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How to Un-"Fumble" a Problem with Maggie Mechlin · Style Points

• 0:00
  Hello anesthesia enthusiasts and welcome to another episode of Style Points. Joining
• 0:14
  me today is Dr. Maggie Mecklin, who will share her wisdom about root cause analysis. Before
• 0:19
  that, I'll turn it over to my co-host, prior chief resident and now junior faculty here
• 0:24
  at UC, Dr. Nate Moore, to introduce our RSI.
• 0:29
  Hi Sean. I'm here to introduce double doctor Brian Upton, who got a PhD in molecular and
• 0:34
  developmental biology in addition to his MD before joining our program, where he is about
• 0:39
  to start his CA1 year. Brian is going to teach us about basic medical statistics, and I'm
• 0:45
  excited to hear from him.
• 0:46
  No glamorous introduction for this topic here, we're going to be talking about those pesky
• 0:50
  statistics topics that have been showing up ever since the MCAT. Instead of going over
• 0:55
  definitions and formulas, because I doubt that listening is going to be the best way
• 0:58
  to learn them, I instead want to discuss more conceptually why these principles are important
• 1:03
  and why they keep showing up.
• 1:06
  First let's go over sensitivity, specificity, positive predictive value, and negative predictive
• 1:11
  value. I'll refer you to those handy tables with formulas for the exact calculation of
• 1:16
  them. The first question I want to pose is why not just have one number for accuracy,
• 1:22
  as these are all in some way trying to gauge a test's accuracy. I'm sure we've all seen
• 1:27
  ads for something like a pregnancy test that claims to be over 99% accurate. What is the
• 1:32
  problem with that? To demonstrate why this may not be the best way to evaluate a test,
• 1:37
  let's make up a new pregnancy test. If I were to flip a coin, heads or tails means not
• 1:42
  pregnant, and landing on the edge of the coin means positive for pregnancy, how accurate
• 1:48
  would that be? So I'll take my test to our local college football team and give it a
• 1:53
  try. Lo and behold, it accurately identified all the players' pregnancy status. 100% accurate,
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  none of them were pregnant. Now you may think it's rigged, which it is, so we'll try it
• 2:04
  out in the OB clinic. For argument's sake, let's say half of the women are truly pregnant.
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  What is the accuracy of our test now? Say about 50%, it correctly identified women that
• 2:14
  were not pregnant.
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  How about testing our pregnancy test in the general population? Well, with about 12 births
• 2:21
  per 1,000 people in the US annually, and a typical gestation of about a quarter of a
• 2:26
  year, about 0.9% of people are pregnant at any given time. The accuracy of our test in
• 2:32
  this scenario would be 99.1%, or greater than 99% accurate, similar to that ad we may have
• 2:40
  seen. I hope this helps to demonstrate why one number for accuracy is insufficient. What
• 2:45
  we care more about is what percentage of people that are pregnant have a positive result,
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  or the sensitivity, and what percentage of the people who are not pregnant have a negative
• 2:55
  result, or the specificity. And then in the clinic, when we get a positive test, what
• 3:00
  percentage of those are actually pregnant, and when we get a negative result, what percentage
• 3:05
  of those are not pregnant, which are the positive and negative predictive values. I do want
• 3:11
  to emphasize that those last two numbers, the PPV and NPV, are still influenced by the
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  prevalence of the population. In contrast, the sensitivity and specificity do not change
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  as the prevalence changes. Therefore, when evaluating a test, sensitivity and specificity
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  are ideal measures of the test performance, while the positive and negative predictive
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  values are more useful when applying to the test based on your result, as you do not necessarily
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  know if the person in front of you is a true positive or a false positive, true negative,
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  or false negative, just that their test was either positive or negative.
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  Now, stepping away from that example, oftentimes sensitivity and specificity are in opposition
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  of one another. That is, to increase the sensitivity of a test, you often have to sacrifice specificity
• 3:56
  and vice versa. For many tests, this can be done by shifting your cutoff point for what
• 4:01
  a positive test would be. To really improve both metrics, a change needs to be made to
• 4:07
  the test itself. An example of this would be using ALKFAS as a marker for liver injury.
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  While you could shift your cutoff for an elevated ALKFAS to change the sensitivity and specificity,
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  you will continue to have false positive liver injury results due to bony etiologies. That
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  is, the test has poor sensitivity as it stands. To improve the specificity, while not losing
• 4:30
  out on our sensitivity, you could incorporate a test like GGT into the test to improve both
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  metrics. I hope these examples help you better conceptualize
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  some of the statistics concepts that come up on our tests, and I hope this improves
• 4:44
  the accuracy on your test multiple choice questions. Or was that sensitivity? Oh well,
• 4:50
  good luck. Thanks, Brian. I'll do my best to keep the
• 4:54
  podcast as sensitive and specific as possible. Joining us today is Maggie Mecklin. She's
• 5:00
  an associate professor of anesthesiology at the University of Cincinnati. After completing
• 5:05
  a fellowship in critical care anesthesiology, she became interested in patient safety. She
• 5:10
  was the chair of the procedural sedation committee, which she actually handed off to me for a
• 5:14
  while, and eventually became the chief patient safety officer here at UC. As part of that
• 5:20
  position, she became an expert on root cause analysis, or how to un, we'll say fumble,
• 5:26
  a problem. Maggie, thanks for joining us.
