Failure Report: Year 2011 (Part 2 of 3)
May 22, 2012 by Jeremy · Leave a Comment
The only bad failure
is the one from which we fail to learn.
Most organizations put a premium on celebrating successes at the end of every year—we certainly do!
But we also believe that we have a great deal to learn from our failures, so we endeavor to share them and the lessons we’ve learned in hopes of avoiding those same mistakes in the future.
When seeking to tackle intractable problems in an environment like Iraq, missed opportunities, missteps, false starts, and failures are par-for-the-course. There will be no improvement in the political situation in Iraq, in the economy, in healthcare, or in the pursuit of peace without a number of flops and failures along the journey. If we already knew what worked, we all would’ve implemented it by now and moved on.
The truth is, neither the American government nor the Iraqi—neither international nor local NGOs—truly know what works in Iraq. Most of us are making educated guesses and seeking to rightly adapt programs and principles that have proven successful at other times in Iraq or in other parts of the world.
From this point forward, I want to provide you with an annual (and sometimes real-time) assessment of our failures. In absence of such previous reports, I will use a few minutes to highlight our most meaningful setbacks, failures and lessons learned to date.
The three major failures of 2011, to be covered in this series of reports are:
Failure #2: High-mortality Remedy Missions in February/March 2011
Failure #3: The Loss of Our Sulaymaniyah, Iraq Surgery Site as a Major Developmental Partner; Lack of Surgical Capacity Increase As a Result of Remedy Missions Conducted
Let’s get started…
2011 Failure #2: High-mortality Remedy Missions in February/March 2011
In February and March we ran two back-to-back Remedy Missions. One was our second in the southern city of Nasiriyah; the other was our second in the northern city of Sulaymaniyah.
Over the course of four weeks of surgery, mortality rates between the two cities reached 20.5% (7 deaths out of 34 operations).
A few of the losses were very surprising to many on the local and international team and had an extremely demoralizing effect on the team (particularly in Sulaymaniyah). The loss of momentum undoubtedly had a qualitative impact on the care provided as the trip progressed.
Some of the factors were anomalous, such as our lead surgeon contracting an infection in a wound on his ankle that resulted in impromptu surgery inside Iraq to save his leg. But other factors were almost certainly preventable, beginning with case selection and moving to fundamental deficiencies in the hospital equipment and protocols themselves.
A lack of warming blankets, portable oxygen units, a ready blood bank and several other fundamentals led to a less-than-ideal environment for the teaching of pediatric cardiac care. As a result of all these factors and the inherent difficulties of open-heart surgery, mortality rates in the Sulaymaniyah mission reached 22% (four deaths)—unacceptably high by any standard.
None of the deaths were considered “surgical” deaths, in the sense that the child did not die on the operating table, but rather in the post-operative intensive care unit, ward, or—in one case—in the car on the way home after being prematurely discharged by a local nurse the day the international team left the country.
Lessons Learned:
Our international team was very impressed with the local cardiologist for Remedy Mission II in the southern city of Nasiriyah. When it came time to schedule Remedy Mission III in that city, the decision was apparently made to not send a cardiologist on the mission, believing that the local team could handle it. This may have contributed to the imbalanced case selection in RM III and may have led to the situation in which three children died during the course of the mission.
Since that mission, an international cardiologist has been present on every Remedy Mission in an effort to help with case selection and create a balanced schedule of surgeries.
In Sulaymaniyah for Remedy Mission IV, case selection was complicated by the number of stakeholders in the mission. Children were formally and informally (that is, “politically”) put into the mission by the Preemptive Love Coalition, local cardiologists and surgeons, Kurdistan Save the Children (a local NGO), and the Health Directorate.
With regard to Yahya’s case, as described before, I can certainly say that my judgement was impaired when it came to case selection. I can speculate that other entities, in an effort to do right by the friends and patients on their lists, made similar errors in judgement that ultimately skewed the balance of the surgery schedule and its complexities.
When two children died in Sulaymaniyah after the international team left for the airport, we realized for the first time how ill-equipped the local team was to handle relatively simple post-operative care (one child had a positive prognosis in the ICU and the other was already out of ICU and recovering in the ward).
