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.

Have You Seen This Pessimist’s Guide To Benchmarking In Healthcare?

By:  DMKashmer MD MBA FACS (@DavidKashmer)

LinkedIn Profile here.


It sure sounds like a good idea to measure our healthcare processes against standards from other centers, right? It seems like pretty obvious logic that if we benchmark ourselves against how other organizations and professional societies want us to do (or how they perform) that we’ll be better off in the end. Doesn’t it sound straightforward that we should have an external benchmark that we compare to our processes?


Guess what? It’s not, and here’s why. You probably have a long way to go before you benchmark.


Thirty five healthcare quality projects in the last three years have reinforced this simple truism for me:  don’t benchmark at first. Why? There is usually a lot more you have to do before you look to some external agencies for a benchmark.  Here are some of the items that probably need doing before you scoop and apply an external measure to your system.


You Don’t Have A Clear, Usable Definition of What You’re Measuring


For example, your healthcare system probably lacks a clear operational definition of the metrics it wants to measure.  Will you use a definition for VAP (Ventilator Assisted Pneumonia) from the CDC or some other definition?  Does everyone who is performing data collection have the same definition?  Truth is, unfortunately, when you scratch the service…they probably don’t.


You Don’t Know The Voice of the Customer…Or Even Who The Customer Is (!)


You may not even know the voice of the customer (VOC) and key process indicators for your various systems.  Who exactly is receiving output from this system of yours?  And what do they (not you) want?  Get over yourself already and go find who is on the receiving end of your system and what they expect from the system.  You may even need to get out of the building to find out.  (Shudder!)

In other words, until you have a clear definition of what you’re measuring, a way to measure it, and a knowledge that it will significantly impact what you’re doing, you have a long way to go before you benchmark. Let me tell you more. One of the common areas we make with healthcare statistical process control and other quality projects is that we fumble at the one yard line. I mean that we don’t have a sense of a clear definition for what we are measuring or how we are going to measure it. How can we benchmark against an external measure before we even know what we are talking about? All too often, this is exactly what happens.


Consider this story of woe that owes itself to the problems we discussed above.


A Cautionary Tale:  VAPs in the ICU


Once upon a time there was an intensive care unit that wanted to benchmark its performance with ventilator associated pneumonia versus external organizations. (By the way, this is NOT the organization I work for!) It looked around and found typical rates of ventilator associated pneumonias as determined from other organizations. It seemed to make a lot of sense to do this. After all, they could bring their expected performance in line with other organizations. Of course, they wanted to have zero ventilator associated pneumonias as their real goal. What were the problems?


First, they had a non-standard definition of ventilator associated pneumonia. In fact, the operational definition they chose of VAP did not square with the definition of ventilator associated pneumonia from other centers. What did this cause? This caused all sorts of misguided quality interventions.  Alas, they didn’t discover this until a lot of work had been done.


For example, the team adopted a VAP bundle, which also makes a lot of sense. It then went on to perform no less than 12 other interventions in order to achieve quality improvement. Some of these decreased the VAP rate and some (many) did not.  The team spun its wheels and fatigue and staff churn quickly set in.


Another problem with external benchmarking? The team did not have the infrastructure to determine if they were doing significantly better or not. This is a common danger of benchmarking. The fact that the operational definitions did not align made the team add layer after layer of complexity and friction for dubious outcomes in quality. Worse yet, this wild goose chase caused an increase in worse outcomes owing to the variations that all of the ineffective changes caused in the system.  Because quality teams often lack sophistication to do statistical testing and to protect against tampering / type 1 errors, the wild goose chase in healthcare (sometimes from inappropriate benchmarking) really hurts!


I see this all the time and it’s very challenging to avoid in our current healthcare climate. For example, it is always hard to argue against doing more. Intuitively, who wouldn’t want to do more to make sure their patients were safe?  It’s an easy position to support, akin to “putting more cops on the street” promises from politicians.  Who could disagree!


However, it turns out, that when we make too many changes, or changes that do not result in significant improvement, we can unfortunately increase variation in our processes and obtain paradoxically worse outcomes. Processes can become cumbersome or resource intensive, whether that be in terms of manpower or other sources of friction. This is very difficult to guard against.


