But take a look anyway, if you have an interest in process improvement in hospitals. This is a collection of my best posts on this topic.

Thursday, December 20, 2007

An idea for US News and World Report

Here is an open suggestion for Avery Comarow, the editor of the annual US News and World Report ranking "America's Best Hospitals." Why not add to your algorithm extra points for those hospitals that voluntarily publish clinical indicators of the degree to which they harm patients? I am not talking about the usual hodgepodge of outdated CMS data, which are available anyway. I am talking about substantive clinical metrics, like central line infections, ventilator associated pneumonia, and the like. Or the ultimate, the hospital standardized mortality rate calculated by the Institute for Healthcare Improvement.

I can already hear the arguments against this. Who is going to validate the numbers? Which definition of central line infections should be used? How would you compare from hospital to hospital?

Please, put all that aside. Let's just accept as a premise that hospitals that choose to post these numbers do so not for comparative or competitive purposes, but rather to hold themselves accountable to the public for their efforts in quality and safety improvement. Shouldn't that be worth something in the US News listing?

A fallback, if you don't want to change your algorithm. Just create a special box listing the hospitals that post these kinds of results, along with their url, so people from hospitals around the world can check in and make their own judgments about the usefulness of this approach.

Avery, you have become a force in this field. As noted on your blog, your perspective uniquely qualifies you to observe and comment on the efforts by hospitals and other health care providers to improve care and patient safety. Why not use that influence to push the industry along to greater heights by giving space to those who risk holding themselves accountable in this manner?

Wednesday, November 28, 2007

Safety in the NICU

Mark Graban at Lean Blog asked the following question as a comment to a posting below. It is interesting and important enough to repeat here for a larger audience -- and particularly for people at other hospitals who might find the answers of value. I am sure the BIDMC people mentioned would be very happy to provide further information to people from other hospitals. (Also, I have to admit to a little pride in that our folks, who already thought they had a very good plan on this matter, went further to adopt additional safeguards for these very tiny babies.)

"Do you have thoughts to share on the preventable heparin error involving Dennis Quaid's twins in L.A.? What steps is BIDMC taking to proactively prevent that same error from occurring in your hospital?"

After consulting with our people, I posted this initial response, with the help of Greg Dumas, one of our pharmacists:

I asked our folks about the heparin question you raised. Here is part of the response from one of our pharmacists. As you can see, the staff is still working on other ideas.

"Please see the steps below that we put in place prior to the tragic September 2006 incident at Methodist Hospital in Indianapolis.

"1) Heparin Flush Syringes 10 unit/mL are stocked in the NICU Automated Dispensing Machine(ADM). These syringes are stored separately from adult heparin products in an area designated for "Neonate Use Only".

"2) All medications that are filled in the NICU ADM are checked by a pharmacist prior to delivery.

"3) All heparin containing intravenous fluids are prepared by the pharmacy.

"Additionally, the pharmacy does not stock the Baxter heparin products , which were involved in both the Indianapolis and the LA incidents.

"After the most recent heparin incident at Cedar Sinai, our Clinical Pharmacy Coordinator Medication Safety, we decided to evaluate utilizing the bar code technology as an added safety measure. The NICU/Pharmacy Committee will review this at this Tuesday's meeting.

"Providing medications safely and effectively for our NICU population is of utmost importance to our pharmacy."

And, a bit more explanation:

"The Methodist Hospital NICU stocked heparin flush 10 unit/mL in 1 mL vial. The pharmacy technician mistakenly delivered heparin 10,000 unit/mL vials which are used for SC injections for DVT prophylaxis(there are also 20,000 unit/ml vials). This is what caused the 1000 x overdose. The news stories do not say that a pharmacist checked the vials before they before they were delivered. We require all medications be checked by a pharmacist.

"I am comfortable that this could not happen here. We purchase pre-made 3 mL heparin flush 10 unit/mL in 12 mL syringes. These syringes are blue and stored in a special section of the pharmacy designated for NICU only. The adult heparin flush syringes are 100 unit/mL and in a yellow syringe. These are stored with the main inventory far away from NICU stock."In July, we began stocking the NICU with premix heparin IV solutions. This enabled us to remove the heparin 1000 unit/mL 10 mL vial that had been stocked for nurses to prepare initial IV bags for UAC and UVC lines. The RN would add 500 units to the 1 liter bag of fluid.

"We removed the heparin 1000 unit/mL vial in July and the only heparin in Omnicell now is the heparin flush syringe. This was a safety quality initiative that the NICU/Pharmacy committee had started a couple of years ago and finally implemented it this July."

I just received a followup from Susan Young, clinical nurse specialist, in our NICU:

"The NICU/Pharmacy committee met today; pharmacists Karen Smethers and Steve Maynard joined us to look at other safety measures we could use in the NICU to prevent mis-dosing heparin. The NICU has only one concentration of heparin stored in Omnicell - the 10 unit/mL syringe. This syringe has a blue label. There is another syringe available through Pharmacy that is 100 units/mL. It has a yellow label.

"Omnicell has the ability to read barcodes. We decided to use this feature for heparin to provide a double check for the system. Pharmacy technicians load the heparin syringes into Omnicell. When they do this, they will barcode the heparin syringes. This will provide some safety, but will not ensure that all syringes are of the correct concentration because only one syringe can be scanned when filling the Omnicell bin. (To scan each syringe would require the technician to close the draw after each individually scanned syringe and re-enter Omnicell.)

"The second part of the safety will require the NICU nurse to scan the syringe when removing it. This will ensure that she has removed a syringe with the correct heparin concentration, in the chance that a syringe was incorrectly loaded in a batch. These added steps provide some added layers of safety.

"The NICU is moving ahead with implementation of POE. This will also help to prevent errors and overrides when we have a quicker way of sending order sets for medications to the Pharmacy. Admission of infants to the NICU is one time when we remove medications prior to them being overseen by Pharmacy. Umbilical lines require heparin, vitamin K and erythromycin are administered quickly. POE will help with this process. One system issue that interferes with a more rapid process is that infant medical record numbers are generated after an infant is born. The committee will be examining whether it is possible to start that process earlier so that medications that are needed immediately after birth would be ordered and authorized by Pharmacy, in some cases even prior to the birth of the infant. Working with Admitting is key to this part of the plan, and one that is recommended by Karen Smethers as a way to provide more Pharmacy oversight."

Monday, November 26, 2007

Responses to Thanksgiving email

As promised, I want to keep you up to date on responses to the staff email included in the post below. The email certainly struck a chord, and the replies give you a sense of the range of feelings within our hospital. This is the one that sticks with me the most and gets to the heart of what I would like to change: This facility provides great pay and benefits. Fulfillment, though, is something that I seek elsewhere. What a shame that we cause anyone to feel that way!

Remember, these were not anonymous replies, and I am fortunate that people here are so forthright with me. These are mostly unexpurgated and presented in the order I received them, so you get the vicarious pleasure of reading both the good and the bad. And yes, you can laugh (or groan) with me at the humor!

I am guessing that people in other hospitals will see common themes -- or would, if they asked the questions.
Hi Paul,

You're SO right about the fetching!!!

Three things come to mind:

1. On rounds, I spend at least twice as much time looking for patient charts as I do with the patients. This is due to simple lack of consideration by my colleagues who feel they are too important to spend their time putting the chart back when they're done with it---some consciousness-raising here would be great!

2. We had a semi-similar program here in the 80's called "Prepare 21" as in "prepare for the 21st century." (But I'm sure you already knew that. . .) People were very skeptical about the program until they received their first "incentive" check which distributed the cost savings the hospital realized during that quarter from implementing the suggestions made, then suddenly the whole staff was on board and knocking themselves out for new ideas. (It would have warmed your heart if you had been here then.)

3. In the movie "Mean Girls" (a classic) the girls tried to introduce a "cool new word" into the vernacular; that word was "fetch" (as in, "your new sweater looks really fetch.") Maybe the inspiration for the new program's name could come from there???

All the best for a great Thanksgiving (the best holiday of the year, since it is the all-American, non-sectarian, no-gift-giving-pressure holiday devoted to family, eating, and football.)
What a wonderful email Paul !!

