Healthcare is at least a decade behind other high-risk industries



By:  David Kashmer (@DavidKashmer)

Did you know?  Our field lags behind many others in terms of attention to basic safety.  For those of you who focus on healthcare quality & safety, that’s probably old news.  After all, the Institute of Medicine said exactly that in its To Err Is Human report…from 1999 (!)

Here’s a portion of a recent post I wrote up for which describes exactly that & includes a link to that report:

Healthcare is at least a decade behind other high-risk industries in its attention to basic safety.

In 1999, the IOM published “To Err Is Human,” which codified what many quality experts in healthcare already knew:  in terms of quality improvement, healthcare is at least a decade behind.

More recently, a widely criticized paper from Johns Hopkins cited medical errors as the third leading cause of death in the United States. Even if you don’t agree that medical errors are the third leading cause, the fact that medical errors even make the list at all is obviously very concerning.

First published in

Click here for entire article:

What you may NOT know is that our field lags when it comes to the adoption of other emerging trends.  For example, here’s a graphic from earlier this year:

Healthcare lags other fields
Healthcare lags other fields

Now, all of that said, I spend a lot of time wondering exactly why we lag in certain key areas.  Here’s what I’ve come up with, and I’m interested in any thoughts or feedback you might have.

(1) Using the word “lag” supposes that the direction everyone else is going is some sort of goal to be achieved or a type of race

It seems to me that the way the graphic above sets things up implies a progression or goal of digitization.  In that graphic, it seems as if we are ranked in terms of progress toward some endpoint of digitization.  Let’s take some time and consider whether framing the situation as progress toward some digital endpoint really makes sense.

Perhaps no one likes technology more than me.  I tend to be an early adopter (and sometimes an innovator) with new devices and software that help me get done what I want to do both personally and for patients.  Yes, I use a Fitbit.  (Not so special nowadays really.) And I use services like to look for meaningful correlations across things I do, such as how much sleep I get with how I perform.  This system takes me no time (it all happens under the hood) and sometimes even gives me non-intuitive correlations, which are perhaps the most useful.  Here’s an example of what I mean, but this one is weak and I wouldn’t do anything differently based on it:


The bottom line is, I think, every time I see a Big Data article or learn about how websites figure out things about my health that I don’t even know, well, I think we are pretty much all-in on this progression towards the digitization idea…at least I am!

So, on this one, I believe that (yes) there is a meaningful progression toward digitization across industries and, yes, I feel it’s more useful for healthcare to get on board than it is to lament where things are going or to question whether digitization is meaningful for healthcare…and I especially feel good about it when I remember the days of my training and how I used to have to hunt for Xrays on film, yet now I have the Xray or CT scan on my computer instantly!

(2) In part, we are slower to adopt because we deal with people’s health.

We don’t build cars or fly planes, really.  Although certain lessons learned from other industries are very important, many in healthcare believe our service is different.  Some are even skeptical of whether we should adopt tools that worked well across other industries.  We work with people’s health, after all.  In the United States especially, that’s a very big deal and many regard it as a true calling.  So, being the careful people we are (I often wonder just how risk-averse we are) it seems to make sense to me that our field may be slower than others to adopt new things.  It’s very conservative and maybe even highly adaptive to be that way.

When it comes to certain aspects of our work, like patient safety and quality, I should add here that there are well-worn tools that apply to all services–even services like ours called healthcare.  We should adopt these, and unfortunately are still behind.  I’ll add that adopting these tools helps us as providers even as it helps our patients.  (If you’re interested in specifics, take a look at Volume to Value.)

So, bottom line here:  part of why healthcare may be slower to adopt emerging trends is because we feel very strongly that only the best, well-worn, known tools should be applied to people’s health.

(3) Sometimes we are slower to adopt because much of the push to adopt has come from outside

About three months ago, I’d just finished speaking at a quality improvement conference in Philadelphia.  This one had over a thousand participants from diverse companies.  It really ran the gamut from Ford to Crayola to large hospitals to DuPont, and each participant was focused on quantitative quality improvement.  After my talk, there were lots of questions.  One really struck me in particular:

“How can you improve healthcare quality when you still get paid even when things are bad?  I mean, when I make a car if there’s a quality problem and it comes back, I eat that cost…”

This audience member really hit it on the head.  Isn’t it difficult to advance topics like quality (where healthcare is a decade behind) if you’re still reimbursed even when there’s a quality issue?  What he’d hit on is the tension between a pure fee-for-service model versus value-based reimbursement.

I was able to tell him that healthcare is transitioning, right now, away from being paid even when there’s a quality issue to a model where reimbursement is much more focused on value provided to patients.  I also shared with him that things aren’t easy, because we all have to agree on what exactly value and quality means in healthcare, but that we are getting there.  We talked about how buy-in from everyone in healthcare for quality initiatives (and more rigorous, quantitative ones), I think, will increase in the next 10-15 years as a result.  Sure enough, I think we can see this is already happening:

Click image for entire article.

