Monday, December 13, 2010

My Day at a Free Clinic: The Truth Behind the Rhetoric

I just got back from a most remarkable experience: volunteering at a free clinic in Charlotte, NC.

Like many of you, each day I read my Daily Digest to be aware of the health care news of the day. The political rhetoric about the work ethic of the unemployed has been awfully harsh lately. Opinions about health policy and the tug of war between the two political parties that appear on the editorial pages of our nation’s newspapers seem very disconnected from the reality on the streets and country roads of the United States.

I had the opportunity to hear the stories of hard-working and proud Americans who have lost their jobs, and with the jobs, their health insurance. It’s these stories that make the policy issues come alive, and drive home the absolute necessity for clinicians to help create a system that is worthy and respectful of the character of these Americans.

Mary, 60, is a well-educated woman whose COBRA coverage expired two months ago. She lost her job as a loan evaluation specialist at a bank 20 months ago. She paid the full cost of coverage for her health insurance under COBRA because she knew the consequences if she developed a serious illness, and couldn’t pay for the costs of care.

With hypertension and thyroid disease, she’s familiar with generic drugs that keep her costs down. She’s not sure what she’ll do to cover the years until Medicare coverage becomes available, because she’s caring for her 87-year-old mother, and helping her son who moved back home when he lost his job. She’s also back in school re-training as a health care billing specialist, because even “dumbing down” her resume to not appear overqualified for many jobs hasn’t helped her land any interviews. She takes care of herself, and relies on her faith that she will make it through her difficult situation.

Susan, 45, is a wife and mother of two elementary school children who stayed behind in New York to continue working at her job when her husband got a new job in North Carolina. Though living apart as a family was difficult, as an accountant she knew it was necessary to get through the recession. She was the first to lose her job. A few months after moving to NC, her husband’s job disappeared. Neither has been successful in finding new work. She told me her children have health care coverage, and that her kids have been very supportive of her as a good mom, even though times are tough for the family.

Those were just two of the nearly 1,200 people who showed up for the free clinic. Not only was I privileged to be part of their lives for a few minutes, but it was an opportunity to work as a team with nurses, other physicians, and volunteers to help others in this season of hope and goodwill. The young physician (six months out of internal medicine residency) working in the cubicle next to me was my lifeline to high quality, current medical thinking. She thought my years of experience were equally as important. We made a good team yesterday. Thank you, Nicole.

Finally, on behalf of other ACPE members who served as volunteers yesterday, we thank Ed Weisbart, one of your ACPE colleagues who is a leader for the National Association of Free Clinics, for letting us know of this opportunity. Included with Ed in making this happen is our own Charisse Jimenez, who helped us get the word out.

Interested in volunteering or making a donation? Visit the National Association of Free Clinics to learn more. In addition to practicing physicians of all specialties, residents and medical students are welcomed to volunteer. The NAFC also needs mid-level practitioners, nurses and everyone else who can help, clinically or nonclinically.

Monday, November 29, 2010

A Good Death

My friends and family must be outliers from what many physicians tell me about patients’ demands for expensive, and often futile, care.

Several friends are facing terminal illnesses. Their concerns are about overtreatment and getting into situations that diminish the quality and dignity of their lives. They tell remarkably similar stories of listening to their oncologists’ recommendations for additional (but debilitating) chemotherapy. Then they decide to forgo the recommendations because it doesn’t fit with how they want to live. Their biggest concern is having a good death, because they already know life will not be long.

My Mom has a debilitating disease. She wanted enough diagnostics to know what the problem is, and then told her doctor that she’d come back when the symptoms got bad enough that she would consider medication. Not yet.

Grandma Winchester, my 93 year old mother-in-law, is another good example of health economist Michael Grossman’s theory of consumers’ demand for health and healthy days – not necessarily health care. Health and healthy days provide us opportunities to do what we love, whether it’s time with family, hobbies, or meaningful work. Time spent in doctor’s offices or hospitals is not a preferred way to spend her days.

Within the past year, she’s chased a bear out of her kitchen and been evacuated twice from her 600 square foot cabin in the Colorado Rockies because of nearby forest fires. She stays in shape by hiking, shoveling gravel on her mile long driveway and walking two miles round trip every day to get the local newspaper and her mail. She gave up driving a few years ago because she wasn’t as sharp as she wanted to be. But she still drives her snow plow truck in the winter to plow that driveway.

