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.

Monday, February 25, 2008

How things don't get fixed

So, as we start to implement BIDMC SPIRIT, here is a classic tale of a complaint and a solution that doesn't solve the root cause problem. Note that all people involved are very well intentioned, responsive, and caring of the patient , but how -- without a little prodding -- an underlying problem would have been left unsolved. By the end, we are headed in the right direction!

Note to me from a friend of a friend:

Amy S. suggested that I write to you about the difficulty that I have had registering on the BIDMC PatientSite. Quite simply, I tried to register as a patient and received a "Confirmation of Registration Request" by e-mail on February 11, 2008. I have still not received a username and temporary password. I currently correspond by e-mail with my primary care physician here in Worcester and find it quite helpful. The BIDMC patient site seemed to offer even more in terms of usefulness to a patient. It is frustrating and a little disquieting to discover that his piece of technology does not run as smoothly as I as a patient would hope the care at BIDMC runs.

My reply:

Hi. I am forwarding this to people here who can be helpful.

Reply to me from our CIO, with a copy to the right person in his place:

Happy to help. ABC, could you check on [this patient's] registration?

Note to the patient from ABC, with copy to me:

You are now registered for PatientSite. If you need further assistance, please do not hesitate to contact me.

Note to ABC from me:

Thanks. Now, I am curious as to why it didn't work for him. Can you explain? Is there anything we need to do to help others avoid this problem?

The IS person's reply to my query:

He sent two requests to register with Dr. X in the XYZ clinic. These requests typically go to office staff, and they did not respond to his requests.

My reply to administrative director in that clinic, with copies to others.

Well, let's pursue this and get to root cause and solve it, so it doesn't happen to future patients. (Pat and Jayne, also please note and offer BIDMC SPIRIT advice and assistance to [the AD] as needed.) Remember, no blame! Solve the problem.

Reply from AD, to me alone (!):

Thank you. Will follow-up with the admin staff.

Reply to the AD from me, again with copies to all others:

But, wait: There may be lessons for other clinics as well, so please do not do this in isolation. That is why I continue to copy others on this email thread....

Jayne, the VP who was copied, jumps in and says:

Dear All,

I will call a meeting to discuss the process for signing up for patient site. It would be good for everyone to understand the full process. Once we all know the full protocol and who is responsible for what portion of the process clearly without misunderstandings, then we can improve and re-document the process and roll this out to office assistants also as appropriate. Also, we need to ensure that the physicians also understand that they too need to approve their participation in patient site as I understand that has been a concern in the past.

ABC, can you bring a process flow of how IS and offices handle requests and timelines of the process for approval. Also, how is it fully communicated to the patient, etc. Then we can discuss other components that contribute to a less than optimal response to the patient and solve to root cause, then roll out to all, the improved system so that everyone understands their roles.

Saturday, February 23, 2008

The SPIRIT lives on

Here are several more comments from people being trained as part of BIDMC SPIRIT, our program to enhance the workplace for our staff. I hope you all are not getting tired of this, but I think it is important to continue to share these observations -- both internally and with those of you in other hospitals -- to give a sense of how a program like this gets rolled out and what issues are brought to the fore.

I love the observations – wish they were longer because you can learn so much by watching other people’s work.

Think that seeing other areas of the hospital creates huge benefits in understanding how pieces fit together and how remarkable the people of the organization are.

I like the idea of having SWAT teams who can bring fresh eyes from across the organization to observe and help improve work in each area.

I’m worried about the documentation that may be caused by the Spirit program – we can’t let documentation overshadow problem solving.

There are still some important elements of the program that haven’t been clearly enough defined so I don’t know what to do tomorrow when I get back to work.

We need to get physicians and mangers from the “supplier” areas into the orientation soon so that everyone who is working on problems together is doing it using the same method and eyes and people don’t get stalled on all their early problem call-outs.

I did not expect to be able to see problems since I didn’t know the work well, but I was easily able to see many problems. At one point I saw seven problems in six minutes!

It would be useful to have scripts for starting the investigations that help us get started on the skills that the Value Capture staff demonstrated today.

This experience was so important for helping “throw out what you think you know” and create a whole new way of thinking.

We have to think carefully about what the staff will hear about what is expected of them and of their managers.

