IE Discipline of the 80s from GMI- classic video

IE Discipline of the 80s from GMI- classic video - This was state of the art in General Motors video production at the time - created by some students to promote Industrial Engineering

Advance Directive Completion by Elderly Americans: A Decade of Change - are the internet postings accurate?

Advance Directive Completion by Elderly Americans: A Decade of Change is the correct report title….but….are the internet postings accurate?

 Dr. Maria Silveira and her team at the University of Michigan Medical School recently published a report in Journal of the American Geriatrics Society, “Record number of older adults completing living wills, trend had little impact on hospitalization rates”

I reached out to Dr. Silveira for her thoughts as well….

What caught my attention was the various related internet postings on the report, for example like:

·        Advance Directives More Popular over Last Decade – Source 1

·        More elderly Americans completing advance directives – Source 2

·        Nearly Three-Quarters of U.S. Seniors Have Living Wills – Source 3

·        Many More Americans Issue End-of-Life Instructions – Source 4

·        Record Number of Older Adults Completing Living Wills – Source 5

·        More Elderly Americans Completing Advance Directives – Source 6

My concern is using the term Advance Directive (AD) and Living Will (LW) and End-of-Life (EOL) Instructions interchangeably maybe confusing the public, and is some of internet postings may be providing quotes that are not entirely accurate.

 The Silveira et al 2014 report defines the terms as follows:

-         Living Wills (LW)as “written instructions about the treatment or care decedents wanted to receive during the final days of their lives.”

-         Advance directive (ADs) as “summarize preferences for life-sustaining treatment and surrogate decision-maker in the event that one loses decisional capacity and requires medical care.”  Note: I think the use of the word “and” is important.

-        Durable Power Of Attorney For Health Care (DPAHC) as “any legal arrangements for a specific person or persons to make decisions about the decedent’s care or medical treatment if he or she could not make those decisions him or herself.”

So unfortunately, the AD and LW are not the same thing, and if these article headlines are using them as if they were the same, what else did they get wrong?? Well let’s take a look...

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Quote - An advanced directive is “anything you prepare in advance of your death,” according to lead study author Dr. Maria J. Silveira. – from Source 1

Not Accurate – The definition for an advance directive from the report is stated above.  This may have been from an interview, but I doubt it from someone like Dr.  Silveira, based on the thoroughness of the report.

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 Quote - The recent study found that most people both appointed a surrogate and left their treatment preferences known. – from Source 5

Not Accurate – So according to the report’s definition of an AD – “summarize preferences for life-sustaining treatment and surrogate decision-maker”

Here is the actual information from the report  – “Of those with AD data,

-        63% had some kind of AD before death

-        45% had a LW

-        57% had a DPAHC

-        38% had both"

So let’s look at the numbers again

-         63% had some kind of AD before death – what does “some kind” mean? Versus definition provided in the report

-        45% had a LW - Not an AD

-        57% had a DPAHC - Not an AD

-        38% had both - This might an AD, if both meets the report’s definition, assuming the term both reflect the “and” requirement.  The public’s confusion may come from the reference to “most people” as stated in Source.

It would also be helpful to clarify what the reference to “some kind of AD before death” means.

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Quote - The percentage of seniors with living wills -- also called advance directives -- increased from 47 percent in 2000 to 72 percent in 2010 – From Source 3

 Accurate sort of…  See the use of the terms living wills and advance directives as the same thing?  That is inconsistent with the report’s definitions.   The report does quote the 72% number, and here is the quote “The proportion of decedents with an AD increased from 47% in 2000 to 72% in 2010.”  Now I am getting confused.  The report references 63%, 45%, 57%, and 38% numbers - but I could not figure out how the 72% number is being calculated.

