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JC Physician blog – News for M.D.s from M.D.s at The Joint Commission

Written by and for physicians, the biweekly JC Physician blog discusses health care issues of interest to doctors as well as other topics that may touch on ethics, the environment and current affairs.

NOTE: Physician are encouraged to submit guest blogs for the JC Physician blog. Those interested should contact Social Media Specialist Sean Ostruszka.


Inspiring Change

Nov 12, 2014 | Comments (0) | 1309 Views

edupree4-14By Erin DuPree, M.D., FACOG
Chief Medical Officer and Vice President
The Joint Commission Center for Transforming Healthcare

“People change what they do less because they are given analysis that shifts their thinking, than because they are shown a truth that influences their feelings.”
– John Kotter, The Heart of Change

The health care industry is changing rapidly. With that change comes ever-increasing challenges: payment changes, government mandates, public reporting, technology costs, and informing and engaging patients. The impact to physicians is enormous. Even though physicians find great pride and satisfaction in caring for people, burnout is a real concern.

That got me thinking about how physicians can LEAD change instead of being the recipients of change.

The delivery of health care requires skills that no one learns in medical school: finance, accounting, team building, regulations, information technology, operations, quality improvement – all requiring new knowledge and skills. 

After all, we lead patients through changes every day.  In my OB-GYN practice, I led patients through the various stages of preventing a pregnancy, planning for a pregnancy, the actual pregnancy, and the inevitable changes after the new baby arrived.

Yet, as physician leaders, we are usually reacting to change -- the latest regulation, the flavor of the month from the CEO, or a new nursing leader in a key service line. 

As Kotter’s quote indicates, change requires touching people – their feelings and their hearts. In order to lead change we have to get in touch with our own hearts and invite others to do the same. This was basically the LAST thing I was taught in medical school! Avoiding emotions and learning the nuts and bolts of complex diseases was all that mattered. 

As physician leaders, leading change requires inspiring those around us. One of the best ways to do that is to make it personal -- tell a story, look for the resisters and listen to their concerns. Paint a vision of the future. We do this every day when we care for patients. We listen and we tell stories. We know what health and successful treatment looks like. We can lead patients in dealing with the unexpected changes because, usually, we have seen it hundreds, if not thousands, of times before. We can share the vision of success with them. If we can lead change with our patients, we can lead change in the hospitals, offices and systems in which we work. 

As I went through the fourth (or was it the fifth?) round of electronic medical record (EMR) implementations, I shared stories with those around me of my frustrations with the implementation that impacted my patients and my practice, yet ultimately was successful. The stories resonated and inspired those around me; it gave them the confidence that they, too, could get through the massive changes associated with an EMR implementation.

It’s time to get in touch with your heart, your stories, and inspire those around you: being a physician leader is as much about being a human being as it is about being a doctor. This is how to lead change.

Envisioning a safety culture - The perspective of one psychiatric hospital

Oct 29, 2014 | Comments (0) | 1520 Views

Anne_BauerBy Anne C. Bauer, M.D.
Field Director, Accreditation and Certification Operations

To me, it’s one of the most moving and inspiring, parts of surveying an accredited psychiatric hospital.

As the last day rolls around and the leadership session begins invariably the subject of high reliability in health care comes up. That topic usually spawns talk of how staff and leadership envision a safety culture at their facility. As a surveyor and field director, I have had the privilege to witness many of these conversations, and they rarely fail to move me.

During this time, staff are usually incredibly honest about having more to achieve, but, of course, they are eager to share what they are doing consistent with their particular vision of a safe health care environment.

At a recent leadership session, several board members attended, and they started the conversation by sharing their visions of a board which is very active in establishing and maintaining a safety culture at their psychiatric hospital. One board member joked about having seen more types of toilet paper holders than he could imagine as they searched for the one that presented the least risk to the patients. Another board member described his pride that their board had been through the building many, many times and knew the facility inside and out. Involving front-line staff in changes to the physical environment is often cited, as it was in this session, when the example of installing a door alarm to decrease elopement of patients was discussed. The first proposed location for the alarm was ruled out by the staff because they wouldn’t be able to hear it. So the plan went back to the drawing board.