I learned the importance of staying on point to fix problems one-by-one so that we don’t try to solve multiple problems at the same time and fail at all of them.

I’d like to know how this process will effect human resource evaluations and whether we will be changing our forms and processes to align them with Spirit.

We have to be careful not to confuse Incident Reporting and Spirit, but also to potentially use both processes on the same problem sometimes to incorporate appropriate (non-patient/worker identified) transparent learning and real time problem solving for some of our dangerous events.

We have to address the off shift, weekend, and holiday help chain or we will make many of our employees very frustrated.

The Spirit program and this orientation create a common ground and a common language for problem solving that will be useful to change our culture.

I would have preferred that the packet that was handed out could have been sent sooner. It was not the same information that came over the e-mail. The positive was getting into the field and seeing all the situations staff are dealing with. Also seeing leaders with experience helping us. Having the direction of people who will be trainers was very helpful.

I agree. During the debrief after the problem solving, hearing from what the other groups worked on in the other departments – their experience, their action plans, that was was helpful to me.

Coming in I dreaded that this would go on for 8.5 hours but it by very fast and it was very informative. I can see it happening. I was involved in the envelope saga. It was amazing to follow it through and see all that can come from one little envelope.

This was a good tool to organize problem solving. It forces focus, etc. Organizationally, it can’t hurt. For me it will definitely help in organizing problem solving and solutions. On the side of needing improvement, sometimes it seemed we were looking for problems. It would have been nicer if there would have been more actual call outs from the staff while we were there. Maybe preplanning to be there at busier times … so we’re there when people are ‘freaking out.’ 

The case examples we did, the role plays, were very good to prepare us and get us ready for the floors. It gave us tools. On the negative, going during lunch time inhibited follow-up. Folks can stagger their breaks on the floor but it’s still a hard time.

This is my second time out. I am less in awe (which means confused). The process seems more “backed up,” clearer. The staff are very open. On the concern side, we are still in the learning phase, and we are supposed to be starting very soon. Some things are still fuzzy … that’s going to be very hard.

The process of building the scientific method in the morning was very helpful but out on the floor in the afternoon it sometimes felt like a solution in search of a problem (when you’re a hammer everything looks like a nail). The staff may be so used to workarounds it was hard for them to get into it. It was great getting into the field … the dialogue with the chief tech was just great.

This was my third time. Its amazing to see it come together. To go from this being very uncomfortable for me today, as co-facilitator, to see the program really shaping up. It won’t be perfect but we need to be ready to say – as I will say to my division – we need to be ok with a little clunkiness. Our biggest challenge and the key will be to really use this to empower the staff.

The roleplays were really helpful and really important to do. I still feel like we need more tools to use to actually solve problems. Not instead of the training we are doing but as a “plus.” There are 10 or 20 key ideas out there that we would really find helpful. A few sessions on those would help.

The positive was to be on the unit and see what staff are dealing with, to see the opportunity to help. Within just one hour to get to the root cause of a problem like that … was great. A concern is the time involved from the help chain people. I also worry how this process will fit with others [internal queuing of work orders], that it won’t be used to move other things to the top of that queue.

This was my second time. It was definitely much clearer and more solid. The training was well organized. I have concerns about people’s time. The little problem in the mail room – the implementation plan is not going to be so fast to come together. It is important to try in real time though. I see that.

The role plays were helpful. Learning about other areas, being non-clinical myself. The tools were a good basis but make them easy to access and painless to use … if not people won’t use them.

I enjoyed the whole day. It gave me a knowledge base of root cause problem solving that I didn’t have. It opened up possibilities for me in my thinking. I want more tools to help promote this in my departments and not have this be seen as burdensome.

As we get to action planning it will reveal tensions in the organization. That’s how we’ve done things in the past, and people dig in. For example, the envelope problem. Some may say don’t do x because we care about y. These things will reveal tensions; it’s how we resolve them that will be key. I also want us to consider the benefit of outside eyes today. When this starts, if it’s just me and my staff working on these things there’s less value in breaking silos and seeing things fresh. I’d like to build in those outside eyes.

The observation was wonderful and helpful. I would have like to review the material, observe in the AM, then come back to process, then go back to the floor to problem solve. It’s easier to start this where we know. I would have liked to have started in our own departments, on problems that stay there. Not jump into things in the middle that cross over into other departments. Could we start this this way? Staying away from the interdisciplinary problems?

