What if?

Just thinking, along the lines of a New Year's resolution. What if all of the hospitals in the Boston metropolitan area -- academic medical centers and community hospitals -- decided as a group to eliminate certain kinds of hospital-acquired infections and other kinds of preventable harm? And what if they all committed to share their best practices with one another and to engage in joint training and case reviews in these arena? And what if they all agreed to publicly post their progress on a single website for the world to see?

Let's start simply. My candidates:

1 -- Eliminating central line infections (Metric: The number of CLIs, as defined by the CDC. Goal = 0)
2 -- Adopting the IHI bundle to help avoid ventilator associated pneumonia (Metric: Percent compliance with the bundle. Goal = 100%)
3 -- Adopting the WHO protocol developed by Brigham and Women's Hospital's Atul Gawande for surgical procedures (Metric: Percent of surgical cases in which the pre-op, time-out, post-op checklist has been followed. Goal = 100%)

The medical community in Boston likes to boast about the medical care here, but we don't do a very good job holding ourselves accountable. This would be a terrific way to prove that we are serious about reducing harm to patients and that we can cooperate across hospital lines for the greater good.

Caller-outer award of the month

A key part of BIDMC SPIRIT is the idea that everybody in the organization is encouraged to call out problems they see in the workplace, problems of safety, efficiency, or anything else.

A few weeks ago, when holding their retreat, our Board decided to create new monthly award. Instead of honoring someone who had solved a problem, they would honor someone who had called out a problem. The idea was to provide further encouragement through the organization to those who notice and mention problems.

The first award has now been presented, to Gloria Martinez (in picture), who called out the problem with the delivery of specimens from the GI department to the pathology laboratory. This led to a complete revision of that delivery process, which later spread to other areas as well, as noted below.

Gloria received a congratulatory letter, plus two super tickets to a Red Sox game of her choice next spring.

Spreading the story of discovery

Several weeks ago, I told you the story of how we had improved the process for getting GI specimens to the laboratory for analysis. But part of BIDMC SPIRIT is to transfer the lessons learned in one setting to another.

I received a report last month that the process that was developed to improve specimen pick-up and transport in the GI department was successfully implemented in all other interventional procedural areas in the medical center. Our folks note, "This process was designed to provide a timely and safe transport of specimens bound for the departments of Pathology and Cytology. (These types of specimens are especially sensitive in nature due to the fact that they are often un-recollectable.)"

"This new process, developed by a multi-disciplinary team of staff from all levels, ensures that specimens are signed out in a timely manner while also providing full reconciliation at the point of intake. It improves the process for employees preparing the specimens for transport, those providing transport and those receiving the specimens in pathology, while minimizing the chance that any specimens will be misplaced or misassigned."

The 5S's + 1

Here's more about the CPD Lean rapid improvement event discussed below. It is in the form of report to the entire OR community from the director of that area, Elena Canacari:

Last week we completed a 5S Rapid Improvement Event in the West CPD decontamination room and in the OR core tech room. We spent much of our time on sorting out unneeded items (S1) and continued through each of the other 5 “S’s.” We even decided to add a sixth “S” for SAFETY because our team identified many opportunities to improve the safety of the staff who do the work. We accomplished a lot this week, and this improvement process will continue.

Let’s take a closer look at the 6 S’s:

1. Red tags and "sorting things out"

Clutter clogs up physical and mental flow of material and information. We went around the CPD and OR areas and looked for things that were broken, dirty, homeless, over stocked or no longer needed. We used 5S red tags to identify all of these items and we placed them in a “red tag holding area” so we could decide what was really needed and what was not. Once this was done, we realized how much space all of the unused items were taking up and how much space we could now use for the items we actually need!

2. Why is it necessary to set locations?

Set locations is another name for smart placement. Organization is the first step in rearranging work flow and we want to avoid reaching, bending and searching to use the items we need. Like items are now co-located and commonly used items are at eye-level, so no one needs to bend over or use a stool to reach items. In addition, there is no need to search for items now that we gave them all clearly defined homes as well. We want to create good flow with no barriers.

3. S3 is scrub, shine, and sweep

Before we could move ahead with our improvements, we cleaned the workplace to prepare it for new organization. This included mopping the floors, scraping off old labels, washing the walls, and shining counters and shelves. A clean workplace is a happy workplace!

4. Create standards

When you walk past CPD or go through the OR core tech room, you will notice parking places for trash and linen bins, color-coded signs to direct flow of instruments and kits, and taped areas to separate dirty areas from clean ones. Different colored shelves now help to set different levels of priority for turnover of dirty instrument trays and time tickets will be used as a new technique for visual communication. These are all methods for creating standards so that anyone who is involved in the process can have the right materials, in the right place, and at the right time.

5. We need to sustain the gains!

Everyone is an owner of the process and we should all be proud of our work. Building relationships between departments was an important part of the Lean journey, and in addition to teamwork between CPD and the OR, we now have friends in facilities, environmental services, housekeeping, and infection control. Practice makes permanence, and it is all of our jobs to communicate with other staff to share knowledge, highlight successes, and catch people doing the right thing.

6. Improving Safety in the Workplace

During our “waste walk” through both areas, many of the team members identified wastes that could impact the safety of the people doing the work. In keeping with the Lean principle of respecting people, the team decided that it was important to address safety issues. Some safety issues that the team addressed were marking off space in front of the fire extinguisher and hose, removing fabric materials from the decontamination rooms, marking off space in front of clean sinks, adding hand sanitizer and germicidal wipes, among many others. As important as it is to make process improvements, it is as important to ensure the safety of the process and the safety of those involved.

Feel free to stop by and provide feedback. Remember, this is a work in process. We are not waiting for perfection, but are going to make small incremental improvements that lead to big gains.

Should you have any questions, feel free to ask anyone on the event team, or speak to the management team. Thanks to the entire 5S event team: Ray Clarke, Heideman Zayas, Anderson Gray, Deborah Kravitz, Cheryl Wiggins, Kelly Cormier, Marti Cunningham, Jack Field, John Dzialo, and to the Lean team: Alice Lee, Bonnie Baker, Jenine Davignon, Kim Eng, Brandan Holbrook, and Samantha Ruokis.

Thank you to the Lean 5S Event Team. We look forward to your input and involvement. Elena

Don't stop. Don't stop. Don't stop.

Whenever we run a Lean rapid improvement event as part of BIDMC SPIRIT, we ask the participants to fill out a questionnaire. One question we ask is, "Was this a worthwhile experience, why?"

We had an event last week in one of our central processing divisions, the place where surgical instruments and supplies for the ORs are cleaned, sterilized, and maintained. The group comprised CPD folks and also nurses and surgery techs from the ORs. There are often tensions between these two groups, as misunderstandings arise in the stressful OR environment between the people in the two areas who are pursuing parallel parts of the same surgical processes. But, look at the answers to the question above after three days of very hard work together:

Yes, I feel like I was exposed to so many other departments and learned so much about the amount of time it takes to accomplish what you would think of as simple goals and tasks.

Yes, this event uncovered and exposed the process issues between OR/CPD. I feel that this is a good beginning, but will have to continue with other Lean projects to prove process and standardization.

Yes, I think it shows people how changes can be made and they can be effective and well received. Don't stop. Don't stop. Don't stop.

This was a worthwhile experience. I was able to learn more about the facilitation of good communication. I was able to learn more about effectively engaging others. Issues that affect both productivity and employee satisfaction were clearly revealed.

Yes, because the safer we are the better the Department is.

Yes, finally the staff sees that this whole process was not just lip service. Everyone in CPD and the OR has gotten involved.

This was more than a worthwhile experience. It shows how much can be accomplished when people put their ideas together and work as a team.

Yes, it involved multiple team members from different departments working on a common goal. Everyone's input was valued.

I was able to learn more about my co-workers' ideas, talents, and values. I found that particularly rewarding. The process provides many tool for creating change.

Short story: Good news

While you can go to our website to follow our overall progress on eliminating central line infections in our ICUs, here's something more: Although we have frequently had months where there were no hospital-acquired central line-associated bloodstream infections in our ICUs, October was the first month ever in which we had no such infections in the ICUs or in any other unit.