• 5:29
  Thank you. I'm excited to talk about this. Well, before we get started, I still want
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  to ask you my favorite get to know you question, the, who would you invite to dinner question.
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  So if you could invite anybody to dinner, even somebody from history or the past, who's
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  it going to be? I'm generally very bad at answering questions
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  like this. The best thing I came up with was Taylor Swift, one of my daughters, and I really
• 5:53
  enjoy her music and different levels, obviously. My other daughter insists that she hates Taylor
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  Swift, she is not a Swifty. Why do we have to listen to this in the car, mom? And then
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  she quietly sings along to it and eventually privately confessed to me that she's now half
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  of a Swifty, but that I'm not to tell her sister that.
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  So what would you, I would think it would probably be difficult with her schedule to
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  get her out to a dinner, but if you did get her, if you did get her out for what is likely
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  to be a very expensive dinner, what are you, I'm sure what would you ask her about? What
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  are you going to talk to her about? I'm curious about how she goes from thoughts
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  that she has or life experiences and translates them into songs or, you know, almost poetry.
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  I actually have a cousin who's got a master's in poetry.
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  Oh, wow. And said that. Right. And one of the things
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  she was recently talking with me about, about how talking about reading Taylor Swift's process
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  and actually looking at her lyrics is the closest she's seen recently to a lot of the
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  process that a lot of famous poets have talked about and write about for their own writing.
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  And I found that full line of thinking intriguing.
• 7:14
  Excellent. Well, the next thing we have to talk about, I know a lot of people maybe wrinkle
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  their nose out or aren't huge fans of, but you potentially say actively grown in a way,
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  but you know, we can call it whatever. Well, what do you like to call this topic?
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  I think there are a lot of things that could go into it, but when I'm talking to family
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  or friends, I refer to it as problem solving, obviously, specifically, we're going to talk
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  a little bit, I think about root cause analysis, which is one type of cause analysis. I won't
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  go too long down that specific rabbit hole because there are plenty others to go down.
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  But it really is. And I'm going to use one of my beliefs here. It really is understanding
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  a problem then figuring out how to unf**k it so it doesn't exist forever. And I like
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  that a lot, cognitively, as well as from thinking through how we can help people both on the
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  patient side, on the associate side. It can be more creative than it might initially seem
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  that I just love truly a million parts of it.
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  So you became patient safety officer or chief patient safety officer. How does that happen?
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  How do you get invited to that position? Nobody has ever asked me to do that.
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  I'm giggling because I am not someone, much like the question of who would you want to
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  have dinner with is something I struggle to answer. I'm not a long term planner. And I've
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  been really fortunate in my life to do what I think of her call falling forward, where
• 9:02
  I just keep doing things and then, oh, look at this opportunity. Oh, look at that opportunity.
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  Well, I guess I'll try that now. For myself, it kind of started a couple of years after
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  I was attending. The person who had been the medical director of the same day surgery in
• 9:22
  PACU here at our main hospital, UCMC, they retired from that role. I took that over.
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  I found myself trying to do some quality improvement work around length of stay in the PACU. And
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  that was a real life adventure. From there, I fell into chairing the sedation committee,
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  as you know, because you got to fall into that for a while, your own self or maybe intentional.
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  I'm not trying to put that paradigm on you. It was fun while it lasted.
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  And then I ended up working on a very specific project that had to do with sedative medications
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  in MRR and patients who had had some safety events. And I ended up personally developing
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  a relationship with a person who was the chief safety officer at that point, who then asked
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  me to come in underneath her and do some similar work and then time and organizational changes
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  and kept working through improvement work and solving problems. And then I got asked
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  to do it. So what is root cause analysis? Tell us more
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  about definitionally or what it means to you or give me some background.
• 10:40
  Yeah. You know, I think all of us, and especially probably in all industries, but I only really
• 10:45
  have healthcare. We know the things that go wrong on a day to day basis. We know why we
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  think they go wrong on a day to day basis. Some of them people have tried to solve in
• 10:55
  the past. Some of them people have mostly given up on and accepted. And the goal of
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  root cause analysis is, is that when you see a problem, trying to figure out exactly where
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  it's starting so that you can put into place a solution that will truly prevent recurrence.
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  So for example, a while back we had an event where a patient, the initial thought was that
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  the root cause of this was that a patient wasn't properly identified. You know, we always
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  talk about, make sure you check their bracelet, look at the name, date of birth. And we all
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  get sick of that. The patients get sick of it. No one wants to talk anymore about their
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  name or when they were born. And the initial pass at looking at this was, well, so and
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  so just didn't do the patient identification correctly. And why didn't they do it? We just
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  need to tell them that they need to do the right thing and they know it. And then, you
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  know, if they do it again, they probably end up with consequence. And no one goes into
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  probably any job, but certainly healthcare with the goal of creating a ruckus all day,
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  every day. Pretty much everyone goes to work with the intention of doing the best they
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  can to help not only their patients, but also their colleagues and to move things along
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  in a positive direction. And so really, when you think about it, anyone who doesn't properly
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  identify a patient probably isn't doing it because they're a jerk or that they forgot
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  that that's part of their job or whatever else. There's always something underneath
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  of it. And really the root cause analysis is aiming to find out, okay, well, what's
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  underneath that and how do we actually solve it? For my own self, I have a couple very
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  prominent memories of times where I came to work trying to do the right thing and did
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  the wrong thing. Once as a CA1, I had two syringes in my pocket. We often have syringes
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  in our pockets, or at least back in that day we did. And they were labeled, but I was focused
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  on this. This is my first case. I got against the OR. All the steps, especially as an early
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  CA1 between meeting the patient and getting into the OR, I was thinking about all of that.
