Tsana Associates: NHS

Knee jerk problem solving and conflicting inter-departmental targets

Wed, 27 Feb 2008 12:43:19 GMT

Where? The NHS.
Who? The British Government.
Why? Incompetence.
Dr John says what he thinks about it... Sarah is 55.
She works in security at Birmingham Airport. If a female causes a 'beep' as she goes through, Sarah does the body check. She has been working at the airport for 18 years. Before that, she worked for W.H. Smiths. In her late thirties she had the best part of a year off work when she went into renal failure during her second pregnancy. She recovered but with compromised renal function and hypertension. I have been seeing her regularly for years. She is intelligent, conscientious and she does not take time off work with coughs and colds. Sadly, over the last two years, her kidneys have packed up and she is on peritoneal dialysis (PD). To complicate matters further she has developed diabetes. During the three months when she was approaching PD she felt wretched and had long periods of work. As soon as the PD started she picked up dramatically.

Her employers at the airport treated her fairly. They offered her early retirement on medical grounds with an augmented pension. She had no idea if she would ever be able to work again, and so she took it. She is a single mother. Her ex-husband departed many years ago, and she has brought up two boys single handedly. They are both now at University. Sarah is proud of them. They have their student loans but she tries to help them financially as often as she can, which is not as often as she would like.

Sarah cannot manage on her pension. She was not a high earner and even with the augmentation, the pension it is not enough. She needs to work. Also, she wants to work. She signed on, and has been actively "jobseeking". She has been for numerous interviews but, as soon as she talks about dialysis, she can see the employer's faces fall. She has become dispirited. She is not used to being unemployed. She came to see me yesterday. She has just had another interview with the Jobseeker Commissar. She had previously told them she had been off work with 'kidney problems' but had not gone into details. Yesterday, she did. The commissar's reaction was immediate.

"Go and see your doctor and tell him (tell him, note) to sign you off work so that you can get invalidity benefit."

Naturally, I refused. I do not need directions from Alan Johnson. I know what my job is. I have no time for the work-shy. Sarah needs to be taught a lesson, so this is what I said to her:

"It's idle benefit scrounging scum like you who are bringing this country to its knees. Why should the taxpayer featherbed idle malingerers like you? Stop whinging and get behind a till at Tesco. Do something with your life, you indolent sod. People like you make me sick."

Oddly, that is not true. I signed her off work for six months, and I shall keep her signed off until she gets her transplant or reaches retirement age.

This is a classic example of government hypocrisy. GPs are being blamed by Alan Johnson and the DOH for the high number of people drawing invalidly benefit but at the same time another branch of government is pressurising the unemployed, and their doctors, to get people onto invalidity benefit. It makes the unemployment figures look better.

GPs will not act as government police officers. We act for our patients not for the government. I will not deliberately issue a fraudulent certificate, but I will always give the benefit of the doubt to my patient. And 'Renal failure, peritoneal dialysis & diabetes' in a 55 year old is unchallengeable on a certificate. Sarah will not be called for an independent medical. Sarah is ready, willing and able to work 'with limitations.' Who does get called for medicals? Often it is those with chronic mental illness which the inexperienced doctors who work for the benefits agencies do not have the skills or often the understanding of English to assess properly. It is so much easier to take benefits off a schizophrenic.

Soon, of course, GPs will be gone. Patients such as Sarah will see some callous, protocol driven quacktitioner at the polyclinic who knows nothing of their previous life and will not hesitate to offer a "wellness" certificate. There will be a financial bonus for quacktitioners who hit government defined wellness certificate targets.

I want no part of this health policing. By Dr John Crippen. [NHS Blog Doctor]

Scandal of patients left for hours outside A&E

Wed, 27 Feb 2008 08:46:42 GMT

Hospitals were last night accused of keeping thousands of seriously ill patients in ambulance 'holding patterns' outside accident and emergency units to meet a government pledge that all patients are treated within four hours of admission. Those affected by 'patient stacking' include people with broken limbs or those suffering fits or breathing problems. An Observer investigation has also found that some wait for up to five hours in ambulances because A&E units have refused to admit them until they can guarantee to treat them within the time limit. Apart from the danger posed to patients, the detaining of ambulances means vehicles and trained crew are not available to answer new 999 calls because they are being kept on hospital sites.