I want to extend thanks and appreciation to those who do the work and deserve the credit: Lots of nurses everywhere, MDs, PEVAs, our IV team, radiology, and others who place and care for the lines.

This time, it's about us!

A message I just sent out to people in our hospital. Thanks to Paul O'Neill, former CEO of Alcoa, for his advice and inspiration on this front. If this can be done in a mining and manufacturing environment, we surely should be able to do it in a hospital.

Dear BIDMC,

We have now been engaged in BIDMC SPIRIT for over six months, and we have accomplished a lot. But, we have also learned a lot about how to make it work better. I’ll talk about that below, but first this.

When I first introduced SPIRIT to you, I emphasized how we wanted to reduce hunting and fetching and improve the work environment in that way.

Now, we need a new focus.

It’s time to crank things up, but in a new direction.

Last year, there were 891 on-the-job injuries of BIDMC staff members – more than two a day! Almost one hundred of our colleagues were injured to the extent that they were unable to work for five or more work days.

You probably know that we have set ourselves a goal of eliminating preventable harm to our patients. It is time to do the same for us!

I have told our vice presidents that I personally want to receive a report of every employee injury in the hospital within 48 hours of its occurrence. I want a description of the injury, what caused it, and what we are going to do to help avoid that kind of injury in the future. Over time, we will uncover patterns and trends and make this a safer place to work.

We will soon have a running total of staff injuries on our portal. We will have a graphic showing how long it has been since the last injury. Right now, that is measured in hours. We’d like to change the interval to days, weeks, and eventually months. Whether slips and falls, exposures to blood and body fluids, injuries from patient handling, our goal is to drive the number of cases down to zero.

I need your help, though. There is something you can do right now to help jumpstart our safety efforts: Do a SPIRIT call-out.

1. Identify safety hazards or near misses you have experienced or look around your work place to identify potential harm.
2. Call out the problem to your manager/shift leader.
3. Work together to identify the root cause of the problem immediately and solve it as soon as possible.
4. If you and your manager can’t solve it locally, your manager can use the Help Chain to reach beyond your unit/department.

Remember: Call-outs that point to a bigger, medical center-wide problem will go up the Help Chain to the leaders of BIDMC.

SPIRIT Update
We have seen some incredible successes with SPIRIT, but we have also learned from you comments and suggestions that there were some problems with our initial approach. Through it all, we have confirmed that the basic principle of SPIRIT is strong – the people closest to the work are the best problem-solvers.

Your feedback told us:
• There is uncertainty about what to use SPIRIT for – hunting and fetching? Patient care problems only? Big problems? Little problems?
• It was unclear when to do a call-out instead of a regular operational response to a problem, like calling Service Response.
• Using the SPIRIT log was frustrating and it was unclear whom on the help chain to contact. Entries were often made – sometimes anonymously – without a constructive way to act on them.
• There is confusion about how SPIRIT, Lean and other quality improvement efforts are related. The short answer is that they are all different ways of solving problems and improving quality – SPIRIT through staff call-outs; Lean through a trained team of specialists that works side-by-side with staff; and Healthcare Quality and other staff through a wide range of activities, from incident reporting to Joint Commission preparation.
• You need more resources to understand and use the SPIRIT principles – and more practice.

When we started SPIRIT, we expected that our first try would probably need some improvement. We fully intended to improve SPIRIT itself over time, just as we are trying to improve our work environment.

So here's what will change:
• As noted above, the second year of SPIRIT is beginning with a focus on a specific topic – safety in the work place.
• We will more actively use our formal patient and staff incident reporting systems to identify problems.
• More training and coaching through actual problem solving efforts – for all staff, managers and physicians – in person and through easier access to materials and tools.

Here’s what will remain:
• Those of you who are engaged and using SPIRIT principles are encouraged to keep it up and let us know about your work.
• We will continue to share with you stories about how SPIRIT, Lean and quality improvement projects are working.

Sincerely,

Paul

Great progress to the west

OK, so not really that far west, but in Northampton, MA, at Cooley Dickinson Hospital. The press release follows. Congratulations to the entire group for a job well done!

NORTHAMPTON, Mass – It’s been one year and 28 days since a Cooley Dickinson Hospital ICU patient has become sick with ventilator-associated pneumonia, a serious infection that can occur in people who rely on ventilator machines to breathe.

“As of Nov. 29, that’s 393 days since the last ventilator-associated pneumonia infection,” Daniel J. Barrieau, director of respiratory care services says of an infection that in October topped a list of the most costly and common hospital-acquired infections.

According to the Centers for Disease Control’s National Healthcare Safety Network Report, Cooley Dickinson’s accomplishment of preventing Ventilator-Associated Pneumonia or VAP ranks the hospital’s performance in the top 10 percent of the nation’s medical/surgical intensive care units (ICUs).

VAP can occur in patients who, because of severity of illness or condition, require mechanical ventilation. When the ventilator tube that pumps life-saving air into vulnerable lungs becomes contaminated, the tube can act as a pathway for bacteria or secretions to enter the respiratory tract, paving the way for VAP. According to the Institute for Healthcare Improvement’s (IHI) website, VAP typically “afflicts up to 15 percent of those in ICUs so weakened by illness or trauma that they need mechanical help to breathe.”

Physicians and staff at Cooley Dickinson are working to eliminate VAP and have adopted a zero-VAP philosophy. Says Barrieau, “We are being aggressive about eliminating VAP, and our track record demonstrates our commitment to delivering the highest possible care to our patients.”

This aggressive approach is paying off. Barrieau says VAP infections in Cooley Dickinson’s intensive care unit have gone from 5 in 2007 to zero as of Nov. 29.

“Besides searching for clinical solutions to the VAP problem, we asked ourselves, ‘what could we change about our culture and our systems to improve our outcomes?’” says Barrieau.

This culture change began in 2005 when team of respiratory therapists, physicians, nurses, quality improvement staff and infection prevention specialists adopted a set of instructions from the Institute for Healthcare Improvement known as the IHI ventilator bundle. The IHI bundle offers a series of interventions determined to be the best evidence-based practices related to reducing the risk of VAP to patients.

Then, Barrieau explains, staff began to “push beyond the bundle of strategies to look for other ways to reduce the risk to patients and eliminate VAP altogether.”

They scrutinized the VAP cases to identify patterns and trends. For example, their analysis indicated that patients on ventilators for more than 19 days, those with difficult intubations and those who required transportation within the hospital were the most vulnerable.

Using an approach called clinical Microsystems, where front-line teams are empowered to make improvement decisions based on scientific data and best practices the team evaluated how each clinician relates their daily work and actions to VAP.

“Doing the minimum is not enough to achieve our zero-VAP philosophy,” states Barrieau. He says clinicians in a culture of zero VAP understand how their actions matter and that acting to reduce risk is part of the clinician’s standard practice.

In addition to preventing VAP infections in patients and providing best-practice care, there is a significant cost savings to the hospital. In 2007, based on Cooley Dickinson’s VAP prevention measures, the organization saved $200,000 by reducing or eliminating the occurrence of the infection and reducing the patient’s length of stay in the intensive care unit.

In 2006, the Institute for Healthcare Improvement named Cooley Dickinson a mentor hospital in three clinical areas including VAP. Since then, Barrieau and his colleagues have presented Cooley Dickinson’s VAP elimination strategies at professional conferences, and he has served on the Mass. Department of Public Health’s Healthcare Associated Infection Task Force.

In December 2007, Cooley Dickinson was one of three hospitals in Massachusetts to receive the Betsy Lehman Patient Safety Award for the organization’s work to eliminate hospital-associated infections including VAP.

In October 2008, Cooley Dickinson was featured in the Joint Commission Journal on Quality on Patient Safety and lauded for breaking new ground in quality improvement.

The five healthcare groups that contributed to the guide include the Healthcare Infection Control Practices Advisory Committee (HICPAC), the Society for Healthcare Epidemiology of American (SHEA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology, Inc. (APIC) and The Joint Commission.

The ad I would buy

I was joking with a friend the other day that the Boston Globe Spotlight team (their investigative group) has managed to become a profit center for the newspaper, rather than a cost center. How so? Well, the main subject of two recent articles, Partners HealthCare, has been buying a series of editorial page ads in anticipation of the articles and today published a full page ad in response to them.