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  And so I grabbed the syringe that had the pepsin in the right lane in it and I gave
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  it, but it didn't have the pepsin in the right lane. It had an opiate in it. And fortunately,
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  the room was ready for us. We went back, we induced the patient shortly thereafter. Everything
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  went fine. No one was hurt. The patient felt great. But I still remember that. It's got
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  to be at least 15 years later. And I don't remember it positively. And I had something
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  conceptually like that as a fellow too that really stood out where I was trying to do
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  the right thing, but my head was in a bunch of other places and thought I was giving someone
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  their home medication back, that it turns out they hadn't taken a long time. And then
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  their hospital course was longer because of all the fallout from that. So we all are coming
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  here to try to do the right thing, but the system's not always set up to allow that.
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  And there's so many workarounds when things don't work that it becomes the whole system
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  itself. And I realize this is a very long answer to a short question, but I really,
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  the whole point of cause analysis of any type is finding out the true problem and then fixing
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  the true problem in a way that will work. So those are the only two mistakes that you
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  have made in your career. That's my understanding. Yes. And zero as a parent and zero as a staff.
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  So those are just the only two. Excellent. Well, I'm glad that we have approximately
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  the same record. Right, right, right. That's great. So how do you know when you need to
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  do a root cause analysis? What does that look like? That's a great question. And I think
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  there are some individual isms, both as an organization and in general in broad, broad
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  strokes, probably almost every healthcare organization would do root cause analysis
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  for some time when a patient was hurt and we know that there was a defect in our system.
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  And defect can mean either that we don't have a process to address a certain issue. So that's
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  a defect. We don't have a process that we need where we do have a process, but it's
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  either antiquated or not updated or never followed. And we do these workarounds or where
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  we've got a process and for whatever reason, we just completely didn't follow it. So defect
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  plus harm here at UC health is we almost always do root cause analysis for those. So there
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  are a couple other flavors of cause analysis that we may do in some instances. So for instance,
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  people who fall and get injuries there, it's usually the same root causes for that. And
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  sometimes we group those together, which is called common cause analysis. But so deviation
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  and harm. We also do it for instances where maybe there's a deviation or defect or an
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  absent process and no one was hurt, but you can tell that, holy, we're really lucky no
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  one was hurt with this. We need to solve this before it's a problem for the next person.
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  So near misses. Yes. We partnered with Press Ganey back in 2019 and kind of adopted their
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  system of that categorization and cause analysis where they call, they actually call, they
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  have three categories, serious safety events, which are the ones with serious harm and deviation.
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  Precursor safety events, which are the ones with either minimal harm or no harm and deviations.
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  And then near misses in this definition actually means their deviations, but they never even
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  got to the patient. So that would be like, I got the wrong drug from pharmacy and it
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  never even made it into the patient's room. I send it back. Whereas they got the wrong
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  drug up from the pharmacy and I gave it to the patient, but they didn't have any harm
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  would be a precursor in that language. Okay. Same principle. So can you give me an example
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  of something that would obviously be something that you would want to do a full root cause
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  analysis on so we can use it as an example. What if it was maybe you took the wrong patient
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  back to the O R. Yeah. Yes. And it's interesting you bring that up because presumably you would
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  identify that certainly before an operation began, hopefully before they even went to
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  sleep. And it's interesting because particularly if we talk about the events where no one's
• 18:04
  hurt, it's a real sometimes adventure to get all the right stakeholders and experts on
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  board to doing a cause analysis because we're all of an outcome focused and caring. Well,
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  if no one got hurt, then what's the deal? But yes, things like that would be big or
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  in the past we had a number of events perioperatively where we were having a movie either creating
• 18:42
  smoke other than as intended by the device or small fires or we've had certainly one
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  of the things that comes up a lot that's relevant to periop would be a wrong site procedure
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  would be a big one. Okay. Let's say they've chopped off the left knee instead of the right
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  and the patient's very upset and now it's your job to do the root cause analysis. Where
• 19:09
  do we go from here? You get the email in your inbox that they've gone after the wrong leg.