Though she loves her doctor and has gotten excellent care, she hates going for a visit because it means she has to impose on one of her children or grandchildren to drive her to town. Instead, she appreciates that her physician answers her questions by email. She’s talking about getting “DNR” tattooed on her chest.

About two years ago, her husband of sixty-seven years died in their cabin – just as he always wanted, sitting by his favorite fireplace. Despite being paraplegic for almost sixty years from the polio epidemic, he never developed a pressure ulcer – even in his final days. His family made sure of that.

Grandma will die in that cabin someday. Her family will make sure of that.

I read somewhere that 80% of Americans say they don’t want to die in a hospital or nursing home. But 80% of Americans do die there. The reasons are undoubtedly complex.

Think about your own wishes and what members of your family want. Lots of expensive care, waiting for the next test result, cooped up in a hospital? Maybe some do, but many other people just want to have healthy days, and realistically know they won’t live forever.

What is a good death for your patients? Have you asked?

Wednesday, October 27, 2010


The word came up in two separate conversations, from two very different people. Every two weeks, we ask someone associated with ACPE to spend 45 minutes sharing his/her insight on the trends occurring in health care. Both people are nationally known, one a recruiter, the other a physician leader. With the number of physician leadership roles growing rapidly in the past few months, I want to share their comments because they’re important for both job seekers and leaders who plan on staying in their current organizations.

The recruiter said physicians seeking a new position for all the wrong reasons are spotted very quickly in the process. These physicians often say they’ve discovered how talented they are in management and know they would be successful in their first full time management role. They haven’t invested in management training because they possess “natural talent”, are highly critical of the leadership of their current organization and say they no longer enjoy clinical work. The term the recruiter used to describe their demeanor? Arrogant. Further, these doctors are quickly dropped from candidacy.

What does arrogant mean? Here are a few definitions – none of them conducive to effective leadership! “Overbearing pride evidenced by a superior manner toward inferiors.” “Haughtiness.” “Contemptuousness – the manifestation of scorn and contempt: every subordinate sensed his contemptuousness and hated him in return.” “The trait of being imperious and overbearing.”

The other guest, a health system physician CEO, said over the years he had to fire several excellent clinicians who had very poor communication skills and lacked self-awareness. They often had very good analytic abilities, great insight into problems and solutions, but could not manage a civil word with peers, subordinates or superiors. Some were friends. Again, the term arrogant was used to describe their behavior.

With teamwork replacing autonomy and independence, arrogance is a trait that will derail you and your career. It’s OK to be proud of your achievements as a physician, but it should come across as quiet confidence to others on the health care team. Some physicians DO have a natural talent for leadership and business. Most of us, however, must learn new concepts and behaviors we weren’t taught in our medical training. I’ve heard stories from coaches and mentors about successful behavior change in arrogant physicians who recognized how they were being perceived, and sought to change. Some of my most valuable experiences have been helping smart, talented physicians change their behaviors.

If you’re one of the hundreds of physicians who are looking for a rewarding role in leadership or management, be sure your first interview puts you in the best possible light. We want you to be successful. Many people are watching and curious about the impact of more physician leadership in the health care industry.

Tuesday, October 5, 2010

Notes from the road: An optimistic view of the future

Physicians are preparing to lead health care change across the country. This is perceived by some entrenched interests to be a threat. To patients and their families, and to physicians’ co-workers, this is a very positive development. I think whoever is closest to patients and consumers will be in the best position to impact change.

Crisscrossing the country over the past few weeks, here’s what I’ve seen and heard to justify my optimism. In Iowa, a large predominately rural health system has launched its Physician Leadership Academy. Each of the thirty-seven physicians were enthusiastic about learning how to improve dysfunctional work processes, develop innovative strategies, and find ways to improve patient outcomes of care. The initial class was nearly 50 percent larger than anticipated, and next year’s new class is equally committed and talented.

In South Carolina, the hospital association and medical association held a joint meeting to discuss what health care reform means for their communities. I talked with several ACPE members during that meeting. I learned that South Carolina has been collaborating with Atul Gawande on the surgical checklist project and with IHI on quality initiatives. The sense of common purpose and respectful disagreement on issues (not people or motives) between the medical society and the hospital association was very impressive. When it comes to interdisciplinary teamwork and measuring health care outcomes, I think South Carolina is a special place.