Our conversation reinforced for me that much of the quality push, and digitization push, has come from outside of healthcare.  When the adoption of electronic health records and other forms of digitization are incentivized via meaningful use initiatives, and the HHS department explains that more and more of reimbursement will be tied to value-based metrics, it’s clear that a significant portion of the push to adopt emerging trends has come from outside what may be considered the typical traditional healthcare sphere.

Items that were typically hailed as improvements in healthcare, over the last hundred years, included game-changers like general anesthesia, penicillin, or the ability to safely traverse the one to two inches between the heart and the outside world with cardiac surgery.  (Prior to the development of cardiac surgery, some famous surgeons had previously predicted that route would forever be closed!)

Now, especially to physicians, it can be harder to see the value in moving in these directions.  Many in healthcare feel they are pushed toward them.  Yes, every physician wants the best outcome for the patient, yet seeing quality as the systematic reduction of variation along with improvement in the central tendency of a population is not always, well, intuitive.  Given the backdrop of the very specific, individualized physician-patient relationship, it can be challenging to understand the value of a quality initiative that sometimes seems to play to eliminating a defect which the patient in front of the doctor seems to be at low (or even no) risk for.

I’m not saying whether any of this is good or bad, and I’m only sharing what is:  we may be slower to adopt these trends in healthcare because they have often come from outside.  Rather than commenting on whether this is good or bad, it seems to me that the trend does explain some of why the field is slower to adopt these changes.

Having worked in healthcare for more than a decade through many venues, from cleaning rooms in the Emergency Department to work in the OR as a surgeon, I can share that yes we in healthcare are behind other industries in terms of adopting key trends.  However, I believe this is much more understandable given the nature of our work that directly (and individually) affects quality and quantity of human life, as well as the fact that (for better or worse) much of the impetus to adopt these trends has come from the outside.  I consider it my responsibility, and all of ours as providers, to be on the lookout for ways in which we can adopt well-worn tools that already exist to improve quality and digitization in our field.  Let’s make our call to action one where we get on board with these trends for at least those aspects that we reasonably expect may improve our care.

Warning: Will Your Quality Improvements Really Last?

David Kashmer, MD MBA MBB (@DavidKashmer)



OR turnaround time is a classic opportunity for quality improvement in hospitals. The surgeons typically say it takes way too long to clean and prepare the ORs.  The materials management and housekeeping staff often add that they’re doing everything they can to go as quickly as possible–without sacrificing their safety or doing a bad job for the patient.  Anesthesia colleagues may add that they too are going as fast as possible while completely preparing the rooms and maintaining patient safety.  However, the rest of administration will remind the team of an estimated cost of OR time so as to put a face on the costs associated with that downtime when no one is operating in the ORs.  I’ve seen these range from as low as $50/minute to as high as $100/min!


Here’s a classic quality improvement project


Here, then, is a classic project that involves many stakeholders,  shared OR governance, and an obvious opportunity to decrease what many hospitals consider non-value added time (VAT).  I bet it’s a project that your healthcare system has performed before, will perform soon, or is eyeing as a potential for significant quality improvement.

And you know what?  Even if you’ve gotten this challenging project done in your healthcare system, the issue may not be behind you my friend.  Let me tell you why…

Once upon a time, at one hospital, the goal of an important quality improvement project was to reduce that turnaround time in the operating rooms.  And wow had it ever worked!

The team had adopted a clear definition of turnaround time, and had used a DMAIC project to significantly decrease that time–it was almost like a NASCAR pit crew in there.  It was safe, orchestrated, complete, and really helped the rest of the staff improve OR flow.  The time required to turnover a room had also become much more predictable, and this decreased variation in turnover times was also a big help to patient flow and scheduling.

The team used several classic tools, including a spaghetti diagram to decrease wasted motion by the “pit crew” team, a kanban inventory system, and a visual control board to notify all of the players in the process (Anesthesia, Surgery, Pre-op Nursing, & the holding room) when the operating room was ready to go.  They saved days worth of wasted motion (time spent walking) for the OR prep crew when projected out over a year’s worth of turnovers.  The OR staff could complete about one extra case per room per day.  Truly amazing.

…but only three months later, the turnaround time had crept back up again to where it had been before the changes–a median of 25 minutes per case.


Good quality projects never die.  And if you plan them right, they don’t even fade away.  –Anonymous


Nobody noticed, at first, that the turnaround times were slowing down from great to just pretty good again, until one day the OR got very backed up because a couple of turnarounds took 40 minutes. The Chief Surgeon wasn’t happy and didn’t hesitate to tell anyone she could how she felt.

