Fun Works

I enjoyed reading Fun Works - Creating Places Where People Love To Work by Leslie Yerkes. She suggests that encouraging people to have fun at work reaps benefits of increased productivity, creativity and employee retention. Sounds like a prescription for the healthcare system.

She's not talking about having fun socializing at work (although this is important). She writes about integrating work and fun into a "culture of fun". There are great stories about Pike Place Fish, Harvard University Dining Services and Southwest Airlines. All these businesses emphasize a focus on their customers' experience, and how satisfying and invigorating this can be for employees. Sounds suspiciously like patient/family-centred care...

I was particularly struck by her comments on taking risks in order to "harness and develop the full potential of employees":

The integration of fun and work requires expansive thinking and risk taking. When we utilize expansive thinking, we learn to 'think beyond the box.' When our thinking expands, we create the room for fun to come into our work. Only then can we embrace the risk of integrating fun and work.

To embrace risk taking means to try new things without fear of criticism, to be able to make mistakes and welcome them as learning, without fear of punishment. To be successful at risk taking, we must overcome our fear of failure; we must be able to bring our whole selves to work without fear of rejection. Once we are successful at expansive thinking, risk taking itself becomes fun.

Nothing great in history was ever accomplished without risk. The risk for great success is the same as the risk for failure - extremely high; the risk involved in producing mediocrity is extremely low. To succeed greatly, we must risk greatly. (My emphasis) Risk is inherent in innovation and innovation is the life-blood of our future. Lead the way into the future - don't follow.

Expand your thinking, embrace the risk of fun and work.

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Tech Notes III

Here's 3 recent blog tweaks. (Tech freaks only...)

I had to reinstall the collapse/expand post hack from Hackosphere. I don't know where it went, but it suddenly stopped working. Something I did must have reset the template. I found another version (again, Hackosphere) that takes the reader to a post page when "Read More..." is clicked. I like this feature because...

I'm tracking reader interest using Google Analytics. This is another free Google application that lets bloggers see how many visitors they have, where they live, what pages they read, how long they spend on each page, and lots more information. Previously, if a reader surfed to my blog's main page, they could read recent posts without having to go to that particular post's separate webpage ("post page"). Google Analytics would show that as a visit to the blog's main page but wouldn't tell me what content readers were actually looking at. (Google Analytics is good, but it can't read your mind. Yet.)

Now I should get results on what content is holding people's interest. Why do I want to know? Because it's all about you! If I'm going to spend time writing this blog, I'd like to make it interesting for visitors.

Finally, I added a labels column on the right of the page. It's very simple to do using Edit Template in Blogger. I label most posts into categories/labels, so if there's a certain flavor of post you're interested in, click on that label.

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Selling EHR

HRH Queen Elizabeth II has a YouTube channel and, according to this story, has very recently "embraced...major technological advances" such as the internet, cellphones, Blackberries and iPods. I think this would qualify her, according to Rogers' innovation adoption model, as a late-adopter of information technology.

She's still ahead of many physician-laggards.

It's tempting to ridicule physicians who are reluctant to use electronic health records (I think I just did!) But, for those of us who are keen to promote the use of EHR, we need to understand why well-educated, tech-savvy physicians often resist implementation of EHRs.

(DISCLAIMER: I'm a member of our health region's recently-formed IT Steering Committee so I'm a little evangelical about this stuff.)

I'm already sold on the virtues of EHR: reducing paper clutter, rapid access to patient information, easy transfer of information between care-givers, decision support, less scut work, etc.

But, in order to win over skeptics, we need to provide an EHR system that goes beyond moving from paper to pixels. We need an EHR/IT system that changes the way we can practice medicine.

We need WOW! (Don't try to figure out the acronym - it's just WOW!)

We need to put together an EHR/IT that sells itself - that flies off the shelves. We need the EHR equivalent of an iPod/Wii/WOW (OK, this time it's an acronym - ask a teenage boy).

Our EHR needs to do COOL stuff.