In Nevada, a large physician group has been managing financial risk for a few years, and doing very well. I listened to a sophisticated conversation at breakfast between two of the attendees about the clinical and financial management of heart failure patients across the continuum. I assumed both were physicians. Wrong. One was the CFO. I believe these kinds of conversations will become commonplace in integrated systems, ACOs, and medical homes if health care change continues in that direction.

In Nebraska, a rural community is beginning an important dialogue with its hospital board, independent and employed medical staff, and hospital staff about how to become a “physician led system, managed by business professionals”. Everyone will have to imagine how their roles will change, and what it means for relationships with large tertiary care centers in nearby cities.

In San Antonio, Texas several dynamic young physician leaders from different branches of the military remind me that some of the best teamwork training and practice occurs in our armed forces. When an individual fails, the whole team fails. They hold both individuals and teams accountable for serious safety events. They correct the problems that lead to the adverse outcomes.

If you see a system around you that frustrates you, or isn’t good for safe and reliable patient care, start now to learn what you can do to change it. Your satisfaction in helping to lead change, and see your role as a physician in a new perspective, will give you exciting new options in your career.

Wednesday, August 4, 2010

Dog Sleds and Teamwork -- Or How a Team of Huskies Made Me a Better Manager

Years ago, before beginning my management career in health care, I trained our four Siberian/Alaskan huskies to pull a dog sled. My motivation was to allow our toddlers to enjoy the winter wilderness with a smile on their faces. Kids love dogs, and a down sleeping bag wrapped around them makes for a nice trip in the back country.

Now this is going to be dangerous: I’m going to share some insights on working with a team of dogs and how that might have some relevance to working with people when you and your team have a goal in mind. We love our dogs, but we should have at least that same love and respect for the people we work with, don’t you think?

There’s always a first time when you and the team get together to try something new. Each one of the huskies individually would instinctively pull on my ski-joring rope when I went cross country skiing. I thought getting each of them to work together would be a piece of cake. But the first time I hooked up the four dogs in their harnesses it was a disaster! The dog I chose for the leader was Junior, the oldest and alpha male of the group. Strong beyond belief, he was always the aggressor in the yard. I assumed that the others would follow his lead. Wrong. Junior would stop pulling to turn around and snap at or fight with the others. Harnesses were tangled, none of the others wanted to pull.

I was quickly growing frustrated -- and so were the dogs. I decided to “punish” Junior by putting him at the back, in the “wheel position” – the first dog immediately in front of the sled. I chose the youngest dog (Togo) with the mellowest personality of the group for the lead. Lo and behold, much to my surprise and delight, the team ran with the characteristic excitement and enthusiasm of a high performing sled dog team! Junior loved being in the wheel position because he could keep an eye on the others, and it was the best position for the strongest dog. The others (Wiley and Lupe) appreciated being able to run faster. The dynamics changed very quickly among the four of them.

Over the years, you learn valuable lessons about teamwork. Don’t expect your team to do something that you wouldn’t do yourself. Got a hill to climb? Get off the runners and run up the hill with them. Lost and unsure about which trail to take in a whiteout? Trust your team. Their instinct is correct and deserves your trust and faith. Praise them for a job well done. Keep the momentum going. Don’t slam on the brake suddenly and stop the forward movement until you’ve crossed the finish line.

I noticed that every time I stood up to use the footbrake to slow the team down, I’d lose my balance, and sometimes fall, bringing the team to a complete stop. “What’s your problem?” they seemed to be saying when they looked back to see why we weren’t moving. One day I asked a veteran sled dog driver how he managed to avoid falling when using his brake.

“I never use it until the race is over. I stay low like the dogs, dragging my feet or knees. Standing up on one leg, and raising the other to stomp on the brake, elevates your center of gravity, and makes you unstable.” I have no idea how that relates to our teams at work, but I thought it was interesting.

Wednesday, June 23, 2010

McChrystal's Downfall

How have you been perceived as a leader lately?

What’s fascinating about the uproar over General Stanley McChrystal's conduct is that it's not focused on differences over the war strategy in Afghanistan. Instead, it's about a leader’s behaviors. General McChrystal’s situation has a lot to teach us about leadership!

First, it demonstrates the fragility of titles, positions and roles of authority. You are in your position because a more senior member of your organization made a decision that they could trust you to be a valuable part of a team. Once that trust is fractured, your lofty title can disappear in an instant.

