Better and Escape Fire

Still reading Better by Atul Gawande about quality improvement in healthcare, by a surgeon I believe partly responsible for the preoperative check list which received so much publicity a year or two ago.

Three main sections:

1. Diligence; devil in the detail?
2. Doing right; good rather than harm, or nothing
3. Ingenuity; thinking and doing differently to what has been thought and done before (Change?)

Finishes with some recommendations for being a 'positive deviant'

1. Ask an unscripted question
2. Don't complain
3. Count something
4. Write something (in a blog perhaps)
5. Change

The person who recommended it to me, a Patient Safety expert, recommended Escape Fire by Donald Berwick to read next....a collection of speeches

From the introduction to Donald Berwick's Escape Fire (by Frank Davidoff MD);

Donald Berwick's revolutionary posture;

1. Positive (as opposed to negative, must be a good thing)
2. Recognition of medicine as a social act (as a team we can be more effective than as a collection of individuals)
3. Action orientated, expects performance and provides the tools

Some of the (more noteworthy) tools

• Name the problem
• Build on success
• Take leaps of faith
• Look outside medicine
• Set aims and show constancy of purpose
• Understand systems
• Make action lists
• Never - ever - lose sight of the patient as the central figure

Why publish as speeches?... Why speeches don't make good reading first:

1. The speaker's need to underscore key points by repetition can get in the way of written text
2. Speakers are real time social events in which the speaker connects with his audience...print is passive, generic, non-living, puts distance between author and reader (which can drain the life out of a speech)
3. Each speech has to stand on its own; publishing several related speeches has unintended redundancy

But:

1. These speeches have coherence and energy
2. Feedback was that copies of the speeches would be valuable to the audience
3. Speeches over a time could show change..make it possible to 'illustrate the trajectory of movement in medicine'...allow 'the intrinsic synergy among the speeches to emerge'...'not all redundancy is bad'

The speeches don't deal with:

1. Clinical work
2. The reality of individuals not up to the job
3. The dark side of improvement work (watch this space, more to come, I anticipate, if the dark side doesn't win me over)

One of the most important messages:

• Dependence on collective wisdom. But be inspired to mount the improvement barricades.