Here's a great NEJM article (c/o Atul Gawande's website) that lists some cool stuff EHR/IT could be doing for us (our patients, I mean!). This article is 4 years old - that's 26 in tech years. We're seriously behind!

Which of these options/opportunities described in the article appeal to late-adopters/laggards? We need to know. We have to ask.

Over the holiday season, I was shopping for a new TV. One salesman wanted to set me up with a 52-inch wall-mounted model. He showed me a football game in high definition. The picture and sound were incredible.

He didn't make the sale.

You see, he didn't bother to find out my needs. I don't watch sports or rent many movies. My kids don't need 52 inches of SpongeBob. The screen had to squeeze into a cabinet recently vacated by our defunct TV set.

If we want to have physicians accept (even embrace, a la HRH) EHR, we (the salespeople) have to find out their needs. How do they practice now? How can EHR make their practices better, easier and safer? What are their concerns about EHR?

Hard sell won't work with physicians. At the first hint of something being forced on us, we circle the wagons and become as stubborn as mules (among other cliches). Administrators planning to implement EHR must sincerely engage physicians in the process.

Early. Often.

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Google to the rescue!

If anyone needs to take advantage of Google's online Calendar application, it's my friends Paul (an ophthalmologist) and Pam (a psychiatrist). Check out their daily schedule in this Star-Phoenix column, "Hectic hockey parents".

If they leverage the power of online scheduling, they could probably fit in a 6th child.

Or a nap. It's their call...

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He's making a list, checking it twice

Not Santa Claus... Your surgeon!

The World Health Organization is beta-testing a Surgical Safety Checklist as part of their "Safe Surgery Saves Lives" initiative. You can see the elements of the checklist here.

It's purpose is to improve communication between OR team members and avoid preventable errors during surgery.

Saskatoon Health Region's (SHR) already has a policy that a similar, somewhat shorter, checklist will be reviewed immediately before each procedure in the operating room. Our checklist is read out by the OR nurse and includes:

Confirmation of the patient's name

Confirmation of the surgery planned (including which side of the body is to be operated on)

Review of any patient allergies

Asking the surgeon whether perioperative antibiotics are required

Make sense to do this? No-brainer, right? I'll bet if you've never worked in an operating room, you just presumed that some kind of "pre-flight check" was standard procedure.

Well, it is now, but it's only recently adopted. And not wholeheartedly accepted.

Surgeons are a very conservative bunch. And we tend not to like ideas that come from outside our community. Especially if the new ideas are perceived as being extra work for not much gain. SHR's preop checklist policy certainly fell into that category, at least initially. (I admit to being an early skeptic.)

Probably the best judges of how this policy is accepted by surgeons are OR nurses. In a completely arbitrary and invalid survey of OR nurses (read: gossip in the lounge), I found that surgeons' attitudes to the preop checklist varied widely. Some surgeons accept the policy and actively participate in the procedure. Many ignore the checklist as it's being read out. (One colleague commented to me that "it's a nursing procedure, not for surgeons.")

A few surgeons actively deride the checklists. I overheard a surgeon who mocked the nurse reading the checklist, saying "C'mon, I know you have to do this, but do you really think it makes any difference? Like I don't know what procedure I'm going to do on this patient?"

Well, doctor, check out the comments in these recent blog posts regarding wrong-side surgery and preop checklists in general:

Suture for a living (The final paragraph says it all: Most important is for everyone involved to be engaged in the process...)

More than Medicine (Think how much effort/anguish could have been saved by creating a system to prevent these mistakes.)

And, if you're still not convinced, watch Tom Shillue's standup comedy bit about wrong-side surgery.



He makes it sound ridiculous. Because it is ridiculous.

Every member of the OR team should be actively involved in the preop checklist process. Maybe we should include one other person: the patient. I don't mean that the patient should listen and confirm the checklist in the OR - that would be impossible if they are sedated or asleep.

Instead, patients (families, caregivers, etc.) could be made aware that this is SHR's policy. They can be informed of this as part of their preop orientation. They may choose to confirm with their surgeon that he/she will make sure that the policy is followed during their surgery.

