Sunday, January 20, 2013

Joe Ketcherside, MD The Ultimate Goal of Healthcare

Fiscal and Physical Asset Management has much to do with context.  That is, what circumstances brought you to acquire a particular asset? A recent post from Joe Ketcherside, MD, Co-founder, President, CEO of Cognovant Inc caused me the hit the rewind button.  I thought about the greater context in which we operate.  Getting Dr. Ketcherside’s perspective is important to me because of the path reflected in his résumé:
- Product Manager for a software company
- Chief Medical Officer
- Chief Medical Information Officer
- CEO of 2 informatics and consulting companies

I asked him, “What do you think should be the ultimate goal of healthcare whether it be government, IDN, Medical Center, or Hospital?”  For me, these types of ideals should drive the asset management program.

Dr. Ketcherside’s reply:
My thoughts on the ultimate goal of healthcare are shaped by three phases of my life.  As a surgeon, I was in a combined academic/private practice and cared for many patients.  In my journey through healthcare IT, I have worked both as a designer and manager for vendors and in senior leadership positions in several health systems.  I have seen things from the other side of the exam table - as a patient and helping family members through complex health issues.

I actually don't make a distinction between government health care, IDNs, or private physicians. In all of those organizations, our focus is the same – the patient.

Speaking first from my position as a physician, there are some principles I used in care.

-      Understand why the patient is here and what is wrong. That was partly to make the diagnosis of the immediate physiological issue that brought them, but additionally to include understanding how this medical issue fit with their job, their family, their beliefs.  Cutting something out and sewing them back up without addressing these other issues didn't necessarily mean they went back to life and work successfully.

-      Be a good steward of limited resources. By that, I mean to be cost-effective in care, consider the financial impact to the patient as well as the clinical.

-      Consider the patient's beliefs and desires in my recommendations for care. Most medical answers aren't black and white, so helping the patient consider alternatives is key. Many of the issues I treated as a neurosurgeon had their origins in lifestyle choices. I know it sounds strange from a neurosurgeon, but choosing to be sedentary, choosing to smoke, to drink and drive, to not wear a seatbelt or helmet, and so on were the origins of many of the ills I treated.  Engaging my patients in managing their health was crucial.

My goals as part of a healthcare system were similar.  But, the economic factors must be considered even more. The organization must remain financially viable, even if it is a non-profit.  My favorite CFO pointed out “no margin, no mission” in reminding us that if we managed irresponsibly there would be no health system to care for those in need.

My experience as a patient probably has the greatest impact, even with my knowledge as a physician. Several key areas draw my concern:

-      What’s really wrong and what will it do to me?  Am I going to die sooner than I thought?  Am I going to wish I was dead?  Will treating this be worse than the disease?

-      How will I pay for this?  What is going to change in my life and my career?  Who is going to take care of me/Mom/other relatives?

-      Where do I find answers?  How do I learn more about this disease and its treatment?  How do I ask the right questions?  How can I feel like I have a little control over my world?

-      How to get involved?  How can I keep track of the important labs and medications?  How can I communicate with the doctors?  How do I make sure this all works right?

If you ever want to feel helpless just try being a patient or care for a seriously ill family member.

These all tie together in my ultimate goals for healthcare, and guide my work as I develop tools and systems to improve health outcomes:

- To find the best way to resolve the acute issue that presents in a way that fits with my patient's needs, beliefs and goals.

- To help my patients understand how they can influence and manage their own health  live their lives to the fullest.

Achieving these require us to strive to help people have the knowledge, tools and resources to maintain their wellness, and to recover from illness to the best of their abilities. 

Wednesday, January 16, 2013

Openness Policies and Surgical Site Infections

Consider what would happen if every hospital had openness policies instead of a gang of lawyers  waving nondisclosure agreements.  

According to this new report by NBC News  and the Center for Public Integrity,, openness in the area of surgical site infections is not being aided by many state governments.  The report talks specifically about issues surrounding surgical instruments.

Will better openness policies help reveal a pervasive problem?

Wednesday, January 9, 2013

Haldor Advanced Technologies

For those not familiar with why tracking surgical instruments is absolutely necessary, you may want to click here,Tagging And Tracking Surgical-Instruments,, and then return to this post.

In the Intelligent Hospital Today, I wrote of creating visibility through Fiscal and Physical Asset Management.  This blog post follows up on 2 of the 4 points in that article:
-Developing data quality through simple everyday practices
-Empowering people to improve performance and make processes better

Why only these 2 points?  Mostly, because associating an asset to revenue generation and developing decision-making tools are matters of understanding how to pull comprehensive information from applications.  Haldor Advanced Technologies allowed me to look at their system, ORLocate®, under this perspective.  They promote ORLocate® as a “surgical instrument tracking and management system” that captures the complete life-cycle of surgical instruments from sterile processing to the operating room and back to sterile processing.

Starting with developing data quality in and through simple everyday practices:
In CoveringYour Asset by Exposing the Butt-Ugly Truth, the acquisition process led to the work center embracing the solution because managers and technicians drove the process toward the leadership goal.  They saw the solution well… as a solution, an assistant to help get the job done better.  Asset Management looked at reports. The work center cared for the equipment and simply looked at the monitor when needed. They looked at date time stamps and locations for a specific device or categories.  I looked at categorized and departmental utilization - the same data, different reasons.  The system reinforced their chosen process.  Compliance was much less of an issue. 

