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Wagging the dog: Can Accreditation Organizations influence each other?

In last week’s issue of HCPro’s Accreditation Insider, there was an item regarding the decision of the folks at the Healthcare Facilities Accreditation Program (HFAP) to update their Infection Control standards for acute care hospitals, with the intent of alignment with CMS expectations (you can find the article here) We’ve certainly covered the concerns relative to Legionella and the management of risks associated with aerosolizing water systems and this may only be a move to catch up on ground already covered by other accreditation organizations (our friends in Chicago already require the minimization of pathogenic biological agents in cooling towers, domestic hot- and cold-water systems, and other aerosolizing water systems), but I’m thinking it might also be something of a “tell” as to where survey focus might be drifting as we embark upon the second half of 2018. Certainly, waterborne pathogens are of critical importance to manage as a function of patient vulnerability (ideally, we want folks to get better during their hospital stays), so it makes perfect sense for this to be on the radar to some degree. At this point, the memorandum from CMS outlining their concerns has been with us for about a year, with an immediate effective date, so hopefully you are well-entrenched in managing those water systems. If this one is still on your to-do list, I think it’s probably advisable to making it a priority to get it to your “to-done” list. But you should definitely check out the latest “clarification” from CMS. While the memo indicates that this does not impose any new expectations or requirements, it does make it a little clearer as to what surveyors are supposed to be checking.

As I think Mr. Gershwin once opined about summer and the easiness of living, it would be nice to be able to set a spell and take one’s shoes off, but vigilance is always the order of the day.

On a somewhat lighter note, I just finished reading Our Towns – A 100,000 Mile Journey Into The Heart of America, which outlines the efforts of a number of (mostly smallish) municipalities across the United States in positioning themselves for a positive future (positive positioning—I kind of like that). The focus is mostly on the socioeconomics of different parts of the country, with a focus on how diversity can be employed in bettering a community (that’s probably a little ham-handed as a descriptor, but you can find an excerpt here if you like). As my work allows me to travel to a lot of places, while I haven’t been to a lot of the same destinations as the Fallows, I do recognize a lot of the stories and a lot of the challenges facing folks lately (and I think you might, too). I would describe the tone of the book as hopeful, so if you’re looking for something to read at beach/pond/summer cottage, etc., you might consider giving Our Towns a shot.

 

A quiet week in Lake Forgoneconclusion: Safety Shorts and Sandals!

But hopefully no open-toed sandals—maybe steel toed sandals…

Just a couple of quick items as we head out of the Independence Day holiday and into the heat of the summah (and so far, scorching has been the primary directive up here in the Northeast—hope it’s cooler where you are, but I also hope it didn’t snow where you are either…but I guess if you were in Labrador last week, all bets are off).

When last week’s musings on the ligature risk stuff in the July Perspectives went to press (or when I finished my scribbling), the new materials had not yet made their way to TJC’s Frequently Asked Questions page, though I thought that they might—and that’s exactly what has happened. To the tune of 17 new FAQs for hospitals, so if you haven’t yet laid eyes on the July Perspectives, head on over to the FAQ page and immerse yourself in the bounty (that’s a somewhat weird turn of phrase, but I’m going to stick with it).

While you’re there, you should definitely poke around at some of the other stuff on the FAQ page. There are lots and lots of recommendations for risk assessment types of activities, so if you’re looking for some risk minimization opportunities, you might find some useful thoughts. Of particular note in this regard is the practical application of safety practices in those organizational spaces for which your oversight is somewhat more intermittent; I’m thinking offsite physician practices or medical office buildings and similar care locations. Depending on where you are and where they are, it might not be quite so easy to keep a really close eye on what they’re doing. And while I tend to favor scheduling surveillance rounds with folks in general, I also know that if you don’t stop by from time to time, you might not catch any lurking opportunities (and they do tend to be lurksome when they know you’re coming for a visit). In a lot of the survey results I’ve seen over the last 18 months or so, there’s still a pretty good chunk of survey findings generated during the ambulatory care part of the survey process. Safety “lives” at the point of care/service, wherever that may be—definitely more ground to cover now that in the past. At any rate, I think you could use the FAQ stuff as a jumping off point to increase the safety awareness of folks throughout—and you can do that independently of anyone’s vacation schedule (including your own).

Hope you and yours had a most festive 4th!