In our post-mission Impact Evaluation Report, we published the following statement:
Our post-mission conferences and deliberations on the matter resulted in the following protocols:
1. A mandatory reduction in “RACHS-1 scores” presented to the international team by the local team
2. A mandatory international ICU team to be left behind after surgeries stop to stave off post-mission ICU deaths and errant discharges
3. A postponing of our next planned mission to the Sulaymaniyah Center for Heart Disease due to lack of preparation of materials, equipment, staff, and protocols
If you have any questions or concerns about this report, the decisions we’ve made, or the direction we are going, please email me at your convenience. I would love to hear from you.
 |
Jeremy Courtney lives and loves in Iraq as a co-founder and Executive Director of the Preemptive Love Coalition. He's also the father of two spectacular children, and married to the lovely Jessica Courtney. When not absorbed in PLC work he can be found writing songs and singing about hope and future. Follow Jeremy on Twitter: @JCourt. |
Hussain: The Good News & The Sad
May 8, 2012 by matt · Leave a Comment
Friends, Hussain’s surgery has been post-poned. That’s the sad news. Our lead surgeon’s foot is injured, and he needs surgery and rest. As discouraging as this is, it’s for the best because it will allow our surgeon to fully heal and then provide Hussain with even better treatment.
Now for the good news: Our goal for Hussain is 75% complete—we just lack $1,000!
Will you help Hussain make it to the finish line by donating toward his surgery? If just a handful of you give $10 and $15 gifts, he’ll be there. And anything you give beyond that goal will go toward helping other children at the next Remedy Mission.
It’s discouraging that something as small as a foot injury can keep Hussain and his friends from surgery, but we believe Hussain is worth the wait. Please continue to pray for Hussain and to wait for his healing with us.
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As PLC's Press Secretary, Matt Willingham writes, reads, edits, tweets, updates, and works with a camera so as to connect hearts and minds to Iraqi children in need. On the side, he likes reading stories, devouring the great food his wife cooks up and exploring DSLR work. He's also mildly obsessed with Twitter: @mehtin. |
Failure Report: Year 2011 (Part 1 of 3)
May 3, 2012 by Jeremy · Leave a Comment
The only bad failure
is the one from which we fail to learn.
Most organizations put a premium on celebrating successes at the end of every year—we certainly do!
But we also believe that we have a great deal to learn from our failures, so we endeavor to share them and the lessons we’ve learned in hopes of avoiding those same mistakes in the future.
When seeking to tackle intractable problems in an environment like Iraq, missed opportunities, missteps, false starts, and failures are par-for-the-course. There will be no improvement in the political situation in Iraq, in the economy, in healthcare, or in the pursuit of peace without a number of flops and failures along the journey. If we already knew what worked, we all would’ve implemented it by now and moved on.
The truth is, neither the American government nor the Iraqi—neither international nor local NGOs—truly know what works in Iraq. Most of us are making educated guesses and seeking to rightly adapt programs and principles that have proven successful at other times in Iraq or in other parts of the world.
From this point forward, I want to provide you with an annual (and sometimes real-time) assessment of our failures. In absence of such previous reports, I will use a few minutes to highlight our most meaningful setbacks, failures and lessons learned to date.
The three major failures of 2011, to be covered in this report are:
Failure #2: High-mortality Remedy Missions in February/March 2011
Failure #3: The Loss of Our Sulaymaniyah, Iraq Surgery Site as a Major Developmental Partner; Lack of Surgical Capacity Increase As a Result of Remedy Missions Conducted
Let’s get started…
Failure #1: Leadership Indecisiveness on the Case of Six-Year-old Yahya
This was a major lesson in leadership that potentially affects every area of our organizational and team life, couched in the saga of one very specific family.
I was walking home from work one night in Iraq in early 2010, when my phone rang. On the other end of the line was a man, knocking on the door back at my office, in hopes of meeting me and presenting the case of his nephew, Yahya, to me for surgical consideration. I asked if we could meet tomorrow, but he was insistent and there seemed to be great urgency in his voice. Instead of postponing the meeting, I gave him directions to my home and met with him over tea.
From early on, the situation was less than ideal. Yahya had already received one charitable heart surgery and the second one that was being requested was bound to be difficult.