The surgeon may then choose one of these responses:

Yes, certainly. I believe this is an important part of the system we have put in place to ensure your safety while you are in our care.

What a load of crap! Do you really think that reading out some bureaucratic garbage is safer than my years of surgical experience? Either you trust me or you don't!

Now that should be a no-brainer.

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Mum's the word

I was listening to some rap music today. Not that I had a choice - it was coming out of a Jeep four miles away. - Nick DePaulo

I was listening to an elderly lady's medical history and vital signs today. Not that I had a choice - it was coming out of a paramedic student four metres away.

The young man was presenting his patient's medical history to his supervisor and an ER nurse. I had nothing to do with that patient, but the student's booming voice gave me an earful of her life story. Everyone else in the ER, including patients and their families, could hear him clearly.

The thing that bothered me most about this situation was that no one called him on it. Neither his preceptor or the nurse suggested moving into a more private location to have this discussion of confidential information. Their acceptance of this potential breach of privacy validated this behavior for the student.

Certain hospital environments make it difficult for staff to preserve patient confidentiality. Crowded, multi-patient areas such as ERs, recovery rooms, critical care units and 4-bed rooms (yes, we still have them at my hospital!) are particularly challenging.

For example, when patients are brought into the recovery room after surgery, it's critical that the OR nurse and anaesthetist inform the recovery room staff about the details of the surgery, the patient's medical history and current condition, as well as plans for the immediate post-operative period. This is done in a room where patient beds are separated only by a thin curtain. And it's sometimes done in a loud voice, in order to be heard over other conversations and the noise of monitors and other equipment.

I can hear the excuses and objections now. "You can't expect us to leave the room to sign over a patient. I've got to watch 3 or 4 other patients." Or perhaps, "We're using medical jargon anyway. Laypeople wouldn't understand what we're saying."

Well, yes, I understand the constraints of the work environment. But if we're committed to respecting our patients' privacy, we should at least try to solve this.

If you're a healthcare worker in one of these hospital areas, ask yourself these questions:

- Do I keep my voice quiet when discussion patient information in patient care areas?

- Where possible, and safe for my patient, do I insist that private information be discussed away from other patients and staff?

- Do I model ethical behavior to students and trainees?

And, most importantly:

- How would I feel if I were the patient? Would I want my personal information made public without my expressed permission?

I wonder what people think when they hear us bellowing patient histories across a crowded ER. Does it affect their confidence in our professionalism?

But, back to the paramedic student. What should I have done? Point out what he was doing? Suggest they find a private spot to discuss the case? Probably. But, I didn't know any of the people involved and they didn't know me. I couldn't think of a tactful way to raise the matter without them mentally labelling me a nosy, know-it-all, arrogant physician. So I did the next best (or perhaps, better) thing.

I mentioned it to one of the senior ER nurses. She has an easy, personable manner and I thought the comments would be well-received from her. She agreed that the problem was too common in the ER and that she would mention it to the student.

I love when someone else does the dirty work.

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Who was that masked man?

Wow! I had no idea how many blogger docs were out there until I started poking around in Medicine 2.0. But what's with the anonymity?

I agree with Jay Parkinson - if you're a professional and have something to say about your profession, why not put your name on it? If it's controversial, be ready to support your opinion. If it's offensive, don't post it. Sooner or later, you're going to get outed. It just depends on how badly someone wants to find out who you really are.

I cringed recently while reading a post on Urostream, by keagirl, an anonymous urologist from "A Big City, USA". I generally enjoy this blog, but this time, she lists various euphemisms used in office notes to disguise what she is really saying about a patient.

Use these puppies at your own risk, keagirl! If one of your patients asks for a copy of her records, how will you explain what you meant when you called her "challenging and loquacious". Maybe you could bafflegab her, but what about her lawyer? A judge? Professional review board? Especially when you've published a glossary on the internet.

I guess that's why anonymity is so important.

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