Tue, 22 Jan 2008 08:14:02 GMT

Clegg to outline vision for NHS - BBC News.

BBC News

Clegg to outline vision for NHS
BBC News, UK - 2 hours ago
Liberal Democrat leader Nick Clegg is due to outline his ideas for the NHS, which are expected to focus on a "care guarantee" for the elderly. ...
Lib Dems' free care for elderly vow The Press Association
Reforming the Lib Dems Spectator.co.uk (subscription)
Clegg attacks health 'inequality' BBC News
all 6 news articles

[nhs - Google News]

Mon, 21 Jan 2008 07:27:29 GMT

Steam-clean machine maker wins NHS deal - Financial Times.

Steam-clean machine maker wins NHS deal
Financial Times, UK - 5 hours ago
By David Blackwell An Aim-listed company has won the right to supply steam cleaning equipment throughout the NHS to combat superbugs such as MRSA and ...
PRESS DIGEST - FINANCIAL TIMES - JAN 21 =8 Reuters
all 2 news articles

[nhs - Google News]

One-person ambulance plan 'could risk lives'

Tue, 11 Dec 2007 10:39:31 GMT

Plans to answer more emergency calls with one-person ambulance crews could put patients' lives at risk, according to critics. However the Government today defended the plans, saying that it would free up resources for other calls. Health Minister Ben Bradshaw said that sending a 'single responder' rather than a double-crewed ambulance would mean a quicker response time. He said: "Fast-response vehicles can often get to the scene faster than traditional ambulances and can provide assessment and care until a further response arrives." His comments came after reports that all but one of the ambulance trusts in England have submitted plans for greater use of 'solo responders' to help meet new response time targets. By Gary Cleland Last Updated: 9:30am GMT 11/12/2007

Thu, 06 Dec 2007 08:00:12 GMT

NHS staff strike in support of 'whistleblower' - Guardian Unlimited.

Daily Mail

NHS staff strike in support of 'whistleblower'
Guardian Unlimited, UK - 19 hours ago
Thousands of NHS staff are expected to take part in protests today in support of a nurse who was sacked after speaking out against privatisation of services ...
Doctors support sacked nurse Manchester Evening News
Health staff protest at âo[breve]unjustâo[dot accent] sacking of nurse Healthcare Republic (press release)
Strikes feared over sacked nurse Channel 4 News
all 8 news articles

[nhs - Google News]

Tue, 04 Dec 2007 08:13:46 GMT

Advisers hit out on NHS cash - Financial Times.

Advisers hit out on NHS cash
Financial Times, UK - 3 hours ago
The advice of a high-powered board of business people set up to counsel the government on working with the private sector was systematically ignored by ministers and civil servants, according to a letter seen by the Financial Times. The commercial advisory board - whose members included investment bankers, lawyers and a former regulator - quit in September, declaring it was "wasting its time" as the government moved to scrap much of the second wave of independent sector treatment centres (ISTCs) on which it was, in part, advising. ...

[nhs - Google News]

Fri, 30 Nov 2007 07:41:01 GMT

The Need for Clean Hospitals. Our Unsanitary Hospitals - WSJ.com

That's "Clean", not a typo of "Lean." Good column in the WSJ today by Betsy McCaughey, head of the Committee to Reduce Infection Deaths organization (link).

She asks why restaurants and meat packing plants get inspected more than our nation's operating rooms.

"Restaurants in New York are inspected, without prior notice, once a year. In Los Angeles, inspections are done three times a year, and restaurants must display their grade near the front door. After L.A. instituted this inspection system in 1998, the number of people sickened by food-borne illnesses fell 13%, according to the Journal of Environmental Health. Other cities are now following L.A.'s lead.