What had kept the gains from being sustained? (You’ve probably seen these culprits before.) It was a combination of factors. Two new people started in the OR; one longtime employee in the facilities-services department had retired. The new people weren’t educated all that well about the turnaround system, and they also didn’t know exactly where everything was yet.  But that wasn’t the real problem.


Failure is much more likely when there’s no control plan


In fact, the quality-improvement team hadn’t built a control plan into the system. The first sign they may have had a problem was when the Chief Surgeon fired off an angry e-mail to the rest administration and most of the staff.  The signal should’ve come much earlier, when the variation in turnover times increased unexpectedly.  That signal could’ve been noticed weeks before.

How?  The team could’ve used an ImR control chart (more on that here) to notice that the range of times for room turnover had gone out of control.  The team could’ve had someone, a process owner like the OR administration, positioned to sound the alarm that the process needed to be solidified when, weeks earlier, several other turnovers took an unexpectedly long time.

Fortunately, in this case, the project team recovered.  They quickly deployed an ImR chart and also reviewed their data.  The Chief Surgeon had been correct:  yes, those cases did take an unexpectedly long time when viewed in the context of the OR’s data.  A root cause analysis was performed and the quality team quickly realized that several issues lined up to make those times take so much longer.

After addressing the issues, the team was back in full swing only a week or two later.  The pit crew was back at it, and the NASCAR-like precision had returned.


The take-home


The lesson:  creation of a control phase plan to maintain the good work you & the team have done is an essential part of quality improvement projects.  Without an excellent control plan, it is very difficult to maintain the improvements you’ve made as a foundation for future improvements.  Failure to plan a control phase is, unfortunately, planning to fail.


Excerpt originally published as part of Volume to Value:  Proven Methods for Achieving High Quality in Healthcare

Here’s Why Business Education Is Important For Physicians

By:  David Kashmer MD MBA FACS (@DavidKashmer)

What’s dangerous is not to evolve.  –Jeff Bezos

Once upon a time, a young man went to work every day providing an invaluable service for his local community.  The work was considered essential, in fact, to help make sure people were safe and were able to get done what they needed to get done in order to live their lives.  Now, that position no longer exists in our society.  The job:  lamplighter.  It could’ve been milkman or a host of others.

Oh, did you think I was leading up to a job in Healthcare?  No problem!  Insert radiology file room clerk (not many around since the dawn of the electronic medical record and PACS integration).  Colleagues, here’s the point:  if you think of Healthcare as static, well…stop!  The story I share above about lamplighters could easily be another role in the hospital or perhaps, some say, an entire medical specialty.

I invite you to think of Healthcare, and your role in it, as more like navigating an ocean instead of walking a beaten path.  And in oceans, my friends, things happen.  Unexpected weather, accidents at sea, and moments of amazing calm are each represented in different measures at different times.

Let’s talk about the tumultuous state of Healthcare.  Like me, you’ve seen:

  • increasing numbers of employed physicians and declining numbers of private practices
  • significant time spent (more than 20% of our days in many reports) on documentation in electronic health records.
  • increasing focus on defensive medicine owing to many factors including the modern climate of tort law

Now, let me be clear:  I’m not commenting on whether this is bad or good…I’m only saying that this just is.

Ok, now let’s get to where we’re going:  in order to navigate the highly complex ocean of Healthcare, physicians need tools.  And, unfortunately, we often weren’t given these tools in medical school.  Now, I agree that medical school should help us understand disease & its treatment.  We should focus on the basics of baking the cake of how to deliver excellent, compassionate care to people.  Much of the rest is icing.  We may even learn how to be lifelong learners…but what then?  

Nowadays, we have needs that medical school didn’t directly address:  we need a different mental model because times in healthcare have changed.  Why?  Because the only constant thing is change.  The Affordable Care Act, the ongoing transition from a system focused on volume of services delivered to one centered on value of care delivered, and a swell of other influencers have made the practical side of what it means to provide care very different than what the tools we took from medical school were designed to address.

So what about these situations where the waves surge so high that our boat is threatened?  What about situations where we have no map or compass?

Tools for the ever-changing landscape, ones that build strategies, teach us how to maintain the financial viability of our practice, or otherwise guide us in this often-challenging ocean…well, those tools are not included in our medical textbooks.  Those tools, ones that enable us to provide high quality care, create a new practice of our own, or to allow us to practice at a higher level as an employed physician…those tools are more typically found in business textbooks.

How exactly is a Relative Value Unit (RVU) defined?  What exactly is an acid test ratio, and what does it tell me about my practice?  How can I create a system in my hospital as an employed physician that helps me provide routine, excellent care?  These questions, and others, are answered by a toolset that we’ve often seen little of in Healthcare.  These are more commonly found in the business world and those are the ones that help us navigate amidst an uncertain future.