With Haldor, 2  key components to simplicity are  the ease of use through an intuitive user interface and the variety of components.  Intuitive applications together with the variety of components reinforce the significance of physical tasks in an end-to-end process. The picture below is of an RFID tagged instrument and a tag reader.  Haldor advertises that its RFID tags are capable of withstanding sterilization, liquid and the mechanical vibrations generated by ultrasound.  The scan time for one of their reader-enabled surfaces is estimated at “8 seconds per 50 instruments as compared to 2-3 seconds for each instrument with a 2D matrix”.

Tagged Instrument and Reader 

The tagged instrument and a tag reader (RFID Reader) serve as a simple way to capture the data from daily processes.
-  Haldor attaches the tag firmly to the surgical instruments.
-  The tag stores information - Unique identification code of type and serial number.
-  The reader sends a message asking the tag for this information.
-  The tag responds.
-  The reader receives the information and passes it toward the software application. 

For example, the reader may ask the tag, “What are you?”
The tag  responds with categorical and unique information, “Forceps, Number 12345.”

More information on this pair of forceps can be tied to this record.  This may include manufacturer, part number or a further description.  The tag could have responded, “Kelly forceps, curved 5½ inch.”  This step is more about ensuring data is captured easily in each step. The process for data quality does not really start here.

Data quality starts with Haldor helping clients load information about each instrument and building the inventory.  Haldor offers help by advising on best practices concerning names, categories, descriptions, etc.  They will:
- attach the tags to most standard instruments
- associate the appropriate information to the tag
- load the initial inventory

A word of caution about any initiative toward data quality: it has been my experience that some hospitals disengage from the process during this initial period.  The vendor is pushed to become responsible for decisions organizations should retain.  Whatever goes wrong, blame the vendor.   This goes the same when a solution provider can build best practices into workflow and guides.  From my perspective, disengagement is a serious mistake.  Users who depend upon a vendor's application to provide reports and manage an area really need to understand the data fields and how to access that data in the new application.  Honestly, it may take a while.  But, in every case, my time was well spent going through this process beforehand because I have seen the results of not doing so.  Avoid the Dive Weights! If you have read Covering Your Assets byExposing the Butt-Ugly Truth, that means something to you.  

Once quality data is associated to the tags and uploaded to the software application, the daily tasks involve placing multiple instruments in front of a reader and touching a button once.  

Haldor RFID Scanner Reading Multiple Instruments

The reader sends the information to the software application.  The application dates and time stamps each transaction and assigns that scan to a step in the instrument care process.  This is performed in each step from collection to dispatch.  The system will alert if any instrument misses a step.  The records are maintained every day throughout the entire life cycle of each tagged instrument.

Haldor offers a variety of components to keep tasks simple and to optimize workflow.  This leads to implications for the operating room as well.  These are Reader-Enabled surfaces and bins.  Again, the estimated scan time is “8 seconds for 50 instruments vs. 2-3 per seconds for each instrument with a 2D matrix”. 

Reader-Enabled Surface (Can be configured for Back Table or Mayo Tray Setup)

The surfaces provide tracking for SPD, and counting for Back Tray and Mayo Tray setups.  Haldor states that current covers and bags can be used with their hardware.  The surfaces reconcile instruments going in and out of the surgical field as well, preventing tools from being left inside a patient’s body (Retained Surgical Items).

They offer 2 devices to ensure all sponges, used and unused, are reconciled to the total count brought into the operating room.  The Sponge Tray and the Sponge Bucket provide this capability.
-  Haldor tags the sponges.
-  The tray counts unused sponges.
-  The bucket counts used sponges.
-  The software application reconciles the unused sponges in the tray and the used sponges in the bucket to the total count brought into the OR suite.
-  There is a method of adding to the total sponge count as well.

Tagged Sponge

                Sponge Tray                                          Sponge Bucket

Locator: detects hidden or covered items

-Empower people to improve performance and make the processes better
When I asked Haldor about this particular criteria, they showed me the guidelines and practices built within their software: AORN recommended practices (updated July 2010); The Joint Commission standards and Patient Safety Goals-CAMH Update 2 (September 2010).  In other words, Haldor’s approach is to simply, reinforce, and educate users by integrating international best practices within the daily workflow of technicians.  If the technician encounters an instrument care process in which the local guidelines are not in compliance with internationally recognized practices, the technician or manager can request a change and have hard reference material to support it.

In this example, Haldor shows how integrating ORLocate® into a hospital wireless network can electronically connect instrument management in the OR and SPD with other platforms.

On the patient treatment side, this allows assigning sets and instruments to a patient.  The result is auditing for each tagged instrument that entered into an operating room and the sterile field for a particular patient.  I did want to touch on integration for another reason too. It can directly relate instruments and sets to a revenue generating person (the surgeon), and the revenue’s paying person, (the patient). Overtime, the utilization, maintenance cost, and inventory, etc. can be compared directly to revenue.  And maybe… just maybe, this will answer the long term issue of excess equipment inventory.  

To close, one final word of advice, when acquiring any technology, write an acquisition plan that returns distinguishable vendor proposals in regards to strategic and operational goals.  For example, if your goal is to electronically track 100% compliance in all steps in the surgical instrument care process for each instrument and use on each patient, put that upfront, even in the first paragraph.  That will help guide an acquisition plan and process capable of keeping every stakeholder in the game.