Second, like the General, many of us physicians have superiors who are “civilians” – e.g. not clinicians, not doctors. When we find ourselves in disagreement with our non-clinical colleagues, do we state that disagreement face to face, or do we make demeaning comments about them to our subordinates? I suspect that sometimes the stresses of leadership and management make all of us say and do things that don’t reflect well on us. One of my friends who once worked with McChrystal told me that the behavior described in the Rolling Stone article, in which McChrystal openly disparaged other high-ranking U.S. officials -- was out of character from the man he knew a few years ago. Still there’s no excuse to ridicule and disparage the thoughts and ideas of others who may disagree with us.

Third, are you a role model of professional and respectful behaviors for your staff? If your closest staff feel comfortable belittling others, they may be acting that way because you a). exhibit those same behaviors yourself, or b). you haven’t told them it’s unacceptable behavior. Do you routinely attribute not-so-flattering motives to people who disagree with you, or whom you perceive as adversaries? I find my judgments about the motives of others are more often wrong than right. I try to ask them rather than assume I know their motives. I hope my failure rate on fundamental attribution error is decreasing as I get older and more experienced!

It’s hard to imagine how this situation could have ended without McChrystal being replaced. Not only did McChrystal’s comments demonstrate disdain and disrespect for his superiors, but his inner circle of leaders was guilty of the same behaviors!Would you want to work in an organization or unit where these behaviors were the norm?

Ask yourself what you would do if you were the CEO (President Obama). Knowing that our preference as physicians is to avoid confrontation or conflict, would you have fired the general yourself? Asked HR to do it? Found a way to live with the situation while you gave the general another chance? Would you find out how the front line troops felt about their commanding officer before making a decision?

Maya Angelou says, “People will forget what you said. People will forget what you did. But they will never forget how you made them feel.” As leader of your practice, business, unit, or health system, how do your staff and colleagues feel about working with you?

Tuesday, May 11, 2010

Lessons from ACPE's Annual Meeting

It always takes me a few days to unwind from the intensity and new ideas coming out of our Annual Meeting. This year's meeting in Washington, D.C., and that's me in the picture with my wife, Janet, and an actor who portrayed one of the "founding doctors" during our induction ceremony for Fellows and Certified Physician Executives.

At the meeting, we heard from Dave Snowden about Complexity Theory and how it can be applied to the chaos of health care. He pretty much exploded many of the status quo ideas about a linear, predictable and manageable control mentality when it comes to improving our health care system! His analogy of parents trying to “manage” a 6 year old’s birthday party and all the unexpected twists and turns inherent in such an endeavor was hilarious.

He mentioned that we should be aware of “outliers” from the norm. Thinking about that, I met two medical students who found their way to our Annual Meeting and asked them why they came. Both were curious about physician leadership and system change. At least one has already decided he wants to be involved in system change when he graduates. I want to meet more outliers like these, and like the many young physicians who were attending their first ACPE meeting and are excited about being agents of change.

It feels like a renaissance is occurring among a growing number of physicians. No longer content to watch from the sidelines, or rail against powerful forces with major roles in health care, these physicians are excited and optimistic about the role they can play in shaping the system to better serve patients, and the professionals who work in the system. Many said they’re tired of the “us vs. them” way of thinking. They know that the strategic importance of financial statements, linking quality and safety to the business functions of medicine, and knowing how to influence organizations to change are new knowledge content that will be important.

We heard from David Cutler, a health economist, and from six leaders who gave us updates on what they expect in payment, safety, comparative effectiveness research, IT, medical home, and integration. The innovators among us – probably most of us – were imagining what new ideas can disrupt the status quo, and change the health care landscape.

Finally, I want to thank Harry Leider for his leadership as President of ACPE over this past year. He demonstrated to me, to our Board, and to our members how enlightened and effective leaders work. One of Harry’s greatest achievements was organizing seven Task Forces on key issues. Their reports were given in person to the Board. The analysis and recommendations were insightful, strategic, and very useful. You’ll be seeing more in the months to come about what ACPE is doing to implement those recommendations. Thanks to the more than 200 members who contributed to this vital work.

Monday, March 29, 2010

A Good Friend at CMS

The Obama Administration is set to disclose that Donald M. Berwick is its pick for administrator of the Centers for Medicare & Medicaid Services, according to a report from the Bureau of National Affairs.