So, once upon a time, an entire job disappeared.  Don’t be the next lamplighter and wind up snuffed out by a towering wave of disruption.  Build a better map to navigate what are sometimes treacherous waters–waters which will likely become only more challenging to traverse in the years to come.


How Well Do We Supervise Resident Surgeons?

By:  David Kashmer (@David Kashmer)


I was recently part of a team that was trying to decide how well residents in our hospital were supervised. The issue is important, because residency programs are required to have excellent oversight to maintain their certification. Senior physicians are supposed to supervise the residents as the residents care for patients. There are also supposed to be regular meetings with the residents and meaningful oversight during patient care. We had to be able to show accrediting agencies that supervision was happening effectively. Everyone on the team, myself included, felt we really did well with residents in terms of supervision. We would answer their questions, we’d help them out with patients in the middle of the night, we’d do everything we could to guide them in providing safe, excellent patient care. At least we thought we did . . . .


We’d have meetings and say, “The resident was supervised because we did this with them and we had that conversation about a patient.” None of this was captured anywhere; it was all subjective feelings on the part of the senior medical staff. The residents, however, were telling us that they felt supervision could have been better in the overnight shifts and also in some other specific situations. Still, we (especially the senior staff doing the supervising) would tell ourselves in the meetings, “We’re doing a good job. We know we’re supervising them well.”


We weren’t exactly lying to ourselves. We were supervising the residents pretty well. We just couldn’t demonstrate it in the ways that mattered, and we were concerned about any perceived lack in the overnight supervision. We were having plenty of medical decision-making conversations with the residents and helping them in all the ways we were supposed to, but we didn’t have a critical way to evaluate our efforts in terms of demonstrating how we were doing or having something tangible to improve.


When I say stop lying to ourselves, I mean that we tend to self-delude into thinking that things are OK, even when they’re not. How would we ever know? What changes our ability to think about our performance? Data. When good data tell us, objectively and without question, that something has to change–well, at least we are more likely to agree. Having good data prevents all of us from thinking we’re above average . . . a common misconception.


To improve our resident supervision, we first had to agree it needed improvement. To reach that point, we had to collect data prospectively and review it. But before we even thought about data collection, we had to deal with the unspoken issue of protection. We had to make sure all the attending physicians knew they were protected against being blamed, scapegoated, or even fired if the data turned out to show problems. We had to reassure everyone that we weren’t looking for someone to blame. We were looking for ways to make a good system better. There are ways to collect data that are anonymous. The way we chose did not include which attending or resident was involved at each data point. That protection was key (and is very important in quality improvement projects in healthcare) to allowing the project to move ahead.


I’ve found that it helps to bring the group to the understanding that, because we are so good, data collection on the process will show us that we’re just fine—maybe even that we are exceptionally good. Usually, once the data are in, that’s not the case. On the rare occasion when the system really is awesome, I help the group to go out of its way to celebrate and to focus on what can be replicated in other areas to get that same level of success.


When we collected the data on resident supervision, we asked ourselves the Five Whys. Why do we think we may not be supervising residents well? Why? What tells us that? The documentation’s not very good. Why is the documentation not very good? We can’t tell if it doesn’t reflect what we’re doing or if we don’t have some way to get what we’re doing on the chart. Why don’t we have some way to get it on the chart? Well, because . . . .


If you ask yourself the question “why” five times, chances are you’ll get to the root cause of why things are the way they are. It’s a tough series of questions. It requires self-examination. You have to be very honest and direct with yourself and your colleagues. You also have to know some of the different ways that things can be—you have to apply your experience and get ideas from others to see what is not going on in your system. Some sacred cows may lose their lives in the process. Other times you run up against something missing from a system (absence) rather than presence of something like a sacred cow. What protections are not there? As the saying goes, if your eyes haven’t seen it, your mind can’t know it.


As we asked ourselves the Five Whys, we asked why we felt we were doing a good job but an outsider wouldn’t be able to tell. We decided that the only way an outsider could ever know that we were supervising well was to make sure supervision was thoroughly documented in the patient charts.


The next step was to collect data on our documentation to see how good it was. We decided to rate it on a scale of one to five. One was terrible: no sign of any documentation of decision-making or senior physician support in the chart. Five was great: we can really see that what we said was happening, happened.


We focused on why the decision-making process wasn’t getting documented in the charts. There were lots of reasons: Because it’s midnight. Because we’re not near a computer. Because we were called away to another patient. Because the computers were down. Because the decision was complicated and it was difficult to record it accurately.


We developed a system for scoring the charts that I felt was pretty objective. The data were gathered prospectively; names were scrubbed, because we didn’t care which surgeon it was and we didn’t want to bias the scoring. To validate the scoring, we used a Gage Reproducibility and Reliability test, which (among other things) helps determine how much variability in the measurement system is caused by differences between operators. We chose thirty charts at random and had three doctors check them and give them a grade with the new system. Each doctor was blinded to the chart they rated (as much as you could be) and rated each chart three times. We found that most charts were graded at 2 or 2.5.