In our 2007-2010 Failure Report, I noted our decision to restrict the complexity of children we sent abroad for surgery after a series of deaths caused us to reconsider our risk tolerance. Yahya was definitely on the high end of our new risk tolerance.
I chose to refuse surgery to the family based on our new priorities.
Months later, after a new check-up, Yahya’s mother and father brought him into our office to inquire again about the possibility of surgery. I’ll never forget sitting with them in my office explaining our decision to decline surgery funding for Yahya.
Then, with all the persistence that you would expect from a mother, she appealed to me again not to turn away their little boy.
I think one thing that non-profit directors and program directors fail to say often enough is this: “I am a human. I’m swayed by the kindness or brashness of our patients and, at times, it heavily influences how I make selection decisions.”
I could not continue to say “no” any longer. I said “yes” (with conditions).
Our surgeon in Istanbul was clear from the beginning that his surgery would require a “valved conduit” (an additional $5,000 expense or more) and licensing agreements in Turkey at the time had caused a shortage of such devices.
Cody Fisher (Development Director) did a great job reaching an agreement with Medtronic providing Yahya with a donated conduit, but the timing of receiving the conduit was still beholden to the licensing agreements that were being worked out in Istanbul.
All these factors together ultimately led to Yahya missing our July 2010 surgery group to Istanbul. We refunded the family’s portion of the money they had contributed for his surgery.
Shortly thereafter, in August 2010, we conducted our first Remedy Mission inside Iraq—our new programatic focus on localized training and development. The mission was such a huge success, I became convinced that we needed to cease all funding for outside surgeries and focus solely on development work inside the country.
But I also felt a sense of commitment to Yahya and his family, who were basically caught in the transitional period between one programatic focus and another.
What I should have done at that point was send Yahya to surgery in Turkey, finish our commitments there, take the free valved conduit from Medtronic, and finish our work in Turkey strongly. What I did instead was place Yahya on an upcoming Remedy Mission and take the Turkey option off the table for the family.
What I didn’t account for very well in that decision was how the complexity of Yahya’s case would fare in a development setting; a setting in which local capacity was far below that which he would have received in Istanbul.
In the chaos of Remedy Mission IV, a number of things went badly. Among them, Yahya’s family probably did not receive the proper explanations that they should have about the risks of his surgery and they probably felt very vulnerable about the decision to go forward with the risky surgery or forever miss their opportunity.
It was difficult to assess all this in real time, in part because I was so hopeful for Yahya and his family. In my optimism, I did not see or recognize a few red flags. But even that is not the whole truth… I remember hesitations—“red flags”—even as I sit here today. I willingly suppressed anything that was not hopeful and optimistic. It seemed noble, brave and right.
But he wasn’t my child.
Yahya’s surgery presented many complications that ultimately required doctors to operate through the night. When Yahya arrived in ICU around 5 or 6 a.m. the next morning, he was deemed stable enough for the surgical team to go to the hotel for a few hours of sleep. Before their bus even arrived at the hotel, though, Yahya had passed away in ICU.
I would not normally include a single death in a year-end Failure Report. My point is not that I feel bad and need catharsis. It’s just that Yahya was different, and not only because he had a name or because his family hosted us for dessert in their home and shared tea in mine. No, Yahya was different because I flipped-flopped on the family so many times. I said “no.” Then “yes.” Then “no” again. And then “yes.” And then he died.
Organizationally, the failure was related to a lesson we were just beginning to identify in our 2007-10 Failure Report: we are not the best qualified to select children for surgery. The suggested way forward at that time is still right: we have handed child selection over to a committee of local healthcare providers and our international surgical team. There will still be deaths that we regret deeply, but they will be less a function of our role and influence in the child selection process.
Personally, the failure was related to my inability to make a decision and stick with it. I always had a bad feeling about Yahya’s likelihood to endure surgery. That was why I denied funding more than a year prior to his death. I had good reason to deny funding. But I went back on my hunch. Fair enough… I wanted to give a family a chance. But I never really got over my fears of his death and that made me unwilling to go all in with the family. I hedged over spending extra money on his expensive valved conduit. And even when the conduit was donated, I found other reasons to delay surgery for fear of spending a lot of money (including the family’s) on a surgery about which I was always suspicious.