Learn from this instructional fairy tale: Align the operational definition you are working with, with your benchmark. Or better yet, don’t benchmark at first.


Important Thoughts on Benchmarking


So, if I’m telling you not to benchmark first, what is there to do? My recommendation is to follow the DMAIC process where there is a clear definition and those definitions are measured in rigorous statistical ways. This means having a team together that adopts a standard definition of the item that is being studied. I can’t say enough about that.


The operational definition for your particular item must align with the eventual item you want to benchmark. Typically in non-rigorous healthcare quality projects, this does not happen. Before you go on to accept the benchmark that you so badly want to look toward, make sure that this definition can be measured in adequate ways.


A measurement systems analysis and other measurement vagaries can really throw off your quality project. You can end up forever chasing your tail or the benchmark if your measurement system is not statistically rigorous or useful. Does the outside institution obtain the benchmark rate from retrospective cleaned data warehouses? Or did they obtain it prospectively right from the process? These are things you’ll have to wrestle with and it may make a difference in the benchmark you accept and what you think represents quality.


If the benchmark you are looking toward is a zero defect rate or some similar end point that’s one thing. However, typically we use benchmarks to get a sense of what a typical rate of performance is. As taught to me by experience and Lean and Six Sigma coursework: don’t benchmark until you have rigorously improved your process as much as possible. And when you do benchmark, I recommend that you have carefully aligned your operational definition, measurement system, and even the control phase of your project with this eventual benchmark.


Do you have thoughts on benchmarks? You probably feel, like I do, that used properly benchmarks can be very useful for quality projects…but when used carefully!  Have you ever seen a benchmark used inappropriately or one that caused all of the issues raised above? If you have, let me know, because I would love to discuss!

How You Measure The Surgical Checklist Determines What You Find

By:  DMKashmer MD MBA MBB FACS (@DavidKashmer)


Have you ever wondered how a measurement system affects your conclusions? There are several ways we’ve mentioned that the type of data you choose affects a great deal about your quality improvement project. In this entry, let’s talk more about how your setup for measuring a certain quality endpoint determines, in part, what you find…and more importantly, perhaps, how you respond.


The Type Of Data You Collect Affects What You Can Learn


Remember, previously, we discussed discrete versus continuous data. Discrete data, we mentioned, is data that is categorical, such as yes/no, go/stop, black/white, or red/yellow/green. This type of data has some advantages including that it can be rapid to collect. However, we also described that discrete data comes with several drawbacks.


First, discrete data often requires a much larger sample size to demonstrate significant change. Look here. Remember the simplified equation for discrete sample data size:




where p = the probability of some event, and delta is the smallest change you would like to be able to detect.


So, let’s pretend we wanted to detect a 10% (or greater) improvement in some feature of our program, which is currently performing at a rate of 40% of such-and-such. We would need sample size:  (0.40)(0.60)(2/0.10)^2, or 96 samples.


Continuous Data Require A Smaller Sample Size


Continuous data, by contrast, requires a much smaller sample size to show meaningful change. Look at the simplified continuous data sample size equation here:


(2 [standard deviation] / delta)^2


This is an important distinction between discrete and continuous data and, in part, can play a large role in what conclusions we draw from our quality improvement project.  Let’s investigate with an example.


A Cautionary Fairy Tale


Once upon a time there was a Department of Surgery that wanted to improve its usage of a surgical checklist. The team believed this would help keep patients safe in their surgical system. The team decided to use discrete data.


If a checklist was missing any element at all (and there were lots) it was called “not adequate”.  If it was complete from head to toe, 100%, then it would count as “adequate”. The team collected data on its current performance and found that only 40% of checklists were adequate . The teams target goal was 100%.


Using the discrete data formula, the team set up a sample that (at best) would allow them to detect only changes of 10% or larger. That was going to require a sample size of 96 per the simplified discrete data formula above.


The team made interesting changes to their system. For example, they made changes so that the surgeon would need to be present on check-in for the patient, and they made other changes to patient flow that they felt would result in improved checklist compliance.