Why aren't hospitals held to the same rigorous standard? The consequences of inadequate hygiene are far deadlier in hospitals than in restaurants. The Centers for Disease Control and Prevention estimate that 2,500 people die each year after picking up a food-borne illness in a restaurant or prepared food store. Forty times that number -- 100,000 people -- die each year, according to the CDC, from infections contracted in health-care facilities."

What leads to infections? Some of it is a classic Lean "standardized work" issue:

These infections are caused largely by unclean hands, inadequately cleaned equipment and contaminated clothing that allow bacteria to spread from patient to patient. In a study released in April, Boston University researchers examining 49 operating rooms at four New England hospitals found that more than half the objects that should have been disinfected were overlooked by cleaners.

Why is this? Lack of training? Lack of clear standardized work? Lack of time to do their job properly?

She then writes:

"Hospitals used to routinely test surfaces for bacteria, but in 1970 the CDC and the American Hospital Association advised them to stop, saying testing was unnecessary. The CDC still adheres to that position despite a 32-fold increase in MRSA infections. CDC officials say that lab capacity should be reserved for tests on patients.

Testing surfaces is so simple and inexpensive that it's used routinely in the food industry. Is it more important to test for bacteria in meat processing plants than in operating rooms?"

If we have lab capacity issues (that testing is done in a hospital lab), there is another opportunity for Lean, to improve flow and to free up capacity. The healthcare industry has smart people and the tools to fix all of these problems, we just need the leadership and the attention to be paid to these issues. The public needs to start standing up and demanding better.

It's not just hospitals, either, it's doctor's offices, which get no inspection at all. McCaughey tells a story of a physician who was REUSING NEEDLES (yes, you read that right) with patients. Who in their right mind does that?

The New York State Department of Health called Dr. Finkelstein's reuse of syringes
a "correctable error," and is allowing him to continue to practice under observation.

I know I often write about not blaming people, but this is not an "error," it's a "violation," which involves choices that doctor is knowingly making. How can he not be held more accountable? The state "regulators" knew, in 2005, the doctor was doing this, but they wouldn't suspend his license. Yeah, the state sure is looking out for you in New York. (another article) It's mindboggling that we'll fire and punish people who make an inadvertant error, but we'll look the other way when a doctor is purposefully and intentionally doing something unsafe. They're having to test patients of his for Hep C and HIV because of his stupidity. Ok, enough of that tangent.

Anyway, the WSJ piece is a good article if you have access to check it out. Rupert Murdoch is most likely going to make the WSJ a free ad supported website in the future, rather than relying on paid subscriptions.

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[Lean Blog]

More than 90,000 patients die and almost one million are harmed each year because of hospital blunders

Fri, 30 Nov 2007 07:39:40 GMT

"Errors during surgery, misdiagnosis, falls, infections and complications are all to blame for the problems that contribute to the death and injury tolls in England each year. Surgeons performing an operation, hospital blunders 'kill 90,000 patients' Researchers found that between 8.7 per cent and 10 per cent of hospital stays involved such mistakes and up to a half were preventable". So the other half are just a fact of life??

Fears over NHS patients' records

Fri, 30 Nov 2007 07:35:39 GMT

Patients' confidential medical records are regularly being accessed by people who have no right to them, research by the BBC has revealed. Figures obtained under the Freedom of Information Act reveal that in the last year there have been several data security breaches.

Fri, 30 Nov 2007 07:30:34 GMT

NHS 'treats patients as illness'. A health watchdog says some NHS trusts in Wales treat patients as 'an illness not as a human being'. [BBC News | UK | UK Edition]

Thu, 22 Nov 2007 07:38:51 GMT

NHS on course for large surplus. A clampdown on spending within the NHS turns a massive deficit into an even bigger surplus in two years. [BBC News | UK | UK Edition]

NHS 'deep clean' announced

Thu, 22 Nov 2007 07:36:22 GMT

Health Secretary Alan Johnson has announced that all NHS hospitals in England are to undergo a deep clean. The Health Secretary told the House of Commons that âo[base "] as part of a range of measures to tackle healthcare associated infections âo[base "] NHS Trusts will have to submit detailed deep clean plans, including costs, to their Primary Care Trusts and Strategic Health Authorities (SHAs). From Legal & Medical - The online magazine for the medico-legal profession