I enjoyed going out. I’m new to the hospital (3 months). Hearing other managers with their perspectives. One point I’d make is that we need to teach how to respect each other. It can be the most important thing. I spend a fair amount of time looking at things between the OR and other areas. So many problems stem from communication; we need to teach how to have respectful conversations. Another suggestion: have aggressive 6 month feedback on how this is going and what we can learn.

I liked going and observing; I saw a lot of things in my own area’s registration-it was very eye opening.

I enjoyed working with people in other people in other areas, the group setting was nice, it was nice to see the people behind the emails.

This will change the dynamics of what people see as problems; this can break down barriers.

It should remind us all that immediate need for me might not be immediate an immediate need for someone else and we need to show respect for each other.

I like the practical aspect; it builds ownership within and among departments.

Observing the blood bank lead me to understand what our department can do better.

It was interesting to see that something as simple as how we put a label on impacts someone else’s work- we are probably making other departments take extra steps and we don’t even know about it.

Communication is so important; rather than just getting used to it (the problem).

There is a lot of work that will come out of this and some will be hit more than others.

The afternoon was really long.

It is awkward observing someone and I am sure they feel the same way.

How will people stay motivated when we are unable to solve everything, how will we feel about this workload, how can this become part of our intelligence versus hunting through a log.

Thursday, February 14, 2008

Learning to get the SPIRIT

More in our continuing series on BIDMC SPIRIT, our effort to enhance the work environment for staff throughout the hospital. Here are additional comments from people who have just gone through the train-the trainers training program. You can get a feel for both the excitement and the nervousness.

I really liked seeing how other areas of the hospital worked. It was nice having a hands on view of the hospital. It was a long day. The information was great, and you have to go over the material before you go out to try it but it is a long day and a lot to digest.

The process [for problem solving] is a plus. Being able to step back from the daily rush and think through an effective process. What’s needed is even more disciplines in this group.

What was great was learning how one problem can have implications in many other areas, something I never would have imagined. An issue is that a think we will need a little bit of handholding in our own areas, once this starts … help working through some problems until we are used to it.

Loved the trainers. They knew their subject. They were knowledgeable. I am not clinical and it was so interesting to see the work on the floors.

My worry is about the areas that are the suppliers to many areas. They are very gung ho right now but even in training they are getting lots of calls and I worry about them being overwhelmed. We need to develop supports for them from Day 1. Even now they are joking that “It’s 2:00 – SPIRIT training time – so my pager is about to go off.” We don’t want them to burn out … [Later in conversation same participant offered the following idea …] It would be helpful if some of the observation visits could take place in those supply departments. I think it would send two messages. The first is that it would help them be prepared to respond more effectively to calls re: real time root cause problem solving. Second, it would send the message that this is about you, too. And that’s important.

The positive was that we went out and did real problem solving on the floor. It was insightful. It was nice to see challenges that other areas face. It was a long day.

Getting out was great. We have never done that in our other trainings. Great. I need the bibliography that was mentioned – this is just a total shift for us – plus that list of tools / helpful hints for working with staff on real time problems. My barrier or worry is that problems that need to go to other areas [for investigation / solution development ] may take time, and may hit barriers. We may need to get back together once we start and look at how well that is working and revisit our efforts there.

I’m coming away from this today with real good tools to attack problems. The trainers were great. It’s good subject matter. It’s a long day but you probably have to do it in one day. Actually using the tools was great.

It was great. The best for me was being on my own floor and getting to use the tools from the AM in the afternoon. It helped me see things I was seeing differently, in a way the staff could see and feel as well … very helpful. It did help me to think about the roots of things, about why the problems I am seeing are occurring. To improve it, I would send ahead more background on change management coming in, and make sure we had more tools going out.

I liked having no choice about where I observed. Given my experience here, I wouldn’t have picked to go back to peri-op because I assumed I knew how everything worked. When I got back there of course I realized I didn’t know how it really worked.

What was great was that it was experiential. It fundamentally changes training. Great. Giving everyone one way to think about problem solving would be huge. As awesome a task as it sounds, it is totally worth undertaking. The negative was the eight hours is not enough to equip a manager to do it effectively. We need a log for the process of implementation itself. A place that issues and struggles can be called out and learning shared. A kind of help chain support for how to be better at it.