Weeks later, the team recollected its data to discover how much things had improved. Experientially, the team saw many more checklists being utilized and there was significantly more participation. Much more of the checklist was being completed, per observations, each time.  The team felt that there was going to be significant improvement in the checklists and was excited to re-collect the data. Unfortunately, when the team used their numbers in statistical testing, there was no significant improvement in checklist utilization. Why was that?


This resulted because the team had utilized discrete data. Anything other than complete checklist utilization counted in the “not adequate” bin and so was counted against them. So, even if checklists were much more complete than they ever had been (and that seemed to be so), anything less than perfection would still count against the percentage of complete (“adequate”) checklists. Because they used discrete data in that way, they were unable to demonstrate significant improvement based on their numbers. They were disappointed and, more importantly, they had actually made great strides.


What options did the team have?  Why, they could have developed a continuous data endpoint on checklist completion.  How?  Look here.  This would have required a smaller sample size and may have shown meaningful improvement more easily.


A Take-Home Message


So remember:  discrete data can limit your ability to demonstrate meaningful change in several important ways. Continuous data, by contrast, can allow teams like the checklist team above to demonstrate significant improvement even if checklists are still not quite 100% complete. For your next quality improvement project, make sure you choose carefully whether you want discrete data endpoints or continuous data end points, and recognize how your choice can greatly impact your ability to draw meaningful conclusions as well as your chance of celebrating meaningful change.

5 Great Time-Saving Tools

By:  DMKashmer MD MBA MBB FACS (visit me on LinkedIn here.)


Have you ever looked at what you do everyday?  No, no–I mean really looked at it.  Not just the “here’s-what-I’m-doing-today” type of review.  I mean a data-driven, how-do-I-spend-my-time review.


It takes effort, and some focus, to keep a time journal or use some similar tool.  For me, it took more than a month to get something down on paper that was useful and really showed me how I use my time.


That month lead me to find several useful tools that help me use time not just more efficiently but more effectively.  Today, I want to share with you some of the most useful tools and tips that I hunted down in response to my month spent in review of how I squandered, wasted, or otherwise just plain mis-used my time.  Please learn from my hunt so you don’t need to find these yourself!


(1) Dropbox

Have you ever needed a password for a website that you haven’t used in awhile?  What about a birthday, login, or that article you read a year ago and really want to share right now?

You’ve probably heard of the cloud storage service Dropbox.  Yes, it has a great name, because it tells you exactly what it does.  On Mac, PC, iPhone, and other devices, you can easily upload and access your files right when you need them.

This allows you to setup some interesting workflows.  For example, did you know that you can share a dropbox folder with someone else?  So, imagine dictating something into your iPhone and uploading it to Dropbox where your colleague accesses it and transcribes it only to send it to you as an email later that day.

Dropbox is a great app to make data accessible across platforms, available in a timely fashion, and positioned to be useful to colleagues who help you out!

As with other useful apps that may contain data you don’t want shared, remember to enable two-step verification and other security measures whenever possible.  Otherwise, you may have an issue if your laptop ever gets stolen with Dropbox enabled…it happened to me just last year!



(2) Evernote

Yes, you can use Dropbox to create shared Word documents.  However, no application has the ease of use to create searchable, shared, multimedia notes like Evernote.  Your phone and computer can be a portal to notes shared among all the colleagues with whom you work.

Evernote has several great features, and one is that you can email anything directly to your account in the program.  Interestingly, you can even setup a folder to receive all of that data you send to Evernote.  You can then sort it later at your convenience.

These thoughts don’t even touch many of the great uses for this powerful platform.  If you decide that you ever want to really have a look in on Evernote, take a moment and read SJ Scott’s Master Evernote available on the Kindle platform.

As with Dropbox, allow me to recommend that you setup two-step verification.




Ok, now things get more interesting.  Have you heard of  Maybe not…I found this one when it came over from Japan.  I wondered why, nowadays, I always had to carry around a book I wanted to read.  I mean sure, there are Kindle books (and Nook too), yet I mean those platforms restricted my ability to share my books with anyone or to give them to others to read…just like I would with my books.