• 19:14
  Yeah. Now what? So actually oftentimes the hardest part of that process is getting to
• 19:21
  the email phase. Oh, really? Yeah. People as a whole are really hesitant to submit instant
• 19:32
  reports, at least in our health system. It appears to be varying degrees of a problem
• 19:38
  nationwide, but especially with our physicians, learners and providers, there's a lot of mistrust
• 19:46
  of the system and a lot of frustration by some of the incident reporting actual software
• 19:54
  that people just don't put stuff in and then they just walk around and complain. So there's
• 20:01
  no harm in putting in incident reports and it'd be great if people did it more. For things
• 20:06
  like wrong site, someone will usually do that, but that is often one of the biggest hurdles
• 20:13
  is actually getting it reported so it can then go through the funnel. Okay. So it gets
• 20:17
  through the funnel. It does end up in your inbox. Now what? Yep. The next thing is it
• 20:23
  goes to, we've got a multi-professional group that meets weekly that includes members of
• 20:30
  the safety team that I'm part of. It includes our partners with accreditation, risk management,
• 20:36
  experience and relations. We've got a pharmacist that sits on this group, a couple other people
• 20:42
  who meet every week to go through applying these definitions about were there deviations
• 20:47
  in the system, were there harm, or so how much. And that's our main filter for deciding,
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  okay, we've got this incident reporting, does it meet the criteria to then go for their
• 20:58
  investigation? And if this group talks through the event and says, yes, this meets our criteria,
• 21:04
  then it goes on and members of our safety team will dig further into the patient's chart.
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  They kind of identify who are the people who were involved in the event and set up time
• 21:17
  to interview them and talk with them to better understand not only what happened in terms
• 21:23
  of what I can observe in the chart, but also what else was going on in the end of the time?
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  What were you thinking about? What was competing for your attention? What were you potentially,
• 21:36
  what were you thinking was the main problem this patient was having, particularly if it
• 21:40
  was like an inaccurate or misdiagnosis? And trying to do our best to understand everyone's
• 21:46
  headset at the time, because we know that hindsight bias is huge, particularly with
• 21:53
  safety events. And so it's really critical to do our best to figure out, okay, at the
• 21:58
  moment, where were we and what was going on? And that the team takes that information,
• 22:04
  puts it together and comes up with a timeline for the event. After that, we get a group
• 22:13
  of people together who are experts in essentially the type of care that was provided. So for
• 22:18
  instance, something happens in the operating room, we're going to have someone from an
• 22:24
  A to C team, we're probably going to have someone from a surgical team, probably a circulating
• 22:28
  nurse, maybe a scrub tech. It would obviously depend on what the event was. One of the new
• 22:34
  changes that our organization in the last couple of years is that when we bring together
• 22:39
  this root cause analysis team to go through the timeline and see where we have opportunities
• 22:44
  is we, with very rare exception, do not use the people who were part of the incident.
• 22:53
  And that's a kind of a national best practice, maybe international. And the thought is that
• 23:01
  by bringing in people who have similar expertise, but not the exact same person who was there,
• 23:08
  you provide more psychological safety for the person who was a part of the event by
• 23:14
  not then perceiving that they have to come in front of a room and talk about why they
• 23:19
  did what they did. And that hopefully that's not the reality of what the RCA would feel
• 23:24
  like anyway, but people still worry about that. And then additionally, and this part
• 23:30
  is more anecdotally and internally, when we've had people who were parts of the event at
• 23:36
  the cause analysis, the meeting takes a lot longer and we may or may not actually get
• 23:44
  to good causes because again, whether or not it's the vibe that's set in the room, people
• 23:51
  internally feel like they have to justify what they did. So they often talk extensively
• 23:58
  about what they were thinking at the time and why they did what they did, sometimes
• 24:03
  in a defensive manner. And I can't imagine why somebody would be defensive about a mistake
• 24:10
  that they made. And see that exactly. And that's one of the cool things about if we
• 24:16
  actually get to more effective system thinking and cause analysis is again, it's back to
• 24:21
  that whole idea of no one comes to work to cause a shenanigan. The dominoes are not set
• 24:28
  up correctly around you if they fall so easily. And trying to move the thought process from
• 24:39
  I did this wrong, I caused this problem or they did this wrong, they caused this problem
• 24:43
  to why didn't we have the infrastructure for this to go right is really the goal of what
• 24:51
  our team and what anyone doing this work is trying to do all the time. But it's a real
• 24:57
  shift in mindset, particularly in my opinion with people who provide health care directly
• 25:03
  because it's our hands, right? It was my hands on that syringe. I drew up the net, I labeled
• 25:09
  it, I did all that stuff. And so we always feel at least some amount of personal responsibility.
• 25:16
  And so most human beings translate that to their colleagues as well when something goes
• 25:21
  wrong. So for all of those reasons, we try not to have the people who are involved in
• 25:28
  that actual incident itself during the analysis. When the team comes together, we go through
• 25:33
  the timeline and figure out, okay, in a perfect world, where would things have gone different?
• 25:37
  And usually there are one or two places where there would have been an opportunity to make
• 25:40
  a different decision. And then the gang together, which again includes the clinical subject
• 25:46
  matter experts and includes the members of safety team that I'm part of, who are facilitating
• 25:52
  and leading the cause analysis. There are always risk management attorneys around accreditation
• 25:59
  people and patient experience team is often a big part of it as well. And once we decide,
• 26:07
  okay, this is the real step where everything went awry, or this is the real process that
• 26:13
  failed, then we dig into, okay, well, why did it fail? Well, I didn't, I didn't look
• 26:20
  at my syringe correctly because I drew it up. So I assumed I knew which one it was.