Lessons Learned:
1. It’s OK to change one’s mind; but a leadership “Yes” or “No” should mean something. It hurts everyone involved to say one thing, give the impression of support, and never fully get behind one’s own decision. In this case, it played a role in Yahya’s death. He may have died in Istanbul just the same. The death itself is not the failure here. The faulty, character-flawed process by which I made life-altering decisions is.
I said “no.” I should have stood my ground. Or I said “yes” and I should have given that family my fullest “yes” ever. Instead, I said “yes” and stayed on the fence. I won’t do that again.
2. We are not qualified to select children. We are too emotionally attached and we do not possess the knowledge to make a right decision about a patient’s candidacy for surgery. We have handed child selection over to a collaboration between local cardiologists and our international surgical teams.
If you have any questions or concerns about this report, the decisions we’ve made, or the direction we are going, please email me at your convenience. I would love to hear from you.
|
Jeremy Courtney lives and loves in Iraq as a co-founder and Executive Director of the Preemptive Love Coalition. He's also the father of two spectacular children, and married to the lovely Jessica Courtney. When not absorbed in PLC work he can be found writing songs and singing about hope and future. Follow Jeremy on Twitter: @JCourt. |
Hussain, or John Wayne?—See Him Play Cowboy With His Doctors!
May 1, 2012 by matt · Leave a Comment
Have you picked up on how much Hussain enjoys playing around yet? This was a short video clip from the first time I met this boy.
To track his progress and to interact with Hussain online, check out Hussain’s party page. You can leave him a note and we’ll show it to him once we’re in the hospital! Make a short video, craft a poster, or get the kids together to color Hussain with a new heart. Click here to connect with him now!
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As PLC's Press Secretary, Matt Willingham writes, reads, edits, tweets, updates, and works with a camera so as to connect hearts and minds to Iraqi children in need. On the side, he likes reading stories, devouring the great food his wife cooks up and exploring DSLR work. He's also mildly obsessed with Twitter: @mehtin. |
Watch Our Animated Manifesto!
April 24, 2012 by matt · Leave a Comment
Over the last few months we’ve seen an incredible influx of new readers and supporters, so it seemed good to put our most informative and successful video to-date back on the blog.
Whether you’re brand new or if you’ve been here a hundred times, watch it and let me know your reaction. Is it naive? Spot-on? Over-the-top? Email me!
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As PLC's Press Secretary, Matt Willingham writes, reads, edits, tweets, updates, and works with a camera so as to connect hearts and minds to Iraqi children in need. On the side, he likes reading stories, devouring the great food his wife cooks up and exploring DSLR work. He's also mildly obsessed with Twitter: @mehtin. |
Saddam, Sanctions, & Surgery—Another Chat with Hussain’s Dad
April 17, 2012 by matt · Leave a Comment
A couple weeks ago we had you listen in on a phone conversation with Hussain’s dad. He shared about their family’s long search for a surgery and how eager Hussain is to get a new heart.
I spent several afternoons playing with Hussain while he was waiting to have his diagnostic tests run, and let me tell you, this kid loves to play. Hussain was easily the most fun person to be around at the hospital, and all the time we spent together made me even more excited to stay in touch with him and his family while they wait for surgery. Here are some of the recent questions we asked Hussain’s dad:
Dad—“It’s a big tragedy to have a child with Down Syndrome and to watch them suffer everyday while you can’d do anything to mitigate their pain, but we still thank God for everything and hope for the best for our child.”
PLC—”Our partner doctors said it was illegal to provide medical treatment to children with Down Syndrome under Saddam Hussein’s regime. Is that true?”
Dad—“Yes, but that was not the biggest problem. The biggest problem was that we lived under the embargo which didn’t allow any medicines or vaccines to be imported to Iraq unless it was under the memorandum of understanding between Iraq and the United Nations. The meds were very costly and we couldn’t afford to purchase any for our sick child. “
PLC—”We know Hussain loves to play, but what is his favorite thing to play? Does he have any hobbies?”
Dad—“He loves playing soccer with the neighbor kids, and he really likes to ride his bicycle.”
