Dr. Frederick Southwick, Harvard Fellow and Author of “Critically Ill: A 5-Point Plan to Cure Healthcare Delivery”

Welcome to Conversations on Health Care with Mark Masselli and Margaret
Flinter. Mark is the Founder, President and CEO of the Community Health
Center, Inc., a provider of primary health care services for the uninsured and
underserved in 13 cities and 218 service locations in Connecticut. Margaret is
Senior Vice President and Clinical Director of CHC and is a Family Nurse
Practitioner by profession.

Conversations on Health Care is a weekly look at the people and ideas that are
transforming the delivery of health care in America and this week, Mark and
Margaret, will be speaking with Dr. Frederick Southwick, author of Critically Ill: A
5-Point Plan to Cure Healthcare Delivery. In the Tech Report segment, Marianne
O'Hare looks at a computer chip designed to help prevent heart disease. And we
begin with this week’s bright idea.

(Music)

Margaret Flinter: Each week, Conversations highlights a bright idea about how
to make wellness a part of our communities and everyday lives.

Mark Masselli: When the Federal Health Reform measure goes into effect in
2014, millions of Americans are going to be added to insurance rules, adding
pressure to primary care systems that already are experiencing a shortage of
practitioners. It's expected that community health centers will become vitally
important when used for serving the health needs of these additionally insured
Americans. The Blue Shield of California Foundation, one of the California’s
largest health care grant making organization, sees this as a critical time to
bolster community health centers to better accommodate the wave of new
patients, while maximizing opportunities presented with the Affordable Care Act.
Since 2003, when they launched the Clinic Core Support Initiative, the
Foundation has donated $47 million to clinics throughout California to improve
their ability to provide quality care to the underserved population. CEO, Peter
Long, last week, announced an additional $7 million grant to strengthen the
state’s network of community health centers.

The money is being earmarked to assist existing clinics with operating funds,
assist some clinics in better utilization of electronic medical records and create a
database from the state’s highest performing health clinics to provide a model of
excellence for other clinics to strive towards including training the next generation
of community health center leaders. A health foundation, funding improvements
to clinics and health care training to improve access to quality care for our most
vulnerable citizens, now that’s a bright idea.

(Music)

Mark Masselli: Today, Margaret and I are speaking with Dr. Frederick Southwick,
Professor of Medicine at the University of Florida in the Infectious Disease
Division. He is also a Harvard fellow at the Advanced Leadership Institute and
author of Critically Ill: A 5-Point Plan to Cure Healthcare Delivery, which comes
out soon. Dr. Southwick, welcome to Conversations on Health Care.

Dr. Frederick Southwick: Thank you Mark.

Mark Masselli: As an internist and infectious disease specialist for over 30 years,
you have seen a lot of misdiagnosed and medical errors during that time. In fact,
your former wife was at one time a victim of a series of medical errors that almost
cost her, her life. And I think it's well known that the medical errors or mistake
cause probably over 100,000 deaths per year. Could you start off with the larger
picture and shape up the dimensions for our audience of what the costs are to
the health care system both in terms of human toll and financial cost as well?

Dr. Frederick Southwick: Yes. I think Mark these are the key elements and one
of the primary motivators for me to write this book. And the case that I describe
in the book about Mary I think reflects that human toll. This is only one person,
one family. So if there are 100,000 deaths, there are probably over a million
injuries that are very profound, probably more than that, and not only that, each
individual has at least 10 close family members or friends that are profoundly
impacted by that death. And they never -- I can tell you from my own personal
experience, you never forget what happened to a loved one. That remains with
you the rest of your life. But also the caregivers that make these errors due to
poor systems they are what we call second victims. They also suffer. If a nurse
gives a wrong medication and it kills the patient, imagine how that nurse feels. In
general, they actually, in most cases they leave the profession and move on
because they cannot deal with the suffering and pain that they actually caused.

And then if you look at the finances, I actually broke down the cost of Mary’s
care. If it had been routine, her care would have cost about $16,000 while if
because of the complications and errors the actual cost was more like $95,000.
If there are 100,000 deaths, it's somewhere in the order of $20 billion to $30
billion in losses. So these are huge amounts of money that we really can't afford,
and on top of that, much more to me a greater concern is the personal cost of
these kinds of injuries and deaths.

Margaret Flinter: Dr. Southwick, you begin each chapter of your book with a
compelling detail or a question from the experience of your former wife and the
medical crisis and near-death from a series of disasters. And it's a very gripping
personal story. But you make the point that you blamed the doctors initially in her
case for their mistakes but then you start to really understand the systemic
nature of the underlying problems in care delivery so you started seriously
studying other models like in automobile manufacturing. What can we learn from

those systems like manufacturing systems that can fundamentally help improve
health systems and safety?