• 26:25
  I didn't, I was task focused at the time. And so I wasn't thinking about, oh, I have
• 26:33
  two syringes that have the same, that are the same size in my pocket. I was thinking
• 26:39
  about, okay, they don't have a hat on yet, but I'm supposed to be in the room and the
• 26:45
  surgeons in there tapping their foot. I need to get, I need to find their hat. They need
• 26:49
  to give their family member hugs and kisses. I can tell that this is a patient and their
• 26:54
  loved one who are going to struggle to part for a few minutes, but, but I'm already behind
• 26:59
  this, you know, all this other stuff. So it's really, we're really trying to move the analysis
• 27:08
  from, okay, what happened to why did it happen? What's the process that failed? Not that there's
• 27:13
  a person that failed. So as the group all agrees on why this failed and what the process
• 27:19
  was, and we worked to come up with, I don't know, what kind of solutions would work. Our
• 27:25
  UC health RCA process has been continuously iterating and improving for some time. One
• 27:32
  of the things we're working on now is historically we've tried to identify, okay, well, this
• 27:38
  failed, so we're going to do this. Well, this happens, we're going to do this. We're going
• 27:41
  to do this. But we know that the first idea is not always the best idea. And we also know
• 27:47
  that other organizations struggle with similar problems. And so we're trying to move action
• 27:52
  items to things that we can maybe either test out or research more and not get super granular
• 27:58
  in the meeting. That's actually new and we haven't gotten to testing that yet, but that's
• 28:02
  one of our next steps. So after we identify the correct cause, which is again, a really
• 28:08
  critical piece because when you have the wrong cause, you solve the wrong problem. And it
• 28:15
  may still be a problem. It may still be a cause. It may still be a problem. But if it's
• 28:20
  not the cause and the problem, you don't prevent that same thing from happening again. So we
• 28:25
  identify the cause, we talk with action items, and then we send out the people who are the
• 28:31
  clinical leads in that area. So for again, an OR event, it would probably be like a manager
• 28:37
  or a physician medical director to engage their teams to figure out the best ways to
• 28:43
  execute and solve the problems. One of the big issues that we recurrently see with determining
• 28:50
  action items is everyone wants to update the policy or educate or remind. And to be clear,
• 28:57
  those are all important steps. They are absolutely critical. However, you can't end there because
• 29:03
  we know that doing all of those, those are at best an 80% success rate. And then the
• 29:10
  farther away you get, your reminders fade from people's mind, I guess the education
• 29:14
  fades. And so we need to do things not only that include all that and setting the groundwork
• 29:19
  in the future, but we need to do things that are better stop gaps than just reminders.
• 29:24
  I've been talking for a real long time. So where should we go next?
• 29:31
  Everything that you've been talking about makes me think of one of my favorite things
• 29:35
  to tell medical students and residents about systems level solutions, which I think one
• 29:40
  of the best examples is the pin index safety system, or the diameter safety system.
• 29:46
  Yes. So, and I always tell residents, by the way, that the anesthesia machine is very important
• 29:53
  and knowing about it and checking it is all very important. I am not the guy who's going
• 29:57
  to tell more things in the anesthesia machine and how they work. But yes, that is exactly
• 30:02
  perfect that our nitrous is one color or oxygen is another, our air is another, and that you
• 30:07
  can't physically attach a nitrous tank to your oxygen backup tank. It's not physically
• 30:13
  possible. They're shaped differently, they're sized differently. I don't remember the specifics,
• 30:17
  but it's not physically possible. So that is a solution that has a high level of reliability.
• 30:23
  And there's a whole reliability science that actually then maths and tells you what the
• 30:27
  failure is. That's probably at least a level three reliability. It probably is higher,
• 30:34
  except in healthcare, we don't really find higher than level three. So most of the discussion
• 30:37
  pops out there. But there's less than a 1% chance of that family, whereas our education
• 30:42
  is a level one. But yes, if you can find the analogous solution as the pin index and the
• 30:48
  back of your machine for your backup tanks for all of this stuff, oh my God, it'd be
• 30:53
  amazing. But that doesn't exist for. I would be remiss here if I didn't include my favorite
• 30:59
  inappropriate mnemonic for the cylinder, which you can remember, which is you piss in a cylinder.
• 31:06
  So pin index safety system is the one that goes with cylinder. I love that. Well, that's
• 31:14
  how I got through residency. It's a bunch of stupid mnemonics like that. But it's perfect.
• 31:20
  That's perfect. I'm glad that I was able to share that with everyone. That's fantastic.