Relying on the placement of MGH and Brigham and Women's Hospital in the top ten of U.S News & World Report the ad notes that:

[T]here are real differences in quality between hospitals. Year after year Partners HealthCare hospitals rise to the top of this list because of investments in teaching, research, safety, and technology. Our patients continue to choose us time and again, especially for complex treatment. And the ultimate measure of quality is that physicians and other hospitals in the area frequently send their most challenging cases to our teaching hospitals.

We realize that there are costs associated with excellence. teaching hospitals, including MGH and Brigham and Women's, care for the sickest patients, the most complex diseases. We subsidize a broad range of service, some of which lose money, such as psychiatry and community health centers.

I can't afford these kind of ads, so I'll offer some thoughts here.

Can we please start by agreeing that these are two very impressive hospitals, staffed by superb physicians, nurses, and others, and deserving of substantial praise in many, many respects? We can also agree that they are destinations for very sick patients and that they subsidize many important services that receive insufficient reimbursement from private and public payers.

But, can we also agree that the differential in rates received by these two hospitals and the doctors working in them is not related to documented, quantifiable differences in quality between them and, say, BIDMC and Tufts Medical Center, two academic medical centers that are also acknowledged for their excellence and that are also destinations for very sick patients and that also subsidize many important services that receive insufficient reimbursement from private and public payers?

Can we also agree that, likewise, there is no documented, quantifiable difference in quality between Partners' community hospitals (like North Shore Hospital) and other community hospitals (like Beverly Hospital)? And yet, the rates received by those community hospitals and the doctors working therein are generally higher than the non-Partners community hospitals.

And finally, can we agree that the higher rates received by community primary care doctors and specialists in the Partners system are not related to documented, quantifiable differences in quality between them and non-Partners community doctors?

When you cut through it all, that is what the Globe stories were about. Everybody knows that Partners is able to achieve higher rates from private insurers because it has more market power than others in the Boston area. The Globe simply documented the figures that we have all heard about for years. Who can quarrel with this business model, envisioned at the creation of Partners years ago and executed superbly?

The issue for today, it seems to me, is whether in a region characterized essentially by nonprofit hospitals and nonprofit insurance companies, the government agencies that supervise those charitable institutions should care that this imbalance exists. This is more a question to be asked of the insurers than of the providers.

Now, here's the heart of the question. Is this a zero sum game? Is there some fixed pot of insurance premiums to be allocated, so that if rates for other hospitals were to rise, those for Partners hospitals would have to fall?

Regular readers of this blog know that my answer to this will be, "Wrong question." The correct question is how much money could be saved in the health care delivery system if we were all to invest in quality and safety and other process improvements. The answer is, "A lot." The first step, though, is to move towards basing rates on the quality of care delivered -- to give the proper incentives to make progress in this direction. Sorry, not quality as portrayed by a magazine, but as documented from actual clinical records, the kinds of records maintained by all of us, in real time, every day of the year.

Let's measure improvement in avoiding central line infections, ventilator associated pneumonia, "codes" on medical floors, and other preventable harm. I'm not saying that reimbursement rates should be mainly based on a comparison of hospital A's to hospital B's infection rate. Perhaps it would actually be more effective to emphasize the rate of safety and quality improvement within each hospital as an entity. And, please, let's get away from pay-for-performance reimbursement systems that use process measurements of the type collected (and two years late) by the government. (By the way, some of these have uncertain validity or perhaps harmful clinical results, e.g., 4-6 hour timing of the first dose of antibiotic for patients with pneumonia in the face of an uncertain diagnosis.)

In summary, I don't think Partners needs to defend itself for executing a thoughtful business plan. I think it is the public officials who supervise the nonprofits in the health care sector who should feel some time pressure. They need to figure out, and quickly, how to fix the disconnect between reimbursement rates and the degree to which hospitals achieve quality and safety improvements. It is the pursuit of those improvements that offers us the first and best hope to control the rise in health care spending in Massachusetts.

Farr better

Another wonderful application of Lean process improvements on one of our floors, done in conjunction with our BIDMC SPIRIT program. A seemingly simple reorganization of the supply closet. It always seems to prompt the question, why didn't we do this before? Well, the answer is that people are so busy doing work-arounds and getting by that they don't have time to get better. (By the way, the title of this post is a play on words: The work was done on the 5th floor of our Farr building.)

A note from our Lean guru, Alice Lee:

I know there was a comment in your blog asking if RNs should be organizing a supply room. Well, they are among the primary users of the supply room and know best what items need to be co-located, what items can be retired, what additional items need to be added, what the correct par level is (after analyzing usage trends). There is a true sense of ownership with full participation at all levels so the work is sustained.
The RNs and PCTs as well as MDs go in the supply room many times a day and waste many, many minutes a day searching for things, not finding them even if they are, there due to the disorganization and overstock of so many items.
We have a place for everything now that makes sense and locates the most frequently used items at eye level. As we transform each unit, the nurse manager and medical director marvels at how much of a crowd pleaser this is with the staff. Morale boost!
I know there have been comments also about whether the rapid improvement approach is the right one. Most of the work is actually parsed and distributed throughout a month in preparation for the 2 day concentrated effort to make the physical changes needed. It is hard work that is fun and builds a closer team. It brings people together that may have had an adversarial relationship previously (Unit staff & distribution staff). This is not unlike the ED and Lab working together to solve the hemolysis problem.

Even the meal tray

As far as I'm concerned, you can take all those posted quality metrics and throw them out the window when you get a letter like this one that I received from a patient:

BIDMC is a special place. The nursing care deflates your stress about being in the hospital. The doctor's talent makes you believe you have the best possible care. The atmosphere makes you feel that people like their jobs and feel invested in them, so you feel that everybody is paying attention, whether they are cleaners, food service, transport, department heads, trustees.

I especially noticed the employees' investment in their jobs. (NURSE: "Doctor, I noticed you are testing Ms. X for TB. If we believe she might have TB, should we institute those protocols now?" TRANSPORT: "The nurses are really busy. I'll reconnect your oxygen so you can go back to bed and I'll tell them that I did." NURSE: Let's not wait for the bed to be changed. I want it to be dry for you when you have these fevers." She changed the bed and me three times that night.)

Symbol of cooperation regardless of rank or function: Nobody left my room without taking my meal tray with them.

No retreat by the Boards

About a year ago, the Boards of BIDMC and BID~Needham met in an educational and planning retreat to decide on their priorities for both hospitals, one a large academic medical center, the other a small community hospital. The result was a four-year commitment to eliminate preventable harm and to dramatically improve patient satisfaction in the two hospitals.

Today, the governing bodies again met to reaffirm these goals, to learn more about how to achieve them, and to plan their agendas for the coming year. They were assisted by some special guests.

First was Steven Spear, Senior Fellow at both the Institute for Healthcare Improvement and the MIT Engineering Systems Division. I have written before about some of Steven's ideas and research. Here, too, he discussed the manner in which the best complex organizations deal with the problem of how to obtain process improvement. He noted that the first step in improving a complex system is being transparent about what is going wrong because "we need to know it's a problem we need to solve." As opposed to a transactional mindset, in which the emphasis is on making decisions because you assume you know enough to make the right choice, he emphasized the value of a discovery mindset. Under this approach, you have to have humility that an educated guess is not likely to be right, but that it provides an opportunity for learning. You also need to be sufficiently optimistic that you will achieve improvement over time, aided by iterative discovery. In short, the key is "humble optimism."

Spear emphasized that one of the jobs of a governing board of a hospital committed to transparency is to stand by the medical and clinical leadership and staff during the inevitable periods in which there will be adverse publicity resulting from this openness. "Watch their back," he advised.

The next session consisted of a panel comprising doctors and nurses from the two hospitals, focusing on their perspective on the progress towards quality and safety improvement and receiving their advice for activities by the Boards that could support these objectives. They were unanimous in their support for the importance of transparency as a key part of process improvement.