I am proud to be a part of BID.
I think it should be named The 3rd Hand...since every nurse wishes she/he had an extra hand and also, tends to multi-task beyond the call of duty.
Hello Paul,
It might be a "fun" idea to have a contest on picking the program name.
My program name would be "let’s have fun getting it done".
I loved this communication. I’m ready to get involved!
Hope your Thanksgiving is also wonderful…
Hello Mr. Levy,
Hospitals typically make use of an antiquated hierarchical form of management. This is true for the BIDMC, and we keep using a playbook which relies on scolding and belittling the staff. And yet we continue to call upon outside consultants to speak with the staff, while year after year the existing management teams treat input from the front lines with contempt.

Why can’t our current management staff learn from their own teams? Is it a feather in our cap to point out that we are hiring—paying for—outside consultants to find out how we can improve? Can we not "capture value" and get "lean" with our current leaders? Whenever I have an opportunity to answer survey questions, I always respond, "Please talk to your staff."
I’m convinced that this could work.

I don’t mean to have a disrespectful tone. This facility provides great pay and benefits. Fulfillment, though, is something that I seek elsewhere. How many former managers in our midst want nothing to do with leadership positions? Your concern and good wishes for Thanksgiving—and for the general improvement of the professional development of the staff are genuine and appreciated. Thank you.
Truth is, we also spend tragic amounts of time documenting instead of being in contact with patients. Even more than fetching.
I love this idea.

When I am rounding, I spend a lot of wasted time looking for and "fetching" charts that were not put back on the rack after someone used them. This shows lack of respect for whomever they think will put them away (reminds me of my teenager…)
Thank you. Happy Holiday to you and to your loved ones as well. My suggestion for the title is "Let us make it work, TOGETHER".
Dear Mr. Levy,
What a wonderful way to start my day. My motto has always been in my 30+ (ahem) years that "This is not just a paycheck". I truly believe if this program is successful, that employees will take pride in their work and feel "valued" and that they are not here to simply put in their time and then go to the bank for survival. The increased self esteem will also be such an added perk.
I hope you have a safe and happy holiday as well.
Mr. Levy,
I normally don't write back on these sorts of things, but this one has caught my attention. I personally can answer no to two of your questions. Many employees in my position feel like the extra's we do go unnoticed but if we make an error it is immediately noticed. Each day I come to work and think about the person on the other side of my counter (the patient). I treat each patient as if he/she was my mother or father. I try to instill in others that patients come here because they are usually sick. This is especially true in my division (thoracic surgery). The last thing any patient or family member needs to hear is "I don't know" or feel as though they are bothering us. I love what I do for work and I would relish the thought they our supervisors would notice a job well done. Telling someone they have done a good job goes a long way and brings a smile to the employee. Feeling good about your job is an important part of doing a good job. Thank you for taking on a project to make each employee feel as thought he/she is a valued employee. My suggestions for a name for your upcoming program are: Feel good at work and I matter.

Happy Thanksgiving.
Hi Paul,
This is very, very exciting news. Your idea is wonderful. I have one suggestion that you might find of value. It may be helpful to create a hotline, either a phone or email based response venue that allows employees to report stuck ideas.

The one thing that is very discouraging is when people work hard on finding solutions only to have them get "lost" in the system. One of the major stumbling blocks in a large institution like this is that what one person does can and often does affect others in different departments. So when a change is proposed, it has to go through a committee. It is important that feedback be given to those who worked on a solution, especially if it is discovered that one aspect of the problem is made worse by the proposed solution. They should be encouraged to work with the department to find an acceptable solution.

In order for employees to feel empowered, they need to have a voice in finding out what is happening to their proposal.

I really appreciate your leadership. We are truly lucky to have you as our team captain.
Dear Paul,

Happy Thanksgiving to you and your family also. I want to compliment you on the wonderful vision you have at just about everything you do and say and plan, I truly appreciate all your efforts.

Yes, you caught my attention and in my opinion you are right on target. I think BIDMC does a superb job generally but I believe there is always room for improvement. The thought that keeps coming to my mind about what to call the 'program' is to look at it from the perspective of why these "work-arounds" can be so prevalent. I think it is because of how we all choose at times to 'overlook' things. Such as "oh well that was the last 'whatever', I don't have time to tell somebody my patient needs me now, I am sure someone else will order more", etc. I think a good name for the program might be DO. Which I believe would stand for Don't Overlook. If just a few more people chose to not overlook something we could be even better than we already are to our patients and fellow staff.

Thanks for caring so much.
Good day Mr Levy,

You should name the programs (DRKN) it identify the three questions. D is for dignity, R is for respect, K is for knowledge, and finally N is for notice.
Hi Paul
I find this idea intriguing, I have a suggestion with a little humor attached:
S uggestions
M aking "SMILE"
I nstitutional
L ife
E asy

Enjoy the Holiday
Good Morning Mr. Levy,
This message may be one of hundreds that you receive this morning alone; I just wanted to drop a quick note to thank you for your timely message. This is an issue that I have been bringing in to work recently. It's nice to know that it is being discussed and that more is to come.
I wish you and your family a wonderful Thanksgiving.
What comes to mind-
Smart Care
Working Smart
HOW ABOUT "FETCHING R-E-S-P-E-C-T"------I think ARETHA FRANKLIN would respect this choice!!!!!!!
A suggested name for this program: RESPECT = Representing Evaluating Specialties Provides Excellent Consistency Throughout

Happy Holiday!
Hi Paul,
This is VERY exciting! I work in the OD group. I've spent a lot of time with the Nursing groups for the survey work......one of their big complaints is this "fetching" you describe. They're tired and frustrated.

I look forward to learning more about this critical initiative!

Happy Thanksgiving to you and your family. Drive safely.
Good Morning,
Happy Thanksgiving to you and your family!
One suggestion for a program name – "Streamline to Success"
What a great idea….When I worked as an Operations Coordinator for Nursing it was a daily challenge.

Maybe we could call it "finding Nemo".
I love my job....always have.....you might make it more fun?...bring it on
Good morning Mr. Levy
I know you are very busy and I appreciate your time.

I have been wanting to email you for a bit now.............I came to BIDMC in September as a new Med-Surg CNS for the East Campus. When you spoke to my orientation group you said "if you find something wrong or can't figure out why we do something, tell me soon........for in a very short time you will get used to this way and you won't be of any use to me."

Well, there were a few things here and there but nothing dramatic that you probably weren't already aware of. I have been involved with the LEAN project and that certainly has had an impact on changing work habits, etc.

So why am I writing? Well, two reasons...............
First, I want you to know how genuinely privileged I feel to work here at BIDMC. I have never felt so welcomed or respected. I chose to come here (yes, I had several other offers) and have never regretted that decision. My days are long and challenging but I couldn't work for or with better people.

This Thanksgiving, I have much to be grateful for.

Second, I'd like to be part of the Value Capture project in any way you deem appropriate. I have been trying to find a way to bring the FISH philosophy here to BIDMC http://www.fishphilosophy.com/ It is a simple concept really and incorporates much of what is part of the Value Capture culture....... It is based on the way business is conducted at the Seattle Fish Market.......honestly, I couldn't make this up!

A. Make their day...............what can you do to make your positive energy contagious?
B. Be there..........being fully present in the moment to all of our customers, internal and external. How are you"being" on the job?
C. Play...........is there a way to bring fun into an otherwise serious situation?
D. Choose your attitude.............you can wake up everyday and 'select' your attitude. Hey, everyday you wake up is a good day as it sure beats the alternative!
....all of this may seem simplistic and obvious, however it has true value and is worth considering.

Thank you for your time and attention. I wish you and your family the very best this holiday season.
Here is my idea.
BID Real MC Time! Or just BIDMC Real Time!
I've been an employee at BIDMC since 1981 and I've seen quite a few changes. We used to have a program called "Prepare 21" where employees submitted ideas and were rewarded with ones that worked and made a positive difference. Art School, perhaps teaching was my first career choice, but soon after marriage and a child, I came to then named "Beth Israel Hospital" and it was one of the best decisions I've made. I continue to enjoy my work today.
I now working in Ambulatory Education & Systems supporting our Ambulatory clinics and working hard to make things work for the practices (and I do teach)! I love taking a creative/out of the box approach to things! Here is my "creative" suggestion:
The BID-HIGH Plan or The BIDMC-HIGH Plan or simply
"Bidding to Better, Caring to Win"
Thank you for your hard work to better this Institution.
A suggestion below:
"Revolutionize Your Job!"
Free your work flow from cumbersome processes and unnecessary paperwork to get to the heart of patient care and support.
For the new program's title:
"Because it's right" or It's only right""We're only human" or "Do the Right Thing" or"WHat I learned in kindergarten""It doesn't take much"or"It never hurts to be kind".
Corny, I know, but, I look forward to the program.
Mr. Levy- Happy Thanksgiving to you and your family. Name for the new program--- "Our Work is Fun!!!"--
Dear Paul,
What a refreshing email! It really hits home. There are countless work-arounds every day that we take care of patients. As a nursing supervisor on the evening shift, I get paged for many most basic, mundane things all the time. Interestingly enough, items that should already be at the point of care are prime contenders! Well, the other night I had this dream: I was paged to bring, get this, a bag of composted manure. Yes, you read that right. I woke up and laughed out loud! So, my "fetching" went from the ridiculous to the sublime! At least they didn't want a bag of lime, which is VERY heavy and could have resulted in a work related injury. I applaud your new idea and I hope it can be very successful.

