We've moved!

Thanks for visiting Plain Brown Wrapper! The blogging fun has moved to Adventures in Improving Access. See you there!

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Budget cut blues

My HQC blog has moved to Blogger to join Plain Brown Wrapper.
The Sask. budget is coming down in a few weeks, and I'm already worried about QI drawing the short straw.

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What's wrong with this picture? - XV Don't mess with success!

Hi! Long time, no see.

Thanks to Mark Wahba's keen eye for this one:




Bright yellow "Sharps" containers are ubiquitous in health care facilities. Pointy, pokey stuff goes in them after it's been used. This reduces the chance of needle-stick injuries. While the containers come in different shapes and sizes, their uniform yellow color is a strong visual cue as to their presence and purpose.

However, someone tried to "re-purpose" this large sharps container for something else. They had relabeled the contained, but that label didn't last long. Even if it were now being used for regular garbage, it's still unsafe because the staff emptying the garbage wouldn't be expecting uncovered needles in the container.

Surely, you say, a person would stop and think before dropping sharps into this container. After all, there are clues that it isn't a real sharps container: it's sitting on the floor, there's no safety top to prevent people's hands from rooting around inside.

You'd be wrong. Mark mentioned that he had dropped one sharp into it already. And why wouldn't he... the containers give a (supposedly) unique visual cue.

The best part of this story is that Mark pointed (sorry...) out the problem to the department manager, and the practice was stopped!

Here's another example of someone messing with visual cues:



Clean isolation gowns used to be folded and stacked on carts outside a patient's room. You would put one on, enter the room to perform care, and then discard the dirty gown into a laundry hamper outside the room.

Then, someone had the idea of leaving the gowns unfolded, in large plastic linen bags. I'm sure that saves a lot of time by cutting out the folding process. Unfortunately, the "clean" plastic linen bag with rumpled gowns in the bottom of it just screams "Put your dirty laundry in here!" Once a dirty gown has been dropped in, the entire bag is contaminated, and has to be laundered again. Or, worse, the wayward gown is not recognized and then is a source for cross-contamination for another patient.

I've made the mistake myself.

Someone has recognized that it's a problem and tried to remedy it with a hand-lettered sign on the bag. Nice try, but the sign presumes that the person about to dump their dirty gown into the bag is approaching it from the side the sign is on. Also, it presumes that they can read English.

We get clear and important information from standardized visual cues: Skull and crossbones on a plastic bottle - Poison!, Red light - Stop! They prompt us to act, or prevent us from harmful action, in critical situations, without the need for deliberation. Don't ignore people's mental inertia when redesigning the system.

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Welcome Canadian Health Improvement Forum attendees!

Thanks for coming to my presentation of BOMB! How a (failed) career in standup comedy made me a better surgeon. I look forward to receiving your feedback. Please click here to take the survey. You'll need the password from your souvenir postcard!

This survey closes on Tuesday, March 31.

P.S. Got time on your hands? Check out "What's wrong with this picture?"

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Surgical checklists hit the big screen!

Well, almost. The ever-topical TV show, ER, featured surgical checklists in a recent episode. If that's what it takes to get the momentum going on implementation of checklists, I'm OK with that. Pressure and interest from the public will be a very powerful force to convince recalcitrant OR staff. (And, when I say recalcitrant OR staff, I think you know who I'm talking about.)

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What's wrong with this picture? - XIII

Last week, I noticed someone had nailed a green doodad onto the door of each operating room.




Any guesses what it's for?




I suppose this is a trick question "What's wrong with this picture?" because this is really an example of great design. WWWTP is usually about bad design, but I'm going to broaden things a bit to allow for this doodad.

It's a room marker in case we have to evacuate the OR because of a fire or other disaster. The fire marshall checks each room to make sure it's empty, then closes the door and flips the doodad up so it rests on the door frame in an upright position:



If anyone opens the door again, the doodad swings back down to its original position, indicating that the room may have been reentered.

Simple. Brilliant. Sweet.