Once we were satisfied that the scoring system was valid, we applied it prospectively and scored a sample of charts according to the sample size calculation we had performed. Reading the chart to see if it documented supervision correctly only took about a second. We found, again, our score was about 2.5. That was little dismaying, because it showed we weren’t doing as well as we thought, although we weren’t doing terribly, either.


Then we came up with interventions that we thought would improve the score. We made poka-yoke changes—changes that made it easier to do the right thing without having to think about it. In this case, the poka-yoke answer was to make it easier to document resident oversight and demonstrate compliance with Physicians At Teaching Hospitals (PATH) rules; the changes made it harder to avoid documenting actions. By making success easier, we saw the scores rise to 5 and stay there. We added standard language and made it easy to access in the electronic medical record. We educated the staff. We demonstrated how, and why, it was easier to do the right thing and use the tool instead of skipping the documentation and getting all the work that resulted when the documentation was not present.


The project succeeded extremely well because we stopped lying to ourselves. We used data and the Five Whys to see that what we told ourselves didn’t align with what was happening. We didn’t start with the assumption that we were lying to ourselves. We thought we were doing a good job. We talked about what a good job looked like, how we’d know if we were doing a good job, and so on, but what really helped us put data on the questions was using a fishbone diagram. We used the diagram to find the six different factors of special cause variation…


Want to read more about how the team used the tools of statistical process control to vastly improve resident oversight?  Read more about it in the Amazon best-seller:  Volume To Value here.

Cover of new book.
Cover of new book.


Changes To Make To Your System…And Ones Not To (!)

By:  David Kashmer (@DavidKashmer) LinkedIn Profile here


Originally published as part of Volume To Value:  Proven Methods For Achieving High Quality In Healthcare


Catheter-associated urinary-tract infections in hospitalized patients are considered “never events”—they should never happen. When they do, the hospital is penalized by Medicare and third-party payers. The issue can really burn a hospital. Naturally, hospitals are very interested in ways to avoid UTIs. One hospital I worked at had tried several solutions, and some turned out to be bad choices. They tried taking catheters out of patients before those patients had a chance to develop an infection. That sounds like a good idea because, in general, removing a catheter as early as possible is a good thing, but it’s not good if it’s removed too early. That’s an important distinction that didn’t get made, and catheters were being removed too early for many patients. In critically ill patients, for instance, the catheter may be needed to follow the patient’s urine output carefully. Many ICU patients could not be monitored appropriately once their catheters were removed too early. The hospital also tried out perhaps the worst possible solution, which was just not sending samples for urinalysis so they wouldn’t have to make the diagnosis. Obviously, that’s something we don’t want for patients. If a patient gets an infection, we want to know about it and treat it. At this hospital, when patients did get a urinary tract infection, it was recognized much later.  So what can be done?  What does a good solution to a healthcare system problem look like?


In its attempt to solve a problem, the hospital chose bad solutions that, in some cases, actually made patients sicker. Bad solutions often have a certain look about them: they’re solutions that are difficult to implement, are expensive, are otherwise prohibitive, take multiple steps to get done, don’t work or just generally make things worse.


What do good solutions look like? Above all, a good solution is implementable. A good system makes it easy to do the right thing and hard to make a mistake. A good system is error-proof because the playing field is tilted toward making it easier to do the right thing. In designing the system, the questions are always “What’s easy for the physician or healthcare provider?” and “What’s the right thing for the patient?” and “What’s doable?”




If a patient comes to the hospital with an existing UTI, then the hospital isn’t generally responsible for it as a hospital-acquired UTI that the patient received in their institution, and therefore the hospital doesn’t get penalized. (Of course, the hospital is still responsible for diagnosing and treating the patient properly.) Obviously, the key is to test patients at admission, especially ones who are at high risk, to find out if they already have a catheter-associated UTI or that they’ve come in with a UTI even if no catheter is present on their arrival. The test is very quick, inexpensive, and easy. To make it a routine part of admissions across the hospital, however, isn’t always easy. At one hospital where I worked, the center had to decide what changes to make to its system to ensure that every patient, not just the obvious high-risk ones, was automatically tested for a UTI at admission. The solution was fairly obvious: allow nurses to obtain the test, via a standing order from physicians that included certain criteria regarding for who should receive the test and results. The urinalysis becomes part of a comprehensive outside hospital (jokingly nicknamed the “OSH” for “outside hospital”) workup for patients who come from other hospitals, nursing homes, rehab centers, or even retirement communities. These facilities are like “outside hospitals” because their patients are similar to transfers arriving from other hospitals “outside” the one we’re describing. This urinalysis test doesn’t hurt the patient at all, it’s very inexpensive, and there’s very little to no downside risk. This small, simple change turns out to be a big help for the patient and the organization. The comprehensive approach catches not only UTIs but also other problems, such as deep venous thrombosis. That’s another condition that can penalize the hospital if the patient develops it during a stay, so it’s better to know if they’re coming in with it, both to prevent a penalty and to get treatment started right away. Deep venous thrombosis can kill a patient. Part of the OSH workup in the hospital where I worked included a test for deep venous thrombosis.


