Silverman Institute Inaugural Event

I just returned from celebrating the inaugural event of BIDMC's Silverman Institute for Health Care Quality and Safety. The Institute was created by a generous donation from our Board Chair Lois Silverman and her late husband Norman, and is the focal point for our quality and safety programs, as well as academic programs in that field. The event was also the inauguration of a new lecture series, entitled the Michael F. Epstein, MD Lectureship on Clinical Quality and Patient Safety, generously funded by numerous donors in honor of the hospital's previous chief operating officer.

Our speaker was Dr. Brent James, from InterMountain Health Care. He had a lot of useful things to say about the quality improvements in his system, but the focus of the talk was "Doing Well by Doing Good: The Business Case for Quality."

My main take-away: Within a very few years, we will face a hockey stick pattern of unfunded shortfalls in medical costs paid by the federal government. At that point, there will be four main options: (1) raise taxes; (2) decrease Medicare benefits; (3) shift funds from other programs, like education and national defense; and (4) reduce payments to providers. Which of the four do you think is most likely to be preferred by elected politicians? Number (4), of course. "The money is not going to be there. The business strategy of providers has to be based on managing the cost structure of clinical care." Improving the quality and safety of care is the most efficacious way of doing that.

So, quality improvement has to be a core business strategy for hospitals. Now is a good time to start and learn how to do this. As Brent notes, "It was not raining when Noah built the ark."

Dear hospital colleagues: Do we really need this reason, also, to reduce harm in our hospitals? Well, it can't hurt to be reminded that there is a financial case to be made, in parallel to the humanitarian aspects. Early adopters will do better when the rain starts to fall.

When SPIRIT helps patients

For those of you following my stories about BIDMC SPIRIT, you know that our main purpose in starting this process improvement program was to enhance the quality of the work environment for our staff, those involved in direct patient care as well as in other hospital functions. But we also believed there would be spill-over benefits in improving the quality of patient care -- in ways that are not necessarily related to specific programmatic areas like reducing central line infections or ventilator associated pneumonia.

Here are two recent examples along those lines. I am going to present the log reports in "hospital-speak", i.e., as written by the staff, so please accept my apologies if not all the terms are familiar to lay readers; but I think you will get the picture. I think you will also get a feel for how complex the patient care environment is in a large academic medical center. The first case involves treatment of psychiatric patients entering the Emergency Department. There is a general shortage of psychiatric beds in Massachusetts -- having mainly to do with grossly inadequate reimbursement rates for these patients and also a failure of the state to properly care of patients who should be under its care -- and this shortage spills over in hospitals in the way described in this case. We can't solve those broader societal issues, so you will see how the staff cobbled together an appropriate solution to this particular issue. (Note, for example, how the materials on the "Expressive Cart" have to be carefully chosen so the patient cannot intentionally harm himself or herself.)

On March 5, an Emergency Department nurse called out a serious concern: that patients presenting to the Emergency Department (ED) for psychiatric evaluation are often held in the ED for a number of days while a bed search takes place. During that time, the patient is held in seclusion, without the benefit of therapeutic or diversional material.

On March 10, Michelle McCool, Director of Ambulatory and Emergency Operations; Karen Lottatore, ED Practice Manager; and Kathy Fanning, ED Nurse Manager, had a plan in place to purchase some activity materials by March 17, and to have a physician in Psychiatry approve them within five days. In the meantime, Michelle McCool updated the SPIRIT Problem Log, mentioning that long-term solutions are currently under discussion on a governmental level as well as on an internal, interdisciplinary level between the ED team and Psychiatry leadership.

On March 13, Michelle McCool and five others (Mary Anne Badaracco, MD, Chief of Psychiatry; Dyanna Domilici, MD, Psychiatry; Jonathan Florman, MD, HMFP Psychiatry; Tina Gosselin, RN, Psychiatry Nurse Manager; and Sandi Leitao, Administrative Director of Psychiatry) met to discuss improvements in the care of psychiatry patients with extended stays in the ED. They agreed on an extensive action plan that includes the following:

One crank hospital bed will be available to those patients uncomfortable on stretchers;
Michelle McCool will communicate with Central Processing on this.Patients will be offered items from an “Expressive Cart” which will include cordless radio head sets, non-toxic art supplies, books and other items.
After the acute evaluation is complete, if approved by Psychiatry, patients will be offered more comfortable clothing. (Michelle McCool to obtain a supply.)
A daily team meeting will occur, including Nursing and Psychiatry at a minimum. The team will develop a treatment plan which will be documented daily.
Consider other types of consults – possibly Nutrition, Physical Therapy and Occupational Therapy – for patients who have been in the ED for more than 24 hours.
Possible assignment of a case manager to patients requiring disposition. Marsha Maurer, RN, Vice President of Patient Care Services is considering this.