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'Difficult' patients

Want to know what patient-centred/patient-directed care could look like? Read "On being a 'Difficult' Patient" by Michelle Mayer.

Then, if you have some time, and a box of Kleenex, go to her blog "Portrait of a Dying Mom".

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Culture eats checklists for lunch

Last month, I made a day trip to Regina on a small, local airline. While I waited for my return flight in their Regina airport lounge, a Canadian Forces aircrew was also waiting. There were about a dozen of them, getting ready to fly out in their huge transport plane. The lounge was small, and the aircrew were quite boisterous, joking and clowning around. What happened next has been on my mind since then. But before I tell you about that...


Pre-op checklists garnered the limelight recently and briefly with the publication of the WHO international study that showed improvement in morbidity and mortality after the checklists were implemented. Just over a year ago, I blogged about WHO's checklist in beta version, and some responses I'd seen in the OR.

Not much has changed since then.

Recently, I was called into an OR room because the staff had difficulty inserting a catheter in a patient anaesthetized for abdominal surgery. I had to do another minor procedure to get the catheter in, and before starting, I asked if we should stop to do the preop checklist. The surgeon, who was waiting in the room, piped up dismissively, "Oh, jeez, come on. I know this guy!", and then proceeded to rattle off the patient's name, planned procedure, general health and allergies, auctioneer-style. "That checklist is such a waste of time", he concluded. There were sour looks on the staff's faces, but I couldn't tell whether it was because they agreed that the checklist was a waste of time, or because they disagreed with his assessment. The charge nurse went through the checklist, despite the surgeon's contempt.

Bryce Taylor, chair of Toronto's Department of Surgery and an author of the WHO report, was recently in Saskatoon to present the report, and discuss how to implement the checklist. One of the OR nurses who had attended the lecture commented that it might be difficult to convince all surgeons to embrace the checklist. I suggested that we needed to come up with the right incentives, perhaps going as far as linking the surgeon's access to OR time to his/her performance on critical patient safety issues. If our administration is truly committed to universal use of a safety checklist, they need to be anticipate that there may be a few surgeons who will push the issue that far.

The nurse laughed. "Can you please let me know when you're going to tell Dr. X that he can't operate until he does the checklist," she snorted. "I want to be in the room for that!"

These are a couple of examples of how the OR culture can affect improvement efforts. "Culture eats strategy for lunch" applies here.

But, don't despair! There are other cultures from which we can learn. Back to the airport...

The military aircrew were horsing around in the airport lounge when one of the officers quietly called out.

"Gentlemen. Let's get ready to fly."

Immediately, the aircrew settled down and gathered round. The officer recited the flight duration, altitude, weather conditions and other details. He called for questions. I suspect the crew members already knew most of the details of the flight, yet were completely attentive for the 1 minute briefing. The officer didn't need to raise his voice, or repeat his call for their attention.

Now, that is a professional, safety-conscious culture.

In my first OR vignette, the surgeon insisted that he already knew all the critical information about the patient and the planned surgery. Well, I certainly hope he would. But he misses the point that the checklist is not just for the surgeon; it's for the whole OR team. Also, the purpose of the checklist goes beyond the recitation of critical safety information. The checklist should foster and be part of a culture of open communication and cooperation in the OR. Check out some of the comments at the end of this Wall Street Journal article about the WHO checklist. People are amazed that checklists aren't already standard in ORs.

I guess it comes down to the Golden Rule. If you were on the OR table (or an airplane!), would you want the team looking after you to be communicating openly with the single goal of providing the safest, most effective service of which they were capable? Or are you comfortable with letting someone hinder, under the banner of professional autonomy, everyone else's efforts on your behalf?

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Healthcare Tales from the Crypt

Fraser Institute's Nadeem Esmail terrifies Wall Street Journal readers with a chilling tale of socialized health care. And just in case we're deciding public policy by cherry-picking anecdotes of health care systems gone awry, the NY Times makes our blood run cold with some south-of-the-border horror. I guess this Scare Off is a draw.

Don't go into the basement without full private insurance coverage!

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Please, sir, may I have an EHR?