I thought there had to be a better way to have my books available, in a less restricted way, when I wanted them.  From a time management perspective, 1dollarscan has been incredibly useful.  For example, you can setup to send your books directly to 1dollarscan.  The service will scan your books (you won’t get them back) and even upload them into dropbox.

One move lets you have digital copies of all your books.  If you want to share your book with a friend, copy your book, or make a copy of a photo from your text…you can!  And if you read a lot, 1dollarscan makes all those books you’ve been meaning to read much more accessible than ever.



(4) GotoMyPc

I had a few unique time management problems:  first, I never seemed to have the file that I wanted on hand.  Second, I would start building something on my 3D printer and would have to walk away.  This left me to wonder whether the file I was printing ever finished or just what happened to it. solves these unique problems and many other more common issues.  First, special files, printer access, and other issues can be reviewed as you login to your computer remotely.  GotoMyPC allows me to virtually sit at the keyboard for whichever of my office computers I need.

Whether I need to check in on a 3D print, get a file I left at the office, or access an application that I only have on my work PC, GotoMyPC has been a great time-saver.

Pro tip:  If you’re in healthcare, watch out…don’t violate HIPAA with your particular use of GotoMyPC!



(5) Voice Recorder HD

This iPhone app is just plain great.  You can dictate with great clarity into your iPhone while driving, through a bluetooth headset, or via the speakerphone feature.  (Hey, I’m NOT recommending that you concentrate on dictating while driving.  Use your own judgement!)

What’s so great about being able to dictate into your phone?  The Voice Recorder app easily uploads files into Dropbox…

…and, of course, you can share the Dropbox folder with a colleague or anyone else you’d like.

Transcription services are available online via,, and many other independent contractor websites.  You can even find a transcriptionist who lives in another timezone, so it’s possible to have all your work transcribed while you sleep. The transcriptionist can download the file to transcribe and email it to you as a word document later in the day.  What a great way to blog, get office work done, or complete that next proforma for work.

It’s quick, effective, and is all because of stringing together these powerful, modern tools.  Remember, if you’re in healthcare, you probably want to use this transcription pathway for administrative work only where there’s no protected health information (PHI) involved.  After all, HIPAA constraints are important.


After a month of collecting data about just how many of my hours I wasted, it was time to find some new pathways to help me be more effective.  I hope you find the five tools above, along with suggestions about how to use them, useful for you in your everyday work flow.


Have some tools, tips, or workflow tricks that you use to work as efficiently and effectively as possible?  Let me know beneath!





Top 10 Tips For Writing Good English In Your Blog Posts

By:  David Kashmer MD MBA MBB FACS (@DavidKashmer)


Sometimes you read something so useful (and clever) that you just gotta share.  For those of who who post on LinkedIn or other social media outlets, this one’s for you.  I found these Martin Garnder’s 1975 book Gotcha:

Below is a list of ten rules compiled by Harold Evans,
editor of London’s Sunday Times:

  1. Don’t use no double negatives.
  2. Make each pronoun agree with their antecedent.
  3. When dangling, watch your participles.
  4. Don’t use commas, which aren’t necessary.
  5. Verbs has to agree with their subjects.
  6. About those sentence fragments.
  7. Try to not ever split infinitives.
  8. It is important to use apostrophe’s correctly.
  9. Always read what you have written to see you any words out.
  10. Correct spelling is esential.

Yes, it’s easy to see the English run amok in the sentences above.  Much more challenging to see them in our own writing!  (Ut-oh, there’s a number 6 in my very own sentence!)

Hope you find this magical top ten list to be a useful reminder of how to write good English in your professional posts on LinkedIn and beyond.

Warning: You May Be Asking The Wrong Questions About Quality

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


A recent blog entry by a colleague of mine (see it here) focuses on the importance of taking care of critically ill patients at difficult hours in challenging situations. This struck a real chord with me, as my focus is on how to construct healthcare services for high quality outcomes. Building a service for high quality means, in part, that service needs to perform similarly under often varying conditions. It needs to be both resilient and robust.  Why is it that many hospital services aren’t constructed to be able to perform at this level, as our colleague asked? What does it take to create a robust service that performs well twenty four hours each day rather than just during the easier times? This entry contends that how and which questions we ask about quality can set our systems up for erratic performance down the line.