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Quote - "There has been a significant increase in rates of AD completion over the last decade, but this trend has had little effect upon hospitalization and hospital death, suggesting that AD completion is unlikely to stem hospitalization before death" – Source 6

Accurate – the report further states that “Future research will need to examine how trends in ACP (which stands for advance care planning) affect trends in hospitalization and place of death” and “it seems unlikely that that a piece of paper summarizing one’s wishes for surrogate decision-maker and life-sustaining treatment would have a large effect on one’s likelihood of being hospitalized or dying in the hospital. To stem hospitalization rates, the decisions to hospitalize, die in hospice, or die in the hospital must be addressed more directly.” 

 So if the expectation was a reduction in hospitals deaths, what happen?   Here is what I think.  If 57% only had a DPAHC, then no DPAHC is going to say, “Do not send Mom to the hospital.”  My Associate is an Emergency Department (ED) doctor and states he sees this every day, no matter if they are at home, at a SNF, in hospice – regardless – the default is call 911 and send to the ED.  He stated not having immediate access to AD or LW document in the ED causes him to do CPR and “break their ribs,” or other care that is not necessary or desired, and the documents are rarely available.

 Silveira et al 2014 report has a sample size of 6,122 from Health and is HRS Retirement Study (HRS) participants who died in a hospital between 2000 and 2010 and were aged 60 and older at death.  According to Dartmouth Atlas of Health Care, 829,827, Care of Chronically Ill Patients during the Last Two Years of Life, died in a hospital in 2010.  The CDC reports for the 60 and older at death in 2010, as 1,969,117 deaths.  So only 42% died in the hospital? Maybe ADs are working…?  Not sure based on these numbers.

The part I did not understand from the report is “It may be that Advance Care Planning - ACP conversations in which individuals are given the choice not to be hospitalized and provided with the appropriate support to safely and comfortably stay home (e.g., with hospice) are much more likely to affect hospitalization rates than ADs are; programs incorporating ADs into a comprehensive program of ACP show that to be the case.”  My understanding of the ACP, AD, and LW is that the choice not to be hospitalized is part of that process.  What am I missing?

 Final Thoughts

The study also provides several comments that might be important for public reading these internet postings.

Silveira et al 2014 report states “Retrospective proxy reports were relied on for the outcomes of interest, and this raises concern regarding the accuracy of the data. Proxies who may also have been the decedents’ surrogate may have been psychologically driven to report greater concordance between the person’s wishes and the outcomes of decision-making, and because many proxies were surveyed more than 12 months after the subjects’ deaths, their responses are subject to recall bias.”

Think about it.  A year after your Mom died, who would want to tell someone, “No, I did not do want Mom wanted.  I did not follow Mom wishes.”  The author’s clearly states it in the report, but the internet postings do not discuss this fact.  

The report also states:

-        Those looking to reshape end-of-life care should create systems that promote advance care planning  (ACP)

-        Future research will need to examine how trends in ACP affect trends in hospitalization and place of death

 Some things to consider:

-        Advance Directive Completion by Elderly Americans is probably is not really 72%

-        Those looking to reshape end-of-life care need to address the following:

·        A business process to educate, create, store and retrieve, and maintain specific medical directives tailored to each person’s unique medical wishes, including “Do Not Hospitalize” and the concept of time, for example, do this for a week, then stop.

·        If sent to the ED, regardless if from home, at a SNF, in hospice, the documents that prevent breaking people’s ribs with aggressive care that is not desired.  Output that is immediately available in the ED, that is clearly “legal & official.”

·        Compliance with all State and Federal laws – the generic ACP websites that exist today do not appear deal with the annoying differences between states and it is very frustrating to spend all the time and energy on ACP, only to be ignored because the paperwork is not correct

-        Ongoing research data needs to be able to capture non-hospitalization end of live events.  How do we get the data of the people with ADs that did not get hospitalized?