Happy Thanksgiving to you and yours.
Thank you! Happy thanksgiving to you and your family as well- This project/training tool sounds like exactly what BI needs! I would call it ‘project moral’ for employee moral because that is the underlying heart of BI.
Sounds like a great idea to me and I'd love to be involved.
Love your blog - have never posted, but always read!
Happy Thanksgiving!
I wanted to write back with a thought. It is clear that like most - or more realistically all - medical center employees, I do a lot of fetching & rework. Certainly some of this is related to inefficient processes, and I agree it's a terrific idea to try to improve these processes.
But another problem is that there is not enough support to enable me to do as much physician work as I'd like to do. I spend a lot of time doing work that a non-physician could do. As you well know, lots of support positions were cut during the hospital's very difficult financial times, and many have never been added back. We manage with fewer personnel, but it means many of us are doing work that really would be more appropriately done by others, and all of us are working significantly harder than we have been in the past.

I had brought this point up at a forum you attended a year or so ago, and you had replied that these concerns were valid, but that medical center's operating surplus was not such that adding staff was realistic.

Working smarter is a good thing, but having enough people to do the job is just as important.
Good day Mr. Levy,

I am writing back as you suggested with my idea. My Suggestion for a Name:

(I would have done the text using text art, but I did not have the option on my workstation).

Happy holidays to you and your loved ones.
Good morning,
The program sounds looong overdue. How about:
"SAS" -SaveAStep (ie get "sassy" about saving time)
Have a great Thanksgiving,
Suggested program name "If I had my way, we would ……..".
Hi Mr Levy,
This maybe a start to a name- (driven) program & it stands for d-dignity, r-respect, I- I did it, v- value, e-encounter, n-noticed.
Happy Thanksgiving
Hello Mr. Levy,
How about the program name of "Innovations"!
Just a thought….This will be a great collaboration and I look forward to it.
Submitted for your consideration are a few names for the new program BIDMC will begin working on over the next several months:

The Quality Time Initiative
The Get There Program
The Work Around Initiative
The Gotta Go Initiative
The Short Visit Initiative
The Short Stay Initiative
The Focus Program
The Focus Factor
The Prime Directive
The Prime Time Directive
The Can Do Initiative
The Ready for Prime Time Directive

Thank you for taking time to read this communication. I hope the Holiday is a safe and pleasant one for you and your family.
I don't have an idea for a name - it all sounds exciting - just wanted to wish you and your
family a Happy Thanksgiving.
Healing the healers.
Hello Paul,
I am very happy to see that you’ve decided to take on this monumentous challenge. I can’t think of a better way for all of us to focus on improving the quality of service to our patients.

My suggestion is to name this the "Mirror Image" Program because every time that I have a chance to improve patient care or go out of my way to help anyone, I always consider it a chance to treat that person as if it were myself or a family member. My mirror image encounter. At least this works for me and I am always happy to regard myself as the kind of employee that I would want my Mother to meet, for example, if she had to visit BI as a patient.

Thanks for listening!
One of my college professors once told our class that "Efficiency" is "doing things right" and "Effectiveness" is "doing the right things". This sounds like what this program is trying to achieve so maybe a good name could be "Achieving Efficiency and Effectiveness at BIDMC" or something like that? I’m not crazy about that exact name though… I think it’d be better if the name told people straight out that we’re trying to improve our ability to "do things right" and "do the right things".
Dear Paul,
Sounds fantastic….I look forward to implementing some of the strategies for home too!
For a title how about "BIDMC - Working from the Inside Out" or "BIDMC - Turning it Inside Out!"
That was the first thing that came to mind. I’m sure it will be very clever! Thanks.
Putting air in the Cadillacs tires
A few ideas for names:
Operation Short cut
Operation direct access
Operation Direct path
Operation Straight line
Happy thanksgiving!
"Slam Dunk"
I’m not aware if there is a more efficient process in sports; among leaders, the objective is achieved more than 98% of the time. It can be done with a flourish, but in most cases it is direct and decisive (and has the same value).
Dear Paul,
Here is a suggestion for a name: Project Butterfly Effect.
It is not that funny, but it is both, inspirational and scientific.
From Wikipedia: …" The flapping wing [of the butterfly] represents a small change in the initial condition of the system, which causes a chain of events leading to large-scale phenomena. Had the butterfly not flapped its wings, the trajectory of the system might have been vastly different."
Happy holidays!
I'm glad to hear that we are working on this area that we are in desperate need of repairing. I have often found that we get so caught up in the bureaucracy that we often miss the goal, the patient. I work in the Ultrasound department and I have often heard people say that they were hired to do ultrasounds not office work, which translates into less time for quality patient care. I'm not saying that my co-workers do not strive to offer the best care possible, however, it is exhausting sometimes keeping up with everything else that is required of us.
Thank you, for your constant care and supervision of our facility.

Operation Recovery
Group Care
Caring Group
Fetching Care
How about "STRAIGHT LINE' .....A more direct way to deliver care without all the obstacles!
Good morning Paul,
This popped into my head as I popped the turkey in the oven and myself into the shower:
"Heart Work." It speaks to the staff's work ethic, dedication, compassion, commitment to quality, and, of course, and caring.
BTW, I've been a patient rep here for five years and elsewhere for another five.
I would very much like to team up with you when this program launches. You could use someone who can accurately portray the patients' points of view as you make this place even safer and smarter.
Let's talk (turkey?)!
Dear Paul, The overall idea is excellent, to treat everybody with respect regardless of rank and appreciate others work, but I am not sure how that will cut down all the bureaucratic rules and double work which is forced upon us today. However, in view of the time of launch of this program and its content I think it should be called: "Don’t be a turkey"-program or for short: "No – turkey" program. With best wishes for a happy Thanksgiving
I want to propose the following as a possible name for the new program.
Over time
Lead to

The solution.
Mr. Levy,
Thank-you for the opportunity to contribute to this very important effort. As a new employee here at BIDMC, I am very impressed with the collegiality of the staff and the openness to new ideas. My suggestion for naming this program is: The Patient FIRST Initiative.
The letters in FIRST each represent a characteristic needed to accomplish the goals outlined in your commentary.
This name also emphasizes and reinforces our commitment to the patient. Every minute of every day should be spent with the patient in mind even when we are not directly involved in patient care. This requires each of us to re-evaluate how we go about our daily work, how we interact with and treat each other as individuals, and what changes we can make to provide the best possible care to our patients.
Thanks again for the opportunity to share my thoughts. It is very refreshing to be asked by the President and CEO of a major teaching hospital for your contributions. I am quite sure that I made the correct choice in coming to BIDMC.

what a lovely email!
I look forward to the fruits of this labor.

Now that I am in a non-patient-care role, I do spend a fair amount of time fetching, but more than that I spend time wondering--wondering what my role is, wondering if the person tasked w/ initiating a meeting will get around to it, wondering what the deadline is--basically, wondering how we are going to work together in a team.

In a front-line clinical situation, roles are clearer, more similar to a sports situation, or an industrial process.

The murkiness is draining.

So, I would be infavor of a slogan that captured the clarity of how teams work together.

Since I don't know a lot about sports, I don't have anything clever to offer, but basically something that captures
1. leadership recognizes that it is tasked w/ helping everyone know their role/position and play their best in that position
2. everyone has their own honor at stake for playing their best in their assigned role.

What do coaches say to people to propel them forward in these ways?