A psychologist from the Partial Hospital Program also talked about his vision of a safety culture where they would implement a best practice for following up with patients during the high-risk period after discharge from their program.

Staff from human resources often talk, as they did during this session, of changes in the new hires. In addition to credentials, they look for people with a passion about safety and quality of care, and who seek a stimulating “learning environment” in which to work.

Safety culture, as they see it, is a place where everyone has something to learn, from the doctors to the housekeeping staff.

This particular hospital emphasized that they saw the “recovery culture” in behavioral health care as consistent with high-reliability health care and safety culture because it emphasizes viewing treatment from the patient’s perspective.

“The patients will teach us,” they told us. “The old thinking was program-centric. Now we are person-centric.”

As I said, it’s quotes like these that always make for the best endings of surveys.

The Tragedy of Physician Suicide

Oct 08, 2014 | Comments (0) | 1994 Views

By Paul Ziaya, M.D.
Field Director
The Joint Commission

It was an alarming read, to say the least.

In early September, an op-ed by Dr. Pranay Sinha, titled “Why Do Doctors Commit Suicide?,” appeared in The New York Times. The author spoke to the tragedy that is suicide, specifically about new physicians as they negotiate the difficulties of residency education. The statistics alone were worth the read – nearly 10 percent of fourth-year medical students and first-year residents reported having suicidal thoughts in the prior two weeks.

Residency is a very stressful time. We all remember that.

So despite the nationally implemented reduction in weekly hours for residents and programs implemented to assist with coping, suicide remains a risk. For physicians in general, there may be as many as 400 completed physician suicides each year in the United States. This is a worldwide issue and, as Dr. Louise Andrew noted in her Medscape article, “Physician Suicide,” “Depression is at least as common in the medical profession as in the general population, affecting an estimated 12 percent of males and 18 percent of females. Depression is even more common in medical students and residents, with 15-30 percent of them screening positive for depressive symptoms.”

The factors that may lead to suicide are many and, perhaps related to physician knowledge of and access to medications, physicians have a higher rate of completing an attempted suicide than in the general population.

Depression is difficult enough to recognize in others, but even when physicians recognize depressive symptoms in themselves, the majority fail to seek help; why is a complicated question. Perhaps it’s due to concerns about the potential effect on their careers or the sense that they are supposed to be the healers, not those needing healing.

Joint Commission standard MS.11.01.01 is specifically written to encourage medical staffs to identify and manage matters of individual health in ourselves and our colleagues. Separate from actions taken for disciplinary purposes, it focuses on education of physicians to recognize issues in others and also encourages self-referral in an effort to result in confidential diagnosis, treatment and rehabilitation to “retain and to regain optimal professional functioning that is consistent with protection of patients.”

Physicians, despite all their knowledge, are like everyone else in their risk for depression and suicide. Yet they have trouble getting effective treatment. While resources exist to help, we must continue to remove the stigma and other barriers associated with getting the needed assistance. That perceived stigma is thought of as a dangerous thing to a career or a physician, but we all must remember it pales in comparison to the depression itself.

Yes, The New York Times piece was alarming. Hopefully it’s an alarming reminder that despite efforts over more than a decade to recognize and improve the factors that may affect the rate of suicide in physicians, there still remains much to be done, and we as medical staff leaders and colleagues have an important role to play.

Doing No Harm

Sep 10, 2014 | Comments (1) | 1999 Views

By Paul M. Schyve, M.D.
Senior Advisor
The Joint Commission

Paul M. Schyve, M.D.Primum non nocere – Not many of us remember Latin phrases, but all physicians recognize this one: First, do no harm.

That motto has been one of the principal ethical obligations of physicians ever since it was declared by Hippocrates, the father of Western medicine. Of course, over the years we have clarified its meaning in light of modern medicine. The pain associated with surgery and physical therapy, the unavoidable side effects of pharmaceutical agents, and the unpredictable adverse events in health care have led us to say “first, do no preventable harm,” to discuss with our patients the potential risks and side effects of treatment, and to disclose to our patients unanticipated outcomes of care.