The diversity of this group was a huge plus. We need more prerequisites coming in. It’s a little loose at the end. Coming out of these trainings the managers are saying “Oh my G-d.” If we think about it, we could come out of the trainings with a clear sense of next steps that may help everyone come out feeling more positively.

This is really exciting. I didn’t know what to expect on the floor. It was easy to identify problems. If we do it, it will be incredible. If we can make it a way of life. The question is how to do this. One key thing we identified today was the issue of when managers are called [in the help chain] and they haven’t been trained yet, it can be worrisome. They might say they know “who” may have messed up and you want to rush to say “ no, no we’re looking for a system issue” … so that’s an issue and it’s hard to create safety in the moment.

The basic tenet of safety is key. Once established they (participants in problem solving) were much more forthcoming.

I was struck that doing this on a busy unit at a busy time, seemed overwhelming. But the more we circled back to staff as they were able to give us a minute the more things did move along. Seemed more possible.

At the start, so many things will be identified. For the first month, how should we prioritize? I am worried we are about to open Pandora’s box here.

One idea I had today that you may hear about is to once a year have a BIDMC Spirit Award. Something really meaningful. And done in a way that doesn’t convey the message that only this SPIRIT achievement counts and yours doesn’t matter …

It’s the issue of training that keeps me up at night. I don’t want to do this [act as trainer] until we are ready for prime time. We may need more support for a longer period from the people who’ve done this during their whole career.

This is my second time [training to be a trainer]. Last Thursday, my worry was the sense our staff have of handing over problems to you to be solved. Today, we scared several people. It was definitely not our intent. It’s just that people who have not yet been to orientation respond in the old way, as if “I did something wrong.” We are really going to have to work on that.

I am worried about tomorrow on my unit. I will talk to them about this experience today. I am not sure they are going to wait until March 1 to call out. It’s a good thing, I know. As they become more used to identifying problems, it will be a real burden to try to keep up and make this work.

There are tremendous tensions building up in the system about how we are going to be able to do this. Stating the obvious to people about these things is really, really important for leaders to do.

I was struck by how important it is to get the managers involved to work the staff, to not “jump the help chain” straight to the staff level. It’s what’s going to make sustainable solutions possible.

True safety comes in the moment, through the work itself. But can we prepare the culture? Can we have the managers understanding that they are important, they are vital, to work toward sustainable solutions?

Thursday, February 7, 2008

Trainees report back and train trainers

As promised, I want to keep you up to date on our experiences as we implement BIDMC SPIRIT, our process improvement program of the sort described by Steve Spear. We are now at the stage of orienting people and training the trainers, the people on our staff who will train over 600 staff members in the techniques of calling out problems and pulling together help teams to solve them. We are assisted by some folks from a firm called Value Capture, which was founded by Paul O'Neill based on his experience at Alcoa.

After the first session, as part of an effort to improve the orientation and training sessions themselves, the group leader asked:

“Tell me one thing that was great or positive about today/SPIRIT so far … and one thing that was negative or is worrying you.”

Here are the replies:

Great: The observations, the real time problem solving and action plan development. The wonderful openness of Donna (director) and her team. Some of the role plays. Today was an incredibly useful exercise. The train the trainer approach is the right one. Scary to think about doing the training, but workable. As valuable as the Value Capture people are it’s important that we show we really own this in as many ways as we can. What was bad or am I worried about? It’s a long day! The chairs were bad. The room. We are training several hundred people, but only a small portion by March 1st. I am worried we will not have enough people ready with the language and the tools. But somehow I think it will work out. We need to manage expectations and the anxiety. We need to tell people we will not be great at this at first … but it will be a start.

Ditto to everything above. Great was the observation and work on the areas we went to – that was the highlight. We called out that the PACU role play should be further simplified (told as a simple story, holding discussion until end). I also agree about changing the room.

I came in with skepticism … a lot of skepticism … and I am leaving feeling a lot better, less skeptical. Going through this was transformative. My worry is that there are still 1,000 things to learn … will we be ready? Should we cut our teeth by piloting this in a few units first?

Great: The observation and the hands on problem solving. The willingness of the staff to participate! They were really ready. They knew about SPIRIT from Paul’s messages. My worry is the same. Do we really have the readiness to train? Will management be ready. Should we ramp up from a pilot?

