Dr. Fred Southwick is a Professor of Medicine, University of Florida. He’s an expert in applying manufacturing systems and athletic principles to improve health care delivery. He is a graduate of Yale College and Columbia College of Physicians and Surgeons. In 2011 he completed the Advanced Leadership Fellowship at the Harvard Business School where he studied team dynamics, organizing people to bring about cultural change, leadership skills for transforming organizations, and methods to improve quality in safety in health care. In January 2011 he was appointed Manager of New Projects in Quality and Safety for the UF & Shands Health System.
Dr. Fred is releasing a book through No Limit Publishing Group called Critically Ill that touches on the key processes that effective healthcare systems need to have in place to reduce errors and improve the quality of patient care.
Can you tell our readers how your professional and personal experience has led you to write a book on the medical errors afflicting the healthcare system in the U.S.?
I have been an internist and infectious disease specialist for over 30 years, and I have witnessed many misdiagnoses and other errors throughout my career. In 1989, the problem of preventable medical errors was brought home when my former wife, Mary, became ill. The physicians at my academic medical center were distracted and overlooked many critical findings, misdiagnosing her underlying problem. These oversights put Mary in the intensive care unit after a heart attack, and massive blood clots to her lungs, caused respiratory failure. For 15 years, I blamed the individual physicians for these preventable complications, but upon learning about how manufacturing systems could be applied to healthcare, I realized that much of what went wrong with Mary’s care could be attributed to a defective healthcare system and a dysfunctional culture within my academic medical center. This epiphany was the start of a journey to create a handbook to guide individual caregivers on a new path toward more reliable, higher quality care for all patients. I have realized that unless every caregiver and every administrator develops 5 key skill sets, we will never be able to cure our critically ill health centers. No single person can transform how we care for patients. Everyone needs to pitch in, and Critically Ill provides an action plan that all those involved in healthcare should follow to make care safe for all patients.
What is your advice to patients and families of patients concerning this pressing issue?
Patients and families also need to understand the challenges that all healthcare providers face. By reading Critically Ill, they will be able to distinguish a highly effective and safe healthcare system from a dysfunctional and dangerous one. If there are long waits in the clinics or emergency room, beware: this indicates they have poorly managed patient flow and defective systems. If nurses and doctors are multitasking and appear tired and harried, beware. These conditions increase the risk of mistakes that can harm you. When an error occurs, you should expect an immediate, full explanation, a heartfelt apology, and an action plan for how this error will be prevented in the future. If you notice that your doctors and nurses are not working together as a team, watch out. A lack of communication, and poor coordination of care, can result in mistakes and cause you or your family member harm. If you cannot identify the physician who is clearly in charge of your care, realize that there are problems with leadership, and poor leadership can result in delays in treatment that can prove harmful. And, finally, observe how caregivers and other hospital employees treat you and treat other patients and families. You should feel like a VIP, and be treated with respect and empathy. You should expect to be the center of everyone’s attention. If the hospital or clinic personnel treat you as though they are doing you a favor, you are in an institution with a dysfunctional culture. And we know that such toxic cultures are dangerous to patients.
You had the opportunity to attend Harvard University and be a part of the Advanced Leadership Initiative Program. How did your research affect your outlook on your ex-wife’s situation and on the healthcare system?
At Harvard, I took five courses that provided me with the key analytical approaches and principles that guided my research and the writing of my book. Each week, I participated in an Advanced Leadership seminar with the other fellows in my program that discussed how leaders can bring about meaningful and sustainable changes in organizations and in society. This was led by a brilliant professor, Rosabeth Moss Kanter.
I took two courses on patient safety and quality given by world-renowned experts in the field: Dr. Don Berwick, the recent Director of the Center for Medicare and Medicaid; Maureen Bisognano, the CEO of the Institute for Health Care Improvement; Dr. Lucian Leape of the Harvard School of Public Health and Director of the Lucian Leape Institute for Patient Safety, as well as many others. From these courses, I learned about the nature of human errors and the concepts of reliability. I was introduced to the tools for improving quality and safety.
I participated in a course called “Leading Teams” at Harvard Business School, where I learned how the business world has utilized teams to great competitive advantage.
And, finally, I took a very labor-intensive course entitled “Organizing: People, Power and Change,” led by Marshall Ganz of the Kennedy School of Government. This course taught me the fundamental campaign techniques used by politicians, unions, and reformers to organize people to achieve specific goals in the face of uncertainty. And I have been adapting these methods to change the culture of my medical center.
These courses provided me with a panorama, as well as with the specific tools needed to prevent cases like Mary’s from ever recurring. These brilliant professors encouraged me to pull together the tools they offered, and to find additional tools in the literature, to create a very practical action plan for transforming our healthcare system, one person and one step at a time.
Can you tell us more about University of Florida’s Gatorounds? How did this initiative form, and what is your primary involvement?
Prior to attending Harvard, I tried to apply manufacturing systems to multidisciplinary patient rounds in our hospital. I initially adapted Toyota’s production system and used manufacturing analogies in teaching fellow physicians how to apply these systems to shorten the length of work rounds, and to actively involve bedside nurses, pharmacists, and case managers in all patient management decisions. My fellow physicians pushed back, saying that patients were not cars, and manufacturing principles didn’t apply to medicine.