Following break-out sessions in which the Boards and their respective committees planned their agendas for the coming six months, they heard from Lee Carter, former Chair of the Board of Cincinnati Children's Hospital, a national leader in hospital quality and safety. He mentioned the key elements of board involvement in the quality agenda:

-- Pay attention and understand what people on the front line are doing so that they know they are appreciated. Improving quality is very difficult and takes extra work. "You need to let them know that you appreciate them."
-- Encourage transparency. "It is powerful and absolutely necessary. Until you identify what you need to improve you never will improve."
-- Establish and maintain a culture of trust, because without it, you cannot obtain transparency.
-- Measure progress, rigorously and accurately. Quoting IHI's Jim Conway, Lee noted, "Some is not a number; soon is not a time." Quantifiable objectives, with specific deadlines, are key, as is measuring progress towards both the objectives and the timeliness of achieving them.

He left the board members with the following lessons from Cincinnati: (1) We are never as good at something as we think we are; (2) it is very hard work to make transformational, as opposed to incremental, change; (3) we always have slower progress than we think we will, and the board needs to understand that and be supportive; (4) it takes persistence, and the role of the board is to support the attempt and be cheerleaders for the transformation. Confirming Spear, he stated that the board needs to let the clinical and administrative leadership know that "I've got your back" during periods of public scrutiny and the adverse publicity that often accompanies transparency. Finally, says Lee, (5), "After all this, it works" and will save lives and will result in better patient care overall.

About 80 lay leaders left the 12-hour session with a renewed sense of purpose and commitment, enthusiastic in their attempt to improve care not only at their hospitals, but also cognizant that they are partners in a national movement to do the same.

Transparency works! Better than you can imagine.

I just saw clear evidence of the importance of transparency with regard to the reporting of important adverse events and medical errors. Bear with me through the details, but I will not keep you in suspense regarding the conclusion: The wide disclosure of a "never" event in a blame-free manner resulted in an intensity of focus and communal effort to solve an important systemic problem, resulting in redesign of clinical procedures, buy-in from hundreds of relevant staff people, and an audit system that will monitor the effectiveness of the new approach and leave open the possibility for ongoing improvement. If you ever needed a clear example of the power of transparency, here it is.

Back in early July, a patient experienced a wrong-side surgery in our hospital because the staff failed to carry out the required time-out. We disseminated the story of this event to all staff in the hospital. There was a full investigation of the matter, both internally and by the state DPH, and some immediate improvements were made in our procedures. But the more important work was being done by a Safety Culture Operational Task Force co-chaired by a nurse, a surgeon, and an anesthesiologist, and engaging almost two dozen other people from a variety of disciplines and positions in the hospital. Its charge and mission:

To implement and embed the Culture of Safety at the point of care in Perioperative Services, with an emphasis on teamwork and enhanced communications.

They adopted the following principles of patient safety:
-- Building in redundancies and cross checks
-- Standardization
-- Simplification
-- Forcing functions
-- Empowering the grassroots to lead change

They set forth a number of objectives, the first of which were to assure compliance with the time-out Universal Protocol; to script the time-out; and to design and oversee time-out audits. In so doing, they wanted to review and adopt not only the WHO Safety Checklist, but also to incorporate forthcoming 2009 Joint Commission regulations.

The result is pictured above. The document above is the check list that went into use today for all surgical procedures in our hospital. Not shown above is a corresponding computer screen version of the checklist that will be filled out in real time by the circulating nurse as the time out proceeds.

Responsibilities and the order of events is clearly laid out, even to the point of requiring that any radio in the OR is shut off during the time-out so as to avoid aural distraction. Note the forcing function at the very top of the form: No blades, needles, specula or bronchoscopes can be within reach of the surgeon until the full time-out is completed. Also, a system of "secret shoppers" has been set up to quietly audit compliance with these procedures. These are people from a variety of disciplines who normally work in the ORs who have been given this additional job responsibility.

This material was presented today in interdisciplinary grand rounds attended by about 300 people -- doctors, nurses, surgical techs. The response was enthusiastic, as everyone realized the vast improvement this would make in patient safety. And yet, even at this last moment, there were suggestions from the floor that made the process even better.

And then, I just attended a meeting of our Chiefs of Service and senior administrators. I suggested that this kind of effort and the responsiveness seen by our staff would not have happened if they had adopted the traditional approach to a "never" event -- i.e., a quiet discussion among the leadership with a directive to avoid the problem. The response from the three Task Force co-chairs was unanimous: It was because our leadership had the confidence in our staff to go public with this event that the improvement process took on life and energy.

One of our nurse managers today told me that the American Academy of Orthopaedic Surgeons reports that in a 35-year career, an orthopaedic surgeon has a 1 in 4 chance of performing a wrong-side surgery. Three years ago, people in our hospital might have said, "These things happen." We have now learned that they only happen because we let them happen. We let them happen because of our own silence and fear.

No longer.

Getting specimens to the lab

Not to overwhelm you, but this stuff is really exciting for our staff, and I hope you can understand why. I present another result from BIDMC SPIRIT, this one having to do with the collection of specimens. Can you think of anything more vital to how a hospital runs every day? Note that it was called out by a transporter, and see how this caused a varied group of people to work together. What better way to demonstrate our respect for each and every person working here?

This one took a while to fix because it was a pretty convoluted, complicated, and broken process. For those reading this series of posts, please note, though, the repetition of key steps in the improvement process. Part of what is going on here is that staff members at multiple levels in the hospital are learning a consistent way to address process improvement. Thus, the organization as whole grows while individual problem areas are solved.

Where did we start?

On 5/13/08, callout made by transporter regarding amount of time spent and uncertainty re: value added reconciling GI specimens.

After discussion among staff from all departments involved (including front line staff, managers and Sr. VPs), the group determined that the entire process of tracking and transporting specimens from the procedure room to the lab (not just transporter specimen sign-out) offered multiple opportunities for process improvement:

Problems identified included:

§ Location of the specimen tray was far from the procedure rooms;

§ It was deemed unnecessarily time consuming for every individual specimen to be “signed out” by a transporter and not clear that it added safety;

§ There wasn’t an opportunity built into the system for the GI physician to interact with the GI nursing staff so that information could be compared on the specimen requisition and the specimen jar label;

§ Paperwork to accompany specimen was not always completed in a timely and uniform manner;

§ Confusion about transport pick-up times;

§ No reconciliation taking place when specimens arrived in Pathology and no immediate feedback to GI of missing specimens;

§ Time and “peaks and valleys” of volume of specimens delivered to pathology caused operational challenges for pathology;

§ Not all steps were defined and standardized;

§ Process resulted in delays;

§ Opportunities for staff time in all 3 areas to be more productive and satisfied;

§ # and process for hand-offs created opportunities to lose specimens;

§ Frustration/tension among departments (GI, transport, Pathology);

§ Project was good one to provide opportunity for many BIDMC staff to apply Lean/SPIRIT principles.

What process did we use to design new process?

1. Front line staff and managers from each area described current practice and problems.

2. Included GI physician in design process.

3. Drew process flow for entire current process, listing all problems/potential for errors.

4. Group described “ideal” state (using “Lean” principles described below). New process flow drawn.

5. Entire group developed specific steps for each activity in process, understanding each others’ roles.

6. Tweaked process flow as specifics required.

7. Challenged any step that was inconsistent with “design principles” to get closer to “ideal”.

8. Rolled out new process; called out outstanding issues – continued to tweak process; managers shadowed staff; process improved continuously when problems arose.

9. Deemed successful and ready to be “spread” to other procedural areas.


“Lean” principles used to shape “Ideal” new process

“Activity” Principle: Specify all steps in process;

“Connection” Principle: Ensure communication and hand-offs can be carried out appropriately;

“Pathway” Principle: Include no (or minimum) “forks” or “loops”, i.e., each member of the team should have one clear path to follow;

“Improvement” Principle: Use scientific method (data driven, evidence based, willingness to experiment), involve front line staff, keep improving -- “call out” when unable to perform step as specified.

Major Elements of New GI Specimen Tracking/Transport Process

-- Specimen tracking book moved to more convenient central location in GI, reducing delays and distance staff need to walk.

-- Binary connections between staff members: Procedure RN and MD interact directly (when possible) with resource nurse at time of dropping off specimen and req so discrepancies can be discovered and remedied at time of hand-off.

