basically kind of interactive videos like whiteboard type videos where it presented with a case like that patient.
And there's no wrong answer, but you pick, what do you want to do next? And it takes you down a path.
And what this really helps you do is you can take the perspective of other providers.
So, hey, you're going to be the nurse in this situation. You're going to have to make these critical decisions.
Here's what happens when you make that decision. Patients that just die, it might lead to a prolonged hospital course, et cetera.
I took this straight out of aviation. They do this for all their credentialing credentialing.
They do these choose your own adventure simulations, which are amazing.
And simulation based practise, I think this is again, probably a little bit of a unicorn.
But I think that we are going to work toward it.
The hardest thing here is really identifying time and space to do this, but this is about building muscle memory,
having the same people around you, the same environment, the same sites, the same smells when you're trying to manage patients.
And I think it'll be very important as one of the ultimate steps.
So I hope I encourage you to think more about communication.
It is not as simple as a unit directional idea, and I will close you the last couple sign that is just kind of for a few slides, right?
So I'm from Michigan.
If you haven't heard about the team, the team, the team, that's a mantra from Bosch and back where I'd encourage you to Google that and listen to him,
give this speech to the football team many years ago and emphasising it's not about one person,
it's about the team, the team, the team, and we live by this at Michigan.
This is at the tunnel going down to the football stadium.
This is my team, team, team, folks across three institutions that have really been integral again, very in our professional group.
We've got enough folks in the business school.
We got anaesthesiologists nursing directors, nursing nursing surgeon, project managers, residents, anaesthesiologists.
We got people from all spectrum and these are systems engineers. So this is my other team.
They're the ones who let me come here. Sorry. Dr. Henry, I'm almost done, I swear.
But I used to incorporate them much more my talk, but I was told to stop talking about my family.
So. But these are my four children. Cameron, Ryan, Sean and Lyla.
That's my original son, Dodger, who is still alive and well at 13, and I would argue one of the most beautiful dogs on the planet.
This is the matriarch of the family, who is also a full time practising physician and really kind of holds the group together.
And again, none of this work would be possible without this group.
That's it.