Wednesday, January 25, 2012

Political Thought for the Day (1.25.12)

If we want progressive government, it is not enough that we have a progressive president (even so moderate a progressive as President Obama). It's not even required.

If we truly want progressive government, we need a progressive Congress. More specifically, we need a 2/3 majority in both houses - 292 or more in the House and 67 or more in the Senate.

Think what that would mean. If President Obama is re-elected, he has an overwhelming majority, and especially one that can resist a filibuster in the Senate. If President Obama is not re-elected (heaven forefend!), that is a majority that can not only resist a filibuster, but can override a presidential veto.

And note that I haven't associated this with a specific party. There are some troublesome regressive Democrats; and there are certainly out there some progressive Republicans (well, at least there used to be). The issue isn't party, but progressive goals.

So, if we want progressive government, we need a progressive Congress. And it's time we focused on that. The regressives learned this long ago; which explains why we have the Congress we have today.

Thursday, January 12, 2012

First Do No Harm; Nor Allow It To Pass Unnoticed

For more than ten years now a central theme in the lives of hospitals and health care professionals has been patient safety. It has always been a concern, but a significant step was a report from the National Academy of Sciences titled, "To Err is Human: Building a Safer Health System" (linked from here). This study noted how often patients were put at risk, and then sought to identify the causes. According to the Report Brief,

One of the report’s main conclusions is that the majority of medical errors do not result from individual recklessness or the actions of a particular group--this is not a “bad apple” problem. More commonly, errors are caused by faulty systems, processes, and conditions that lead people to make mistakes or fail to prevent them. For example, stocking patient-care units in hospitals with certain full-strength drugs, even though they are toxic unless diluted, has resulted in deadly mistakes.
Thus, mistakes can best be prevented by designing the health system at all levels to make it safer--to make it harder for people to do something wrong and easier for them to do it right. Of course, this does not mean that individuals can be careless. People still must be vigilant and held responsible for their actions. But when an error occurs, blaming an individual does little to make the system safer and prevent someone else from committing the same error.

The report has been very influential, as we’ve sought to improve the safety and the experiences of patients. Of particular importance has been a “non-punitive workplace.” To improve the system requires continuing improvement; and continuing improvement requires data. More specifically, improvement requires identifying problems and mistakes. After all, that information provides the best direction to take to improve the system. Improvement actually requires that staff report problems, and especially errors. To encourage that reporting, healthcare institutions elected to establish a non-punitive workplace. That is, to encourage reporting staff have been told that they could report mistakes without fear of being fired, so that the system could be improved to prevent such mistakes. The efforts at improving the system required that staff report their errors.

And unfortunately it appear that the reporting isn’t happening. A new report was released last week from the Office of the Inspector General of the Department of Health and Human Services titled, “Hospital Incident Reporting Systems Do Not Capture Most Patient Harm.” (you can link to the report from here; and to a New York Times article here). Worse, it appears that the reporting systems fail precisely because the people on whom they rest, the professionals who make or see the problems, don’t know what to report. As it was reported in the Executive Summary:

Hospital staff did not report 86 percent of events to incident reporting systems, partly because of staff misperceptions about what constitutes patient harm. Of the events experienced by Medicare beneficiaries discharged in October 2008, hospital incident reporting systems captured only an estimated 14 percent. In the absence of clear event reporting requirements, administrators classified 86 percent of unreported events as either events that staff did not perceive as reportable (62 percent of all events) or that staff commonly reported but did not report in this case (25 percent).

In a way, this finding  concerned me more:

For the 62 percent of events not reported because staff did not perceive them as reportable, administrators indicated that staff likely did not recognize that the event caused harm or realize that they should complete a report. The most common reason administrators gave for staff underreporting was that no perceptible error occurred (12 percent), indicating that staff commonly equate the need to complete incident reports with medical errors. Other reasons for underreporting include staff becoming accustomed to common occurrences and therefore not submitting reports, such as events that were expected side effects (12 percent) or occurred frequently (8 percent). (Emphasis mine)

Or as the report says in another paragraph, “Although administrators indicated that they want staff to report all instances of harm, when asked about specific events administrators conceded that staff may often be confused about what constitutes harm and is, therefore, reportable.” (Again, emphasis mine)

In one sense, that seems troubling. The determination of harm would seem to be measured based on what did or what could happen to the patient. But, then, that becomes one of the points of decision: if what could happen didn’t happen, was the patient harmed? Or, if it’s an expected or frequent side effect, does the fact (or the assumption) that benefits to the patient exceeded risks mean that the patient isn’t (“isn’t really”) harmed? While we would think that harm would be pretty easy to identify, it may not always be so clear to the professional in the circumstance at the time.

The OIG report recommends the development of a list. That could certainly be helpful. The risk, of course, is that what we see as harmful today may not be an issue in the future; and that the list may soon be dated and inadequate.