-- Consolidation of responsibility: One resource nurse designated to “tag” all specimens. As a result, process occurs in more timely fashion and specimens are delivered more uniformly to pathology.

-- Modification of Sign-Out Sheet: Transporter no longer has to sign out each individual specimen by patient name.

-- Each patient’s specimen placed in single clear bag (easy for nurse to count/identify).

-- Each patient bag placed in large disposable clear bag with single letter designation eliminating need for Transport to return to GI in between and bags to be tracked to Pathology.

-- Completion of reconciliation process in Pathology.

-- Rounds occur more frequently/consistently which GI can count on and delivers more consistent number of specimens to be delivered to Pathology (did not require adding resources as transporter time freed up by not having to complete individual test reconciliation as noted below).

-- Log created so Transport could indicate what time they arrived/which lettered bag they dropped up. This also includes a column for Pathology to indicate # number of specimens that were actually in the bag.

Bottom Line

-- A reduction of 57% in the amount of time between when a specimen was ready for transport and when transport arrived to pick the specimen up.

-- A reduction of 61% in the time it took to transport specimens to Pathology.

-- Freeing up of hours of transport time/day without sacrificing the safety associated with this task.

-- Much improved workflow for the pathology techs.

-- Improved communication between nursing and physician staff, further reducing instances of mismatched information between the specimen label and requisition.

What does this mean to BIDMC?

Reduction in time-wasted activities by staff
+
Clarity in role responsibilities re: specimen tracking
+
Consistent and standard process from point specimen is taken to point specimen is received in pathology
=
Improved Patient Care/Safety Controls + Improved Employee Satisfaction and Collaboration + Better Use of Resources

Next Steps

Spread this standardized process (with refinements as needed given the specific operations and physical layout of each department) to all departments in the medical center that collect and send tissue specimens bound for the department of Pathology.

Fixing bad blood tests

Here's another example of process improvement that typifies BIDMC SPIRIT, with remarkable success resulting from application of Lean principles, applied with advice from our small, but able, Business Transformation group. I supply an edited version of the narrative given to me:

What do you get when you cross well intentioned Emergency Department (ED) Nurses (RNs) with fastidious laboratory technologists? You get a problem, an opportunity, and a bevy of talented professionals poised to collaborate on a mutual solution.

Why would ED RNs do anything that might delay treatment? Why would a lab technologist take an extra 56 minutes to provide a potassium test result? Why…because each role cares deeply about the patient; but in divergent ways. This divergence spoke to us. We had two groups not understanding the impact they had on each other, and combined, their impact on patient care.

As this scenario shows, many patients cross multiple departments and value streams as they receive care. The departments knew that quality was a problem but wanted to benchmark how they stood in relation to the rest of the hospital. One measure of quality in the ED is the hemolysis rate (the rate of defect specimens that skew a patient’s laboratory test results). Data was collected by the ED nurses and laboratory technologists and was then presented in a rapid improvement event to uncover the root cause of the quality problem.

The hemolysis rate for lab specimens collected in the ED was found to be 22.4%, approximately five times their counterparts on the inpatient units (3.9%). This rate had several deleterious effects: patient’s hemolyzed specimens often had to be recollected and retested, therefore these patients had to wait on average 56 minutes longer for lab results, and frustration levels in both the ED and the laboratory were high.

As we knew, hemolysis is a byproduct of improper specimen collection and has an unintended effect on lab results. The effects on results can be can be minor, moderate, or actually cause inaccurate and incorrect results. One test in particular, potassium, is significantly impacted by hemolysis. It is a very significant test for heart patients where small changes can be noteworthy. We saw an opportunity to examine practice, past studies, and identify opportunities for improvement. A decreased hemolysis rate would result in improved ED throughput, reduced length of stay for the patient, fewer recollections (savings in both time and materials), and better patient satisfaction.

To address the high rate of hemolysis in the ED, two in-depth studies were completed. The first was to obtain the hemolysis rates for collections via an IV insertion versus a peripheral blood draw (venipuncture). The second study focused on hemolysis for specimens drawn through the IV using one of three methods: Vacutainer, extension tubing, or syringe. The data indicated that specimens collected during IV insertion showed a much higher rate of hemolysis, especially when using a vacutainer (the ED’s current preferred method).

We also assembled other hospital experts. The phlebotomy manager and a venous access nurse came to our event to observe, comment, and critique our ED nurses and ED techs as they simulated current practices (on a dummy arm). Each of us learned a lot and took note of areas in the process where we noticed a lack of standardization. We were most struck by the variability of practice, not only staff in the ED but of staff around the medical center. Thus, we had a great opportunity to standardize and create best practice for the medical center. A mistake-proof, proper technique is the key to preventing hemolysis.

Our goals were simple: develop a standardized method of drawing labs in the ED by engaging the ED and lab staff who do the work and strive for the common goal of reducing the hemolysis rate by over 18%. This would generate a cost and time savings as a result of fewer patient re-sticks, fewer repeat tests, improved quality due to better sample integrity, and potentially contribute to higher patient and staff satisfaction.

Our intent was not to place blame but rather to really understand the root of the problem. We gathered data from other areas of the hospital which also collected specimens during an IV insertion. Each area reported no problems with hemolysis, but our investigation uncovered they did, in fact, have a problem. None of the tests they ordered were impacted by hemolysis; so these groups were unintentionally blind to the problem. But this showed us that the individual technique of the person collecting the specimens although variable, is less of the root cause.

As we talked about hemolysis, we broadened our outlook and realized how complicated this is to operations. Due to the unpredictable patient flow, changing clinical needs of each patient, and variability of each RN, ED Tech and MD practice-styles, this was a very complex process to define. But we were committed to finding a solution. Each area owned this problem and for various reasons wanted to find a solution. The lab would have fewer critical values to repeat, call, and document. The ED would have fewer patients to re-stick, faster results, and happier patients.

During our time working on this issue we learned and communicated the following to the respective Lab, and ED staff:

• Long tourniquet time (>1 minute) increases Hemolysis
• IV product manufacturer does not support blood draws from IV equipment.
• Medical center IV and Phlebotomy Experts do not teach or recommend IV Draws
• Most ED staff worried about sticking the patient twice (once to set-up an IV and again to draw blood through venipuncture) - creating a negative experience for the patient. However, almost 30% of the time they did stick people twice due to Hemolysis which created a 56 minute delay.

We embarked on a pilot project after the event. Our intent was to stop collecting blood specimens at the time of IV insertion. To accomplish that goal, the ED techs (who only can draw via venipuncture) would draw all of the blood. Prior to the implementation, our phlebotomy team retrained the ED techs according to the Pathology venipuncture standards. Once this process was in full swing, the plan was to review all specimens from the ED and check the tubes for hemolysis and feedback the data to all of the parties on a daily basis. Each day the lab reviews over 100 specimens collected from the ED needing potassium results. We post the daily hemolysis rates and investigate each hemolyzed specimen with the RN caring for the patient. The average hemolysis rate over the past few weeks is now averaging 6.5%. As of this past Monday, this trial becomes the official way we draw blood in the ED.

We realized these incredible results by walking in each other’s shoes, touring each other’s areas, and understanding impacts by using data. We talked to each other and brainstormed together and cooperatively moved forward. Lab staff now attend the ED huddles so continued learning and sharing can take place; even after we solve the hemolysis problem.

In the end, it was our collective actions, willingness to put departmental issues aside, strong desire to improve the patient experience, and ultimate respect for each other’s talents and expertise that propelled our project forward.

Name, Role, Title
Gina McCormack, Pathology Admin, Operations Director
Kirsten Boyd, ED Director, Director of ED
Larry Mottley, ED MD, Quality MD
Jane Dufresne, ED CA, Clinical Advisor ED
Steve Wood, ED RN, RN Staff ED
Tammy Galloway, Chemistry, MGN Chem
Manny Alves, Lab West, Lab Supervisor
Blanche Murphy, Venous Access Nurse, RN Staff ED
Susie Fontes, ED RN, RN Staff ED
Pam Hulme, Phlebotomy, Customer Service manager
Kellie Glynn, ED RN, RN Staff ED
Christine Yennaco, ED Tech, Staff Tech ED
Brian Orsatti, ED Tech Supervisor, Tech Supervisor
Alice Lee, Lean, Office of the President
Kimberly Eng, Lean, Office of the President
Brandan Holbrook, Lean, Office of the President
Bonnie Baker, Lean, Office of the President

Is unilateral public disclosure really necessary?