A good solution is one that is easy to implement, straight- forward, and turns out to bolster other quality and safety issues. The best solution makes it easier to do the right thing. In the case of catheter-associated UTIs and deep venous thromboses, the hospital set up standing orders from a physician that empowered ER nurses to order the tests.


With the DMAIC process—define, measure, analyze, improve, control—you’ll often end up with several can- didate solutions. How do you filter through the changes that you want to make and the guiding principles to come up with the best solution? In the case of catheter-related UTIs, you’d want to find a way early in the process to identify patients who arrive with one. You’d want to define what you’re measuring. It’s very important to align the measurement with the intervention, and vice versa. Are you looking at the percentage of patients who have a urinary-tract infection? Are you looking at reducing the number of hospitalized patients who have one, measured monthly? The endpoint measurement really matters here, because when you implement the program, you may well see an increased rate of urinary-tract infection in hospitalized patients. That’s because now you’re looking for them, so you’re finding them. But on the other hand, with your new program in place, the rate of hospital-acquired catheter-associated urinary-tract infections should be lower.


That leads to a further measurable endpoint: savings from not being penalized by the cost of poor quality. Part of your UTI rate project may include a SIPOC diagram. Many patients come to the emergency room with catheter-associated infections that they got in their nursing home, or a pre-existing urinary tract infection / colonization even if no catheter is present at that time. So, you can look at nursing homes as suppliers who send you patients. One way to reduce the number of patients coming in with UTIs would be to do outreach to the nursing homes to help them manage catheters better and be more aware of the symptoms of an infection. Or you could do outreach only to the nursing homes that send you the most patients with infections. You could make sure that attending physicians who round on nursing homes are sensitized to the problem. But you also have to be aware of the scope of your project and realize that you can’t always influence the people who send you patients. Solutions that work are realistic and within the criteria the team selects.



Most solutions to quality problems in medicine end up creating more paperwork. I rarely see solutions that involve less paperwork. Based on my experience, I estimate that at least 80 percent of the solutions that come out of healthcare improvement projects typically involve more paperwork—another form to fill out, another item on the chart, another checklist.


Now, let me be clear:  I do like checklists. They’re useful and have a place in quality improvement. But they’re only one part of a vast arsenal of what you can do to improve a system. Although checklists are a buzzword and hot topic now, a checklist isn’t always the best, most implementable, or most effective solution. It often just creates more paperwork. Checklists can be a good starting point, but they’re often not the most effective solution in the set of all possible solutions.  (They are, however, infinitely better than nothing!) Physicians today often spend about half of their working day on paperwork. A checklist that only adds to the load often isn’t really helping. For residents, the paperwork is even worse. A lot of it just gets dumped on them, and they end up doing mindless clerical work that doesn’t necessarily improve quality. How much of an impact does this have? We don’t know, because we don’t rigorously measure that sort of work. We often don’t really know if it makes any difference to quality. We often don’t know if we’re doing better or worse for having added twenty minutes of paperwork. I advise us all to look to a wider array of interventions than just checklists.



When a system is error-proofed, it’s a lot easier for every- one to do the right thing every time and a lot harder to make a mistake. This is the Japanese design philosophy of poka-yoke (pronounced “poke a yoke”), also known as error-proofing, mistake-proofing, or sometimes (rarely) idiot-proofing. The idea is to set up a system that’s as immune to human error as possible. Many mistakes are inadvertent; poka-yoke helps avoid them. In manufacturing processes, where the idea was first developed, poka-yoke is used to prevent mistakes before or while they’re being made. The idea is to eliminate defects at the source. For example, on an assembly line, a poka-yoke solution to putting a part in backward might be to redesign it so that it can only fit when it’s in the proper position, or to color it on one side so that you can see immediately if it’s in place correctly. If a part requires the worker to install five screws, provide the screws in packages of five so that forgetting one or using the wrong screw becomes almost impossible. In healthcare, where we’re dealing with humans in fluid situations that require experience and judgment, poka-yoke changes aren’t generally as straightforward as retooling a part. For example, although we commonly use kits that contain everything needed for a procedure such as inserting a central line, often the procedure doesn’t require everything in the kit, leaving plenty of room for human error. In medicine, we have to make it easier to do the right thing even when the right thing is complex and the people who need to do it are very busy and have a lot of distractions. Under these circumstances, poka-yoke solutions almost always mean making something harder, either mechanically, physically, mentally, structurally, or by creating more paperwork. This sounds counterproductive and more like punishment than help, but in fact, by making it harder to deviate from a process or protocol, the system makes it harder to mess up.