But despite these modifications, the basic ethical obligation stands: First, do no harm. For many years, physicians were taught – and believe – that meeting this obligation was focused on our own individual patients, that is, in our patient-by-patient relationships. In order to do no harm to each of our own patients, we needed to be competent in our cognitive and motor skills, and committed to our professional obligations to our patients. We assumed that competence and commitment were sufficient to avoid harm. Nevertheless, as much as we strive to be competent and committed, bad things still happen to our patients.

During the past 15 years, as we at The Joint Commission have studied adverse events, we have recognized that many more preventable adverse events occur than we had thought. It has become clear that most adverse events have not occurred because an individual physician (or nurse, or pharmacist) has insufficient competence or commitment, but because of failures in teamwork and in the systems and processes within which we work. Even when the adverse event resulted from an individual’s error, we have learned that an improvement in teamwork or a redesign of the system or process would have helped prevent the error from reoccurring – it can protect the individual from the “normal, inevitable” human errors that we all make.

All of that means if physicians want to fulfill their ethical obligations to their patients to do no harm, they must invest not only in their own professional competence and commitment, but also in the function of their clinical teams and in the design and operation of the systems and processes in which the teams operate. This investment requires more than the participation in the peer review contemplated by the Joint Commission Medical Staff hospital standards for the credentialing and privileging processes – a peer review that traditionally focused on the individual physician’s competence and commitment. This investment also requires participation in, and often leadership of, quality and safety improvement programs and processes, as contemplated by the Joint Commission Medical Staff and Leadership hospital standards.

Physicians’ ethical obligation to do no harm has not changed over the centuries, but the methods to fulfill this obligation have changed in recent years.  While physicians’ investment in teamwork and in system and process improvement adds to their work, it is a critical and necessary contribution to success in meeting their ethical obligation. As health care adapts, primum non nocere is still a strong thing to remember

Teach a Patient to Fish - Part 1 of a series on patient engagement

Sep 03, 2014 | Comments (0) | 2167 Views

Ronald Wyatt, Medical Director, The Joint CommissionRonald M. Wyatt, M.D., M.H.A.
Medical Director
The Joint Commission

There’s a famous saying about the difference between giving a man a fish and teaching him to fish. I’m going to adapt it.

Ask a patient a question, you get a conversation. Teach a patient to get involved in his health care, you get a partnership.

Partnerships, be it patients and health care professionals or policymakers and government agencies, are essential. Even Avedis Donabedian – the originator of the measurement triad of structure, process and outcomes for evaluating clinical quality – proposed a patient-centric definition in 1966 in which the patient’s involvement “is the ultimate validator of the quality of care.”

There is growing awareness that to achieve the best outcomes, patients and families must be more actively engaged in decisions about their health care. Patient engagement is a precursor to patient activation and a necessary first step to maximizing a patient’s role in their health care.

A patient’s level of activation is inextricably intertwined with patient safety. Activated patients are more likely to avoid medical errors and unnecessary hospital readmissions. In its report entitled “Beyond 50.09 Chronic Care: A Call to Action for Health Reform”, American Association of Retired Persons noted that lower patient engagement is significantly associated with experiencing a medical error and more problems in the health care system, which suggests that health care organizations need to assess and enhance a patient’s level of activation. Less activated patients suffer poorer health outcomes, a higher medical error rate, are less likely to look out for themselves and are less likely to follow their provider’s advice than the most activated patients. The report found that patients’ involvement in their health care is likely to reduce errors, adverse events and nonadherence to treatment.

So, knowing the importance of teaching patients to get involved brings up the next question: How do we do it?

You’ll find the answer in Part 2 of this series, where we will discuss the roles of leadership and staff in this process. And Part 3 will delve deeper into additional, targeted approaches to increasing patient engagement and activation.







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