The second case is more typical of a large hospital. Capacity or staffing or continuity of care problems on one floor that require coordination with several other units to resolve.

Problem: At 8:30 a.m. a staff nurse (Lucy Miller, RN) on Farr 9 needed to page the medical house staff with a question about a patient admitted overnight from the Emergency Department (patient arrived on floor between 3:30 and 4:00 a.m.). The nurse paged the resident listed as covering, but that beeper was forwarded to another resident who stated he was not covering. That resident instructed the nurse to call another resident who also stated she was not covering. The nurse paged the attending physician of record who gave the nurse two additional options to page. At this point, John Ryan, RN, Nurse Manager on Farr 9, became involved and paged the Chief Medical Resident for help in determining coverage.In addition, coverage for the SIRS firm, which often covered medical patients on Farr 9, was not easily identifiable through the online paging system like other medical firms such as MERIT or Blumgart. The nurse had to get the SIRS on call resident information by calling page operator.

Person(s) Describing Problem: Lucy Miller, CN2, Farr 9, and John Ryan, RN, Nurse Manager, Farr 9.

Help Chain Contact: Jane Foley, RN, Director of Clinical Operations.

Root Cause: There were a higher number of medical admissions than usual overnight. The patient was assigned to a different medical firm (team of residents, interns, medical students and attending physicians) than the SIRS firm that usually covers Farr 9 patients. The POE order set did not indicate the correct firm coverage. Why? Until recently, Farr 9 had been primarily an inpatient surgical unit. In early February we moved several surgeons that had been admitting to Farr 9 to the east campus. This left available capacity on Farr 9. Additionally we had a couple of surgeons still operating on the west on vacation and high Emergency Department medical volume – thus Farr 9's population shifted to 40-50% medical service patients. Why? The overall increase in medical patients house wide and particularly on Farr 9 led to some coverage issues for the medical firms. Why? In order to safely spread medical firm coverage, patients on Farr 9 were getting assigned to teams other than the SIRS firm which usually covered F9 medical patients.

Solution After Investigation: The immediate issue was fixed and the correct team assignment was notified, but it took 30-45 minutes. On March 5, Jane Foley contacted Sandra Denekamp, Telecommunications, about adding SIRS on call to the online paging system. Completed.

Action Plan: Julius Yang, MD, Hospitalist, and Todd Pollack, MD, Chief Medical Resident, worked on solutions with Nurse Manager John Ryan, RN, to prevent issue from occurring again:

· Medical firms reassigned to support increased medical volume on Farr 9. (completed by Yang/Pollack)
· Farr 9 RN staff educated about medical staff coverage – virtual pager for Robinson/Kurland Firm; page #s posted on unit and staff educated on how to find medical call schedule on portal. (completed by J Ryan)· Medical house staff will up date POE order set to accurately reflect team coverage. (completed by Yang/Pollack)
· As a back up, if POE order set is not up-to-date, medical house staff will either evaluate patient if critical issue is occurring or locate correct coverage as opposed to giving RN another intern/resident to page. (completed by Yang/ Pollack)
· On call paging system updated to list SIRS firm by name. (completed by Sandra Denekamp)· Automated paging system (generates an automated page to medical admitting resident once bed assigned for patient admitted via ED) updated to reflect new admitting scheme – (completed by Yang/Pollack/Larry Nathanson, MD, Emergency Department)

Democratization 2.0

I heard a great talk last week by Andrew McAfee, a professor at Harvard Business School, about Web 2.0 and, as he terms it, Enterprise 2.0. This expanded into a discussion of the inherent democratization that occurs in the 2.0 environment, from which Andy rhetorically raised the question of how reliable and accurate this kind of approach is. Of course, my immediate response was, "Compared to what?" He then reminded us about the "contest" in 2005 that was held comparing Wikipedia to the Encyclopedia Britannica. The two sources were found to be equally accurate, until several hours later, when the mistakes on Wikipedia had been corrected!