Dr. Frederick Southwick: I think what happens to all families are they blame the
person who specifically cared for their loved one. And that’s exactly what I did
until I understood that these caregivers, I mean they were partly to blame but,
they were victims of very poor systems. And I actually heard a talk by a very
outstanding person in the field Steve Spear who is in MIT. He talked about the
DNA of Toyota and how it could be applied to health care. And I have to tell you
this was 15 years after the episode. I started crying because I realized that I had
blamed those individuals rather than blaming the systems as well. And what we
have learned is in most situations, errors are not caused by bad people, they are
caused by bad systems.

So now what can you learn? Well Toyota I think have been the leaders for over
60 years in an effort to improve quality, to reduce defects in their cars. And there
are three key elements of Toyota. First of all, protocols; every procedure must be
carefully outlined and done in the same way and each of those protocols can be
improved and perfected. So that’s the first. The second is customer-supplier
relationships. In Toyota, one of the key customers is for instance if you are the
part supplier for a frontline worker on assembly line, that assembly line person is
your customer and you respond to them very quickly when they need something.
And this is a major problem in health care that we don’t understand who the
customers are and we don’t respond properly. And the third and very, very
important is constantly improving, looking at your processes, empowering
everyone on the front lines, middle management whatever, looking at the
processes and deciding how they may be improved. In this way, Toyota has
dramatically reduced the cost of their cars, and at the same time, improved,
dramatically improved, the quality of their cars. If we could do the same thing in
health care, we could dramatically improve the quality of care and reduce the
errors.

Mark Masselli: Dr. Southwick, in addition to your research and ideas about using
other industries like Toyota and lean processes, you are also starting to look at
other disciplines from the world of sports. How do you envision medical teams
using playbooks and what other ideas from the world of professional team sports
can also be brought to tackling the problem if you will be in health care.

Dr. Frederick Southwick: At the University of Florida, we have had a number of
championship teams. And I was actually an athlete, I played football at Yale and
lacrosse at Yale. Championship athletic team, the team that wins, makes the
fewest errors. And what’s powerful about that from an American standpoint is
virtually everyone at sometime in their lives has played a team sport or they
watch team sports. Therefore, we already understand how to work in teams, we
already understand the concept of protocols because the playbook is a protocol
and that’s exactly what we need in health care. We in health care know so much

and our vocabulary is so different that we need to look through the eyes of our
patients and that is a very important customer-supplier relationship. And the third
key element is what’s called in sports, game film. The coaches video all games
and then play them back to the players later and they go over what went well and
they go over what could be improved. Now, if each of us in health care would
look at ourselves and say what went well and what we could improve, we could
get better and better and better and really improvement is an iterative process.
In other words, it's small steps, it's continually getting feedback and then
improving based on that feedback.

Margaret Flinter: Dr. Southwick, you wrote the book with a long time nursing
colleague Dr. (09:40 inaudible). You seem to clearly see that the further
empowerment of nurses is one critical milestone in improving the quality of care
and safety for patients. I wonder if you would share with us what are your ideas
or best practices on further leadership governance and autonomy systems that
really do empower nurses, not just nurses, empower all members of the medical
team that take care of patients.

Dr. Frederick Southwick: As I analyzed this situation, I realized nurses are the
frontline of care, they are the ones that are with the patients the majority of the
time and doing other treatments. And therefore, if the systems are bad, they are
the ones that make the error because the systems are bad and they suffer the
consequences. And most important, nurses have no conflict of interest. In other
words, they get paid to care and empathize and comfort their patients. So, one
of the things that I found that’s most important is to always focus on the patient.
And since nurses do that, I encourage them that they be the patient advocate.
When they see themselves in that role, they are much more willing to speak out.

One of the huge problems in health care is what I call the command and control
model of leadership; in other words, the head of the hospital commands
everybody below them to do things. This simply will not work when it comes to
high quality systems and everybody in manufacturing, in fact, the military now
has realized that you have to empower those on the front lines to be leaders and
to speak out and make suggestions for improvement, and those high above have
to listen to those suggestions and help to implement them. Nurses, virtually all
caregivers, have to understand that each of us contributes in a different way and
each of our contributions is equally valuable. In fact, in some cases, I believe
nurse’s care is the most, I do believe, is the most valuable part of patient care.
They should be willing always to speak out when there is something that’s not
going right with their patients. And one of the ways we have emphasized that is
we always on work rounds, we schedule our rounds so that the nurses know, the
bedside nurses know when we are going to be there and we create a huddle and
we make sure that the nurse is in that huddle and when you have a circle, then
everybody feels much more equal.