Great: I was pleased to see the staff’s wariness melt and the problem solving process become fun! I worry that we have to get it deep enough down to the front line staff level. Use the code team example – have an outsider who wears the lanyard who can come and help – objective eyes in an observer – together with maintaining the transparency. Those are the keys to make it safe.

I see that this could be so incredible. But I worry there on the same count. Will we be able to be fully engaged and work staff through the barriers … to really get this rolling. I am somewhat overwhelmed by the number of problems. I don’t want to let staff down. We want it to work for them.

I see the positive culture change here. I loved the value of outside eyes for problem solving. We need to add the additional helpful hints, watch outs, useful phrases to help managers approach this w/employees in real time.

This is transformative. In the middle of doing the work on the floor today it hit me. Earlier in the day, I was hung up on the connection between the log and problem solving, and then it hit me – Is this a tool or is it about a new process and way of thinking about problems. It’s the latter.

Great: It’s simple steps … we laid it out easily and we followed it. Not easy to do but still good. It’s easy to understand (the method). What worries me? We have different skill levels in the organization. I worry about will it be used at a level that it will be used well? I’m worried about time. I worried that we’ll be able to take time away from other things, especially when it’s patient care. I need more tools as a trainer. I’d like more exposure to the help chain; we didn’t have to use it in our problem.

The observation opportunity was fantastic. We struck gold with our group and problem and the staff we worked with. What’s positive is we are pushing decision-making closer to the people who do the work. I worry about training. I need more problem solving exercises to feel comfortable as a potential trainer. Also, I think this is OK/great in departments with a participatory culture, but in departments with different norms if not implemented and supported well it could be quite harmful to the people. We need to think about the involvement of coaches/outside eyes.

I went from being skeptical on the (problem solving) log to feeling it could be very useful … and applied to all kinds of problems. The last module on the log was very useful.

In terms of worries: We have not been good enough messaging that this process is for hunting and fetching problems. We’ve got to be clear about what this is for. And also for the other systems that we are preserving.

Keep in mind, it’s hard when a few things are still blurry. But consider how this is being designed as a process to improve as improvements are suggested. It’s already been improved and will continue to do so.

Have Paul continue to message directly to the staff on this. They hear him. He is such a popular figure. He is clear. They also listen because he doesn’t fill up our e-mail with too many things.

I’d like another review session, to help prepare as a trainer (in addition to the planned development sequence – just a couple hours to go over the design, etc).

Tuesday, February 5, 2008

More on fetching and work-arounds

Some colleagues and I had a chance today to spend some time with Steven Spear, from MIT and the Institute for Healthcare Improvement, who is an expert on the kind of process improvement program we are trying to carry out at BIDMC. That he had terrific and useful insights was no surprise to those of us who have read some of his work.

Steve also made mention of research carried out by Anita Tucker, from Harvard Business School, in which she spent many hours observing nurses in hospitals. (I did not find this particular study, but here is one that summarizes it.) Her conclusions were consistent with my own observations and the points I made in my staff email back in November -- and many comments I received from our staff after that email. Professor Tucker found that nurses who encounter problems or impediments on the hospital floors generally will invent a quick work-around to solve those problems. This makes sense. First of all, they are really busy and just need to get the problem solved. Secondly, most organizations do not provide a way to call out problems and have them solved in a timely or effective fashion. Unfortunately, this pragmatic approach to problem-solving leaves systemic problems untreated and, indeed, aggravated by an additional layer of work-arounds.

As Steve has written in his studies of Toyota and reviews of other high performance organizations, the common characteristic of these organizations is not in their ability to design perfect and complex production or service delivery systems. Rather, it is their ability to discover great systems. They do this by managing their work flow to encourage people at all levels to call out problems; to "swarm" together to solve those problems; to share this process of discovery with others in the organization so that the solutions are diffused widely; and to cultivate the skills of people throughout the organization to be involved in this kind of constant improvement.

It was heartening to hear this reinforcement for the kind of program we are beginning at our hospital, which was named BIDMC Spirit in our own election campaign. I feel like we are on the right track. Now comes the simple (hah!) part -- doing it. Our first training session was held today. Stay tuned for further developments.