-        Ongoing research efforts need larger data sets.  It would be great if the researchers could have access to 100% of the data on all end-of-life events.  This is not intended to debunk the professional use of statistical models in this report.  It is intended to challenge the healthcare IT professionals and the State and Federal government on creating a data source for researchers.  Great news that Feds Seek To Expand Open Data.  This would eliminate the non-value added time spent by researchers trying to qualify, find and munge patient data and spend more time with analysis and insight.   We need a real cool “data input” engine.  We also need the ability to dynamically mash-up different geographic regions, health episodes, etc. in a visualization/analytics environment. 

Dartmouth Atlas of Health Care states “More than 80% of patients say that they wish to avoid hospitalization and intensive care during the terminal phase of illness, but those wishes are often overridden by other factors” and “If more intense intervention does not improve life expectancy, and if most patients prefer less care when more intensive care is likely to be futile.”

My passion is helping the aging get the best care possible at the end-of-life.  Please contact me if you want to discuss this issue.

John M. Cachat

President and CEO

Directed Medical Systems

C 440-915-2650

www.linkedin.com/in/johncachat

www.directedmedical.com

 

 

Do you have an advance directive or living will? That complies with state laws?

Do you wonder while a hospital or doctor visit, you were asked this question?  The answer is because these organizations where required to asked the question starting in 2011.   In 2016, they will be required to go farther if you answer “yes” – they want access to the document(s).

The reason for this post is that there are several well intended websites popping up to help people create advance directives.  HOWEVER – BE CAREFUL.  I have not found any that deal with specific state laws on this subject.  It would be a real disappointment that if you took the time and energy to create the document, that your wishes were not followed do to a state specific regulation. 

Quality Professionals are Losing the War and the Battle

In my opinion - what do you think?

I recently read a piece where some well-intended quality professionals were asked to explain the difference between “correction” and “corrective action.”  I got a weird feeling.  Why are we even having these discussions? What happen?  The battle is to get Executives to understand the benefits of a robust quality management process in order to support corporate goals and objectives.  It is about increasing revenue and lowering costs and lowering risks.

Back in the early eighties, after spending six years in the automotive industry, I switched to the aerospace industry.   I was pleasantly surprised to see a better approach to quality.  At that time, the automotive industry had a bunch of “tools” that were being randomly applied.  Aerospace had the benefits of military based quality management system processes.  Note for the young people, this is before ISO9000.

The aerospace industry simply defined two steps (reference MIL-STD-1520)

-     Disposition – what should I do to fix the NCM
-        Corrective Action – selective application of problem solving efforts to those areas with the highest potential payback, and always for safety related problems

Then we started doing some dumb stuff.  Someone demanded corrective action for every NCM.   The response was “tool broke, tool replaced” or “operator error, operated trained.”  Anything was written into the form in order to get the parts moving again.   Then, we changed to “immediate corrective action” and “root cause corrective action.”   Immediate corrective action is what used to be called a disposition.   Root cause corrective action is what used to be called corrective action.   Then the FDA started using “corrective action” and “preventive action.”  Corrective action is what used to be called a disposition.   Preventive action is what used to be called corrective action.

If quality professionals do not understand all these terms, how do we expect our Executives to understand them?  What would our Executives think if their financial professionals changed the word profit to advantage, or benefit, or value?  That conversation would be silly and non-value added.  Why not go back to basics and communicate with simple terms.  Terms that you could explain to a high school student.   Terms that an interpreter could explain when presenting to a non-English speaking audience.

What do you think?

Five Leadership Lessons From James T. Kirk

http://www.forbes.com/sites/alexknapp/2012/03/05/five-leadership-lessons-from-james-t-kirk/

Captain James T. Kirk is one of the most famous Captains in the history of Starfleet. There’s a good reason for that. He saved the planet Earth several times, stopped the Doomsday Machine, helped negotiate peace with the Klingon Empire, kept the balance of power between the Federation and the Romulan Empire, and even managed to fight Nazis. On his five-year mission commanding the U.S.S. Enterprise, as well as subsequent commands, James T. Kirk was a quintessential leader, who led his crew into the unknown and continued to succeed time and time again.