Mark Masselli: What a great approach! We are speaking today with Dr. Fredrick
Southwick, Professor of Medicine at the University of Florida, Harvard fellow in
the Advanced Leadership Initiative and author of a soon to be released book,
Critically Ill: A 5-Point Plant to Cure Healthcare Delivery.

Now your approach has been really to sort of the bigger picture how to eliminate
types of waste and ineffectiveness in the current system. You have also been
very critical of the overuse of testing. How is the reliance on expensive and
unnecessary test endangering our patients?

Dr. Frederick Southwick: One of the big problems is that physicians who order
most of these tests have not worried about cost or worried that much about or
minimized the likelihood of a complication from a test or a procedure. And what’s
happened is they don’t think about what the likely effect of their procedure is
going to be or their test is going to be. In other words, they don’t ask themselves
how will I change my management if this test is positive or if this test is negative.
Many of the times it turns out that they are simply confirmatory and are what I call
icing on the cake; they really don’t benefit. So, MRIs are actually very safe
unless you happen to have a pacemaker but other procedures are not. For
instance, cardiac catheterization, very commonly used today, and that procedure
has a certain known side effect. For instance, I have seen several patients bleed
into the back of the retroperitoneal area. And what’s happened is when you
increase the capacity to do cardiac catheterizations, it's been shown that the
(13:35 inaudible) will do more of these procedures and some quite often they are
not necessary, in other words they don’t really change the therapy significantly.
So the test becomes overused and the more you do that, the more likely you are
to have a complication.

Margaret Flinter: Dr. Southwick, you are obviously a lifelong learner, and I really
enjoyed reading about a labor-intensive, you described, a course you took I think
at the Kennedy School and you said it taught me the fundamental campaign
techniques used by politicians and unions and reformers to organize people. So
tell us, how are you going to use the art of persuasion to move things forward not
just in one teaching hospital or in one profession but really across the country as
we enter this period of time when the Affordable Care Act hopefully will be
implemented. What’s the art of persuasion you are going to use?

Dr. Frederick Southwick: In order to organize people to change how they think
about the world, you have to actively involve them and recruit them to take
action. So a good organizer is a person who meets people one-on-one, finds
that we share values together and then develops a leadership group then steps
back and allows that group to create a strategy and tactics to bring about a
change that they think is important within an institution. This chapter to me is the
most important for health care because the culture right now I think is caregiver
focus. And one of the key elements, and I have actually been working. We have
a campaign at the University of Florida now based on these principles called the

Physician “I Promise” Campaign, and each physician is working, as an individual,
is promising to in some way enhance our patients’ experience when they are in
the hospital. And what we have done is I have empowered a leadership group of
young physicians who are very energetic, very talented and we have created
together a series of forums. We had a doctor-patient communication forum and
we recruited patients to describe their personal experiences interacting with
physicians and we have had a second forum on doctor-nurse communication and
we had nurses describe how they see a communication with physicians and how
that could be improved. And by doing this throughout the country, I think we can
dramatically change the attitudes.

One of the sad things to me that I just don’t understand is that so many people in
our country are against universal coverage. We know it’s been well shown that if
we talk about deaths; we know that those are not covered because they lack
health care coverage. We know there are 45,000 deaths per year due to lack of
coverage. How can we as a people not be concerned about our fellow man. And
similarly, what we are doing in physicians, we are asking physicians to get
outside of themselves and to focus on our patients, focus on working better with
our nurses, focusing on teamwork, and that’s what we as a nation need to do.
We need to focus on teamwork, on being a community and caring about
everyone and not just ourselves.

Mark Masselli: Well, you are right on about the access and certainly about the
change of culture that’s needed in the system. I know at our health center, we
are a patient level 3 patient-centered medical home, but we are still looking at
how to improve that. We brought together the Dartmouth Institute with the GE
Lean Manufacturing people and really looking through the process of how do we
build a high quality, safe, efficient and patient-centered primary care. And you
are very focused in on patient-centered care, doing more to respect the dignity of
every patient while at the same time making it more efficient and streamlined.
Talk to us a little bit about that.

Dr. Frederick Southwick: We have worked on this the most is a rounding system
that I developed and it’s based on athletic principles we call Gatorounds because
of the University of Florida mascot is the gator.

Mark Masselli: We got that one.