I would love to hear more of that coming from my colleagues' lips!
Dear Paul F. Levy,
I loved your email. Dare I hope that things might turn around for the caregivers here? You have turned this place around on so many levels but here in the OR on the west campus we continue to suffer and struggle to provide high quality care. Not a day goes by that I don’t consider leaving because of system inadequacies. I won’t waste this email detailing our woes but instead look forward.
Based on your description of us fetching…. I think you might call it the Fido Project. It’s fun, it’s light, it’s non- bureaucratic. Your project can be used to transform "fetching" from a verb to an adjective. I have more ideas but right now I have to run to get something.
Thanks for reading,
One less step
Hello Paul,

Well you hit the nail on the head about antiquated systems, etc and also with the 3 questions which allow greatness to be possible. Value Capture is good. It can work here.
I returned to the Deaconess (BIDMC) after working here 25 years ago. I have been caught crying in the bathroom (which shouldn't happen at age 49) both frustrated and disappointed. I thought I was coming back to major league, and I have, except that systems you mentioned are far worse than I had expected for a hospital of such caliber. Even my superiors admit to the chaos. One said to me, "You will learn to function in this dysfunctional environment" - How sad and telling is that!! I want to like my job.

Fetch is a verb which should only apply to a dogs actions, so I will propose your program to be called "No Fetch"
I doubt it'll go over but it is unbureaucratic! How 'fetching' is that!!
how about Absolute Fabulosity? :)
Paul Levy,
Thanks for daring to take the steps that have led this institution to firm footing.

Of the past you underscore:
1. Big institutions, like most hospitals, are based on old patterns and systems.
2. Other fields have progressed in terms of process improvement, but medicine is woefully behind.
3. Personal commitment, hard work, and good will, have allowed patients to get extraordinary care, due to "work-arounds" (despite the suboptimal effectiveness of systems).

Goal: Engage the whole medical center in strategic planning.
We seek, the next steps, to advance the process. How to begin to solve the "underlying work process problems."
It's time for us to get "HIP" to the improvements which will drive this organization to superior continued growth. This name ("HIP") is a mix of bureaucracy and modernism, with a flair that grabs attention. In fact that is also the point of the whole new "not-a-program"--to as much as reasonable advance old bureaucratic positions/patterns to more adaptive ones, but accomplish it with a vigor and flair that is exciting, even trend-setting.

It's time to get "HIP" to the New Directions at BIDMC--You tell us how!! You show the way!!

How to improve HEALTH at BIDMC?
Get HIP--(Join BIDMCs' H.E.A.L.T.H. Improvement Program)

Hospital Efficiency And Long Term Healthcare Improvement Program. H.E.A.L.T.H. Improvement Program

Nice because it ties in older concept of Hospital Efficiency Index (HEI), but emphasizes push towards new directions in medicine towards "health," not more classical/currently accepted "management of illness." Such "management" is institutionally embodied in rigid adherence to "work-arounds" that ought to have long been supplanted by systems adjustments. "Management" has its accepted share of the activity at any time, but dramatic advances in treatment (and institutional effectiveness and patient care) will multiply, when a thoughtful process has been engaged about how we can all get "HIP."

Help us get "HIP." Join BIDMCs' HEALTH Improvement Program.
"Setting the trends (viz. synonym for 'hip') for a Healthy Future." Beth Israel Deaconess Medical Center.

Issue 1: Working together to be a trendsetter. (Regardless of role or rank, I have real knowledge to share with and about My BIDMC--and WE care, listen and respond to every concern).
Visual 1: You or someone else who embodies the institution (like the Apple vs. PC commercials) could dress in a stuffy way (clearly not your usual style), and act as if they are trying to learn a new dance step.

In the distance an employee who had been cleaning the floor or some other work (holding a mop, or a pipette, or a phlebotomy tray, RN pausing as they put something into the tube system, MD looking over while typing a note into computer) could be shaking their head and laughing, while rubbing their head in amusement.

Another shot could have them sitting next to you working through an issue they identified (showing you/us how to be/do "HIP.")

Help us get "HIP." Join BIDMCs' HEALTH Improvement Program.
"Setting the trends for a Healthy Future." Beth Israel Deaconess Medical Center.

Issue 2: "Pain" of doing the "training and (learning) new approaches to our work." "Learning!--When's the test?"
Despite the "it will be fun" argument--I'm sure it strikes fear into seasoned staff, nurse and physician alike, and probably even some administrators. "Once again another new procedure, process, system, and an additional layer of paperwork, I have to learn!?" "Fun!--yeah, hearing you loud and clear boss."
(Learning this set of knowledge, tools and support will enhance my ability to contribute to and enjoy My BIDMC and my private/personal endeavors).

Visual 2: Grouchy caricature of employee reading the "Get HIP" announcement, reads the line, "It will be fun." Retorts, "Fun!--yeah, hearing you loud and clear boss. Another set of papers to fill out." (The really jovial medicine attending who works on IT integration, though not so grouchy, could swing this well also.)

In the background or in another frame, the room where the training is going on, can have Club lights and music and people doing the electric slide, while a few are off on the side learning how to do it.

[Learning the electric slide. It's a 'fun' experience, that most people found at least a little difficult--to have to tolerate the learning process. But after doing so, most have enjoyed years of real fun after just a little time adjusting and learning. To bring this right home, the picture could be 'staged' in the cafeteria, as if the cafeteria were going to be the room used to do the "training." All the chairs tables could be stacked to the side, DJ in place and employees (or actors dressed as such), could dance around for the shot and others act the part of learning the new steps. You've got to be in the shot--nice if a few department heads (RN, SW, Cafeteria, Medicine, Surgery, Psychiatry, etc), could swing over for some of the shots also].

Tag line-- Can you do the Macarena?

Get "HIP." Join BIDMCs' HEALTH Improvement Program.
"Setting the trends for a Healthy Future." Beth Israel Deaconess Medical Center.

Visual 2A Another Visual or another part of Visual 2, could have people doing limbo dancing, where each person's effort is recognized or "Soul Train" Line Dancing where the whole line watches one person do improvised/interpretative dance. (This could emphasize the notion that many people are pausing to recognize and appreciate each person's contribution).

Issue 3: The Fetch-It/Re-Write Paradox
Visual 3: Harried RN/staff/MD, can be seen in a blurred shot running back and forth for papers/medicines/labs/supplies etc. Or frustratingly copying information from one format to another--yet another time, for billing purposes/or whatever reason.

First screen is all that's needed. With tag- "Don't you think it's time to get HIP?" Join BIDMCs' Health Imp . . .

A second screen, could show person with a light bulb coming on above/in their head.

Third screen, Slick (well-groomed, etc) follow-up shot of same person, with- Are you HIP? button, clipped on to their white coat--no longer harried, but now dancing fluidly (or contentedly proceeding) through their work, in half the time with improved accuracy (improved patient care).

Get "HIP." Join BIDMCs' HEALTH Improvement Program.
"Setting the trends for a Healthy Future." Beth Israel Deaconess Medical Center.

Question: Do patient's also have the opportunity to get "HIP?" Could be a way to enhance participation in patient survey's of Quality of Care/Treatment Experience.
Bless you for finally doing something about this!!!! I became an x-ray tech because I never wanted a desk job, but now.....it's just as you said.
Any chance the project could start in the west campus O.R.? There is so much $$$ waste in staff turnover (requiring expensive temporary staff, overtime shifts, etc). Have you ever seen the list of experienced OR staff who have left here (because of frustrations with the systems)? It’s as long as your arm. Most staff didn’t WANT to leave, they just felt they couldn’t tolerate the dysfunction any more. I know that because I have worked here for 20 years and watched my friends leave one by one.
It CAN be fixed. But it requires that someone important care.
Thanks for reading.
As institutions like ours are particularly enamored with acronyms, my suggestion is:
Redefining Efficiency - Valuing and Managing Proficiency (RE-VAMP)
Hello Mr. Levy,
Despite having a militant connotation, I suggest "Mission Ready Program". The program has the concept of what occurs in the military before personnel are allowed to go into the field of combat; that is to have all elements of the process by which we deliver our services functioning at the highest level prior to execution. If we think holistically about the challenges we face, it is much like a battle that we must overcome, or better yet a war. We win our little battles with our workarounds, but the war deals with the underlying problem that seeks and needs resolution. Second, the concept of the hospital’s mission statement is evoked. Again in the military it is known by all what the organization stands for and what guides the organization based on the mission statement. Illuminating the idea of the mission statement brings focus of values and pride to the people of the organization. For us to face the challenges that you have laid out, it is a fitting concept.
Thank you for your consideration.
Dear Paul,
Hope your holidays were wonderful. This new initiative sounds just wonderful and so much in the BIDMC philosophy and spirit. So, in my spare time between patients here are some names. Don’t know if there is a deadline for naming the program and others may come to me if you want more!