Wed, 21 Nov 2007 11:14:25 GMT

NHS database 'could be targeted'. The man in charge of setting up the NHS IT system says "you cannot stop the wicked doing wicked things". [BBC News | News Front Page | UK Edition]

Thu, 08 Nov 2007 09:36:37 GMT

Some doctors 'fail to wash hands'. Patients are urged to challenge hygiene standards as some doctors are criticised for not washing their hands during hospital rounds. [BBC News | UK | UK Edition]

Thu, 08 Nov 2007 09:27:58 GMT

Hospital Safety, Quality and Advertising. I was wondering the other day about hospital advertising that you might see in your community (TV ads, billboards, newspaper ads). With the focus on improving quality and patient safety, is there a hospital somewhere that is advertising itself as a "safer" or "better quality" option? I don't mean advertising that their doctors are highly skilled or "the best." That's different than the quality provided through hospitals processes and systems, the operational aspect as opposed to the clinical/medical aspect.

There are hospitals that advertise their efficiency differences (zero waiting or short waits for emergency room treatment). Product companies, including automakers, are often touting quality (Toyota or new GM ads) or safety (Volvo) in their advertisements.

Has anyone seen a hospital using quality or safety performance as a way of attracting patients? Click comments if you have an example to share. Would hospitals accept this? Is it risky to admit that quality hasn't been perfect all along? Would hospitals find it distasteful to point out that competing hospitals in the community are less safe? I'm curious to see what happens are more quality metrics are made public, through voluntary efforts or government requirements.

I just got a postcard ad in the mail today from a hospital that touted they are:

"leading" (based on what??)
"board-certified physicians" (that seems like a good starting point)
"acclaimed" (by who?) and "recognized" (another fairly empty word)
"providing exceptional care"

I realized it is just a postcard, but there wasn't anything really specific there. I suspect, again, that they are referring to the quality of their physicians as opposed to the quality of their processes.

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[Lean Blog]

Thu, 08 Nov 2007 08:38:55 GMT

NHS superbug figures 'offer hope'. Hospitals in England may be beginning to win the battle against infections, latest figures suggest. [BBC News | News Front Page | UK Edition]

Hospital bug deaths 'scandalous'

Fri, 12 Oct 2007 07:47:25 GMT

The deaths of 90 hospital patients from clostridium difficile are "scandalous", Health Secretary Alan Johnson has said. Kent police have launched an investigation into whether the Maidstone and Tunbridge Wells NHS Trust should be prosecuted for the deaths. The Healthcare Commission said a "litany" of errors in infection control had caused the "avoidable tragedy". The trust said it had not been prepared for "an outbreak of that size and complexity" but had learned lessons. The commission's report said nurses at the trust were too rushed to wash hands and left patients to lie in their own excrement. For many of these patients there may well have been a good chance that they would have recovered if all steps had been taken Mr Johnson said he was shocked by the findings, but denied accusations the problems were caused by staff being put under pressures to meet government A and E targets. Heather Wood Report author

Fri, 12 Oct 2007 07:31:18 GMT

Carly is Mad

Carly Kerson is Mad. She is a bipolar schizophrenic paranoid delusional... look - she's MAD.

As Inspector Gadget will tell you, it is the police's job to look after Carly. It is our job to ferry her to and from mental institutes, to stand at the doors of said institutes to bounce her back in when she escapes. To scour the streets and rivers for her when we don't get to the doors in time. To bind her arms and legs and watch her constantly for twelve hours in the cells when she has one of her "episodes".

In fact, we police need to buck up our ideas. Do you know that there are custody sergeants up and down the country who refuse to have Carly in the cells? Who actually seem to think that being MAD is not a crime! Who suggest that if she is undergoing treatment in a psychiatric unit for people who are dangerous to themselves or others, that unit should take some responsibility for her welfare.