At the same time, we do need to pay close attention. Reporting of these incidents that either harm patients or come close to harming patients is dependent on the professionals serving them. I know that they want patients to do well, and to have things go right. It is important that they also recognize what to report when things don’t go right. Once again, that’s the only way that we’ll know where the issues lie, and what we need to improve.

Sunday, January 08, 2012

On Bull Riding and Baptism: Reflections for the Feast of the Baptism

As I was preparing to preach on the Feast of the Baptism, I was also listening on my computer to professional bull riding.  I commented on that on Facebook, and one of my friends wrote, “Could be an interesting sermon.” This or something like it was my sermon for the Feast of the Baptism, Year B.

My Best Beloved and I have been fans of bull riding for some time. It began some time ago, when she was studying veterinary technology. Just as she was working through her large animal rotation I discovered bull riding on television. We started liking the bulls – magnificent animals! And then I began watching the riders themselves. I’ve spent a career in hospital work. I’ve seen folks in the ER with all kinds of traumatic injuries. So, watching bull riders take falls and blows from bulls that ought to put them into intensive care; and then to see them get up and walk out of the arena, was just astounding.

One thing you see quickly when you watch bull riding (and let me be clear: I am not nor have I ever been a cowboy. I am a fan, but watching is all I’ve ever done) is that the bull rider is fully committed. He gives it everything trying to complete those eight seconds (and, yes, there are women bull riders, but they don’t get on television). They put their bodies, and literally their lives on the line. They are, as they say, all in.

Which brings me back to baptism. We believe that we are baptized, as we say, into the baptism of Christ – baptized into his death and resurrection. Our understanding is that, once baptized, we are all called to be fully committed, and to put it all on the line.

That is, of course, the model we have in Jesus. He was baptized by John, embracing a baptism for repentance, embracing in that sense all sin, including ours. He saw the heavens ripped apart, he saw the dove, and he heard voice of God: “You are my son. I’m happy about this.” From there, as we recall, he went on until he put his life on the line for us. From his baptism, Jesus was certainly all in.

And so we are also called to be fully committed, and to model our whole lives on Christ. That’s what we say at every baptism. Indeed, that’s why we baptize our children, so that they can grow into Christ from the very beginning. We, too, are called to be all in.

Now, one thing that bull riders say over and over is that bull riding is really a mental game. It doesn’t look that way. It looks like it’s a serious physical challenge. The fact is, though, that all those guys are strong and agile and fit. All of them have bodies that put most of ours to shame; and yet some ride, and ride for years, when others do not. All of them fall off of bulls – most of the time short of their eight seconds – and yet they get up again and again and again. That’s about mental determination, about heart.

Which is also part of what baptism is about. We believe that in baptism we receive the Holy Spirit and are strengthened for our lives in Christ. When Jesus was baptized, there was the Spirit, seen as a dove. When Paul reached Ephesus, he found a congregation that had heard of Christ. They had even been baptized, but only to repent of their sins. He baptized them himself, and laid his hands on them, and they did receive the Spirit; and immediately they found themselves empowered in ways they hadn’t imagined before.

So it is as we are baptized into Christ. We also receive the Spirit, there to empower and guide us in our lives in Christ. That’s especially important when we fall short. And we certainly will fall short. We will have our own times when we lose our grips and are thrown off. We will fail to meet the standards we set. None of us has the discipline, the strength – either physical or mental – to always live up to our model in Christ. When we fall, the strength to get up again comes from the Spirit. The voice that calls us and says, “yes it hurts. Yes, it’s hard; but you can get up and you can start again,” is the voice of Christ’s Spirit pleading with our spirits. And without that Spirit, we would surely be lost.

And so there are indeed parallels between bull riding and baptism. From our baptism, we are called, as Jesus was, to be fully committed, to be all in. From the time we come through the water, just as when Jesus came up from the water, our world is torn open and God says to us, “You are my child, and I’m happy about this.” We are empowered by his Spirit to model our lives on Christ. And when we fall short, it is Christ’s Spirit that gives us the strength and courage to pick ourselves up out of the dirt and try again. We have been baptized with the baptism of Christ. We have been baptized into his death and resurrection. We have been called and empowered to model our lives on Christ; and like our model, we have been called to be all in.

Thursday, January 05, 2012

Latest on Endorsement for Healthcare Ministries.

The Episcopal Church has completely revised its web site. So far, I think there's a lot of promise there.

That said, one point that was missed in the first days was information on healthcare chaplaincies. Episcopal chaplains across the country have made their concerns about this known to folks at the Episcopal Church Center. One special concern was accessing on line the application form for Endorsement for Healthcare Ministries. Now the form is available, and you can access it here. Instructions on completing it, and on whom to send it to, are on the form, and those haven't changed.

I know that searches about Episcopal or Anglican Chaplaincy, and especially about Endorsement, are among the most frequent reasons that people find this blog. With that in mind, I wanted to have this information current and available. I'll keep track, and if there are further changes I'll let folks know.