Old Problems: New Solutions
Old Problems/Fresh Ideas
Show Us The Way!
Try It, You’ll Like It!
Solution Central
Staff Strategies
2008: In with the New
Not the same old, same old
Anatomy of the Workplace
Better Idea Design Makes Cents
Better Ideas Deliver More Care
Service Improvement or P.I.G (Process Improvement Group(s))

Saturday, November 24, 2007

More Thanksgiving thoughts

This post is prompted by the following note from one of our chiefs to his staff:

You can't fail to hear from most everyone that Thanksgiving is "my favorite holiday." No exceptions here. Among other things it is a stimulus for me to reach out, express awe and appreciation for the exemplary jobs you do in fulfilling our collective mission. This is not easy work, but the rewards are beyond measure. Thanks to you on behalf of our patients and this medical center.

I have the good fortune to work in a marvelous place like BIDMC, surrounded by well-meaning people who spend their time helping others deal with illness and disease and the real dramas faced by families as they go through difficult times. There are happy times here, too, when people are cured of their illnesses, and the happiest of all, when babies are born and new life arrives -- literally in rooms just a few floors above my office.

While there are daily challenges in the hospital environment, it is the underlying good will of people in these places that is the dominant characteristic. As teenagers in the 1960's, my classmates and I were inspired by John and Robert Kennedy and Martin Luther King, Jr., to enter careers of public service. In our self-centered way, we used to think of our generation as special in that way. But in this place, I see people in their 20's through their 90's who are devoting their lives to alleviating human suffering caused by disease. It is a marvelous commonality of purpose that binds us -- people of all ages, nationalities, religions, and races.

Before I worked here, I wondered (along with many of my friends) if people who worked in hospitals cared anymore. Much of what you hear about hospitals from the outside is related to complaints about insurance rules, difficult working conditions, burnt-out doctors, harried nurses, and rude front-desk staff. I have learned and want to assure my readers that the folks in hospitals do care and care deeply, but the health care environment is often not well suited to bring out the best in people. (By the way, I have learned through my travels that this is not just a US problem.)

Beth Israel Deaconess is characterized by a kind of warmth, compassion, and respect that is legendary, but even it can be a tough and tiring place to work. I view my job as CEO as trying to create a workplace that reflects the deep underlying values of our staff, working to minimize those aspects that inhibit or impair their ability to carry out their heartfelt mission. In this, I am warmly and strongly supported by our lay leaders, members of the community who volunteer to serve on our boards and have the ultimate governance and fiduciary responsibility for this institution. Not many of us are given the privilege of heading up an organization like BIDMC, so I am trying to use my tenure here to make a positive difference for the people who work here.

Last week, I sent the following email to our staff along these lines. Like other things I have shared with you about BIDMC, I am sharing this one. Those of you who are new to this blog might find it surprising that I do so. Regular readers will not be surprised. A hallmark of this administration is transparency -- even when such openness is awkward or embarrassing -- because holding ourselves publicly accountable is the best way for us to improve.

I will also keep you informed of our progress as we move through implementing the program outlined in email. I do so because I think we will learn a lot about ourselves and about the path towards process improvement. I am very confident we will flub up aspects of this as we move along. There may well be those out there who will be quick to judge when we do. But as an academic medical center, one of our jobs is to share what we learn so that it might be helpful to others here in Boston and throughout the world.



What's the most important activity at our hospital? Providing patient-centered care?


But what do we spend most of our time doing? Patient care??

Wrong. It is fetching. As in spending time trying to find a piece of equipment, a certain paper form, or some other supply. Or it’s re-doing work. As in writing the same piece of information in 3 different places.

Admit it. If you are a nurse on the floor or the OR or the PACU, a respiratory therapist in the ICU, a person cleaning surgical instruments in CPD, or a practice assistant in a clinic, think of how much time you spend fetching instead of actually taking care of a patient or doing the job you’ve been hired to do to support patient care – whether that’s running lab tests, preparing food in our kitchen, or repairing a broken piece of equipment. How much of your day is spent in these ways versus face-to-face time with patients or in doing something tied directly to patient care and the support of that care? If you are a typical person here, it is way over 50% and more like 80%.

But I don't have to tell you that, do I?

We might have the latest in cutting edge technology to take care of our patients and the finest doctors, but in a big institution like BIDMC -- like in most hospitals -- the organization of our work is based on patterns and systems that might as well be 100 years old.

The practice of medicine in academic medical centers like ours is a cottage industry. While other fields and industries have progressed in terms of process improvement, ours remains woefully behind.

Every day, thousands of you undertake "work-arounds" to solve the problems you face in delivering care. And you do solve those problems -- by dint of personal commitment, hard work, and good will. As a result, our patients get extraordinary care.

But, because we all invent work-arounds, we often don’t solve the underlying work process problems that pervade every aspect of what we do. And you go home feeling really tired and wondering how you really spent your day.

Over the next several months, we are going to start a program to work on these problems. Our goal is simple. We want to improve the quality of the time you spend here at BIDMC so you can focus on the things that matter instead of working around problems you encounter.

While the goal is simple, the solution is not. We want a solution that will identify and start to solve problems on the floors as they occur. We want a solution that will uncover and fix underlying problems, not result in yet another set of work-arounds.

We have been studying other efforts around the country and have come up with an approach that we think makes sense for BIDMC.

Recently, we had a chance to spend some time with people from a group called Value Capture. They relayed the content of speech by former Secretary of the Treasury Paul O'Neill at the Harvard Business School. He outlined the three questions every employee should be able to answer with a resounding "Yes!" every day in order for an organization to have the potential for greatness:

Am I treated with dignity and respect by everyone I encounter, regardless of role or rank in the organization?

Am I given the knowledge, tools and support that I need in order to make a contribution to my organization and that adds meaning to my life?

Did somebody notice I did it, i.e., am I recognized for my contribution?

Does that sound right to you? It feels right to me. The Value Capture folks, who have done this in some other places, are going to help us design the program for BIDMC.

Let’s be honest. We can’t all answer "Yes!" to these questions today, and, in fact, in many instances we don’t even come close. But our goal is to get there. If this works, we will set a new standard for staff satisfaction and participation in the operation of an academic medical center.

The program will involve some training and new approaches to our work. Most of all, it will involve you. Don't worry. It will not be painful. It may actually -- dare I say this? -- be fun! And in the long run, we won’t see this as a "program", but rather just as the way we constantly improve work and care at BIDMC.

Have I got you curious? I hope so. Stay tuned for more details this winter.

In the meantime, though, I need help. Every program has to have a name. What should we call this one? I am hoping for something decidedly unbureaucratic -- and maybe even with a sense of humor. Please write back with your ideas.

Best wishes to you and your family for a lovely holiday!


Thursday, November 15, 2007

Reply from one of our doctors

People often ask me how our doctors feel about the things I post on this blog. The answer, of course, is as varied as our faculty, and -- trust me -- our faculty is not the least bit shy about letting me know how they feel. After I wrote a post on safety and quality a couple of weeks ago, one of our doctors wrote me the following note. I'd like to share it with you to get your reactions. Please understand that this is a world class clinician who is beloved by his patients and who has an exemplary record in safety and quality. So he is not saying we shouldn't be good at that, but he is saying something about how he thinks the hospital marketplace really works and what I should be emphasizing in public statements.

No one in their right mind could want anything but the safest possible hospital. But complex human organizations are inherently frail in the infallibility department. So while we have to work on this continually, we should not confuse that with "quality".

In the marketplace, people want the "best doctor". You will never hear anyone saying that they picked their doctor because the hospital he practiced at had a better safety record.

While we have to be excellent at safety, quality in the minds of the public is related to whether they think that the care they are getting from their doctor is the best. By this they mean, is the doctor practicing at the very highest level, making the right diagnosis, giving them access to the cutting edge and best therapies. Quality is not how many falls we have, because even though you and I know that the falls are dangerous and kill people, no one comes into the hospital thinking that they are going to fall.

If you make patient safety your acid test, you are not going to attract the kind of patients you need to stay in business. The difference, in the mind of the public, between quality and safety is huge. Quality means the medical care expectations. Safety is merely expected…until something goes wrong.

So, from my point of view, the emphasis at BIDMC has to be on quality, as in finding things that we are simply the best in the world at, and riding that wave.

