Monday, September 22, 2008

Counting for Positive Deviance

In a change of pace from recent posts, today brings a summary of the counting exercise that Kearney and I (with back-up from Michael and Shea) did during our medical adventure. We’ve written up our experiences and will be sharing them with the hospital/clinic folks, as well as posting some extracts of them here. We have two sets of observations: our counting results and then our thoughts on the systems we saw in operation. Today is counting and tomorrow, I hope, will be some of our systemic comments. As background in that area, Bob Sutton from Stanford (author of the No Asshole Rule, which I use as a text in my MBA ethics and leadership class) has a terrific article in the McKinsley Quarterly on “The Ergonomics of Innovation” about the campaign of the Institute for Healthcare Improvement’s campaign to reduce by 100,000 the number of patients who die in hospitals from preventable errors. You can download the article from his website ( if this topic is of any interest… it’s a short, well-written and interesting piece.

Otherwise, we generally had two days of slight slippage this weekend: neither days nor nights went very well as we lost the pain-control rhythm for a while. We think we’re back in a good groove today and the night went pretty well. Plus, thankfully, we’re closing in on the end of the steroids.

This week represents another new phase in recovery: I’m restarting my strength training today, occupational therapy begins on Wednesday and physical therapy on Thursday. Following the good advice of friend L, I’m working on internalizing the tortoise-mindset (as opposed to that of the hare) for this process: slow and sure, with my eyes firmly fixed on the long-term goal of full recovery. The tortoise slow-and-sure approach doesn’t come naturally to me, but now is surely the moment. Social psychology research emphasizes the importance of making a public commitment using the consistency principle, so now all of you have seen me commit to this goal. I know you'll hold my feet to the fire.

And now, for some of our counting results:

Kearney and Tina decide to count
In the epilogue of his book Better, Atul Gawande advises doctors to become "positive deviants," with suggestions for making a worthy difference in the world. Among his suggestions for achieving this, he says "If you count something you find interesting, you will learn something interesting." (Afterword, page 255). This rang a bell for us as we were entering our medical adventure, so the two of us set up a rubric for tracking our interactions with the staff members we were going to encounter. We created a spreadsheet and printed blank sheets that we taped to the back of our hospital notebook. Our methodology was simple: we logged every person we encountered, giving ratings of five simple factors on a 1-5 Likert scale. (We later modified one of the elements to a simple yes/no.) We were sufficiently diligent that we found only a few entries that were incomplete when we began this summary.

Summary of Counting
From Thursday, September 4, the date on which the meningioma tumor was first diagnosed via a CAT scan, through the craniotomy Wednesday, September 10, and until discharge from the hospital on Saturday, September 13, we logged interactions with more than 60 staff members at Carle clinic and hospital. This included staff during:
• the initial diagnostic CAT scan (Thurdsay, September 4)
• an appointment with the surgeon to consult and schedule the surgery (Friday, September 5)
• an outpatient MRI scan preparatory to surgery (Monday, September 8)
• a pre-op insurance clearance (Tuesday, September 9)
• a pre-op medical record session (Tuesday, September 9)
• a pre-op physical and a consultation with an anesthesiologist (Tuesday, September 9)
• check-in and preparation for surgery (Wednesday, September 10)
• a pre-op MRI and the surgery (Wednesday, September 10)
• time in the recovery room (Wednesday, September 10)
• time in the surgical intensive care unit (two nights, Wednesday and Thursday, September 10 and 11)
• recovery time on the surgical floor (one night, Friday, September 12)

For each staff member we encountered, we rated five items on a 5-point scale:
5 completely top-notch
4 pretty good
3 neutral
2 not so good
1 terrible or non-existent

Items rated were:
• did the staff member introduce him or herself to us?
• did the person don gloves or wash hands before touching the patient?
• the listening skills of the staff member
• the clarity of the staff member’s communications/instructions to us
• the helpfulness of the interaction as we perceived it
Given the items, some of the ratings were really yes/no while others were qualitative assessments of our responses. We converted the “washed hands/wore gloves” from the five-point scale to a yes/no scale after the fact, but left the “introduced self” on the five-point scale, as there were qualitative differences in the nature of the interactions.