The police have powers to detain someone who is mentally ill, for their own or others' safety, and take them somewhere to be mentally assessed. In practice, the process works as follows:

PC Bloggs identifies Carly Kerson eating toilet paper at the side of the road.
PC Bloggs removes Carly to hospital.
It's the wrong hospital. Not in the right postcode, you see. PC Bloggs takes her to the next hospital.
This hospital only treats juveniles. And anyway the first hospital is always trying to spam their loonies off on the second one and they have Had Enough. PC Bloggs takes Carly back to the first hospital and refuses to leave.
PC Bloggs must remain with the lunatic. There are only mental health nurses, padded cells and syringes of sedatives available, none of which hold a candle to a poorly-trained, tired and narky policewoman as a method of restraint.
Seven hours later, Carly is sectioned.
Twenty-eight days later, she has been miraculously cured and is released.
Twenty-nine days later, PC Bloggs identifies Carly Kerson eating toilet paper at the side of the road.

And that's if the hospital bother to shut or lock the doors for the twenty-eight days Carly is there.

Carly Kerson is an intelligent woman. She has A-levels. She has a family that once loved her but now have no idea what to do with her. Carly is also extremely ill and maybe always will be. She deserves more than the police holding her arms and legs to the tarmac until she is screaming and terrified. She deserves more than a one-bedroom flat in a block of other ill people, with a "carer" whose job it isn't to put milk in the fridge, and who just calls the police if Carly isn't in when he arrives.

God help the people who are merely depressed. Who aren't violent or manic or seen wandering the streets dressed in a bath-robe.

Not even the police are there for them.

---------------------------------------------------------
Copyright of PC Bloggs.

- PC Bloggs [PC Bloggs - a Twenty-first Century Police Officer]

UK may get clean hospital lessons from French

Fri, 12 Oct 2007 07:11:26 GMT

Britain could be told to learn basic hospital hygiene lessons from France and Slovenia as the European Union joins the battle against superbugs. Proposals for EU hospital cleanliness standards to reverse the rise of drug-resistant superbugs, including MRSA, are expected next year. Britain has one of the worst records in Europe on potentially deadly hospital-acquired infections. The plans to clean up British and other European hospital wards will be modelled on France and Slovenia, both of which have managed to reduce incidence of, and deaths from, superbugs.

Tue, 02 Oct 2007 08:13:02 GMT

NHS is 17th in Europe-wide poll of patients - Telegraph.co.uk.

BBC News

NHS is 17th in Europe-wide poll of patients
Telegraph.co.uk, United Kingdom - 4 hours ago
The survey will be hugely embarrassing to Gordon Brown, who has made the NHS and education his top two priorities. The Euro Health Consumer Index, ...
Tories 'party of NHS' - Lansley BBC News
Tories aim to be 'party of the NHS' Channel 4 News
UK falls further down European health league Guardian Unlimited
This is London
all 9 news articles

[nhs - Google News]

Tue, 02 Oct 2007 08:03:54 GMT

Waste in Philly Pharmacies. Phila. health agency in disarray | Philadelphia Inquirer | 09/26/2007

I saw this in the news as I was leaving Philly earlier this week. Would you run your manufacturing warehouse like this? Dell keeps better track of computer parts than these pharmacies track medications, sadly.

"The Philadelphia Health Department does not keep track of prescription-drug deliveries, fails to remove expired medication from the shelves of its pharmacies, and can't account for more than 2,000 pieces of equipment, the city controller said yesterday."

Just a basic lack of processes and controls:

"...the department does no accounting of its $7.6 million in prescription-drug orders each year. It has no way of knowing whether drugs are delivered as ordered, whether the correct price was charged, or whether supplies have been depleted by theft."

Reading on:

The audit also found six expired bottles of prescription medicine in one health center. Domzalski called that a "dangerous" practice that would end.
Butkovitz noted that city pharmacists, who fill three times the number of prescriptions of their commercial peers, were often too busy to properly keep track of their stocks. Domzalski said that before July, when salaries were raised, city pharmacists were paid about half what their private-sector counterparts earn.