• 31:26
  Okay. So we've done the RCA. We have figured out the problem. We have attempted to address
• 31:34
  the root cause. Now what? How do we know that that worked? Yeah. So our current process
• 31:42
  is that the gang all comes back together at 30, 60, 90 days and potentially if it's not
• 31:47
  done by then every 30 days until it is to say, okay, did we actually get to implement
• 31:53
  the actions we expected? If so, how did it work? And is it still working? And sometimes
• 31:59
  that's sometimes it's coming back to say, oh, you know what? We thought we could do
• 32:04
  this. We actually can't. Sometimes it's this didn't work. Sometimes it's no, we just haven't
• 32:09
  gotten to that yet. Being able to put in a new solution like the pin index takes a long
• 32:15
  time. I mean, we've got some that we're a year out of continuing to do to follow the
• 32:21
  block. One of the hard things is that the actual function of how we divide up our work
• 32:29
  at UC health, it's not a hard thing, but it's just it's challenging is our system
• 32:35
  safety team that leads the RCAs and helps with follow up and making sure we have reliable
• 32:41
  solutions and our clinical teams that do the work are basically different human beings,
• 32:47
  which is great because now we've got two groups with different sets of expertise. But sometimes
• 32:52
  that can cause conflicting timelines and priorities. And, you know, sometimes even back to when
• 33:02
  you're saying, OK, well, what do we do next or what happens next? We find out sometimes
• 33:06
  we end up having what we call deja vu events and meaning that it's essentially the same
• 33:10
  thing again. And usually when that happens, we find that I mean, it could be that our
• 33:18
  solution was quote unquote wrong, but most commonly is that we actually didn't have the
• 33:22
  correct cost as a failure. There's one of the tools we use a lot. It's called the five
• 33:28
  whys. And the principle is that if you ask why five times, it's pretty much always get
• 33:33
  you root cause. But if you say, hey, Mandy, why did you get the wrong drug? Oh, because
• 33:41
  I was trying to. Why are you distracted? Because I'm really out of time and my case is really
• 33:45
  great. Well, why are you out of time? Well, we can't actually address that here. Why are
• 33:49
  you running late? All of that. And so if you keep when someone when you get back and answer
• 33:54
  and you keep asking why. When you can't ask why anymore, that's usually your root cause.
• 34:00
  And if we zoom back out to the example of the patient identification failure, you know,
• 34:06
  well, the person didn't do it. They knew they should do it. Well, you can still ask why
• 34:09
  after that. That's not a cause. And if you if you address that problem that we didn't
• 34:14
  identify the patient correctly as this individual didn't do their job and either I need to give
• 34:21
  them some sort of a disciplinary action or a warning or or I need to remind them or whatever
• 34:26
  it is. And that's your solution. Well, you haven't actually solved the problem. You have
• 34:33
  to keep if you will guarantee have repeat events. So part of the follow up is did it
• 34:41
  happen again? Did it turn out that that we were incorrect in what we thought the problem
• 34:47
  was? As tempting as it is to ask you why for the next five questions, I'm I'm not going
• 34:53
  to do that. Instead, I was just thinking about all the different complex personalities and
• 34:58
  agendas that must come to the table when you bring these big multidisciplinary teams together.
• 35:04
  How do you manage that? That just seems like a miasma of different people.
• 35:10
  You said in real life, that's amazing. Well, you're welcome. Thank you. Thank you. I it's
• 35:15
  actually funny that you asked that literally earlier this morning. I was texting with one
• 35:20
  of our colleagues and I said that I actually think that a third of what I've learned in
• 35:26
  my job is facilitation and redirection in in big group meetings. I think there's a couple
• 35:35
  of things. Number one, it comes back to in my mind, trying to understand another person's
• 35:43
  perspective and their lens and their view of the world and where they're coming from.
• 35:49
  Because again, if we keep coming back to we're all here to try to do the right thing and
• 35:55
  to try to help people. There's something that from their perspective, helping people looks
• 36:01
  looks one certain way, maybe they're thinking of different people or different types of
• 36:04
  help. And you know, it's probably not that no one comes to this to try to derail the
• 36:10
  work and and redirect and sometimes they do come with an agenda to talk about a tangentially
• 36:15
  related problem that they can't stand. And I think this is their own audience. That's
• 36:20
  the case. Generally is addressed with some amount of validating that I'm sure that is
• 36:27
  a problem. And we can talk about that one next or separately. But let's keep focused
• 36:34
  on this so we can get this done. When when there's more work, conflict. There's there's
• 36:51
  a lot of at least in my brain, it's nuanced between like gentle redirection to the other
• 36:56
  end of the spectrum is mom voice, we're not doing that right now. I need to stop. I don't
• 37:05
  do that one a lot. It's pretty effective at getting stoppage. I imagine so. What happens
• 37:12
  next is pretty variable too. But the staff is pretty reliable after that. But but it's
• 37:26
  usually some version of verbally reminding everybody we're here with the same big goal
• 37:31
  and that sometimes we need to either pause and hear someone else out who's thinking about
• 37:36
  it differently or share why we're thinking about it the way we are or mom voice, we're
• 37:41
  not doing that. So there's a lot of different outcomes I imagine that take place and you
• 37:47
  talked about sometimes you don't get what you want and the problem recurs, or sometimes
• 37:53
  you do get what you want and there is a meaningful change. Can you talk in a non identified kind
• 38:01
  of way about what those successes and failures feel like and what lessons you learn from
• 38:06
  either one of those? Yeah. Um, you know, one of the issues that this is more towards the
• 38:14
  failure side that I think everyone's facing now is we know that most of our hospitals
• 38:20
  are pretty full and we know that patients boarding and the emergency departments is
• 38:26
  a big problem. And when patients are boarding, when a lot of boarding because this may not
• 38:34
  be a big part of everyday anesthesia life, but boring usually means that the patient
• 38:39
  came into the ED they can be admitted to the hospital, but there's no space for them to
• 38:42
  go to. So they hang out in the ED for an extra 412 24 48 hours as an inpatient. And, and
• 38:50
  the downstream, one of the downstream effects is that then, okay, there are more people
• 38:53
  in the lobby, there are more people who leave without being seen. And if I'm in the lobby
• 38:57
  for 14 hours for the ED, well, that's a long time that if I'm still there, I'm probably
• 39:04
  quite sick and probably need help. And there's a chance that something could happen to me
• 39:07
  while I'm there. And really one of the, one of the root causes, so I guess that's another
• 39:13
  important point is not everything has just one root cause, but one of the root causes
• 39:18
  of all of that is that to get patients out of the hospital, they have to have a place
• 39:22
  to go. And sometimes they need to go to a nursing home, pre-hub facility and insurance
• 39:27
  requires prior often can take and then you can see how all this goes downstream. And
• 39:34
  in terms of a failure, none of us can fix the healthcare health insurance industry.