Thank you, Andre Picard, for restating the case for a significant investment in the electronic health record. It can't come soon enough.

We (finally!) got the last 3 docs in our clinic on our EHR. Just the fact that our staff don't have to search out paper charts 100's of times a day is a huge bonus. I can hardly wait until the Health Region's lab computer can communicate with our system so results can flow directly into patient records. What are we doing in the meantime? Glad you asked.


We have the most ridiculous, Rube Goldberg system to get patient information from the regional lab into our patient records. The lab generates results electronically, makes them into faxable format, and faxes the results to us. Until recently, we pulled the faxes off the machine, SCANNED THEM BACK ONTO THE COMPUTER (!!!) and then assigned them to a patient's electronic record. (Recently, we got a program working that eliminates the re-scanning step.)

Aside from the amount of staff-time this takes, it destroys the potential of the data. If the lab results we received stayed in electronic format, then our computer could search for, say, all men with a PSA level over 10, or a creatinine over 300, or whatever parameter we wanted to track. But, as the information is stored as a picture of the data, the computer has no idea what information is actually contained in the file. If I want to follow a man's PSA level over several years, I have to re-enter that data into electronic form. Nice use of my time...

The waste (staff-time, opportunity to improve care, etc.) is staggering.

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What's wrong with this picture? - XIV - Oh, my aching neck!

Dictating hospital discharge summaries! Aaarrrgh! I don't know a single doctor who enjoys this necessary evil. (For those of you who haven't had the pleasure, a discharge summary is essentially the story of someone's hospital stay.) Not only does it mean 30 minutes of dictating reports, it also means 30 minutes of cranking my neck into an unnatural position to accommodate the terrible ergonomics of the phone receiver.

Check out the protruding vein on my temple - it's pulsating with annoyance.



Well, you may say, why don't you hold the receiver in your hand and save your neck?



Like this, you mean? Great idea, but that leaves just one hand free to flip through a voluminous, poorly organized and ergonomically-obscene paper chart, to reference lab results, progress notes, etc.

It's a frustrating experience, and that leads to rushed, and possible incomplete, discharge summaries.

I always use a hands-free headset in my office - it's comfortable and convenient. Why don't they have one in the hospital medical records dictating suite? As it turns out - nobody asked for one!

A couple of months ago, I spoke to the person in charge of this area and suggested they try setting up a headset. And...



Now check out the protruding vein on my temple - it's pulsating with joy!

I have 2 hands free to flip through the chart. (Electronic charts would be better!) I'm more likely to dictate a thorough discharge summary, because I'm not frustrated by the unwieldy chart, and my neck isn't cramped.

Not only did they supply the headset: (on one phone, as a pilot - excellent plan!)



They also posted an instruction sheet and a feedback form:





What a great demonstration of how to implement a change:

Address the client's need/problem.

Start with a small test of change.

Make it easy for them to try the new method.

Ask for feedback.

If you don't ask, you don't get! And it only took me 16 years to ask.

Kudos to Sherry M. for setting this up. Thank you very much!

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The grass is always greener on the other side...

Check out US President (not yet, but he might as well be) Obama's video blog of his Economic Recovery Plan. He's going to make sure that all US hospitals and doctors' offices are outfitted with EMRs and are connected to each other (3:50 on the video).

EMR and connectivity are part of his core plan. "Cut red tape, prevent medical mistakes and help save billions of dollars each year..." Looks like his administration gets it.

Who would have thought the American health care system would be showing us the way on this?

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Review of Doctor review sites missing an opportunity

Dr. Kent Sepkowitz informs Slate readers that doctor review sites aren't helpful for patients. But can they be helpful for doctors? I think so - check out this old post.

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More RateMD fodder

Here's a recent article from the Prairie Post. 1762 Sask docs listed on RateMD. There is no escape!

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Welcome CCHSE attendees!

Thanks for coming to my presentation of BOMB! How a (failed) career in standup comedy made me a better surgeon. I look forward to receiving your feedback. Please click here to take the survey. You'll need the password from your souvenir postcard!

This survey closes on Thursday, November 27.