###
We’re just a few weeks away from Remedy Mission X, and we’re hoping to provide Hussain with a long-awaited surgery—check out his page HERE to learn how you can help. We’ll also be sharing his progress on our recently-updated Facebook page.
Stick with us…more to come.
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As PLC's Press Secretary, Matt Willingham writes, reads, edits, tweets, updates, and works with a camera so as to connect hearts and minds to Iraqi children in need. On the side, he likes reading stories, devouring the great food his wife cooks up and exploring DSLR work. He's also mildly obsessed with Twitter: @mehtin. |
“An Idea Worth Living”—Hear Jeremy Courtney Speak At TEDxAustin!
April 12, 2012 by matt · Leave a Comment
“If we live skeptically and only by the principles of risk-management, I fear we’ll miss the opportunity to remake the world around us.”
On a recent trans-atlantic trip, Jeremy Courtney was invited to share about the concept of preemptive love at TEDxAustin’s 4th annual conference.
This talk differed from his TEDxBaghdad talk as he shared new stories and invited attendees to consider how they personally might “do preemptive love.” And the video presents the same question to you: what can you do—small or large—to remake the world today?
After watching the video, would you share it? Your ‘shares’ and support help make our work possible—they can help save lives!
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As PLC's Press Secretary, Matt Willingham writes, reads, edits, tweets, updates, and works with a camera so as to connect hearts and minds to Iraqi children in need. On the side, he likes reading stories, devouring the great food his wife cooks up and exploring DSLR work. He's also mildly obsessed with Twitter: @mehtin. |
Our Struggle With Mortality
April 10, 2012 by Jeremy · Leave a Comment
When you intend to be in the “business” of saving lives, facing up to death can be a difficult thing.
For my part, in leading the Preemptive Love Coalition, knowing how to admit “failure,” when to acknowledge death without assigning fault, and when to let a death go unreported can be very difficult. The inherent difficulties are compounded by my responsibilities to various constituencies, including (but not limited to) the parents, local health care professionals, local political realities, coalition partners, national political realities, and international donors. At any given time, any one of these entities could be pushing for more or less reporting on a specific item; on a specific death and data set that would include a specific death.
In our January Remedy Mission VIII, a little boy named Yousef that we had grown to really love died in surgery. We held him up as a beacon of hope for the future of all Iraqi children facing congenital heart disease. We told his story and proudly proclaimed his desire to be the next world-famous soccer player. And then we asked you to give your money so that he could be saved by a team of international doctors and nurses. We also promised that his surgery would be an occasion for still more training for Iraqi doctors and nurses in our Nasiriyah program in southern Iraq during the mission (which was to be our sixth mission to the center in just 13 months).
Without exposing ourselves to legal action for disclosing confidential information, it will suffice to say that a local trainee made a mistake that cost Yousef his life.
Because Yousef was the first child in line for treatment that mission, we questioned what the psychological impact would be in widely reporting his death. Again, our considerations involved our international volunteers, local politics, coalition partners and international donors most specifically.
Remedy Mission VIII also featured two first-time nurses from the International Children’s Heart Foundation, both of which provided excellent insights into the local situation and helpful critique about the lack of success and development in the Nasiriyah program.
As we struggled to understand the death (the first mortality in 2-3 missions), our focus was on program development and responses to the conditions that led to the fatal error. Once the mission was over, a few more children had died and reporting on any single one of them was basically more than any of us could stand to emphasize at the time.
A typical response from a surgeon might be “Children have to die in order to build a heart surgery program.” And it’s true. But we are not surgeons. We are just a few normal people who have not held the human heart in our hands and who have not trained for this.
I’m writing to apologize for not reporting on Yousef’s death. We sent a private email to all who donated to Yousef’s account and let them know. But we did not endeavor anything more public.
After the mission a close friend who was still praying for Yousef contacted me without knowing he had died. It was then that I realized how many friends Yousef had and realized that it is not donations alone that tie us each to these children we seek to help. We are drawn in by their eyes, their stories and the hope they exude.
I wish now I would have allowed you to mourn Yousef’s death with us. They are not always easy decisions when juggling the preferences of so many stake holders. But somewhere along the way I gave up trying to push the message out because I did not want to come face to face with the story of his death again.