• 39:39
  And that is a pervasive failure that, that we can't ever deal with an organizational
• 39:46
  level. And so sometimes we have to, okay, well, I can't do that. I need to jump over
• 39:49
  something else. There are kind of buckets of recurring events, like we talked about
• 40:00
  where sometimes it's a quote unquote simple process, like patient identification, and
• 40:08
  it fails in 50 different ways. And so it's like whack-a-mole, okay, well, I dealt with
• 40:14
  this patient identification issue that had to do with how the bracelets print. Damn,
• 40:21
  it just happened again. Now, now it turns out this patient identification issue is actually
• 40:25
  because of distraction. Okay. Okay. Whack-a-mole, that distraction problem. No, now this is
• 40:33
  actually the same one that happened with the printers. We thought we fixed all of them,
• 40:38
  but these are actually in a different part of the building and those weren't able, we
• 40:42
  didn't keep up with the maintenance on those or they're overdue for their maintenance.
• 40:46
  And so, so sometimes it's whack-a-mole for the same problem. Some of the things that
• 40:51
  are really cool though, are when we see that the clinical teams get really excited and
• 40:58
  engaged and keep solving their, you know, kind of use the tools that we use in our meetings,
• 41:05
  take them forward to solve problems on their own. We had surgeon reach out to our team
• 41:13
  recently to say, Hey, in this subset of our healthcare organization, I think we could
• 41:18
  improve how we get patients from the operating room to the ICUs in a way that we have the
• 41:27
  right people at the right place at the right time. And one portion of our organization
• 41:31
  actually has a wonderful process for that and another portion doesn't. And so one of
• 41:36
  the cool successes is as we keep moving forward and working with different groups, we can
• 41:40
  keep connecting people together to partner and solve their problems better. I'm not sure
• 41:46
  if that's quite what you were asking them.
• 41:48
  No, that's perfect. I appreciate that. So let's talk about what you see in terms of
• 41:54
  the future of root cause analysis and patient safety. Are there any innovations that you
• 41:59
  see coming to the forefront or what do you think is next?
• 42:03
  One of the things that is now kind of like a hot topic that people are talking about
• 42:08
  and that no one's gets solved is how do you deal with the issue of not just physical harm,
• 42:14
  but emotional harm? So, so yeah, you locked off the incorrect knee. Sure. You know what,
• 42:23
  actually that knee was bad. I was going to need it on anyway. I don't mind, but you know,
• 42:26
  I'm really upset about it. It's not a great example, but right. But I'm really upset about
• 42:30
  it. Or at all, the people at the hospital spoke to me with such disrespect that I can't
• 42:36
  come back here. What do you do with that? There, there are a couple of scales for severity
• 42:44
  and we're trying, we're starting to bring that into our, when I referred to the meeting
• 42:49
  where we classify things and decide what needs an RCA, we're starting to bring that in. We
• 42:53
  still, again, don't have a great solution for it. We haven't come across cases where
• 42:59
  we've had no physical harm, but very, very severe emotional harm that we've then sent
• 43:05
  to a root cause analysis. And to be clear, I don't think that's because it hasn't happened.
• 43:10
  I think it's because we don't know about it. But we've talked about maybe we would do that.
• 43:15
  And one of them is that the other, the other big area is equity. That implicit bias is
• 43:25
  unequivocally part of some of our safety events and how you identify it and then how you actually
• 43:33
  embed it into your analysis to be able to identify it effectively and then how you fix
• 43:39
  it. I mean, good God, everyone's trying to fix implicit bias, but figuring out how to
• 43:45
  solve it is obviously going to be challenging. But the first step is obviously identification.
• 43:50
  And one of the things that I know that I struggle with, and I suspect a lot of other physicians,
• 43:56
  clinicians, and providers do is we just want to fix it. We just want to solve it. And I
• 44:02
  can't fix it. But the first step is to bring it up. And so it's starting when, when something
• 44:08
  happens, if we, ideally this would become our standard and it is not yet, but ideally
• 44:14
  we would identify was there a difference in not only race or ethnicity, which I think
• 44:21
  we think of most obviously in healthcare as part of our social disparities, but also religious
• 44:28
  background, sexual orientation or gender identity. I mean, just go through the whole list and,
• 44:34
  and we most commonly think about those things coming up where I, a healthcare worker is
• 44:40
  taking care of a patient who's a different of a different group than I am. And I don't
• 44:44
  give them as much attention, but it, but it does additionally go in attention is not the
• 44:49
  right word, but hopefully you guys can run with me on that. It goes the other way as
• 44:52
  well that I, a patient have a healthcare worker who's part of a different group and maybe
• 44:57
  I'm a real jerk to them. And then, and that could escalate to the level of workplace violence.