Regular readers will know that BIDMC is remarkably open in publication of clinical outcomes, taking transparency to a place seldom seen in American hospitals. Our governing boards are comfortable with this and are strongly supportive even though it occasionally leads to publicity of the sort that can sometimes get them nervous.

That happened a few weeks ago when one of our Trustees asked the question explicitly, saying "I understand the power of transparency within the organization, but is it wise to be so open about clinical outcomes with the public? Can we be sure that the incremental value, in terms of staff performance within the hospital, merits the exposure of our warts and flaws to the broad public?"

This is, of course, a legitimate question, in that we live in a very competitive health care environment here in Boston, and we certainly do not want to engage in behavior that would undermine the reputation of the hospital and perhaps hurt its financial performance. My answer had three parts: First, an acknowledgement that what we are doing is an experiment; second, that there has been no evidence at all that it has adversely affected our clinical volume or our standing in the marketplace; and third, that studies of organizational change suggest that public disclosure has extra motivational value in encouraging people to engage in continuous process improvement.

Now frankly, I had no empirical evidence of the last point but was relying on presentations I had heard from MIT's Steven Spear and IHI's Jim Conway on this topic. I trust both of them as experts in this field of process improvement, and both have been extremely helpful to our hospital as we proceed with this adventure.

Then, this weekend, I read a somewhat old article that supports this proposition. It is from Health Affairs and is entitled "Hospital Performance Reports: Impact on Quality, Market Share, and Reputation," by Judith H. Hibbard, Jean Stockard and Martin Tusler. You can read it here. The article concludes, based on several hospitals' actual outcomes, that "making performance data public results in improvements in the clinical areas reported upon."

Intuitively, this feels correct for lots of reasons, but it was interesting to see research supporting the conclusion. I wonder if people reading this know of other studies that reinforce or undermine that result. Please comment.

As a final point, I also want to note that in today's electronic environment, it is virtually impossible to keep data "private" if it is sufficiently distributed to the hospital's staff. So, if you don't want the public to know, don't even tell your own people!

SPIRITed Transport

It has been some time since I gave you an update on BIDMC SPIRIT, our employee-driven process improvement effort. In addition to a variety of small projects, we have focused on several large hospital-wide attempts to improve the work environment. One of them is the issue of transporting patients to testing. As I noted back in June,

There have been several SPIRIT call-outs by transporters and other staff related to miscommunication about the mode of patient transport. A request is made for one means of transport (for example, wheelchair), yet another means of transport is what is brought (for example, a stretcher).

At the time, we found the following underlying symptoms:

There is a communication disconnect between Service Response, the testing location, and the unit to which the patient is assigned.
There are no clear cut guidelines as to who decides the mode of patient transport, or when, or how.
Nursing’s way of determining how to send a patient differs from how the testing location might want to receive the patient. Each use different criteria. An unfortunate side-effect is that the transporters are caught in the middle of communications between senders and receivers.
When Service Response gets a call for a patient transport request, the level of detail varies depending on who took the call.
(Interestingly, Radiology has its own system, in which they call the unit to confirm “we’re coming to pick up Patient X in a wheelchair,” but still they end up with the same problem. When they arrive, it turns out that the nurse requested a different mode of transport.)

And here's what we said we'd do:

We are in the midst of collecting a baseline for Radiology and Central Transport on the West Campus. This includes the number of transports per day, and the number of “wrong” modes for each day. This also includes overall transport time. The anticipated time to implementation of a solution is about 4 weeks.

Well, it turns out that this took a lot longer than 4 weeks, but it is because we expanded the scope of the project so it became a design from scratch of the process used by all parties involved in transporting a patient between an inpatient unit and a testing area (e.g., radiology). Go-live for the new approach is this Tuesday. What follows is an outlined summary sent to me by one of our Senior Vice Presidents. She was keen to note that the effort involved participation, suggestions, and energy from people at all stages of this process, exemplifying the whole idea of BIDMC SPIRIT, lots of well intentioned people working together for the good of patients and each other.

We'll see how it goes on Tuesday! As the summary below anticipates, no doubt there will be some glitches, for -- as anyone in any hospital can tell you -- this is a complicated environment. But I hope that you get the point that even solving the glitches together is part of the idea.

---
Where did we start?

Multiple SPIRIT callouts re: mode of patient transport (e..g., transporter arrived on unit with stretcher, nurse thought patient should go in wheelchair.)
Resulted in:
Transporter hunting and fetching;
Delays (impacts our patients, our nursing unit staff, our testing areas, our transporters and transport times, etc);
Sometimes patient went to testing unit on mode that couldn’t be used in that test; test had to be rescheduled;
Confusion among transporter, nursing unit, SRC and testing area staff.

After discussion among representatives of all staff involved, the group determined that entire process of transport (not just choice of mode of transport) from inpatient unit to testing area was:
Not defined/standardized;
Created re-work and delays;
Included less than optimally safe practices;
Created frustration/tension among departments (RNs, UCOs, SRC, transport, testing areas);
Would provide opportunity for many BIDMC staff to apply Lean/SPIRIT principles.

Decision to broaden scope of project to entire process: Starting with request for transport and ending with patient return to unit following test.

What process did we use to design new process?
Front line staff from each area described to each other current practice and problems and found that:
Process differed by unit and testing area;
Some groups are doing extra work that they thought helped other group, but didn’t;
Identified lots of rework and potential for confusion;
Terminology is not defined consistently, leading to confusion;
It was very valuable to learn how all parts fit (or don’t fit) together.

We drew process flow for entire current process, listing all problems/potential for errors, then described “ideal” state and draw a new process flow (making sure we used “Lean” principles” described below) to reach that.

3. Entire group developed specific steps for each activity in pathway, understanding each others’ roles.
Tweaked process flow as specifics required.
Challenged any step that was inconsistent with “design principles” to get closer to “ideal”.

4. Developed approach and materials for staff education, roll out and continued improvement of new process.

“Lean” principles used to shape “Ideal” new process
“Activity” Principle: Specify all steps in process.

“Connection” Principle: Ensure communication and hand-offs can be carried out appropriately.

“Pathway” Principle: Include no (or minimum) “forks” or “loops”, i.e., each member of the team should have one clear path to follow.

“Improvement” Principle: Use scientific method (data driven, evidence based), involve front line staff, keep improving -- “call out” when unable to perform step as specified.

Major Elements of New Transport Process
Scheduling:
Testing area determines mode of transport (exceptions only permitted based on patient clinical condition and only after resource nurse discussed with testing unit to ensure that test could still be carried out).
Only one call made to Unit to schedule patient test, with standard set of info using standard nomenclature. (Currently, many testing areas call several times to give “heads up” of when test probably will be. Nursing staff noted this does not help them.)
Time communicated is the scheduled pick-up time (not test time). That’s what matters to the nursing unit and transporter.
All testing locations to schedule tests/transport via phone (some were using fax, causing staff to look for info in different places)

Patient Preparation:
Clear assignment to and definition of role of UCO in chart preparation and notification of RN re: transport.
Increased communication and established time frame (5 minutes) for nursing assistance with patient departure or arrival.
Involvement of the Resource RN to assist transporter if delay of 10 min. occurs
15 minute maximum time for transporter to wait before going to next job.

Handoffs:
Face-to-face handoff must ALWAYS occur between patient’s nurse/designee and transporter upon patient’s departure AND return to unit. (Important safety improvement and will ensure that patients are receiving appropriate information).
Nursing unit staff ALWAYS to assist transporter in transferring patient to/from stretcher or wheelchair (important safety issue).

Continuous improvement:
Members of design group shadowing transporters first 2 weeks;
Managers assigned to serve as extra “help chain” for first 2 weeks so as much “real time” review of calls outs can be done;
Encouraging call outs for whenever process doesn’t work as designed (and underscoring it’s nobody’s fault);
Meeting 2 weeks post go-live to review all call outs and tweak process (and/or education) as needed.