Thursday, September 20, 2007

Teamwork wins against VAP

Back in March, I gave an update on our efforts to eliminate ventilator associated pneumonia in our ICUs. This requires implementing a five-part "bundle" of steps every day with every patient. You measure compliance in this program by the percentage of time you do all five steps. There is no partial credit.

An additional item is to perform dental hygiene on patients every four hours. The bugs that can cause pneumonia often originate in the mouth.

The goal is to reduce the number of cases of VAP, which statistically have a 30% mortality rate.

We report on this item on our company website, but I wanted to give you a secret advanced preview. The charts above show our improvement with the bundle and with dental hygiene.

I don't want to brag too much -- well, actually I do! -- because these results are spectacular. They are the result of terrific teamwork among several departments of nurses, doctors, and other health care professionals. Our best estimate is that the reduction in VAP from these efforts is amounting to about 320 cases per year at BIDMC. While it is risky to extrapolate to relatively small numbers by applying broad statistics, if the 30% mortality figure is applied to this number of cases, it means that our folks saved 96 lives per year.

For those interested in costs, a case of VAP is estimated to increase hospital costs by about $40,000 per patient. Once again, applying this broad average figure to our specific number of avoided cases (320) means cost savings to the hospital of about $12 million. Hmm, saving lives and saving money by teamwork and rigorous attention to detail. Any lessons here?

Friday, August 24, 2007

Outpatient clinic of innovation

An interesting idea from Ulleval University Hospital in Oslo. (There are some similar concepts that I know of from the US, like MIT´s Center for Biomedical Innovation and Entrepreneurship Center, but this one has its own unique features.) Here´s a summary from Andreas Moan, Director of Research and Education:

The Clinic of Innovation is run like any traditional out-patient clinic with one major difference: The purpose of this Clinic is to facilitate the conversion of ideas from research and medical practice into new services or products to the benefit of both patients and society. We also want to offer the same kind of service to ideas generated outside the hospital, offering our medical and research expertise. The Clinic of Innovation is organized as any other out-patient clinic, offering diagnostic work-ups, treatment and follow-up.

It is a joint venture between the Ulleval University Hospital and Medinnova, a Technology Transfer Office with 20 years of experience in innovation. The Clinic has two main customers: First, people working within the health system with new ideas on how services, treatment, organization or products can be improved or developed. Secondly, the Clinic acts as a bridge into the health system for people, commercial parties, biotech and other research-intensive businesses who may be looking for an initial point of contact to the public health sector.

Culture and language is quite different in the public health system and in private enterprise, and our goal is that the Clinic of Innovation may serve as a meeting point and as translators. Our employees have experience from both the private and public sectors.

Although this Clinic is organized as any other out-patient clinic, there is one major difference: To this Clinic you can refer yourself – please see below.

The Clinic of Innovation offers:

Diagnostic work-ups entailing evaluating your idea’s potential in both research and commercial context, or calling external competence as needed to do so. Depending on the diagnosis, the idea (and its owner) will be offered treatment that may entail
- direct problem solving
- development as a joint venture/active project
- establishment of contact with new networks that we believe will help develop the idea
- referral to group therapy with other innovators facing similar problems

Follow-up means seeing you and your idea back for follow-up and additional referral or problems solving as the idea evolves.

The Clinic of Innovation is also a tool to inform about the importance, possible economical impact and sheer pleasure of innovation. The tools for this activity include media coverage, advertising and visiting relevant people and communities inside and outside of the hospital.

How do you find the Clinic of Innovation?

Physically located at the Ulleval University Hospital in Oslo, Norway.

On the Internet: at www.ulleval.no “Idépoliklinikken” in our rather remote language and at www.medinnova.no

E-mail: idepoliklinkken@uus.noPhone: +47 23 02 70 23

Point of contact: Eli Margrethe Walseth

What can you expect?

New ideas are best submitted by a webform located here Medinnova or by email or phone.

The Clinic of Innovations has weekly intake meetings, so you can expect an answer within no more than two weeks. We may want to contact you ahead of the intake meeting to better understand your concept. Your referral is guaranteed full confidentiality, confirmed on the return receipt you get on our referral form. We will also sign a confidentiality agreement at the first appointment.

Thursday, June 21, 2007

How we manage

I often get questions as to how we manage this place. I usually jokingly reply that we don't manage, we cope. But we really do try to have a close alignment between the medical and administrative staff in support of the overall goals that are adopted each year by our Board of Directors. Those goals, in turn, are guided by our overall mission and informed by the strategic plans that have been approved by the board for clinical care, research, and education.

I thought you might like to see excerpts of this year's annual operating plan to get a sense of what it contains. Those of you who have been reading this blog for a while will not be surprised by some of the items included. There are three main categories -- improvement in clinical results and patient safety; improvement in patient satisfaction; and improvement in the organization's financial results.

Please remember that I am not presenting the complete document. Also, things arise during the year that can cause a change in plans. But this does present an example of the kinds of issues that attract managerial attention at an academic medical center like ours. The plan is based on analysis and conversations among people in all parts of the medical center. To that extent it is "bottom-up." But then it is formally adopted by the senior managerial and clinical leadership and then by the Board of Directors and becomes a "top-down" document against all are held accountable. Of course, it is widely shared with the staff by being available on the hospital's website and in meetings with people throughout the organization.

Fiscal Year ’07 Annual Operating Plan
Each year our budget and related annual operating plan offer new challenges and opportunities for success, and this is especially true of fiscal 07. While our ‘07 AOP is built around the three key areas of quality, satisfaction and financial performance as in prior years, you will note a slight shift in emphasis reflecting the challenges in this year’s budget.

This year there is an increased emphasis in implementing a more rigorous approach to improving productivity, managing clinical resources, and developing clinical pathways and in monitoring and measuring the success of these efforts. Many of you will be asked to participate in these efforts, and we appreciate your support.

We remain committed to and focused on clinical quality and patient safety and satisfaction, as they remain the primary elements defining our institution and its role in the medical community. We have achieved major progress in our quality of care and patient safety and have developed a track record of innovation in these areas. We have likewise seen continuous improvement in our satisfaction scores. In addition, we have been successful in developing programs that support the growth and career development of our employees. In ’07, our goal is to hold these gains and selectively build on the successes in these areas.

As always, this plan is supported by detailed and specific tactics and measures that will ensure our ability to be successful and measure our progress. We will periodically provide updates on these more specific actions to our Board, physicians and staff. We ask for your support and welcome suggestions on how to achieve these goals in FY’07.

Goal 1: Promote Continuous Excellence in Clinical Quality and Patient Safety

a. Achieve the goals in our annual quality and safety plan adopted by the MEC [The faculty's Medical Executive Committee] and PCAC [The Board's Patient Care Assessment Committee], including:
1. Implementing programs for patient safety, environmental safety, and emergency/disaster preparedness that ensures BIDMC’s readiness for JCAHO survey;
2. Achieving top 10% ranking in all the JCAHO/CMS quality indicators;
3. Achieving target performance in hand hygiene in 80% of critical care units and demonstrated improvement in 80% of inpatient units;
4. Achieving further improvement beyond 2006 rate in ICU central line associated bloodstream infection rate and best practice standards for VAP prevention;
5. Achieving influenza immunization rate of 60% of direct care providers.

b. Full implementation of key IS projects in patient identification, OR specimen tracking, and POE [computerized provider order entry] for ambulatory chemotherapy patients.

c. Continue to develop coverage plans and facility plans to meet patient needs and accommodate volume growth.

d. Expand the roll out of the clinical trials patient registration tool to two additional high volume departments/divisions.

e. Develop and implement patient safety initiatives in the Shapiro Simulation and Skills Center including training in the placement of central venous lines and in triggers/crisis management.

f. Achieve higher rates of donor conversion and organs/donor than the national goals for organ donation.

Goal 2: Ensure Outstanding Patient, Physician, and Employee Satisfaction and Loyalty

a. Achieve 95th percentile for patient satisfaction in inpatient, ambulatory surgery, and ambulatory visits and 90th percentile for the emergency department.

b. Complete the roll out of customer satisfaction training and job reclassification in all patient care areas.

c. Implement key recommendations from Referring Physician Survey including formal outreach to first time referrers and identifying selected enhancements to discharge fax for referring physicians.

d. Develop and implement a plan for assessment of core residency program performance in attracting and training residents.

e. Continue to foster open communication between employees and management through Town Halls, Executive Walk Rounds, and Management Roundtables.

f. Create and implement programs to recruit and retain an outstanding and diverse workforce including competitive benefits and compensation programs, career development programs, and leadership development programs to enhance the strength and capabilities of our managers.