I'm tired of the "too busy" excuse. It's not a good excuse, particularly in healthcare. If tasks are important, we MUST make time to do those tasks. We have to eliminate waste to free up time and we need a Standardized Work system to make sure key tasks get done. No more excuses.

And we can't just blame the pharmacists. Lean isn't about making people work harder. If they're already 3x more productive than commercial peers, they're probably already working hard. But, I bet there's still waste in their process that can be reduced, freeing up time to more carefully keep track of expired meds.

Next week, I'm attending a pharmacy supply chain expo, will be interesting to hear more about current issues in that area. I've seen quite a few hospital pharmacies and there are some fairly systemic process design issues -- pharmacies tend to be like other pharmacies (although not all of them have waste to the same extent as those mentioned in the article here).

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[Lean Blog]

Tue, 02 Oct 2007 08:02:42 GMT

Hospitals Learning from Hospitals. Oshkosh Northwestern - Systems turn to ThedaCare

There's a great sense of community and sharing in the hospital space -- something the manufacturing world can learn from, I think. Sure, it's possible to spend your whole career working in a single hospital and never seeing other ways of doing things, but hospitals have a few built-in mechanisms to help with sharing and spreading of ideas:

A history of peer inspections (through certification organizations)
Labor mobility (people jumping from institution to institution)

Can hospitals do more to share best practices and good ideas? Of course. There's such an opportunity for the manufacturing world to do the same thing, especially in non-competing cases. Does your town have an organization of local manufacturers who help each other out? Or, are you hung up on the idea that only people inside your sub-industry and market can help you? You'd be surprised how much a shoe manufacturer might be able to help a company that makes tubing. Having fresh eyes and new perspectives can help. Maybe you can try an exchange with a neighbor in your industrial park? Walk each others' processes and see what questions come up. I've written before about a local Lean group I was a part of when I lived in Phoenix.

Maybe another inherent advantage hospitals have is that hospitals are basically like other hospitals (except for specialty hospitals... but they're still hospitals). Does that encourage better sharing and collaboration? A hospital in Florida might be more willing to help a hospital in Washington, since they're not competitors, so that dynamic is different than in manufacturing.

Back to the article I linked to... it's about hospitals visiting ThedaCare, in Wisconsin, a hospital that gets a lot of attention for their impressive Lean efforts.

ThedaCare is no stranger to finding ways to reduce patients' time in a hospital while ensuring they receive optimum care.

For the past four years, the Appleton-based health system, has applied lean methods, similar to models followed by many manufacturers who are streamlining production to reduce costs.

Those principles also have worked for ThedaCare. Today through Friday, representatives from Appleton Medical Center and Theda Clark Medical Center in Neenah, will meet with about 150 health care leaders from nine different systems across the country.

Read the rest of the article...

Have you tried to increase collaboration in the manufacturing world? What have you tried? What would you like to try? Click "comments" to let us know. What can we do to help facilitate this? We've been able to use the blog a few times to put people in touch (with me playing middle man). Can we do more of this?

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[Lean Blog]

Fri, 28 Sep 2007 11:46:06 GMT

Scrapping lists 'will burden' NHS - The Press Association.

Scrapping lists 'will burden' NHS
The Press Association - 3 hours ago
Scottish Government plans to scrap so-called hidden waiting lists will create an enormous administrative burden on the NHS, Liberal Democrats claimed. ...
SNP rapped over NHS waiting lists Midloothian Today
all 14 news articles

[nhs - Google News]

NHS cleaners 'can do little more'

Wed, 26 Sep 2007 10:15:24 GMT

Cleanliness in hospitals and eradicating "superbugs" are now key priorities and all hospitals will undergo a "deep clean", Prime Minister Gordon Brown has said. A ward housekeeper with 14 years experience in the NHS tells how she feels the burden of responsibility, but says cleaners can do little more to make hospitals safer. Instead of saying what it is that needs to be done, the government should ask the people on the ground - more well-trained cleaners in general is what we need.