With a purposeful grimace and a terrible sound: Even more emergency management!

As much as I keep promising myself that I’ll poke at something more varied, the news of the day keeps turning back in the direction of emergency preparedness, in this case, just a little bit more on the subject of continuity of operations planning (COOP).

Late last week, our friends in Chicago proffered the latest (#41) in their series of Quick Safety (QS) tips, which focuses on elements of preparedness relating to COOPs (nobody here but us chickens). Within the QS tip (small pun intended), our Chicagoan overlords indicate that “continuity of operations planning has emerged as one of the issues that…need to address better in order to be more resilient during and after the occurrence of disasters and emergencies.” The QS also indicates a couple of best practice focus areas for COOPs:

  • Continuity of facilities and communications to support organizational functions.
  • A succession plan that lists who replaces the key leader(s) during an emergency if the leader is not available to carry out his or her duties.
  • A delegation of authority plan that describes the decisions and policies that can be implemented by authorized successors.

Now, I will freely admit that I always thought that this could be accomplished by adopting a scalable incident command structure, with appropriate monitoring of critical functions, inclusive of contact information for folks, etc. And, to be honest, I’m not really sure that having to re-jigger what you already have into something that’s easy for surveyors to discern at the 30,000-foot survey level is going to make each organization better prepared. I do know that folks have been cited for not having COOPs, particularly as a function of succession planning and delegation of authority (again, a properly structured HICS should get you most of the way there). So, I guess my advice for today is to figure out what pieces of your current EOP represent the COOP requirements and highlight them within the document (I really, really, really don’t want you to have to extract that stuff and create a standalone COOP, but if that helps you present the materials, then I guess that’s what you’d have to do…but I really don’t like that we’ve gotten to this point). At any rate, the QS has lots of info, some of it potentially useful, so please check it out here.

As a closing thought: I know folks are working really diligently towards getting an active shooter drill on the books, with varying degrees of progress. As I was perusing various media offerings, I saw an article outlining the potential downsides of active shooter-type drills. While the piece is aimed at the school environment, I think it’s kind of an interesting perspective as it relates to the practical impact of planning and conducting these types of exercises. It’s a pretty quick read and may generate some good discussion in your “house.”

The other shoe is starting to fall: Moving beyond ligature risks!

Well, it does seem like there are a couple of compliance themes asserting themselves in 2018, concerns related to emergency management (relatively simple in terms of execution and sustainability) and concerns relating to the management of behavioral health patients and the management of workplace violence (relatively complicated in terms of execution and sustainability). I think we can say with some degree of certainty that there are some commonalities relative to the latter two (beyond being complicated to work through) as well as some crossover. And while I wish that I had a ready solution for all of this, if I have learned nothing else over the last 39+ years, it is that there are no panaceas when it comes to any of this stuff. And with so many different regulatory perspectives that can come into play, is it enough to do the best you can under the circumstances? As usual, the answer to that question (at least for the moment) is “probably not.”

In last week’s Hospital Safety Insider, there was a news item regarding OSHA citations for a behavioral health facility in Florida for which inadequate provisions had been made relative to protecting staff from workplace violence. As near as I can make out from the story, the violence was being perpetrated mostly in patient encounters and revolved around “failing to institute controls to prevent patients from verbal and physical threats of assault, including punches, kicks, and bites; and from using objects as weapons.” Now, in scanning that quote (from information released by the Department of Labor), it does seem rather daunting in terms of “preventing” patients from engaging in the listed activities. This is one of those really clear division between federal jurisdictions—OSHA is driving the prevention of patients from engaging in verbal and physical threats while CMS is (more or less) driving a limited approach to what I euphemistically refer to as the “laying on of hands” in the management of patients. That said, I think it’s worth your while to take a look at the specific correction action plan elements included in the DOL release—it may have the makings of a reasonable gap analysis if you have inpatient behavioral health in your facility. It appears that the entity providing some level of management at the cited facility was also cited at another facility back in 2016 for similar issues, so it may be that some of this is recurrent in theme, but I think it probably makes sense to take a look at the details to see if your place has any of the identified vulnerabilities.