• 45:02
  And one of the things that we, I think don't appreciate a lot in healthcare is that when
• 45:07
  we talk about workplace violence, that's not just someone goes into a post-hub, so they've
• 45:10
  gone, that's my patient kicked me in the chest. Not a demented patient, but my patient was
• 45:16
  pissed, kicked me in the chest. Happened on a night shift. I was working recently. I didn't
• 45:21
  get kicked. Someone else got kicked. It's the splurring string of profanities that my patient
• 45:29
  yells at me. That also happened to me recently for actually, for the first time in my life.
• 45:34
  I walked out of a patient room when I was trying to pre-op a patient. The second time
• 45:39
  that I tried to pre-op them as they continued to curl their frustrations at me. And I was
• 45:47
  trying to get a couple of information about their history. They were very upset. They've
• 45:52
  been waiting. And I offered several times to continue discussing it with them. They
• 46:02
  were, after they've been able to take a few deep breaths and much like my children respond
• 46:07
  to the deep breaths, that really only escalated the situation. My kids are very vocal about
• 46:14
  hating deep breaths and they're not doing that. But again, in the work that I do, also
• 46:23
  what we look at when we think about equity is if there's an inequity between the healthcare
• 46:27
  provider and the patient, but also just to call out that inequities also relate to workplace
• 46:32
  violence and verbal abuse is workplace violence. So those are kind of the things that people
• 46:38
  are thinking for. Okay, how do we embed this effectively and do it better? Because we know
• 46:43
  that healthcare is not just, did I cut out the thing that was bad and so it closed good.
• 46:48
  It's also, did you feel valued as a human being? Did you feel understood? Were you able
• 46:53
  to ask your questions? It's all those things that we think of, I think in medicine, or
• 46:56
  at least I think of them as mushy or softer. But those are really those human factors that
• 47:03
  I think we need to figure out how to do better. So let's go back to when you were a medical
• 47:10
  student or a resident who is really interested in solving those big problems but didn't know
• 47:14
  how yet. What advice would you go back and give yourself as someone who was interested
• 47:21
  but didn't know what they were doing ostensibly? Sure did not. I think in my mind, the most
• 47:30
  important things are to approach everything you possibly can with curiosity because I
• 47:35
  think that's the biggest way you learn. Sometimes it's hard to figure out where the people are
• 47:40
  with different types of work that you can try to glom onto because that's been one of
• 47:43
  my other techniques of life is just glom off and don't go away. It just if you can't get
• 47:49
  rid of me then you'll have to eventually teach me something or have me do something for you
• 47:54
  to try to figure that out. But it's the cool thing in my mind about cause analysis and
• 48:00
  this kind of problem solving is that you can apply it not only to how you take care of
• 48:04
  patients or how you solve problems at work. But I actually use a lot of this type of thinking
• 48:09
  at home. And again, my kids and husband don't always love it. But why? You can always ask
• 48:18
  yourself questions and part of it is even training yourself to ask the questions and
• 48:21
  the more you can even practice independently. Oh, why do I do that? Why are we doing that?
• 48:26
  Why is this attending doing it this way? But that attending does it that way. And it's,
• 48:32
  you can find out so much cool stuff. So I think being curious takes you so far in life,
• 48:38
  but that's a broad life lesson in my mind. I wish I could say, Hey kids, if you want
• 48:45
  to do what I do, you should do X, Y, Z. But, but I honestly fell into this and I don't
• 48:49
  know what people who do it on purpose, what their trees look like.
• 48:53
  Well, I appreciate you falling forward into this podcast.
• 48:55
  I'm really excited.
• 48:57
  Lastly, any, well, that was an excellent style point. I wonder if you have any other style
• 49:04
  points or points of personal preference that have brought you success in or out of the
• 49:08
  operating room.
• 49:09
  Yeah. In addition to the curiosity, the other one, it sounds fairly hokey is, is a version
• 49:18
  of that, which is in soon assume positive intent. And again, realizing that very few
• 49:23
  people are trying to be a pain in the ass, not, but if you can figure out a way forward
• 49:31
  to get to that, you can usually solve whatever it is. And I think that applies pervasively
• 49:38
  throughout life and work. I've got a million opinions on how we should do all kinds of
• 49:44
  minutiae both in the OR and the ICU. But I don't think we have enough time to get into
• 49:52
  it.
• 49:53
  Well, thank you so much for joining us. I am really happy that you decided to come on.
• 49:56
  Me too. Thanks, John.
• 49:59
  Thanks again for joining us today. If you enjoyed this month's podcast, please feel
• 50:03
  free to drop me a line at stylepointspodcast.gmail.com. Leave a review or feel free to share it with
• 50:09
  your friends. Take a deep breath. Open your eyes. We're all done.