The staff we encountered and on whom we kept records fell into the following categories:
• 4 physicians (2 surgeons, 1 pre-op physician; 1 pre-op anesthesiologist); we did not meet any of the hospitalists who presumably were around and about during my stay; the surgeon was present every day, sometimes twice a day (and during the first night as well)
• 23 nurses
• 4 health technicians
• 3 scan technicians
• 5 blood lab techs/EKG tech
• 6 therapists (2 PT, 3 OT, 1 vocal)
• 3 food deliverers
• 10 receptionists/schedulers/managers
• 2 uncategorized/unknown

Numerical findings.
Scores at the highest levels across the interactions:
69% (36/52) interactions in which an introduction was appropriate occurred at a “5” level
59% ( 19/32) individuals visibly cleaned hands or donned gloves before touching patient (where appropriate)
66% (31/47) had listening skills that we rated at the highest level, “5”
52% (25/48) interactions in which information was conveyed were ranked at the “5” level
60% (30/50) interactions were rated at the highest level of helpfulness

Aggregating the two highest scores (4 and 5):
69% (36/52) interactions in which an introduction was appropriate
59% [(19/32) individuals visibly cleaned hands or donned gloves before touching patient]
77% ( 36/47) listening skills were rated at a high level
71% (34/48) interactions in which information was conveyed were effective
72% (36/50) interactions were rated at a high level of helpfulness

Eight of the 60 staff members (13%) we encountered scored at the lowest level across all interactions.

By Role
Three of four doctors received the highest ratings for every interaction.
One doctor (the pre-op anesthesiologist) was hands-down the worst interaction across the entire time period, in every dimension.

19 of 23 nurses received the highest ratings for every interaction. There were four nurses whose names we never learned; who simply appeared, did things to the patient and then left. This was disconcerting when it occurred, especially compared to the quality and consistency of care otherwise.

Two of the three radiology technicians rated at the highest levels. The third was more ancillary to the process, though an introduction here would also have been nice.

The five lab techs did not consistently introduce themselves, but received the highest ratings on every other aspect of the interactions.

The six therapists from the different services had a mixed record: two were superlative, two were fine and two we never learned their names. They just appeared, took actions, and disappeared.

The three surgical floor Health Care Techs did not wear gloves for taking vitals (probably not necessary?) and otherwise received the highest ratings on every interaction. They added considerable humanity and gentleness to the experience.

Ten office staff members (receptionists, schedulers, etc) were generally effective and rated well. They were more mixed than other categories and also had a lower rate of interaction.

Three different people delivered food ordered from the menu. None introduced themselves (not really required) and each was gloved, personable, helpful and pleasant. Each had a nice manner in getting things established well for being able to eat.

There were two items we didn't track that, in retrospect, we wish we had, especially after reading Sutton & Rao's article.

Patient Identification. We didn’t tally the consistency of patient identification before treatment interactions, and in retrospect wish we had been alert enough to the systemic issues to have done so. Our sense is that this was done at a very high level of consistency. Our collective sense is that date of birth was asked as a matter of course by most, if not all, staff members, before any interaction began.

Administration of Medications. Similarly, we didn’t log the administration of medications and wish we had. Again, our sense is that this was also a very deeply routinized process executed with great discipline: the hospital ID bracelet was scanned before any medication was provided and each and every administration checked in advance on the computer and then entered on the bedside computer afterwards.

Overall, this is an impressive track record of a lot of people in a large and complex undertaking.

The counting we did along the way gave us a joint mission, let us feel that we were not totally helpless/being acted upon as we careened through this most peculiar experience (a brain tumor??) and grounded us. Feeling that we were still us, capable of observing and assessing helped all of us, we think. A side-effect we didn’t expect was that, eventually, the aggregating numbers began to reinforce how well this system in which we were caught up was working on a moment-to-moment basis. As the positive numbers continued to pile up, that realization affected our attitudes in helpful ways. We hadn’t anticipated that—actually, we hadn’t really anticipated anything other than just having an activity—and it was an interesting effect that probably made us easier to deal with for the staff we encountered, too. Finally, the whole mission gave us a handle on being less completely self-absorbed than would have been easy to become.

We’d do this again. Here’s hoping the need never arises.


  1. Hey, looks like you're ready to
    take my job after you get out!

    Carol L.

  2. This is great stuff. I can see the impact on your classes and writing from your observations.

    You are magnificent in your tapping into all capacities. Go for it, while you also adapt to the tortoise guise on your physical work.

  3. Steven and I send love from across the Stratford u A today...Midsummer tonight, Hamlet tomorrow. Thinking of you often and sending all good thoughts, Jill

  4. I was nervous since I had received no news of the surgery. A friend from France sends me the link to this... Wow, I am happy now and I will have a great day.