Wanting to end this week’s installment on an upbeat note, as well as providing fodder for your summer reading list, I was recently listening to the id10t podcast and happened upon an interview with astronaut Leland Melvin, who navigated a number of personal and profession barriers to become the first person to play in the NFL and go into space as an astronaut. His book, Chasing Space, is a fun and thought-provoking read and really captures the essence of what we, as safety professionals, often face in terms of barrier management. I would encourage you to check out the book as well as the interview. As a side note, I’m not sure if you folks would all be familiar with Chris Hardwick and his Nerdist empire, but I think he’s become a most winning and empathetic interviewer, and since I’ve never been afraid to embrace my inner (and outer) nerd, I will leave you with that recommendation (and please, if you folks have stuff that you’re reading and think would be worth sharing with our little safety community, please do—fiction, non-fiction—a good read is a good read!)

Not enough rounding in the world: Compliance and readiness in the face of everyday chaos…

As I was engaged in my walk this morning (the sun just starting to cast its light on the Rockies!), I was pondering the complexities of the healthcare environment as a function of compliance. One of the truisms of my practice is that I am good at finding those points where things don’t quite gel. Sometimes (most times, to be honest), it’s relatively minor stuff (which we know is where most of the survey findings “live”) and every once in a while (mostly because my eyes are “fresh” and can pick out the stuff that’s happened over time; as I like to say, squalor happens incrementally), you find some bigger vulnerabilities (maybe it’s a gap in tracking code changes or a process that’s really not doing what you need it to do). So, after tooling around for a couple of days, folks will inevitably ask me “what do you look for?” and I will stumble through something like “I try to find things that are out of place” or something like that.

This morning, I had something of an epiphany in how that question actually informs what I do: it’s not so much what I look for, it’s what I look “at.” And that “at,” my friends, is everything in a space. One of the process element that gets drilled into housekeeping folks (I’m pretty sure this is still the case, it definitely was back in 1978 when I started this journey), is to check your work before you go on to the next thing, and that means going back over everything you were supposed to do. I’ve had conversations with folks about what tools I’ve seen that have been effective (and I do believe in the usefulness of tools for keeping track of certain problematic or high-risk conditions), but only in very rare circumstances have I “relied” on a tool because I have an abject fear of missing something critical because I had a set of queries, if you will. I would submit to you that, from a compliance standpoint, there are few more complex environments in which to provide oversight than healthcare. It is anything but static (almost everything except for the walls can move—and does!) and in that constant motion is the kernel of complication that makes the job of facilities safety professional infinitely frustrating and infinitely rewarding.

So, I guess what I’m advising is not to limit your vision to “for,” but strive for “at everything—and if you can impart that limitless vision to the folks who occupy your organization’s environment, you will have something quite powerful.

 

Why can’t we have anything nice? Hardwiring safety improvements: Finding fault vs. facilitation

It seems of late I’ve been encountering tales of much fingerpointing, heavy sighs, and the like in the lead-up to a date with our friends from Chicago. To my way of thinking, if there are outstanding/longstanding issues relating to compliance (and it can be just about anything relative to compliance), how much help can it be to keep pointing out the deficiency without working with folks to find some sort of rational/operational strategy for managing their environment? For example, where can one put stuff? I’ve been working the consulting beat for almost 17 years (as I wrap up my 40th year in healthcare—more on that as we approach that momentous July anniversary) and I can tell you with pretty much absolute certainty that there is not a single hospital anywhere that has enough (which would equate to too much) storage space. Clearly some of that deficit is a function of revenue generation potential as an algorithm for space allocation, but even your biggest money-makers tend to have more stuff than space. But I come back to the reality of kicking department managers for the same compliance concern(s) time and time again and (again, this is my interpretation) it just seems like a buck-passing exercise for the folks conducting the rounds— “well, I told them they couldn’t do that—and they keep doing it.” And try as I might, I can’t equate that type of process with anything that approaches performance improvement.

While I recognize (and observe in certain instances) that organizations have made, and continue to make, improvements over time, what is important is not to lose sight of the hardwiring of processes that are designed to sustain those improvements. As noted in the storage example, the physical plant is traditionally not considered a revenue generating concern, but the impact of ongoing maintenance of the physical environment on the delivery of excellent patient care has never been scrutinized more closely. It is of critical importance to develop and implement strategies that allow for those tasked with maintaining the physical environment to focus on those tasks, utilizing point-of-care/point-of-service staff to the fullest extent in the not just identifying, but facilitating management of “imperfections” in the environment.