Kirk’s success was no fluke, either. His style of command demonstrates a keen understanding of leadership and how to maintain a team that succeeds time and time again, regardless of the dangers faced. Here are five of the key leadership lessons that you can take away from Captain Kirk as you pilot your own organization into unknown futures.

1. Never Stop Learning
“You know the greatest danger facing us is ourselves, an irrational fear of the unknown. But there’s no such thing as the unknown– only things temporarily hidden, temporarily not understood.”
Move up Move down

Captain Kirk may have a reputation as a suave ladies man, but don’t let that exterior cool fool you. Kirk’s reputation at the Academy was that of a “walking stack of books,” in the words of his former first officer, Gary Mitchell. And a passion for learning helped him through several missions. Perhaps the best demonstration of this is in the episode “Arena,” where Kirk is forced to fight a Gorn Captain in single combat by advanced beings. Using his own knowledge and materials at hand, Kirk is able to build a rudimentary shotgun, which he uses to defeat the Gorn.

If you think about it, there’s no need for a 23rd Century Starship Captain to know how to mix and prepare gunpowder if the occasion called for it. After all, Starfleet officers fight with phasers and photon torpedoes. To them, gunpowder is obsolete. But the same drive for knowledge that drove Kirk to the stars also caused him to learn that bit of information, and it paid off several years later.

In the same way, no matter what your organization does, it helps to never stop learning. The more knowledge you have, the more creative you can be. The more you’re able to do, the more solutions you have for problems at your disposal. Sure, you might never have to face down a reptilian alien on a desert planet, but you never know what the future holds. Knowledge is your best key to overcoming whatever obstacles are in your way.

2. Have Advisors With Different Worldviews
“One of the advantages of being a captain, Doctor, is being able to ask for advice without necessarily having to take it.”
Kirk’s closest two advisors are Commander Spock, a Vulcan committed to a philosophy of logic, and Dr. Leonard McCoy, a human driven by compassion and scientific curiosity. Both Spock and McCoy are frequently at odds with each other, recommended different courses of action and bringing very different types of arguments to bear in defense of those points of view. Kirk sometimes goes with one, or the other, or sometimes takes their advice as a springboard to developing an entirely different course of action.

However, the very fact that Kirk has advisors who have a different worldview not only from each other, but also from himself, is a clear demonstration of Kirk’s confidence in himself as a leader. Weak leaders surround themselves with yes men who are afraid to argue with them. That fosters an organizational culture that stifles creativity and innovation, and leaves members of the organization afraid to speak up.

That can leave the organization unable to solve problems or change course. Historically, this has led to some serious disasters, such as Star Wars Episode I: The Phantom Menace.

Organizations that allow for differences of opinion are better at developing innovation, better at solving problems, and better at avoiding groupthink. We all need a McCoy and a Spock in our lives and organizations

3. Be Part Of The Away Team
“Risk is our business. That’s what this starship is all about. That’s why we’re aboard her.”

Whenever an interesting or challenging mission came up, Kirk was always willing to put himself in harm’s way by joining the Away Team. With his boots on the ground, he was always able to make quick assessments of the situation, leading to superior results. At least, superior for everyone with a name and not wearing a red shirt. Kirk was very much a hands-on leader, leading the vanguard of his crew as they explored interesting and dangerous situations.

When you’re in a leadership role, it’s sometimes easy to let yourself get away from leading Away Team missions. After all, with leadership comes perks, right? You get the nice office on the higher floor. You finally get an assistant to help you with day to day activities, and your days are filled with meetings and decisions to be made, And many of these things are absolutely necessary. But it’s sometimes easy to trap yourself in the corner office and forget what life is like on the front lines. When you lose that perspective, it’s that much harder to understand what your team is doing, and the best way to get out of the problem. What’s more, when you’re not involved with your team, it’s easy to lose their trust and have them gripe about how they don’t understand what the job is like.