Great healthcare poka-yoke solutions are ones that eliminate or reduce the ability to make a mistake and eliminate some piece of paperwork! Some poka-yoke solutions are very simple, such as pop-up messages on a computer screen or making a form easier to fill in correctly (and quickly) by highlighting where the information needs to go. A good example of a simple poka-yoke solution for hand cleanliness is putting hand-sanitizer dispensers outside every doorway. If you have to look around for a dispenser, you might skip sanitizing; if a dispenser is right in front of you everywhere you turn, you’ll probably use it.


Curious to read more about examples of solutions that work in healthcare quality improvement initiatives?  Read more in Volume To Value here.


Coming Soon: We’re Going From Volume To Value

By:  DMKashmer MD MBA MBB FACS (@DavidKashmer)


Yup, Healthcare is going through a major transition and we all know it.  Whether you’ve followed along with the blog, or even if you haven’t, you probably know that Health & Human Services is transitioning us to a focus on value delivered to patients rather than volume of services we deliver in healthcare.  If you haven’t heard exactly what’s coming, look here.

So, in order to help prepare, I’m sharing tools and experiences with quality improvement that lead to improvements in value delivered to patients.  Take a look at Volume to Value, coming soon on Amazon.

Now, more than ever, a clear focus on well-known quality improvement tools is paramount for success.


How To Avoid Mistakes With Your First Job Hunt As A Surgeon

By:  David Kashmer MD MBA (@DavidKashmer)


Finding your first job as a doctor is a major life decision. The choices you make now are going to have impacts, both in the short and long run, on the rest of your life. You’re at a very busy time in your life—you’re wrapping up a residency or fellowship and you’re getting ready for your boards, and on top of that, you’re about to start job hunting. Busy as you are, put some serious thought into what you want your first job to be. The more you know what you want from that job, the more efficient your hunt will be and the more likely you are to end up with the job that’s right for you.


Timing Your Job Hunt


Chances are that as you approach the end of your training, your inbox is starting to fill up with mail from recruiters and matching agencies. Some recruiters work for employment companies—they’re medical headhunters. Others work in-house for a specific hospital or group of hospitals.


It’s fun and even flattering to suddenly be getting email from people who say they want you, but don’t jump on an opportunity just because it has arrived in front of you. Save the offers that seem interesting but you don’t need to rush into interviews. Most jobs stay open for a fairly long time while the search committee looks around. Unless a job seems so perfect that you want to try to grab it right away, take your time. Don’t dawdle, however. You’ll be done in July and you’ll want to have your job lined up well before then.


If you’re finishing your residency or fellowship, you’ll start job hunting in the last three months to four months. Sometimes, if you’re a fellow in an academic Mecca, the hospital will try to retain you. You’re already there, you’re credentialed, you know the system, you’re ready to go on day one. When a physician goes to a new hospital and has to learn their coding and billing system, there’s a cost associated with that. The hospital won’t be reimbursed all it could be as that physician learns the system—it could be six months before you start bringing in significant income. That delay usually translates into several hundred thousand dollars.


Academic Centers & Salaries


However, benchmark salaries for fellows who stay on are usually much lower than what they could get in a different practice venue. At academic centers, people work very hard and their take-home revenue isn’t as high as what they’d make in another system. But because academic centers also have a lot of positives, many fellows do stay on. They’re familiar with the environment, it’s comfortable, they’re already living there, the kids are in school, their partner has a good job in the area, and so on. If you have a particular research interest that the center is supporting, that’s a good reason to stay.


If you decide to look beyond your current hospital, give yourself plenty of time to develop meaningful options before July comes around. I recommend getting started (seriously) by April or May at the latest. After all, remember that you may need four to six months of lead-time in order to get a license (and be able to work) at this new job. Do a little math: if it takes six months…


Interested in more advice about your first job hunt?  Look here for more from The Hidden Curriculum:  What They Don’t Teach You At Medical School.

Here’s How To Avoid Disaster With Your Contract

By:  David Kashmer, MD MBA (@DavidKashmer, LinkedIn profile here.)


You’ve narrowed down the choices, you’ve gone on the interviews, and now you’re looking very seriously at offers from your top choices. It’s time to do something for which you have absolutely no training: negotiate your employment contract. If you’re like a lot of young doctors, you’ll just sign whatever contract the hospital administration puts in front of you. Maybe that will work out okay—and maybe it will turn into a disaster. With the information in this section, you can tilt the odds strongly against that horrible disaster.