Goal 3: Sustain Financial Strength through achievement of our inpatient and outpatient volume goals and increased focused on productivity targets

a. Achieve 3% operating margin

b. Support growth to achieve budgeted inpatient and ambulatory volumes.

c. Completing the Facility Master Plan and developing list of recommended multi-year facility actions required to ensure adequate capacity for ambulatory visits, surgical cases, and inpatient admissions.

d. Achieve significant productivity improvements required to reach the 07 budgeted cost/case and cost/visit and to prepare for FY08 budget by:
1. Implementing LEAN initiatives in 5 key areas with a focus on reducing costs and enhancing revenue;
2. Strengthening clinical resource management around high cost services in the OR and procedural areas;
3. Developing clinical pathways in partnership with physician program leaders to reduce variability in high volume/high cost DRG’s;
4. Continuing to identify and carry out projects to reduce energy utilization.

Wednesday, June 13, 2007

Online with real clinical results

Here's an email I sent to our staff today. Also picked up by the Globe. Please check out the site and let us know what you think. Now I can stop posting infection rates on this blog . . . .

Today we start a new experiment, a web site directed to the public called "The facts at BIDMC: We're putting ourselves under a microscope." You can find it on the external BIDMC web site at www.bidmc.harvard.edu/thefacts .

What's this all about? It is our belief that the public deserves timely and accurate information about the quality of care at hospitals. There are other web sites that provide some information; however, most of what is available is not current and is often based on administrative data like insurance claims, rather than on clinical data.

So, we decided to create our own. On this web site, you can see how we rate on certain "process metrics" – for example, how closely BIDMC is following recommended guidelines for treatment of heart attack and heart failure. You can also see how well we are doing in reducing harm to patients – such as our progress in eliminating central line infections. We also show how many times we have done certain kinds of procedures, like bariatric surgery, heart bypass surgery and others.

We show the latest numbers we have for all these metrics. Where national comparisons or benchmarks exist, we compare ourselves to them. Where national standards do not exist or where we think they are not adequate, we show our own goals and how we are reaching them. Where we are not doing as well as we would like (such as with hand hygiene), we show that too.

For each item we post, we try to explain how to interpret and use the numbers. Over time, we plan to add more categories of medical services.

As I noted, this is an experiment, so we also provide a page for reviews and comments. I recognize that this is a new experience for all of us – to have our work so starkly laid out and measured for all to see. I hope you all see this as a valuable tool that helps each of us do our jobs better every day. So please take a look and send us your thoughts.

More on mystery shoppers

Several months ago, I wrote a post on our use of mystery shoppers to evaluate and improve customer service. Today Liz Kowalczyk at the Boston Globe covers the story in more depth (and with better writing!) I also find it really interesting to see the different perspective on this technique across the city's hospitals.

Monday, May 21, 2007

Central line infection report

More in our continuing series on central lines infections. As always, these are presented as cases per thousand ICU patient days. Every single case undergoes a multidisciplinary review with department leadership present, after a review by the attending of record and primary nurse, as well as the Central Line Work Group which is overseeing this effort.

The chart above shows that the overall quarterly trend is in the right direction, but as you can see below, there is troublesome variation from time to time. The up's and down's, I guess, are normal, but we all wish they stay down.

Month ----- Infection Rate
Oct 05 ----- 1.67
Nov 05 ----- 1.28
Dec 05 ----- 2.43
Jan 06 ----- 3.07
Feb 06 ----- 1.40
Mar 06 ----- 1.07
Apr 06 ----- 0.00
May 06 ----- 0.59
Jun 06 ----- 1.15
Jul 06 ----- 0.57
Aug 06 ----- 3.03
Sep 06 ----- 2.50
Oct 06 ----- 0.00
Nov 06 ----- 2.38
Dec 06 ----- 1.87
Jan 07 ----- 0.00
Feb 07 ----- 1.15
Mar 07 ----- 3.17
Apr 07 ----- 1.22

Monday, April 30, 2007

What Works -- Part 7 -- Vascular Surgery Successes

This is one of the posts in which I simply brag about the excellent clinical work I see at this hospital.

We see many, many patients here with diabetes. Notwithstanding improved care of diabetic patients, one of the unfortunate problems they face is vascular disease, particularly in the lower extremities. So patients sometimes show up with the prospect of needing a foot or limb amputation.

It turns out that our vascular surgeons are extremely competent at fixing malfunctioning blood vessels, either by grafting new ones or inserting stents to reopen the original ones. There have been many cases where patients have learned that they could retain their foot after this surgery. I have had a chance to watch these procedures, and you really have to marvel at the ability of surgeons to repair extremely tiny blood vessels in the lower leg.

Here is a summary of activity in our Vascular Surgery division. Over 4000 revascularizations have been performed since 1990. The overall mortality rate is 1.1 %, which is substantially less than reported across the country at high volume centers (4.9%) .

The effectiveness of graft surgery is measured by patency, "the state or quality of being open, expanded, or unblocked." The first chart above shows the record for our hospital for bypass grafts to the foot. (On the chart, primary -- meaning no further intervention necessary -- is shown below; secondary -- meaning some revisit for clotting or another problem, is the line above above). Randomized trials elsewhere show one year patency of about 60%. We show similar results five years after surgery.

Another measure of success is the ability to save limbs over an extended period of time. The second chart above shows the results on this score for our surgeons. Many other institutions show 50 to 80% limb salvage after one year. Our place shows 78% after five years.

Monday, April 23, 2007

I think they are reading this . . .

While I know that lots of you out there from all over the world are reading this blog, I really don't know how many people inside BIDMC are. But, every now and then, I get word that someone is and has used what I have said to help motivate their own folks. As I have noted below, in an academic medical center, you are highly dependent on individual motivation to make improvements.

Here's the latest, from one of the leaders of the Emergency Department to every person working there:

From: Tracy,Jason A (BIDMC - Emergency Medicine)
Sent: Sunday, April 15, 2007 1:53 PM
To: Emergency Attendings; Emergency Residents; Emergency Techs; Emergency Nurses; Emergency Registration; Emergency UCO
Subject: Our CEO & "Dirty" tickets

Please note our CEO’s concern about hand washing & infection control at BIDMC:

Contaminating a vulnerable patient with a methicillin-resistant staph can result in a disastrous outcome. Hand washing is needed to keep our ED patients safe.

ED hand washing initiatives include:
- Improved signage & education – signs are posted throughout the ED (thanks Sue) and an educational campaign has started
- Peer-review and feedback – please help educate your peers, off-service rotators, students, support staff, etc.
- Spot checks & mystery observers (by ED team members and ID staff) – these “secret” checks are for statistics and feedback
- Cal-stat usage checks – the hospital tracks how much Cal-stat we use and analyzes usage based on patient encounter models
- “Dirty” tickets – these hand washing violations (tickets) will be given to violators to be signed by their supervisor

Yes, it is very difficult to wash/Cal-stat so much. Yes, it takes extra time. Yes, there are other safety issues to focus on. Yes, it’s fast-paced in the ED.

However, for all the reasons stated in our CEO’s blog, it’s not optional and we must do better.

Please send me any other ideas to improve compliance (short of a Cal-stat dispensing bedside turnstile) and/or interest in helping with this initiative.

Monday, April 16, 2007

What's in a number?

I have been searching for meaningful and effective ideas to present our central line infection rate that might supplement the one we use. We use the ratio of cases per thousand ICU patient-days. This is a good and accurate metric, but the problem that arises when you have a consistently low figure like 0, 1, or 2, is that there will inevitably be variation around it that may not be helpful in analyzing or explaining how you are really doing over time. Plus, is there another metric that gives just a bit more incentive to improve?

I am not talking about what our goal is. Our goal is "zero." Whether expressed as a rate or a simple number, the virtue of "zero" is that it is indeed "zero" in both cases. As Paul O'Neill has often noted, "Setting zero errors as a goal encourages breakthrough thinking, orients work cultures towards continuous improvement, and keeps people pushing toward the goal."

In factories, you often see a sign saying "x days since our last accident" that motivates people to pay attention to safety procedures and practices. We could do that for our hospital, i.e., "X days since our last central line infection," but I am not sure if it would be as effective. For one thing, we have several ICUs dealing with different kinds of patients and different degrees of difficulty in avoiding central line infections.