Not to belabor the point, but the current level of focus on conditions in the physical environment, particularly as a function of the environment’s impact on infection control and prevention, calls for a greater degree of coordination amongst the primary stakeholders. While there is no specific dictate relating to the circumstances under which infection control risk assessments must be conducted; risk management strategies implemented (either through a hardwiring of basic risk reduction in standard operating procedures for certain activities, including repair and renovation activities on patient units), and a reliable process for notification of, and follow-up for, conditions that might nominally be described as “breaks” in the integrity of the environment. Certainly, the proliferation of leaks, stained ceiling tiles, damaged wall and flooring surfaces, etc., would indicate that the current management of this process does not provide enough of a “safety net” to serve the organization and its mission of continuous survey readiness. At this point, the administration of the survey process is clearly aimed at the removal of the “final” barriers between “clinical” and “non-clinical” functions in hospitals. The survey process is based on a clear sense/understanding that the entire hospital staff is engaged in patient care, regardless of their role in that care. The organizations that fare the best during survey are the organizations that have been able to grow the culture in a direction that results in a truly seamless management of the environment as the outer “ring” of the patient care continuum. Each staff member is a caregiver; each staff member is a steward of the physical environment.

I don’t think we can ever hope to be successful until we starting working towards a sheriff-less approach (based on that old saw “There’s a new sheriff in town”). One of the fundamentals of just culture is holding folks accountable, but not without working with them to achieve that nirvana state. I think if punishment (I consider reiteration of sins to be punishment) worked, we’d have a lot fewer findings in the physical environment. I can remember a time when you could get away with a more dictatorial approach to managing the environment, but I don’t think that time is coming back any time soon.

Unfortunately, the regulatory folks aren’t quite poised to embrace the facilitation/consultation model of accreditation surveying, which leads me to my closing thought/suggestion for this week. I am still “anxious” about the whole water management program issue as a function of the accreditation survey process and how it will play out. I’ve heard (but not seen) that TJC has cited folks for (presumably) inadequate water management programs, and I’ve learned over time that these types and numbers of findings tend to escalate before they de-escalate. Certainly, this is something we have to “do” very well, because to do otherwise puts people at risk. As I have in the past, I would encourage you to check out Matt Freije’s latest thoughts on all things water management programs. I suspect that everyone is a different point along the “curve” with this one, but I know one thing—you don’t want to have an outbreak relating to the management of waterborne pathogens. Talk about being “sheriffed”…

What the world needs now: Effective management of workplace violence

By now I’m sure you’ve all noted the unveiling of the latest Sentinel Event Alert (#59 for those of you keeping count) from our friends in Chicago; this particular SEA represents the third swing at concerns and considerations relative to workplace safety, inclusive of workplace violence. But, as I look at the information and guidance provided in the May 2018 issue of Perspectives, it makes me wonder what pieces of this remain elusive to folks, beyond the “normal” operational challenges of providing effective safety education to staff on a regular basis.

So, my questions for the group are these:

  • Have you clearly defined workplace violence?
  • Have you put systems into place across your organization that enable staff to report workplace violence events, inclusive of verbal abuse?
  • Have you identified all the potential sources of data relative to workplace violence occurrences?
  • Are you capturing, tracking, and trending all reports of workplace violence, inclusive of verbal abuse and attempted assaults, when no harm occurred?
  • Are you providing appropriate follow-up and support to victims, witnesses, and others impacted by workplace violence, including psychological counseling and trauma-informed care?
  • Are you reviewing each case of workplace violence to determine the contributing factors?
  • Are you analyzing data related to workplace violence, and worksite conditions, to determine priority situations for intervention?
  • Have you developed any quality improvement initiatives to reduce incidents of workplace violence?
  • Have you provided education to all staff in de-escalation, self-defense, and response to emergency codes?
  • Are you evaluating on an ongoing basis the effectiveness of your workplace violence reduction initiatives?