P.S. Got time on your hands? Check out "What's wrong with this picture?"

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Come out swinging on private health care!

In this corner, CMA president Robert Ouellet weighs in on how private health care will improve access for Canadians.

In this corner, former NEJM editor Marcia Angell, takes a swipe at American-style privatization.

Judge's decision: Angell

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Macs rule! But let's not be stupid about it...

The medical community seem to be committed Mac users.  At our recent Departmental Research Day, several presenters made that clear.  But, in a counter-productive way...


The laptop being used for presentations at Research Day was a PC, but several physicians brought their own Mac laptops. Great to see other Mac users promoting the cause, but it turned out to be a distraction. Because they had brought their laptops (rather than just the presentation on a memory stick) there was an annoying delay between presentations while the PC was disconnected from the LCD projector and the Mac was connected.

This was completely unnecessary for some presenters, as they had used PowerPoint on the Mac and could have easily loaded their presentation onto the PC via a memory stick. I do that regularly and the only compatibility issue I have is if I've used pictures from iPhoto without changing their format to a PC-compatible one. I've been burned on that before and so am in the habit of checking such presentations on my office PC.

Other Mac users/presenters were obviously using Keynote, and so couldn't run that program on a PC. I say "obviously using", when perhaps I should say "obtrusively using", i.e. "Hey, I'm using this cool, Mac-only program. Look at these wicked fonts and catchy transitions I can do!" Those bells and whistles are amusing for exactly 2 slides and then they are a distraction from your presentation's message. If that's the only reason you're using Keynote... don't do it. Stick with PowerPoint (on your Mac, of course) and save us the nuisance of switching platforms between presentations.

I admit that I use Keynote for one particular presentation that requires an animation that PowerPoint can't handle. That means I have to take my laptop along whenever I give that presentation. After experiencing the annoyance of several computer changes at Research Day, I'm seriously reconsidering whether that single animation is really worth the grief of lugging a laptop around, rather than just carrying PowerPoint on a memory stick.

Of course, the ultimate solution would be for the AV people to smarten up and start using Mac laptops. As Macs can run either Mac or PC, it makes more sense to be using the more versatile platform.

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HSBC airport ads - Love 'em!

Having schlepped through more than my usual number of airports this month, I've noticed, and enjoyed, HSBC's ads displayed in various walkways.
The ads feature beautifully-photographed images alternately labelled with antonyms, that, well... Check them out for yourself and you'll get the point.

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Wonder words

Long time, no blog. No excuses, just life.

I was reviewing a patient's chart this morning, and several phrases in nursing/physician notes caught my attention: Patient refused breakfast. Patient denies shortness of breath.

If you're a hospital caregiver, you've seen similar stuff written on charts. Wording notes this way makes it sound like patients are our adversaries. Like we're suspicious of what they say and do. Like the little sneaks can't be trusted. (Oh, he denied shortness of breath, but I think we know better. Refused breakfast, did he? Well, we'll just see about that!)

I've also seen people refer to themselves in progress notes as "The writer" rather than saying "I", as in "The writer observed the patient performing self-care", instead of "I watched Mr. Jones perform self-care." What's the reason for that? Is "the writer" somehow more professional and credible? I also wonder why people write "Patient stated" or "Patient verbalized" rather than "Patient said".

And, if you're a patient, don't ever dare to leave the hospital "Against Medical Advice". If that gets written on your chart, you're branded as an uncooperative jerk.

Which you may be.

But, you may also have needed to deal with an urgent personal matter, and your doctor didn't see fit to make ward rounds and write your discharge order at a reasonable time. "Uncooperative jerk" cuts both ways. " Discharged self AMA" sounds like we're running prisons rather than hospitals.

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Welcome SORN attendees!

Thanks for coming to my presentation of BOMB! How a (failed) career in standup comedy made me a better surgeon. I look forward to receiving your feedback. Please click here to take the survey. You'll need the password from your souvenir postcard!

This survey closes on Saturday, September 20.

P.S. Got time on your hands? Check out "What's wrong with this picture?"

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