For example, we have heard an excellent report from folks in Pittsburgh championing a year without a line infection, but this was for their cardiac care unit only. In our CCU, they are past the 300 day mark without a line infection, but CCUs are lower risk than other ICUs.

Of course, this problem already exists for our composite ICU rate, too. And people will point out that factories have lots of different manufacturing sections with variation in risk. A company-wide figure creates both an overall sense of pride and community and internal peer pressure among the various corporate divisions to not let the whole group down by being the site of an accident.

Would that work within the setting of academic medicine? What's the verdict from those of you out there? Have any of you done this? Did it make an appreciable difference in how people behaved? In public perception of your institution?

Would it matter to you as a prospective patient? If you read a website saying "60 days since our last infection", would you say to yourself, "What an excellent hospital" or would you say "That's a long time -- there is bound to be an infection soon, and maybe it will be me"? Does it work better or worse than posting an infection rate of "1.2 cases per thousand ICU patient-days"?

Friday, April 13, 2007

I want to be proud, but I am not

I had hoped never to have to say such a thing. BIDMC is a wonderful hospital, full of warm, well-intentioned, and competent people who achieve excellent clinical results and even the occasional miracle. But I saw numbers recently that make me cringe. So it is time to let you know -- and to let my staff know -- that enough is enough.

I am talking about hand hygiene. I have raised this topic before and have referred to the national problem. Medical staff can't seem to remember that germs can be carried from one room to another, and one patient to another. OK, they know this, and they believe it. But they can't seem to toss off bad habits and adopt ingrained behavior to make sure they practice proper hand hygiene.

I like to think that things have improved from the 1840s:

Ignaz Philipp Simmelweis, while working as a doctor in Vienna from 1844 to 1850, determined that ... childbed fever was being spread in maternity hospitals by dirty hands. He proved that a chlorine hand wash reduced deaths from 18.27 percent to 1.27 percent. His superiors scorned his findings and eventually he lost his position. In the city of Pest, he repeated the hand washing measures, reducing mortality due to childbed fever to an average of 0.85 percent while elsewhere the death rate was 10-15 percent. Despite acceptance of his work by the young medical students and by the government of Hungary, and being published in medical journals of the time, his work was disdained by the academic authorities of the time.

But, maybe they have not improved. How else to explain the lack of compliance with well established principles of hand hygiene.?

So why am I upset? After months of intensive effort and various education and other campaigns, our compliance with hand hygiene has risen from 52% on our medical-surgical floors to 57%. Sure, it is great to see it rising, but does this result provide confidence to anyone out there that the message has sunk in? And, some floors remain at or below 40%. The results are better in the ICUs, rising from an average of 60% to 71%. But, in the words of our Quality and Safety staff, "opportunities remain for performance improvement and sustainability of improvement."

The results on one particularly noncompliant floor have prompted one of our Chiefs to write to his physicians:

It is bad patient care.
It increases our post op infection rate.
We should be setting the example for the students and nurses.
I have asked [the nurse manager] to have the nursing staff call attention to any physician, resident, staff, PA, med student, fellow, etc) on the ... service who does not wash his or her hands. This is meant to remind you. If I hear of anyone reprimanding a nurse for such a reminder, you will hear from me and it won't be a friendly call. I have no problem with you reminding the nursing staff if you see a lapse as well. Together we must achieve 100% compliance. There is no reason not to.

There is no reason not to. Dear BIDMC, please make me proud.

Thursday, April 12, 2007


Hospitals do all they can to avoid patient falls. Falls can lead to minor cuts and bruises, but they can also cause serious injuries. It is a cruel irony to be injured in a fall when you are being cured in a hospital.

All falls are recorded to evaluate what happened and why. One of our folks was recently looking through our reports and noticed a pattern. Three people had recently suffered falls just as they were about to be discharged. No, not after they left their room and were heading home. But while they were sitting on the edge of their bed, fully clothed, ready to go.

What was happening here? We think that our staff members were receiving a subliminal message: They would see a healthy, dressed person in the room and might not have paid the same degree of attention to the patient as they would have an hour earlier when he or she might have been sitting on the edge of the bed in a hospital gown. Slight dizziness or instability of this person would then lead to the fall.

So, now we have circulated the word to the floors to be alert to this possibility, and we are hoping to see a difference. This takes no major effort, just an extra bit of attention at the right time.

Unexpected problem, good analytical pickup by one of our quality and safety staffers, and a simple solution. Not all safety improvements require a huge effort.

I'm curious whether other hospital folks out there have seen this particular phenomenon, too, and, if so, what you did about it. Ditto for other types of safety and quality observations

Wednesday, April 11, 2007

Central Line Infections, both better and worse

Here are our latest figures for central line infections, measured in cases per thousand ICU patient days. The average over the last several months remains better than for the previous year, but the rate for February comes from two actual cases, worse than January and with 100 fewer patient days. As always, we treat them as sentinel events and try to learn what went wrong and why.

Our folks are really serious about this and, in my opinion, deserve a lot of credit. A friend of mine was recently in the hospital and had one of these lines put in his chest for delivery of an anti-cancer drug. His wife, a medical professional, watched the doctor and nurse insert the line and was very impressed with their understanding of, and rigorous application of, the protocol. (And no, my friends did not mention to their providers that they had read all about this in my blog.)

Month ----- Infection Rate
Oct 05 ----- 1.67
Nov 05 ----- 1.28
Dec 05 ----- 2.43
Jan 06 ----- 3.07
Feb 06 ----- 1.40
Mar 06 ----- 1.07
Apr 06 ----- 0.00
May 06 ----- 0.59
Jun 06 ----- 1.15
Jul 06 ----- 0.57
Aug 06 ----- 3.03
Sep 06 ----- 2.50
Oct 06 ----- 0.00
Nov 06 ----- 2.38
Dec 06 ----- 1.87
Jan 07 ----- 0.00
Feb 07 ----- 1.15

Tuesday, March 27, 2007

A Lean Machine

Virginia Mason Medical Center in Seattle has become famous as the hospital in America that has most dramatically endorsed the Toyota Lean Production System. The senior administrative and medical team, led by CEO Dr. Gary Kaplan, started the process with a visit to Japan and then designed a hospital-wide program to bring greater efficiency to many aspects of the institution's operations. They entitled their program the Virginia Mason Production System and made significant improvements in many aspects of health care delivery.

At BIDMC, we were not prepared to go quite so far as VM, but we did create a small office to test out the heart of the Lean process, Rapid Process Improvement Workshops. In these short-term intense exercises, a team of people from a variety of jobs categories in a given service or production area get together to map out every step in a customer service or production process. Each step is labeled as "value added" on "non-value added", i.e., with regard to accomplishing the objectives of the area, and then the group decides on strategies to eliminate NVA steps. Then, they actually put them into practice to test their efficacy towards meeting goals of service quality and/or efficiency. Other, longer terms plans and objectives are also decided upon and put in place.

One target area for us was our orthopaedic clinic. Like most clinics, there would be check-in, delays waiting to see a doctor, delays waiting for an X-ray, delays waiting to see the doctor again after the X-ray, and so on. In sum, the average time for a clinic visit was about three hours. Is there any doubt as to why there were disgruntled patients, cranky front-desk staff, frustrated X-ray technicians, and angry doctors?

With great support from our Chief of Orthopaedics, a team was assembled, and they went to work, aided by our Lean coordinator and other helpers. The top chart above shows how many NVA steps (the ones with red dots) were in the "before" process, i.e, the "current state". (Observers often find that over 90% of steps in any service or production process are NVA.) The "final state" chart underneath shows the change in relative NVA and VA steps after the Lean review.

The third chart shows the overall improvement in the amount of time a patient has to spend getting that X-ray and physician consult: Down from three hours to about an hour! Let's repeat that. Previous time for a visit -- 187 minutes. Hoped for target by the Lean team after its analysis -- 84 minutes. Actual results -- 6o minutes or less.

Of course, patients were happy. The staff was very pleased, too. Fewer cranky patients at the front desk complaining about long waits. Efficient use of X-ray equipment and Rad Techs' time. And, doctors being able to stay on schedule all day long. And then being able to add additional appointment slots because they knew they could stay on schedule.

The biggest problem: Patients finished their appointments so quickly that their spouses were nowhere to be found. They were still downstairs at the cafe having a cup of coffee, without enough time to read the whole newspaper!