When you’re in the business of saving lives, “almost” doesn’t count.
We miss Yousef. He was a bright light!
And there are many other children out there who need our help; who are likely to survive; who can greatly benefit from surgical intervention. And there are hundreds of doctors and nurses who desperately need to be trained so they can serve these children on their own.
Thank you for continuing to stand with us…
Jeremy
Please feel free to email me with any questions or concerns.
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Jeremy Courtney lives and loves in Iraq as a co-founder and Executive Director of the Preemptive Love Coalition. He's also the father of two spectacular children, and married to the lovely Jessica Courtney. When not absorbed in PLC work he can be found writing songs and singing about hope and future. Follow Jeremy on Twitter: @JCourt. |
We just got off the phone with Hussain’s dad!
April 5, 2012 by matt · Leave a Comment
Dad—“We are well, Hussain’s health is stable, praise God. We are very happy for the opportunity to get surgery for our boy. We believe it is a gift from God, and you are his tool.”
PLC—”How long have you looked for surgery for Hussain?”
Dad—“Over a year. At first were trying to get medical help from Iraqi hospitals or from another country, but neither worked.”
PLC—”And how does Hussain feel about getting surgery?”
Dad—“Oh he is very excited. Every day he points at his chest and smiles saying ‘I’m getting a new heart.’ He also asks ‘when are they going to come to operate on me?’”
###
You can help us answer that last question. We hope to give Hussain his operation at the end of this month, but we need your help bringing the doctors back. Visit Hussain’s page to give toward his surgery and to help give him a new heart!
P.S.—We’re half way toward reaching our financial goal for Hussain! Help us ensure surgery for him by donating below.
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As PLC's Press Secretary, Matt Willingham writes, reads, edits, tweets, updates, and works with a camera so as to connect hearts and minds to Iraqi children in need. On the side, he likes reading stories, devouring the great food his wife cooks up and exploring DSLR work. He's also mildly obsessed with Twitter: @mehtin. |
A Playful Hussain In A Serious Situation
March 29, 2012 by matt · Leave a Comment
On our last Remedy Mission, we met a little boy named Hussain.
Hussain’s unabashedly playful approach to everything makes him a lot of fun to be around. In fact, this kid proved difficult not to be around. Even as Hussain waited his turn to meet with the cardiologist, it wasn’t long before a crowd of hospital staff had stopped what they were doing (i.e., stopped working), and gathered around Hussain to enjoy a game or a laugh.
Play-time abruptly ended and things got serious after a supervisor broke things up and got people back to work (though not before he himself had also played a game of catch with Hussain).
It wasn’t long before the boy was in the operating room for a more in-depth look at his heart problem. The cardiologist (pictured below) informed us that Hussain needed surgery, but that he wouldn’t be able to get it until the next Remedy Mission since the current one was all booked up. They had run out of room, but—with your help—we have the opportunity to bring the team back!
That is why we’re campaigning to save Hussain. You have already given $1,505 for Hussain’s upcoming surgery, but we still need your help to reach our goal of $5,000. Please visit this page to help provide Hussain the lifesaving heart surgery he needs, and be sure to come back next Thursday for another Hussain update!
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As PLC's Press Secretary, Matt Willingham writes, reads, edits, tweets, updates, and works with a camera so as to connect hearts and minds to Iraqi children in need. On the side, he likes reading stories, devouring the great food his wife cooks up and exploring DSLR work. He's also mildly obsessed with Twitter: @mehtin. |
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OUR BLOGGERS
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Matt Willingham is the PLC press secretary and writes primarily on politics, history, general updates and visual peacemaking through photography and film. |
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Cody Fisher is a PLC cofounder and writes primarily on program development and peacemaking by giving us a lens into the lives of the real people we love. |
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Jeremy Courtney is a PLC cofounder and writes primarily to emphasize our vision and values, including organizational and financial transparency. |
Preemptive Love Coalition provides lifesaving heart surgeries for Iraqi kids in pursuit of peace between communities at odds. We offer the 30,000 Iraqi children suffering from life-threatening heart defects a chance at the surgery they need to save their lives. With our world-class international surgical partners we create long-term solutions by training local Iraqi doctors and nurses so they can sustainably save lives without our help.