Bottom Line
Reduction in time-wasted hunting & fetching
+
Alleviation of frustration and confusion (for both staff and patients)
+
Clarity in role responsibilities re: transport
+
Consistent and standard communication throughout patient transport process

= Improved Patient Care + Improved Employee Satisfaction and Collaboration + Better Use of Resources (through minimizing delays)

Sunshine in Worcester

Douglas Brown writes an important op-ed in today's Boston Globe about the experience of his hospital with public reporting of clinical outcomes. His conclusions are below. Please note again: Transparency is not about competition. Is about each institution making itself better and safer, and sharing what is learned across the health care system.

What have I learned?

First, public reporting works. It created a strong incentive to improving our quality. Second, responding to the crisis transparently, while more risky, was the right thing to do. At times, even lawyers must lean into the discomfort of transparency. It was the best course for our patients, our staff, and our community. Finally, humility saves lives. There is nothing more humbling than having to suspend a program. But it taught us to never accept the status quo, to know we can always get better, and to highly value a culture of learning and continuous improvement.

Transparency, a reprise

The Institute for Healthcare Improvement offers an occasional 2.5 day course for hospital senior leadership teams, which they call their Executive Quality Academy. They admit hospital teams to develop action plans to lead quality improvements in their organizations. (The group above is from Winchester Hospital, a very fine community hospital in Eastern Massachusetts. There were also folks from Stanly Regional Medical Center in North Carolina, the Indian Health Service's Red Lake Hospital in Minnesota and North Dakota, and several hospitals in Florida.) Dr Vinod Sahney, one of the faculty members, asked me to come by this last week and talk about the role of transparency in this kind of effort.

As I did, it occurred to me that recent arrivals to this blog might not be familiar with how I have used it to experiment with reporting of clinical results, with the hope of helping to hold our organization accountable for meeting quality improvement metrics. As I said in an article in Business Week about one year ago:

There are often misconceptions as people talk about "transparency" in the health-care field. They say the main societal value is to provide information so patients can make decisions about which hospital to visit for a given diagnosis or treatment. As for hospitals, people believe the main strategic value of transparency is to create a competitive advantage vis-à-vis other hospitals in the same city or region. Both these impressions are misguided.

Transparency's major societal and strategic imperative is to provide creative tension within hospitals so that they hold themselves accountable. This accountability is what will drive doctors, nurses, and administrators to seek constant improvements in the quality and safety of patient care.

Rather than repeating my IHI talk here (boring!), I am just going to list below some key posts to which I referred during my session. (Who needs PowerPoint if you have a website!) If you are interested, you can follow them through and get an idea of the journey we have taken during the past two years. As always, I welcome comments on these, but I am also seeking comments from those hospitals that have also tried this approach, so we can learn from your experiences, too.

These things happen -- a description of the point of view, all to often found in hospitals, that a certain level of harm that occurs to patients is "just the way things are."

We saved one person's life -- one of series of posts on our effort to eliminate (yes, eliminate) central line infections.

Teamwork wins against VAP -- one of a similar series on our efforts to eliminate ventilator associated pneumonia.

Aspirations for BIDMC and BID~Needham -- the story of how our Boards established an overall goal for these two hospitals of eliminating preventable harm over the next four years.

Source material -- Detailed background on the material behind the Boards' votes.

Next stage of transparency -- A link to our website documenting our progress, quarter by quarter, towards the goal to eliminate preventable harm.

The message you hope never to send -- How we used transparency to learn from one of the most egregious errors that can occur at a hospital, a wrong-side surgery.

Surprising use of Lean

A note from one of our rehabilitation staff, who had gone through an exercise in learning and applying Lean principles in the occupational therapy clinic:

The Lean organizational concepts have been helpful for me with patient care and in one case recently in particular!

Recently I treated a young patient with early Alzheimer's who needs to organize home etc. to help him with memory impairments. It was very helpful to show him some of the ways we have organized our department to improve our efficiency, particularly with the labeling. I feel that those same concepts will be helpful for him to organize in his home environment as it needs to be extremely organized to help him with memory impairments.

I don't know if people elsewhere have used this approach in a therapeutic way and put this story out there to see if so and to welcome comments if you have. (Mark Graban or others, do you have examples of this from your extensive experience?)

Lean is not about dieting

Following yesterday's story, here's another example of the Lean methodology in action, as presented in an email from one of our nurses to her colleagues this week. Note the involvement from others in the hospital that have had experience on their own floors. Wait, are they having fun, too!? I have heard too many reports of that. Quick, call out the seriousness brigade and put a stop to it.

From: Serrano,Marjorie I. (BIDMC - Nursing)
To: Nursing Farr 6 All
Subject: LOOK At THE CLEAN SUPPLY ROOM!!!

Lean Update on Farr 6 Clean Supply Room

As you could see, there was a lot of activity in the clean supply room today. The Lean team from the President’s office, Distribution plus 11R’s Marnie Pettit, RN and Martha Clinton, PCT, and Farr 7’s Beth Morrison, and Catherine McCollin worked with the Farr 6 team to redesign the clean supply room for better flow. We will be back tomorrow to continue this work.

We received training on key Lean principles which taught us that spending time searching and fetching items means less time spent on real work – time with our patients. Even when we can easily find an item, does it make sense for us to put items out of reach, i.e. too high or too low? Why not imitate the supermarkets that place frequently used items at eye level, like bread!

Lean calls these non-value added steps, “waste”. We spent the day removing as much waste out of the clean supply room process as possible. Last week, we counted the par stock right after it was fully stocked, then counted again the day after before it was restocked. This gave us the number used for one day and was used to determine the amount needed on your supply room carts (called the par number). We realized we had more stock than we needed in some cases and not enough in other cases based on this count so we removed all excess stock as well as added additional stock where needed.

Once we regained additional space, we organized the stock logically by function and for flow. For example, you will see we now will have zones for Housekeeping, ADL, GU/GI, Wound Care, Procedures and Respiratory. We then placed the most frequently used items at eye level to reduce bending and reaching. Most items are now in bins and the bin sizes indicate the amount of stock needed. The bins will have 3 labels: the “common name label” on the front of the bin – what most of you call the item, the “picture of the item label” on the bottom of the bin to tell you when that bin is empty what belongs there, and finally the “reorder label” also on the bottom of the bin that tells you the item number, cost & the ordering amount so when you are out of an item, you have the information needed when calling distribution.

Some examples of changes:

Items moved to the kitchen: Pitchers, liners, straws, cups
Items moved from Med Room to Clean supply room: Stat Lock for Piccs
Some skincare items were removed at the suggestion of the wound care specialist. These items will be reevaluated at the wound care task force tomorrow. (Keri Oil, Keri Lotion, Duoderm, Sheepskin, A+D Ointment, Antibiotic Ointment
Items that were added include: Duoderm Gel, Barrier Wipes, 5x5 Allevyn Foam, Non sterile suction tubing, Wound Cleanser, 9” armboards
Cable ties were moved to the resource drawer with the gun
Flashlights are now stored on equipment shelf in RN station.
Sustaining the gains

Lean taught us that this is a continuous improvement process so please give us your feedback and we will continue to improve. All of us own this process and keeping the Clean Supply room neat and tidy depends on all of us.

Thanks to Marnie, Pam, Bettyna, Marie, Singh, Beth, Catherine, Marnie, Martha, Bill, Jenine, Sam, Brandan

Margie

Bullish on the Container Store

Before

 

After

Quick, buy stock in the Container Store. As we continue with our expanded use of Lean process improvement techniques at BIDMC -- often originating from a BIDMC SPIRIT call-out -- a big part of each project seems to be reorganizing stuff. Here's an example from a recent exercise in our food service area.

The "before" picture shows you what things were like for the folks who organize and retrieve kitchen and serving supplies. Notice the mish-mosh of boxes, and look to see how hard it is for the staff member to reach the high shelf. Also, consider how dangerous it is for her to do so, with the chance of boxes falling on her head. The supplies themselves are kept in the original packing boxes, requiring someone to open a box each time something is needed. Only after opening the box, too, can they see if the inventory is running low.