This is a lesson that was actually imprinted on me in one of my first jobs, making pizzas for a franchise that doesn’t exist anymore. Our general manager spent a lot of time in his office, focused on the paperwork and making sure that we could stay afloat on the razor-thin margins we were running. But one thing he made sure to do, every day, was to come out during peak times and help make pizza. He didn’t have to do that, but he did. The fact that he did so made me like him a lot more. It also meant that I trusted his decisions a lot more. In much the same way, I’m sure, as Kirk’s crew trusted his decisions, because he knew the risks of command personally.

4. Play Poker, Not Chess
“Not chess, Mr. Spock. Poker. Do you know the game?”

In one of my all-time favorite Star Trek episodes, Kirk and his crew face down an unknown vessel from a group calling themselves the “First Federation.” Threats from the vessel escalate until it seems that the destruction of the Enterprise is imminent. Kirk asks Spock for options, who replies that the Enterprise has been playing a game of chess, and now there are no winning moves left. Kirk counters that they shouldn’t play chess – they should play poker. He then bluffs the ship by telling them that the Enterprise has a substance in its hull called “corbomite” which will reflect the energy of any weapon back against an attacker. This begins a series of actions that enables the Enterprise crew to establish peaceful relations with the First Federation.

I love chess as much as the next geek, but chess is often taken too seriously as a metaphor for leadership strategy. For all of its intricacies, chess is a game of defined rules that can be mathematically determined. It’s ultimately a game of boxes and limitations. A far better analogy to strategy is poker, not chess. Life is a game of probabilities, not defined rules. And often understanding your opponents is a much greater advantage than the cards you have in your hand. It was knowledge of his opponent that allowed Kirk to defeat Khan in Star Trek II by exploiting Khan’s two-dimensional thinking. Bluffs, tells, and bets are all a big part of real-life strategy. Playing that strategy with an eye to the psychology of our competitors, not just the rules and circumstances of the game can often lead to better outcomes than following the rigid lines of chess.

5. Blow up the Enterprise
“‘All I ask is a tall ship and a star to steer her by.’ You could feel the wind at your back in those days. The sounds of the sea beneath you, and even if you take away the wind and the water it’s still the same. The ship is yours. You can feel her. And the stars are still there, Bones.”

One recurring theme in the original Star Trek series is that Kirk’s first love is the Enterprise. That love kept him from succumbing to the mind-controlling spores in “This Side of Paradise,” and it’s hinted that his love for the ship kept him from forming any real relationships or starting a family. Despite that love, though, there came a point in Star Trek III: The Search For Spock, where Captain Kirk made a decision that must have pained him enormously – in order to defeat the Klingons attacking him and save his crew, James Kirk destroyed the Enterprise. The occasion, in the film, was treated with the solemnity of a funeral, which no doubt matched Kirk’s mood. The film ends with the crew returning to Vulcan on a stolen Klingon vessel, rather than the Enterprise. But they returned victorious.

We are often, in our roles as leaders, driven by a passion. It might be a product or service, it might be a way of doing things. But no matter how much that passion burns within us, the reality is that times change. Different products are created. Different ways of doing things are developed. And there will come times in your life when that passion isn’t viable anymore. A time when it no longer makes sense to pursue your passion. When that happens, no matter how painful it is, you need to blow up the Enterprise. That is, change what isn’t working and embark on a new path, even if that means having to live in a Klingon ship for awhile.

Final Takeaway:
In his many years of service to the Federation, James Kirk embodied several leadership lessons that we can use in our own lives. We need to keep exploring and learning. We need to ensure that we encourage creativity and innovation by listening to the advice of people with vastly different opinions. We need to occasionally get down in the trenches with the members of our teams so we understand their needs and earn their trust and loyalty. We need to understand the psychology of our competitors and also learn to radically change course when circumstances dictate. By following these lessons, we can lead our organizations into places where none have gone before.