When you see the salary on your employment contract, you might be tempted to just say yes and take the money. That’s the approach a lot of young doctors take, to their cost. That salary number should be just one part of the starting point for your negotiation.

Before you meet with the hospital administration to discuss your contract, think about your negotiating position. A good starting point is the BATNA. This is an acronym for Best Alternative to a Negotiated Agreement. The principles were developed by the Harvard Negotiation Project back in the 1970s. In 1981, they became the basis for a wildly popular book by Roger Fisher, William Ury, and Bruce Patton called Getting to Yes: Negotiating Agreement Without Giving In. I recommend reading it when you’re done with the content here.

BATNA nicely summarizes your ability to influence the outcome of a negotiation. You develop the alternatives to the deal in front of you based on what’s most important to you. Your strength in negotiation is directly related to your BATNA. The better the quality of your executable options, and the more you have, the better you can influence the negotiation.

Having a good BATNA makes you more apt to talk about alternatives with the other party to the negotiation.  And if you’re more willing talk about alternatives with the people in front of you, you’re more willing to push the structure of the deal and how it needs to look. As physicians, because we don’t know about business stuff, we tend to see negotiations with the hospital as an adversarial “us versus them” situation. I take, they give—that’s called positional negotiating.

You can dig your heels in and say “I need this,” but in reality, a better negotiating path is to understand what the interests are of the other side. That’s very different than the positional negotiating described above.

Their real interests may be different from what they’re articulating in the first contract they park in front of you. If what they really want is someone to come in and take on a large administrative component, yet they’re reimbursing based on clinical work and straight RVUs, you probably want to influence that so that they get what they really want rather than their standard contract. That can be challenging, but can be more worthwhile in that both you and the other side may be much more poised for success with an agreement that represents what you each actually want.

You need to educate them a bit even as you’re learning from them what their interests are. You’re trying to satisfy the interests behind what they initially ask for. It’s a different way of looking at it than “I win, you lose,” which I’ve found is more typical doctor’s way of looking at it.

Remember, on the other side of the negotiation, when it’s all done, you’re going to be working there. You need to make sure the relationship is reasonable and that relationship starts as you negotiate with the hospital or whatever team you’re joining. This is one good reason for going on a lot of interviews. The more alternatives you have, the better your position to compare the current offer. Too many interviews give you diminishing returns, but you want at least three or four high-quality alternatives to get a sense of where you want to be. It’s not always “more is better.” It’s important to develop meaningful alternatives—ones that you can actually execute if you need to.

The interview process itself is time-consuming because you’ve got to prepare for it and then go do it. The hospital pays for your transportation and hotel and sets it all up for you. You don’t usually have any significant out-of-pocket expenses, but your time has value. And sometimes you’re up against a deadline—you need to get some cash flow going. Sometimes the closer deadline is on the other end. The position needs to be filled before their current surgeon goes on maternity leave, for instance, or before the end of the budget year.

In negotiating, you need to have as much information as you can. You want to know more about them than they know about you. At the interview, you’ll probably be asked about your timeline. It seems like an innocuous question and usually comes with “When are you looking to make a move?” But in reality, giving up your timeline allows the other team in the negotiation to have a little more control. If you know the hospital wants to fill the job in two weeks, you have information about their timeline. You can leverage that because they have a deadline. They may be willing to come around a little bit faster than they otherwise would, so they may be willing to negotiate some other points to get you to sign on the dotted line and get the job filled. In general, my advice is to make it seem like you have all the time in the world and to use that to get a sense of what their timeline is.

In reality, young physicians are usually finishing their residencies or fellowships in July. Everybody knows that, so every interviewer knows your timeline. You could say to them, “Well, I have plenty of time. If I don’t find something, I’m going to take some time or work across the country as a locum surgeon, so I don’t need a position until August or September,” but in reality, most young people need a job by July and the hospitals know it. That’s why we have this cynical saying which I mentioned earlier: “In your first job, you’ll probably get your brain stolen.” You’ll be under-reimbursed because you need a job now. You’re more likely to take any serious offer without really negotiating.



As part of preparing for the contract negotiation, it’s helpful to prepare a list of five or six points that are really important to you. One of those points, however, should probably be a pawn—something you’re willing to sacrifice as part of making the deal. You’d like to have it, but you’d be willing to give it up.

As you give it up, you can use it to negotiate the points that are more important to you. For example, you might say, “Well, if I can’t have 20 weeks of vacation, then I need to have a different call schedule.” Twenty weeks of vacation is obviously a lot and you didn’t really expect them to agree to it, anyway, so it’s an easy sacrifice. This technique is called “log rolling” because you take one point and roll it into the other.  It also takes advantage of the reciprocity effect…


The above excerpt is from The Hidden Curriculum:  What They Don’t Teach You In Medical School.  For more information about contract negotiating techniques for physicians (page 53) look here.