Members of ACPE are quite familiar with Don’s work and writing as a physician, CEO of the Institute for Healthcare Improvement, and one of the authors of the Institute of Medicine’s landmark reports calling for greater safety and efficiency in our nation’s health care system. I think Don is a great choice to lead the country’s largest source of funding for health care services. If he survives the confirmation process (never an easy task), here’s what we should expect, and why he’s up to the challenge.

First and foremost, Don knows that the health system should be designed with patients and consumers as the primary focus. He’s written and spoken eloquently about his personal experiences with mistakes and poor communication among members of the health care team during his wife’s serious illness a few years ago. He’s made the impact of errors and poor communication very real to care givers and health care leaders through the voices of Americans who have lost children and spouses from medical error to the attention of the health care industry by allowing them to share their stories with us. Hearing their stories and their determination to prevent similar tragedies from happening to others should make us no less committed to a safer health system. Look for CMS to have a relentless focus on health system safety.

Consistent with his focus on consumers, watch for a spotlight to be shown on the cost of care. These federal funds for Medicare and Medicaid come from our taxes. We have every right to demand that CMS funds are being spent for essential services, delivered efficiently. Recent articles on communities that have BOTH high quality and low cost are worth re-reading. If you haven’t looked at the Dartmouth Atlas recently, you might want to see how your region or community compares to the best cost performers – and ask yourself why. Overuse of medical services will be a hot topic.

Now that insurance reform changes have been passed, I expect the next large change to come in how physicians and hospitals are paid. Many health policy experts have pointed out the flaws in the fee-for-service system when quality, safety, and lower costs are the goal of a nation’s health system. Based on his experience as a pediatrician, IHI’s experiences with promoting greater efficiency , and imagining an idealized design in which a system is perfectly designed to achieve the results it gets, we should be prepared for a transition to bundled payments, and/or capitation for large populations. This means that another wave of integration between physicians and hospitals will occur.

Recent reports suggest discussions have already begun across the country as balance sheets of independent group practices deteriorate in the recessionary economy, and health systems are seeking clinical leadership to deliver lower cost care with high quality. Add to this equation the preference of young physicians for employment by a large organization, and we’ve already got momentum for change in the alignment of hospitals and physicians.

Finally, Don has the characteristics of a “Level 5 Leader”, as described by Jim Collins in this best selling business book, Good to Great. Noting the common leadership traits that make these leaders highly successful, he describes men and women who understand from personal experience what’s happening at the front lines of their businesses or industry, like most physicians in leadership roles. They “turn information into information that cannot be ignored”. They’re ambitious for their enterprise (not themselves). They’re quick to give credit to everyone but themselves when everything is going well, and take personal responsibility when things aren’t going well. They lead with questions, not answers.

Please join me in asking what we can do to help Dr. Berwick transform our health system to one that’s more responsive to patients’ concerns about quality, safety, and cost. This is the time to use what we’ve been learning about leadership, influence, reliability and teamwork. The next few years are going to be exciting ones for all of us!

Monday, March 1, 2010

Physician Leadership: The Next Generation

I’ve had a couple of really great weeks.

I had lunch the other day with several physicians who are here in Tampa for the Certified Physician Executive tutorial. Almost all of them were in their thirties. Last week I was at a meeting with CMIOs, many of whom were in the same age group. This is a very energetic and determined group of physicians who have a whole different set of challenges than many of us have had, or are currently dealing with. I left these two separate meetings with optimism for the future of health care and a determination to make ACPE a place where they can get the help they’re seeking. Here’s what I heard.

Many of these physicians already have advanced degrees in management. They’re very articulate in defining leadership and management challenges in health care. They decided during their medical training, or before, that they wanted to be in leadership or management roles. All of them are familiar and facile with information technology as a means to improve health care. Some of them were tapped for IT roles because of the perception that they’re “technodocs”. Direct, one-on-one patient care is not their preferred career path. They want to maintain both a clinical role, and a significant leadership or management position in whatever organization they’re working with.

They note that the health care industry is extremely hierarchical. Leadership positions are usually given to physicians who are much older than themselves. They’re being pulled into leadership roles primarily because they have IT skills, and because they really enjoy the opportunity to improve a system. Unlike many mid-career or older physicians who describe being pushed into management roles somewhat reluctantly, this group is very excited about shaping the next generation of health care.