The "after" picture shows you the change. Notice that the top shelf is now off-limits. Meanwhile, supplies have been organized in see-through containers, each with a clear label showing what is packed therein. The bins are easily pulled to permit removal of the supplies. And, because the original delivery boxes have been emptied, inventories are clear on a continuous basis.

As we say in the hospital world, this is not brain surgery, but it does require a thoughtful view of the work situation. That view, by the way, is constructed by the people who work in this area, not by some high ranking administrator. They get guidance from our Lean project team in the basic principles, but they are the ones who own the solution.

Next stage of transparency

Several months ago, we announced some audacious goals for BIDMC that were established by our Board, including elimination of preventable harm by 2012. We also promised that we would publish our progress towards that goal. We have now set this up on our website here. You can watch to see our data each quarter in each of the several categories listed.

When we were getting ready to publish these numbers, some of our trustees asked if we could put the numbers in terms of the percentage of cases in which there was preventable harm. By that measure, the number would be very, very small, about 40 cases out of over 200,000 in a calendar quarter, about 2/100's of a percent.

We said, "No, the point is to emphasize that each of the case involved an actual human being." Describing them as a percentage would dehumanize the physical impact on a real person, someone's mother, father, sister, or brother.

Last week, I was invited to give a lecture on this topic at the Harvard School of Public Health, and a different question was posed by a doctor in the class. "How can you set a target of zero," he asked, "when we know that zero is impossible?" I replied, "Putting aside the question of whether zero is impossible, the most motivational target is zero. If you say that we are trying to reduce, say, infections by 20 percent per year, people will feel satisfied if they meet that target. The idea is to establish creative tension for the organization by adopting an audacious goal. And, by the way, in certain areas, other hospitals have shown that zero is attainable for extended periods of time for certain types of error-avoidance."

At the other end of the spectrum, we are taking criticism from some people who see an inconsistency between these efforts at transparency and our lack of discussion or disclosure about particular cases. But we need to do that for reasons of patient privacy or for other legal reasons. For example, when a malpractice case is filed, we cannot and will not discuss that case publicly. For one thing, any comment we make can be construed as a violation of the patient's privacy. For another, as any lawyer will tell you, it is simply bad policy to discuss issues of this kind of litigation in a public forum. The plaintiff's attorney faces no such constraints, of course, and might perceive some benefit in holding a press conference to discuss the case. While we understand a reporter's desire to write a balanced story, our reply usually has to be, "No comment."

But outside of a particular lawsuit story, what are we going to say and disclose about all these cases of harm that are summarized on our website? The answer is that it depends. You can see from the chart that there are currently over 100 cases of preventable harm per year spread over several categories. As we have recently, when we think a specific case warrants wide public disclosure to help our staff be alert to a major challenge or teaching opportunity, we will give it wide circulation. Other specific cases will be given more limited distribution among our staff, consistent with their value in teaching about the need and means for quality improvement in a given sector of our hospital. And, in other situations, a pattern of several cases of a certain type might be presented to particular segments of our staff as a warning of a problem area.

We understand that our inclination towards transparency will garner criticism from some who think we are not being transparent enough when they have an issue or curiosity about a particular case. That is a by-product of what we have chosen to do, and we accept that.

Another by-product is that publication of these numbers may give the impression that we harm patients more than other hospitals. After all, we publish our numbers, and they do not. And many cases we publicize to our staff will inevitably be considered newsworthy by the local media. This, in fact, is why doctors and hospitals often don't like to talk about this stuff. Fundamentally, they don't want to be judged by the general public and the media, whom they deem to be unqualified observers of the medical scene.

Anyway, I want to assure you that there is no indication whatsoever that we harm patients more than other hospitals. (In fact, we know that our figures for certain types of hospital acquired infections are well below average.) But please remember that every study or analysis ever done indicates that hospitals rank highly among the country's public health hazards. Don't think that you are more safe in a place just because they don't talk about their errors. We believe that the only way to improve in this arena is to be open and honest about your mistakes and thereby enable people to learn from them.

Pump TV

On June 30, I told you about our plans to solve the pump problem using the principles of BIDMC SPIRIT. We decided to document this problem-solving process with a home-made video. Here's the first of these videos, which presents a pretty good description of some of the problems and the perspectives of a lot of people working here. I am betting that those of you who work in other hospitals will watch this and think we filmed it at your place! Stay tuned as we work through this.

SPIRIT list

I know this might not seem as serious as the posts below about wrong-side surgery, but we have made good progress with a lot of call-outs through BIDMC SPIRIT. Some of these may seem somewhat trivial to you, but please remember that fixing even a "minor" item that takes up the time of a nurse or other caregiver creates more time to actually be with patients, improving the quality of care and reducing the chance of errors -- not to mention improving the work environment for that person and many others, too. Remember, too, that these resulted from real people on the floors calling out problems that previously would have resulted in perpetual work-arounds. I think this is good stuff.

So, here's just a running a list from the last several weeks:

The abandoned bikes outside the Farr building have been removed, freeing up spaces for employees to leave their bikes.

It is now easier to find precaution gowns in the ED.

BIDMC’s evening shuttle has expanded its service to provide transportation to Ruggles Station upon request between 9pm and 11:30pm.

The many incorrectly functioning aspects of the mobile computing unit used in the Trauma SICU have been fixed.

Several new documents have been posted to the SPIRIT site to assist with discussions about SPIRIT and its best use. Take a look under “Reference Documents.”

Chair alarms on Farr 9 are easier to track.

CC6A no longer runs out of menus for patients.

Surgical residents can respond to trauma team pages more quickly now by exiting the Palmer and Baker call rooms through doors previously locked at night.

Clinical staff no longer need to hunt around as much for missing suction set-ups on 11 Reisman.

A bathroom on Palmer 2 has reappeared (actually, just the sign had disappeared, but some staff did not know there was a bathroom there).

Nurses and respiratory therapists in the MICU 7 no longer have to tend to ventilator false alarms as often; an equipment default has been fixed.

Patient confidentiality is better assured in certain Dermatology exam rooms now that shredders have been placed in them.

Omnicell restocking on Farr 5 happens at a time more convenient for nurses and for distribution of morning meds.

There is a new process for completing updates to the OMR dictionary—new medications will be recognized more frequently.

CVICU staff no longer have to hunt around for a wheelchair; there is a designated wheelchair and space to store it.

Inpatient RNs have read access to webOMR.

The SPIRIT log has a built-in search function; please use it to gain insight into call-outs that might bear similarities to yours.

The Patient Profile on POE now lists the need for an interpreter when necessary so all care providers are aware of it.

The Farr 7 breakroom no longer receives calls for Psychiatry.

Incorrect instructions for patients scheduled for ambulatory surgery have been updated to include correct check-in location.

There is now a streamlined system for repairing patient call lights promptly on Farr 9.

Patients requiring an MRI or CT are no longer delayed by IV access needs.

New measures are in place to help prevent inadvertent activation of the code center disaster recording.

New signage is helping visitors to the Trauma SICU find the correct waiting room and prompt assistance much more easily.

Patients miss far fewer nuclear bone scan appointments because they now receive appointment reminders.

Patient phone jacks no longer get pulled from the wall on Reisman 11.

Staff in the ED now spend less time looking for tubes to send to the Blood Bank or STAT Lab.

Laptops on Farr 6 no longer need to be rebooted before use.

West Campus MRI techs are more easily and reliably reached via pager.

Vital sign log sheets will now be reinforced to prevent ripping and loss.

Sharps bins on Shapiro 9 and the PACU are being emptied on a schedule more aligned with their actual use.

The Deaconess 2 house staff lounge now has a speaker for broadcasting Code Blue signals.

Lunch is ready for ED patients when they need it.

Nurses on Farr 7 can find a pulse oximeter when they need one.

On 12 Reisman, blood pressure cuffs and parts are better organized and stored.

East Campus CT Techs now have a printer in their immediate workspace.

A better plan is now in place to supply the SICU A&B with enough pillows.

Employees should no longer receive a bill for care following an occupational exposure.

The Dermatology Unit now has a new system to maintain adequate supplies of essential medical items.

Discharge medication lists are now simpler and easier to understand.

Accounts Payable has a new mailbox for invoices to streamline processing.