Sorry to get all Katie Couric on you, but I’m going to have a colonoscopy on Friday. I turned 40 last October and I have some family history that leads my doctor to get one done now rather than at 50.
Unlike Katie, I won’t be broadcasting mine live, but I’ll share some articles and reflections on the process and, being process focused, what could go wrong. It’s a very necessary procedure, but there are, sadly, some very unnecessary and preventable risks.
According to Dr. Wikipedia (backed by journals):
This procedure has a low (0.35%) risk of serious complications
That’s about 1 in 300 patients, put another way.
For those of you who speak Six Sigma, that’s a 99.65% first time yield and a 4.2 sigma level.
That’s not going to scare me away.
Maybe I should have asked what my physician’s complication rates are. What are the complication rates at the surgical center where this will be done? Is this safer than being at a full-blown hospital or doesn’t it matter? Should I be more of an “engaged patient?”
Should I have asked more questions of my primary care provider? Why did she refer me to this GI specialist? Is he a “Best” doctor? Does that matter?
If I treat them as a supplier (respectfully), should I be able to walk the process and see what they do to prevent, say, instrument or scope disinfection errors?
Should I have asked:
- Show me how you disinfect the equipment
- Show me your training records for the people doing this work
- Show me your equipment maintenance records
- How do you verify that the work is being done properly?
- Have you had any complaints or incidents in the past?
I had my pre-procedure phone call on Monday. Maybe I should follow up and ask a few of these questions, even if I can’t go “walk the gemba” to check things out myself. What would you do?
Of course, I didn’t have data or information available to me to know:
- Which specialist is best at this?
- Who has the highest or lowest complication rates?
- What are the prices for different doctors or locations?
I don’t know how a busy person makes an informed decision.
These problems seem to happen way too often:
A Seattle hospital is under investigation after hospital officials revealed that more than 100 patients were put at risk of infection because medical instruments were cleaned improperly.
A breakdown in training resulted in instruments used during colonoscopies being improperly cleaned, hospital officials said.
Scopes used during colonoscopies were found to have been cleaned improperly last November, according to a hospital statement.
Technicians used improper cleaning techniques on the scopes between July 2011 and November 2013, hospital officials said. As a result the hospital has started notifying 106 patients who were at risk of infection as a result of undergoing a colonoscopy during that time.
“We’re going to look for what went wrong and what can be done and what has been done to stop it from happening again,” agency spokesperson Donn Moyer told ABCNews.com.
Why was there a breakdown in training? What are other hospitals doing to prevent this same problem? It’s good to react using good problem solving and improvement mindsets (looking at the process, figuring out how to prevent reoccurrence), but you can prevent these incidents to begin with?
A new study disturbingly discovered that an average of 15 percent of flexible endoscopes used to examine GI tracts and colons at five hospitals were harboring “bio-dirt”–cells and other material from previously examined patients. This was even after the instruments had been cleaned.
And that yucky finding is likely to be matched at other hospitals across the country, according to study author Marco Bommarito, Ph.d, lead research specialist at 3M’s infection prevention division.
“During a day [a single] scope may be used on half a dozen to a dozen patients–maybe even more.”
The article also says:
A guideline issued by the American Society of Gastroenterology said documented cases of infectious complications from endoscopic procedures were as rare as 1 in 1.8 million procedures.
But Bommarito thinks the actual number might be higher. He noted that it will not necessarily be obvious that a person’s disease came from an unclean endoscope used on them.
So you have detection problems and self-reporting problems. Will some healthcare organizations cover up problems and not inform patients?
“One of our physicians asked the staff, ‘how do you clean these instruments?’ It was through that process, they identified that we weren’t using the high-level disinfectant,” Hamby said.
I realize “bad process” and “bad process management” runs rampant in healthcare. Poor training. Poor supervision.
These are not worker problems — they are management problems.
“What stops contaminated fluids from backing up into this tube is this crucial green valve,” he said, illustrating with a colonoscopy tube. “Investigators found not only was this valve missing, but this tubing wasn’t being cleaned in between patients.”
In surprise inspections at 42 VA medical centers on May 13 and 14, investigators found that only 43 percent had standard operating procedures in place and could show they properly trained their staffs for using their equipment.
According to Denver’s 9News , patients who had colonoscopies between July 17 and Aug. 13 were being contacted via telephone and mail and told to be tested for HIV and hepatitis after it was discovered that the hospital’s disinfecting machine was not working properly.
According to the suit, filed last week by attorney Jennifer Coughlin, the hospital failed to fully disinfect a scope that had been used on four previous patients last September.
A letter to the woman from St. Charles CEO Jay Henry acknowledged a programming error led to the final disinfecting steps to be skipped.
The Miami Veterans Administration (VA) hospital is holding its chief accountable for improperly washed colonoscopy equipment that may have exposed 2,500 veterans to diseases, reports the Miami Herald.
After the colonoscopy scandal, the VA’s Administrative Investigation Board began inspecting the Miami VA facility and found it to have “poor quality control, lax supervision and sloppy procedures,” notes the Miami Herald.
Secretary Shinseki confirmed this was not a one-time or limited place occurrence. Shinseki went on to say this concern is shared system wide across VA hospitals, clinics, and medical facilities.
Shinseki’s analysis concluded this problem was not the fault of a person not doing their job. Instead, this situation presented itself because of lack of proper standards being in place in all VA medical facilities. Following the investigation into the problem, more proactive procedures were put into place to make sure this practice does not continue.
A cluttered procedure room with five combustible oxygen tanks, “questionable” air quality, possible patient exposure to toxic fumes, contaminated garbage under the procedure table and a lack of monitoring of patients’ vital signs during procedures.
However, the most troubling of the observations are related to the possibility of dirty devices used during the scope procedures.
Some, like biopsy forceps, weren’t being sterilized using the right equipment, the report says.
During one procedure, inspectors watched the doctor dip forceps in a formaldehyde solution to get rid of a specimen and reinserted the forceps into the patient’s esophagus.
Healthcare is in no position to get on a high horse and lecture Toyota or GM about quality, eh?
About LeanBlog.org: Mark Graban is a consultant, author, and speaker in the “lean healthcare” methodology. Mark is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as The Executive Guide to Healthcare Kaizen. Mark is also the VP of Customer Success for the technology company KaiNexus. He lives in San Antonio, Texas.