If your response to any of these questions is “no” or “not sure,” it’s probably worth (at the very least) some discussion time at your EOC and/or organizational QAPI committee, but I have a strong suspicion that most of you have already identified the component pieces identified above in your own efforts. That’s not to say that there aren’t improvement opportunities relative to workplace violence (as there likely always will be), but I do think we’ve made some pretty decent strides in this regard over the past few years. There was a time when the incidence rate was sufficiently concentrated to certain healthcare environments (cities, urban areas, etc.), but, and this is probably the toughest risk element to truly manage, it appears that workplace violence can happen at any time, anywhere. In some ways, it reminds me of the early days of the Bloodborne Pathogens standard and Universal Precautions; it was frequently a struggle for safety and infection control folks to sufficiently encourage good behaviors (and lord knows hand washing can still be a struggle), but much of what was initially viewed as foreign, inconvenient, etc. has finally been (something close to) hardwired into behaviors.

Again, I’m not convinced that this revisitation of covered territory helps anything more than increasing the risks of getting hammered during a survey if you can’t specifically identify how your program reflects their expert advice, but maybe it will help to gently remind organizational leaders that this one’s not going to go away.

It was a fine idea at the time: Safety story of the week!

Now it’s a brilliant…

I think we’ve hung out together long enough for you to recognize that I have some geeky tendencies when it comes to safety and related things, sometimes straying beyond the realm of health care. And this is (pretty much definitely) one of those instances.

Over the weekend, while listening to NPR, I happened upon a story regarding safety concerns at the Tesla factory out in California and how operating at the brink (cusp?) of what’s possible can still fall victim to some time-honored realities of the workplace. The story, coordinated by The Center for Investigative Reporting, and aired on their program Reveal (you can find the story, and a link to the podcast of the story here) aims at shedding some light on some folks injured while employed at Tesla. While I can’t say that there’s the figurative “smoking gun” relative to decisions made, but it does seem to fall under the category of “you can make the numbers dance to whatever tune you’d care to play.” I thought it was a very well-done piece and while there may not be specific application to your workplace, I figure you can always learn from what others are (or aren’t) doing. At any rate, I can’t tell the story as well as they have (the podcast lasts about 55 minutes; the SoundCloud link is about halfway down the page), so I would encourage you to give it a listen.

One other quick item for your consideration: We chatted a few weeks ago about the shifting sands of compliance relative to emergency generator equipment and I wanted to note that I think it would be a pretty good idea to pick up a copy of the 2010 edition of NFPA 110 (it’s not that large a tome) or at the very least, go online and use NFPA’s free access to their code library, and familiarize yourself with the contents. Much as I “fear” will be the case with NFPA 99, I think there are probably some subtleties in 110 that might get lost in the shuffle, particularly when it comes to the contractors and vendors with whom we do business. Recently, I was checking out an emergency generator set that was designed and installed in the last couple of years and, lo and behold, found that the remote stop had not been installed in a location outside of the generator enclosure. Now I know that one of the things you’re paying for is a reasonably intimate knowledge of the applicable code and regulation, and emergency power stuff would be no exception (by any stretch of the imagination) and it perturbed me that the folks doing the install (not naming names, but trust me, this was no mom & pop operation that might not have known better) failed to ensure compliance with the code. Fortunately, it was identified before any “official” survey visits, but it’s still going to require some doing to get things up to snuff.

I have no reason to think that there aren’t other “easter eggs” lurking in the pages of the various and sundry codified elements brought on by the adoption of the 2012 Life Safety Code®, so if you happen to find any, feel free to give us all a shout.

The exodus is here: Are you prepared?

Some say not so much.

First off, many thanks to the standards sleuths out there that assisted on solving last week’s missing EP caper; it’s nice to know that I am not merely orating into the void (oration being a somewhat hyperbolic description of this blog—lend me your eyes!).

Now, on to our continuing coverage of emergency management stuff.

The ECRI report outlining the Top 10 Patient Safety Risks for 2018 (if you missed it last week, you can download it here), does make mention of all-hazards emergency preparedness as #7 on the Top 10 list, though I have to say that their description of the challenges, etc., facing hospitals was whatever word is the opposite of hyperbolic (I did a quick search for antonyms of hyperbolic, but nothing really jumped out at me as being apropos for this discussion), pretty much boiling down to the statement that “facilities that were prepared for…disasters fared better than those that were not.” And while there is a certain inescapable logic to that characterization, I somehow expected something a bit weightier.