Dr. Frederick Southwick: Yeah. And Gatorades, we call it Gatorounds, after
Gatorade. One of the key elements of all athletics and all systems is the
fundamentals and one of the key fundamentals is how we communicate
efficiently. So what we did is we created very efficient and whenever possible,
we actually try to do all rounding in the patient’s room. So one of the things that I
emphasize is obviously athletics means teamwork. A key member of the team
has to be the patient and somehow this is ignored, who is going to take care of
themselves 95% of the time. So if we don’t include them in the team, when they

leave the hospital, they aren’t going to know what to do. And I think perceiving
them as a member of the team makes them more equal because after all it’s their
body, it’s their life and we really need to listen to what their concerns are so that
they will comply, so they will follow the treatment plan.

Margaret Flinter: Dr. Southwick, one more sort of question I would like to go at
relative to the people who provide the care and you have talked about burnout as
a huge concern. It’s a huge concern along the whole continuum of care and I
thought you made the great observation that if a patient or their family sees their
caregivers looking exhausted and harried, beware, because that burnout can
have a direct impact on quality and safety as well. Tell us about this five point
plan you have written about and how that might really increase the vitality and
wellbeing for the whole health care team.

Dr. Frederick Southwick: Anyone who influences others to improve the care of
our patients is a health care leader and that means everyone in the system can
be a leader. Now, when everybody feels empowered to bring about change, they
develop a new autonomy, a new sense of significance that makes their job so
much more enjoyable. So that was one key, is leadership I realize. Then
obviously we need to understand manufacturing, athletic systems, we need to
understand the nature of human errors and how to assess those human errors
and create systems to improve them. And then one of the most important
elements, the fourth element is teamwork. Many doctors and particularly
physicians I think don’t understand how to work well in teams. The sole
practitioner model, the Marcus Welby model still persists in the minds of many
physicians. We need to understand that we have to work in teams and be
coaches rather than dictate what goes on. And then the fifth element, which we
have talked about, is learning how to bring about cultural change. Each of us
can campaign to bring about cultural change.

So if you create a positive culture, if each of us feels we are a leader and are
autonomous, if each of us is within a system that is efficient and reduces waste, if
each of us is in a system that minimizes errors and each of us feels part of a
team and has a team spirit, we will create a true joy at work. And each of us will
become more focused on the ultimate goal which is improve the well being of our
patients.

Mark Masselli: Well said. Dr. Southwick, we like to ask all of our guests this final
question. When you look around the country and around the world, as it relates
to improving health care, who should our listeners at Conversations be keeping
an eye on?

Dr. Frederick Southwick: Well, one of the things that I think you will notice is that
most of the dialog is by politicians, administrators, economists, and the actual
caregivers and the patients are not speaking out. And my hope is that through
this book, and through interviews such as yours, that we will begin to hear those

that are on the frontlines that are either benefiting or being harmed by the care
and those who are giving the care and are affected by these systems that we
have, will begin to actually speak out on what is needed to improve patient care.

Mark Masselli: We have been speaking today with Dr. Frederick Southwick,
Professor of Medicine at the University of Florida in the Division of Infectious
Diseases and Harvard fellow at the Advanced Leadership Institute. He is also
the author of Critically Ill: A 5-Point Plan to Cure Healthcare Delivery, which
comes out soon. Dr. Southwick, thank you so much for joining us today on
Conversations.

Dr. Frederick Southwick: Thank you, I enjoyed talking.

(Music)

Marianne O'Hare: I am Marianne O'Hare with this Tech Report. A genomics
researcher has developed a tool that has helped scientists across multiple
countries and dozens of heart studies identify what could be the next target area
for preventing and treating heart disease, the world’s leading killer. Dr. Brendan
Keating of the Center for Applied Genomics at Children’s Hospital of Philadelphia
designed a chip that could cross reference up to a million potential gene variance
per person and which ones were likely to lead to heart disease.

Dr. Brendan Keating: 2000 heart genes, about 50,000 markers and then it was
genotype in about 210,000 individuals across 60 different studies.

Marianne O'Hare: Meaning, a possible new treatment using anti-inflammatories
to either prevent or treat the illness.

Dr. Brendan Keating: It's very tough right now to assess an individual risk based
upon that. But it just gives us a very strong indication that that information is a
key mediator in coronary heart disease.

Marianne O'Hare: The Cardio Chip, a prime example of how open source
science and technology are intersecting the speed of discoveries for the source
of illnesses and possible preventive treatments and cures. I am Marianne
O'Hare.

(Music)

If you have questions for Mark Masselli and Margaret Flinter, or would like to
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