I was watching the University of Florida play Ohio State in the NCAA Football Championship when one of the linemen jumped off-sides. I blurted out, “Systems error,” and immediately realized that football and other team sports used principles identical to Toyota’s, and other manufacturers’, to win games. Successful manufacturing companies and athletic teams employ 3 key strategies:
1. Playbooks – Just as in automobile manufacturing, which uses carefully designed protocols that each person on the assembly line follows, athletes follow playbooks that define what each member of the team will do, and where and when they will perform the specific task. I realized that in order to coordinate care just like athletes, all members of a multidisciplinary rounding team needed to know their job descriptions and follow playbooks or protocols to assure that the team efficiently performed all tasks. Rather than producing cars or scoring touchdowns, the goal of healthcare teams is to efficiently and safely improve the health of patients.
2. Know who is passing and who is catching – A key condition for successful manufacturing companies is the establishment of highly stable and functional customer-supplier relationships. This is analogous to who’s catching and who is passing. If the quarterback is not familiar with how fast the receiver can run and how he likes to catch the ball, the pass will be unsuccessful. The same principle applies when doctors are supplying patient care orders to nurses. They need to know how each nurse best understands their instructions, and the nurse must provide feedback to the physician acknowledging that all instructions are clear.
3. Game films – This is the most important principle for all systems. Game films mean constantly looking at each play or process, and asking what went well and what could be improved. All effective systems, whether they are in manufacturing, athletics, or healthcare, must create multiple feedback loops that continually assess and improve each process.
I was the creator of Gatorounds, and I have been coaching this system for the past 4 years. Initially, when I began changing the way rounds were conducted, I created great anxiety among my fellow physicians. The difficulties I encountered served as my motivation to apply for the Advanced Leadership Fellowship at the Harvard Business School. I realized I had to learn how to more effectively improve our systems of care. This new understanding has allowed me to improve my ability to bring about needed improvements, without creating disabling and destructive resistance. We have now piloted the Gatorounds system for a year, and will be disseminating this approach throughout our internal medicine in-patient service over the next 6 months. Please see http://gatorounds.med.ufl.edu for more details.
Why do you think it is so important to begin implementing these ideas and practices with caregivers at the very beginning of their careers?
To use another athletic analogy, a tennis player who learns an improper technique for his or her backhand is much more difficult to coach and improve than a new player who has not learned bad habits. Our health professional schools need to teach our nursing, medical, and pharmacy students the correct approaches from the beginning. These highly effective habits have the potential to persist throughout their entire careers. In order to prevent having these habits extinguished once the students come to our wards and clinics, we must also teach our more senior nurses, physicians, and pharmacists to practice these same approaches. Because our more senior caregivers will have bad habits, this task promises to be more difficult. One potential approach may be to simply encourage senior caregivers not to resist the more effective systems approaches of new trainees.
Can you share with our readers one thing nurses, physicians, and healthcare professionals can do to minimize these preventable deaths?
The single most important thing that all healthcare professionals need to learn and practice is true teamwork. I believe the understanding of how to come together as a team to practice effective teamwork is as important as learning how to take a history exam. Teamwork increases the number of eyes and ears, as well as brains, focusing together on how to improve each patient’s health. A team approach has been shown in the business world to enhance creativity, reduce errors, improve job satisfaction, and improve the communication required for effective coordination of complex processes. Teams encourage each individual to get outside of him- or herself and focus on the team’s goal or goals. In the case of healthcare teams, that goal is high-quality, safe, efficient, patient-centered care.
How can business owners do their part to help in this initiative?
By reading Critically Ill, business owners will gain an understanding of the key processes that effective healthcare systems need to have in place to reduce errors and improve the quality of patient care. This new expertise will encourage them to demand that the healthcare systems they use and pay possess the characteristics of companies like Toyota, Southwest Airlines, and Publix Supermarkets. They will demand that they have effective systems in place to minimize human error, demonstrate effective teamwork, and have adaptive leaders who are leading change and practicing distributive leadership, as well as organizing employees to create a culture that embraces these necessary conditions.
What is your end goal for all of your work and your upcoming book?
I have been a medical educator and biomedical investigator, as well as a clinician, my entire career. Over the next decade, I plan on utilizing scientific approaches to create new methods for disseminating improvement throughout our health systems. My book will serve as one vehicle for dissemination, as will face-to-face coaching, consulting, and speeches. I am hoping to also utilize social media, and possibly television, to spread my teachings. Allying with many outstanding experts in the field of healthcare quality and safety, I am hoping to train thousands of frontline caregivers to apply the 5 skills described in Critically Ill: 1) Understand and apply manufacturing and athletic principles to patient care; 2) Understand human error and effectively utilize the many well-developed tools to reduce errors; 3) Learn and practice effective teamwork; 4) Become effective leaders who are capable of leading changes in the way all healthcare providers care for patients; and 5) Become effective organizers capable of changing healthcare system culture to support the many changes and improvements required to achieve high-quality, safe, efficient, and patient-centered care.
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