That said, the ECRI report does at least indicate that there may have been hospitals that were prepared, which is a little more generous than hospital preparedness was described in the report from our friends at the Johns Hopkins Bloomberg School of Public Health Center for Health Security (you can find the report here). The opening of the Hopkins report goes a little something like this: “Although the healthcare system is undoubtedly better prepared for disasters than it was before the events of 9/11, it is not well prepared for a large-scale or catastrophic disaster.” Now that is a rather damning pronouncement, and it may be justified, but I’m having a bit of a struggle (based on reading the report) with what data was used in making that particular pronouncement. I’m not even arguing with their recommendations—it all makes abundant sense to me from a practical improvement standpoint—and I think it will to you as well. But (I’m using a lot of “buts” today), I’m having a hard time with the whole “is not well prepared” piece (in full recognition that it is healthcare as a single monolithic entity that is not well prepared). Could hospitals be better prepared? Of course! Will hospitals be better prepared? You betcha! Could hospitals have more and better access to a variety of resources (including, and perhaps most importantly, cooperation with local and regional authorities)? Have the draconian machinations of the federal budgeting process limited the extent to which hospitals can become prepared? Pretty sure that’s a yes…

Could the nation (or parts therein) experience catastrophic events that significantly challenge hospitals’ ability to continue to provide care to patients? Yup. Will the nation (or parts therein) experience catastrophic events that significantly challenge hospitals’ ability to continue to provide care to patients? Probably, and perhaps (given only the weather patterns of the last 12 months or so) sooner rather than later. There have always been (and there always will be) opportunities for hospitals to improve their level(s) of preparedness (preparedness is a journey, it is not a destination), including building in resiliency to infrastructure, resources, command leadership, etc. And while I appreciate the thought and preparation that went into the report, I can’t help but think that somehow this is going to be used to bludgeon hospitals on the regulatory front. In preparation for that possibility, you might find it useful to turn your emergency management folks loose on a gap analysis relative to the recommendations in the report (again, I can’t/won’t argue with the recommendations—I like ’em), just in case your next accreditation surveyor tries to push a little in this realm.

Cylindrical musings and nudging as a compliance strategy

Howdy, folks. After surviving the battering of this past weekend’s tumultuous weather in the Northeast (I got to experience it twice—once in Indiana and again back home), I’m going to be (relatively) brief for this week’s missive.

First up, hopefully most of you are familiar with the TED Talks concept (all the info you need about that you can find here) and NPR has a weekly program that kind of crystallizes some of the TED offerings in their TED Radio Hour. This past weekend (no TV, so we had to huddle around the radio, just like in olden times), the program revolved around the use of gentle pushes or nudges to change behaviors (you can hear that broadcast here). As safety professionals, I think we are all acquainted with the various attempts to get folks to do our bidding when it comes to safe practice (that sounds a little authoritarian, but it’s kinda what we’re up against) and I thought the entire program really gave me some food for thought in how we might come at compliance from a slightly different perspective. I thought some of the ideas were fascinating and definitely worth sharing, so if you have a spare 55 minutes or so (the webpage above does break it out into the individual sections of the broadcast—I think it’s all good, but whatever description seems most interesting to you would be a good starting point), you might give it a whirl…

I also want to bring you some hopeful news on the cylinder storage segregation front; when this whole focus started, quite a few folks were cited for storing non-full (empty or partial) cylinders in the same location as full cylinders. I don’t know when The Joint Commission posted the updated FAQ on cylinder storage, but, and I quote, “Full and partially full cylinders are permitted to be stored together, unless the organization’s policy requires further segregation.” I know this whole thing was the bane of a lot of folks’ existence, particularly after we had to work so diligently to get folks to secure the cylinders properly, only to have this little paradigm shift towards the edge of darkness. I believe that this will make things somewhat simpler in the execution (make sure your policy reflects the allowance for full and partials to be stored together—they’ll be looking to review that policy).

As a final, non-safety note, I just flew cross-country and was able to watch Gary Oldman’s performance as Winston Churchill in Darkest Hour. I’ve always been something of a history buff, with World War II as a central theme and must tell you that I thought it was a really great performance and a fine movie (or is it a film?). It really points out the power of consensus and the use of the spoken word to galvanize folks (which kind of ties back to the nudging—though Sir Winston’s nudge packed a lot of wallop). At any rate, I thought it was very well done (no surprise about the Best Actor Oscar) and probably my favorite since Lincoln (the movie, not the car or President…though Lincoln in the Bardo was a very interesting book…).