How much money have you wasted today on bad and/or duplicate data?

I talk with a lot of Quality and other Business Professionals that are very frustrated that they spend a significant amount of time re-typing, checking, re-checking data used in Management Review Reports. No one wants to present the Executive management reports that are wrong.

There is no better time for QA and other business professionals to address this issue by looking at next generation development and integration tools.

Send me an email to jcachat@silicocorp.com if you would like to hear more about this.

Silico to Offer IQS, Epicor and Infor/Visual Manufacturing Customers an Exciting Alternative

FOR IMMEDIATE RELEASE:
9AM EST, JUNE 6, 2011

Silico to Offer IQS, Epicor and Infor/Visual Manufacturing Customers an Exciting Alternative

Better Technology, Lower Cost.

Cleveland, Ohio, June 6, 2011—Several IQS customers contacted John Cachat, President of Silico and former Chairman and Chief Vision Officer of IQS, after they had a chance to see the new IQS web product. “Disappointed, frustrated, even angry, are some of the words describing the marketplace feelings with the IQS web product,” stated Cachat. “We do not want to let these companies wallow in old technology, and that’s why we decided to create a new QMS offering.” Silico is offering special incentives for any IQS customer moving to this new platform until December 2011. Several IQS customers have already signed up. This special offer also applies to Epicor Advanced Quality and Infor/Visual Quality users as their quality modules are based on the IQS software.

Silico will be hosting a 90 minute web meeting on Tuesday, June 21st at 2:00 PM EST to demonstrate this exciting next generation quality management system (QMS) framework. You can register for the event at http://www.silicocorp.com/events.html. Anyone interested in QMS software is welcome to attend.

The phone calls and emails from IQS customers and other companies looking for QMS software are increasing every week. Many companies are several versions behind in their QMS license, and when trying to get the latest version they are forced to spend tens of thousands of dollars in past maintenance fees to stay with old technology. “Any time a company is looking at that kind of money, they are going to start the buying cycle over and look at new software vendors,” stated Tim Fallon, Vice President of Silico.

“The biggest competitive advantage Silico has in the marketplace is that the technology is not limited to Quality. The Silico platform can support many IT initiatives because IT departments can use the Silico platform for other web based application development. This means that IT departments are now supporting the Quality professionals who no longer have to fight the “IT battle” to get their project approved. In addition, companies want Business Intelligence. Not just the analytics that are part of the Silico platform, but an application that is designed to help people do their jobs. The days of software being used only to capture data are over. Software must help people plan, execute, and learn,” continued Fallon.

Cachat clarified that the Silico QMS software is NOT a typical commercial off the shelf software (COTS) product. The Business Process Management technology used offers complete end user flexibility in web form creation and business rule workflows. The Silico QMS is an extensive set of “best in class templates” (based on decades of experience and expertise in the Quality space) that allows companies to rapidly create their forms and define their processes. This environment saves a significant amount of time in training and deployment, and it also eliminates expensive software customization fees charged by traditional software companies using old technologies. The Silico Technology is entirely web based and can run on iPads, tablets and cell phones to support both plant floor and remote access. All you need is a browser. If you are going to attract the next generation workforce, you will have to have next generation technology.

Cachat also plans to repeat his previously successful efforts to engage ten large organizations with very attractive enterprise pricing as a benefit of helping Silico launch this new offering. Several companies are already engaged with Silico to discuss unlimited enterprise software licensing.

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About Silico Corporation
Silico helps organizations improve by focusing on people, processes, and then technology—in that order. Silico's business process management (BPM) services include state of the art technology for rapid solution development®. Silico’s Quality Management System (QMS) Instant Application Framework allows you to start with the web-based QMS templates and rapidly configure your forms and your processes with integrated workflow at the speed of business, without programming. www.silicocorp.com