They’re interested in learning how to position themselves in the eyes of system leaders and board members as potential senior leaders – even as physicians who are still early in their careers. Because they’re young, many older physicians feel they can use their personal connections with senior leaders or board members to make life difficult for them when change management issues are not to the liking of senior colleagues. Their spouses sometimes ask them if their CMIO role will lead to anything else after the IT implementation is completed, or whether their system leadership opportunity ends with that job. I think that’s a very fair question, and one that deserves an answer.

If you’re in a high level senior leadership role at your organization, would you do anything different if you knew that the youngest physicians making an impact in your organization might be impatient for more significant leadership opportunities? Have you mapped out a career path with them that fills their needs for a satisfying career in health system leadership? What would you tell them about positioning themselves for those higher level roles if they’ve already gotten their MBA or MMM, and if you’ve been noticing how quickly and elegantly they’re able to define a thorny issue in your organization compared to older physician leaders without that leadership and management training? If you thought that one of the youngest physicians on your staff was the best leader for key organizational roles in quality, IT, safety, operations, or even the CMO role, would you discount their suitability because of their age? Can we create organizational structures for the health care systems of the future that are less hierarchical, more teamwork oriented and less age-dependent?

Thursday, January 28, 2010

The Blunt End vs. The Sharp End

Clinician leadership. Integrated health system. Accountable Care Organization (ACO). These are the concepts and words being discussed, debated, and defined at our Winter Institute in Naples, FL over the past few days. They’re the same words and issues I heard last week at one of the nation’s premier MHA programs. We’re talking about strategies, structures, compensation methodologies, alignment challenges, and the economics of integration. Why are these topics at the “top of the charts” of what both physicians and non-clinical health system leaders are listening to, and talking about?

First, many health systems and physician groups are anticipating changes in payment that reward quality, outcomes, and safety – regardless of whether any health care legislation emerges from Washington. Clinicians with additional knowledge competencies in integration strategies, compensation methodologies, will be vital to successful implementation of integration strategies.

Second, for medical groups and health systems to be viable economic enterprises, the bottom line must reflect improvements in quality and patient safety. One of the questions discussed in the Advanced Quality course was, “What’s the cost of a Never Event?” The discussion included a financial analysis of Never Events and complications, AND how to mobilize clinicians to develop better communication techniques, and change the culture of the entire organization to address the cost of poor quality and outcomes.

The power and importance of clinician leadership can be summarized using a concept familiar to system safety engineering and accident investigation. It’s called the sharp end-blunt end model(1) of how organizations and the people who work in them interact. Imagine an inverted isosceles triangle representing an organization. The blunt end is where boards and senior organizational leaders develop missions, strategies, and goals for the organization. The sharp end is where the organization’s people, processes, and technology touch its customers (patients). In health care it’s what happens to a patient, in the ED, ICU, lab, radiology, ambulatory care, etc. When an organization’s mission, vision, values, and goals are translated into appropriate specific individual human behaviors and actions at the sharp end consistent with blunt end strategies, it’s performing at a very high level.

Clinicians are intimately familiar with activities and behaviors at the sharp end, because that’s where we’ve spent many years of our lives. We’ve experienced the frustration of inefficient work processes, and understand how harm can occur to our patients. Now imagine a clinician entering strategic and operational discussions at the blunt end. There’s tremendous insight and wisdom that can be contributed to decisions about what to improve, how to improve, and what observable behaviors at the sharp end will indicate that improvement is happening.

Just being a clinician isn’t enough to be effective in a leadership or management role. We have to learn about strategy, influence, basic health care finance, and organizational dynamics to really be effective in making change happen. Just as we have our own language and thinking styles, non-clinical leaders have theirs. Breakthrough change comes when new insight emerges from understanding how solving your problem can solve someone else’s problem at the same time. Ask yourself what value you can bring to an integrated system, ACO, clinic, business, or workplace in the health care sector. Maybe it’s traditional one-on-one patient care at the sharp end. Maybe it’s that, plus helping out at the blunt end to design a system that works first for patients, and secondarily for the professionals – both clinical and non-clinical – who care for them.

(1)Cook RI, Woods DD. Operating at the
Sharp End: The Complexity of Human
Error. In Bogner MS, ed. Human Error
in Medicine. Hillsdale, NJ: Erlbaum and
Associates; 1994:255-310.