It’s No Easy Task To Design For Quality


First, it’s important to realize that creating a service that performs at difficult hours is very challenging. My colleague’s entry gave me a reason to write up some tips and techniques to make the job easier.


One of the biggest keys is actually data collection. That is, first, the team must focus on its data rather its gut or how it feels things are. Remember, this is because most service industries perform at a rate of one defect in every thousand opportunities. My claim is that level of defect, well known to pervade service industries, is very challenging to feel on a day to day basis. Staff often think things are going great (or at least very well) because 999 times out of 1000 things do, in fact, go fairly well. It lulls one to sleep.  However, in high stakes fields like healthcare, we’ve demonstrated that a defect level of 1 in 1000 opportunities is completely unacceptable. For more on the reasons why, look here.


How Data Are Collected And When They Are Collected Is Key


Just as important as being willing to look at (and respond to) data is making sure that the data are being collected in a way that’s non-pejorative. One of the barriers in healthcare, as we’ve previously discussed (here and also here), is that we often equate data collection with an out-to-get-you mentality. (Maybe it’s related to tort law and malpractice issues–who knows.) It’s important that the data be collected regarding the team as a whole and not be personally assignable in any way. This key to the process improvement system creates a process that is non-pejorative, and lessens the chance that the process improvement system will be used as a weapon by one provider or staffer against another. It helps ensure that people will participate and be willing to collect, review, and respond to data.


Another important idea concerns collecting data from the entirety of the system. Often, when we see process improvement done, it’s focused on the hours from which it’s easy to get data. Those are the good ol’ nine to five hours. However, as my colleague points out here, trauma (for example) is “a disease of nights and weekends”. So, for high stakes, challenging services lines like trauma, it’s even more important to sample performance during nights, weekends, and other times from which it is generally more difficult to get data.  Those are often the key times!


It is important to realize how the answers we get to questions about quality are often framed by the nature of the data we collect. Let me say it again:  in healthcare, we need to collect data from those hard-to-get times because that’s when issues line up and the bad things have a higher risk of occurrence.  Remember the advice to collect data directly from the process whenever possible rather than sampling cleaned data from hospital databases–prospective data taken right from the action is often a lot more valuable.


Design In A Way To Respond To Surges In Volume


Next, for services like trauma, acute care surgery, and hospitalist medicine, one of the important concepts is surge capacity. How well does the system absorb large influxes of patients? Sometimes patients come in as multiple trauma activations at once. Three to four patients (or more) may show up at one time followed by long stretches in between of one patient arrival at time. Therefore, the ability to flex up to provide the same level of care when three or four patients come in together is every bit as key as performing well when one patient at a time enters the system. The capacity to be resilient and robust must be consciously designed into the system.  Usually a failure mode effects analysis (more on that FMEA technique here) will reveal how focus should be placed directly on events such as multiple trauma activations.


The Questions We Ask Determine The Systems We Build


So, at the end of the day, my colleague’s question about why things aren’t designed in healthcare to run consistently over 24 hours is based, in large part, on the nature of the questions we pose to our systems. The questions we ask with data, and how we ask them, leads us to design systems that are more apt to work well from 9AM to 5PM.  The first of these counts is we often don’t collect data or respond to it for fear of personal reprisals. Second, if we do collect data, we often don’t collect the data to completely embody the robustness of the system. A third major challenge is that our data often don’t reflect the surge capacity in these high stakes situations where multiple patients may enter the system at once. Concentrating on each of these important ideas allows us to create a high quality, robust system that has a better chance of humming along consistently for 24 hours a day.


Knowing Obligates Us To Act


Once we know these important facts, if we are serious about quality and robustness in our system, we become obligated to progressively improve our care during those times when weaknesses in our system line up–especially nights and weekends.  We’ve learned to avoid framing certain questions about quality in the wrong way.  When we collect data from the full house of the system, we become obligated to respond to it, as a team, in a meaningful way for the good of our patients.