This reminded me of a post I wrote several weeks ago about my hope to create the organizational equivalent of a wiki. And, of course, it relates to all the stuff I have been boring you with about BIDMC SPIRIT. The underlying premise is that a democratic approach to problem identification and problem solving is what makes it possible for a complex organization to discover ways to improve. As Steven Spear notes, the alternative method -- trying to design the perfect complex system in advance using the traditional business hierarchical approach -- is unlikely to produce a sustainable and efficacious solution, especially in an environment characterized by structural change.

Can health care institutions learn this approach to adaptation and improvement? The jury is still out.

Teaching from the test

Here is a recent entry from the SPIRIT call-out log, as an example of the types of things that are found and the process for fixing them. Sometimes existing sources of information are not effectively used because of a lack of knowledge or training about them. As always, the key here is not to blame anyone. It is to solve the problem called out and then to promulgate the solution throughout the organization.

PROBLEM: The lab test entered in the lab (Metanephrines) was different than the lab ordered on order requisition (Methemoglobin).

ROOT CAUSE: Why was Metanephrines entered into lab system instead of Methemoglobin? Metaneprines was selected from the list of 9 choices displayed in the blood lab information system when lab assistant typed in "MET". Assistant selected metanephrines (plasma) because asked a coworker what to select was told to pick this one because purple top vial is associated with plasma. Methemoglobin was not an option to select. Why was methemoglobin not an option to select? Assistant was working in blood lab information system. Methemoglobin is a blood gas test and is an option in that system only. Why was the assistant working within the blood lab information system? The requisition that the EP lab sent to the lab was a blood lab requisition not a blood gas requisition. Why did the EP lab send a blood lab requisition? The person requesting the lab test was unfamiliar with the test and did not have the information necessary regarding the type of tube and requisition to use. (Asked 4 people in cath department and lab and received inaccurate information and sent purple top and blood lab req. )

SOLUTION: Design a way for workers to have accurate information regarding which blood tube and requisition to use for each test. (Access to electronic URL that contains the lab resource manual on BIDMC website.)

ACTION: Wayne (Lab department manager) demonstrated the online lab reference to the nurses in the EP lab. Will continue to work with lab and nurses to work on a way for them to have the information that they need when requesting lab tests. Wayne will also work with his staff regarding a way to call out for help when the exact lab test requested is not an option to enter into the system.

Notes: The problem was found serendipitously when looking at a lab requisition for another issue (a half-printed patient plate). Wayne learned as much as he could from his staff then activated the help chain to request help in further investigation in the EP lab. Nurses in EP lab and in our small group were unaware of the online resource available to them and grateful to learn about it. This surprised Wayne. Question for consideration: Are the other nurses in the organization aware of this extremely useful tool and if not how can this be communicated to them?

The power of SPIRIT

From Jane to me (I have embedded the link to the SPIRIT post below):

Pat suggested I share the email below with you regarding my initial impressions of the Spirit program. As background, I was a longtime “old BI” nurse and left clinical practice back in the 1990s to do writing and other projects, which led to launching a consulting business a number of years later. However, after 11 years, I found I missed clinical practice, and I chose to return – albeit on a very limited basis (about 20 hours a month). This is becoming a lot of background - - but! - - folks in nursing were amazing in helping me get back on my feet, providing many hours of re-training and encouragement – just wanted to mention that also! I spend most of my time in the ED, and my email to Pat was following my shift last evening.

I think Spirit is fantastic; thanks for creating the environment where this is possible.

And her note to Pat, one of our SPIRIT organizer/trainers:

Just a quick note to say I think the SPIRIT website is fantastic. I used it last night to log my first “problem.” As you and I have discussed, as someone re-entering practice, and as someone who doesn’t work a whole lot of hours, I think I have a vantage point that is free of what you have called “tolerance of deviance” - - -I haven’t built up that tolerance, so some of these issues are just glaring me in the face. I am so pleased to have a way to share them.

That said, I’m a little worried about posting too many things!! Let’s discuss more when we talk next.

It is interesting to see the range of things posted. The few skeptics who are posting are disheartening, but I predict that attitude will die out quickly.

Here is a quick anecdote from my shift last night - - one that I think shows that just having this in place may help people become more aware of problems that they will then just solve on their own. Several people came through the ED looking for pillows. It is a chronic problem – lack of pillows. My tech had said to the pillow-searcher, “We don’t have any. We never have any.”

I was talking to my tech about this, and about how this could be logged into Spirit. (He was initially skeptical of the whole idea of SPIRIT but, I think, warmed to the idea!). Anyway, as I was showing him the program and encouraging him to log it in, he said, “Well, you know, we can call for pillows any time we want.” You could almost see a light bulb going off over his head - - saying, “Well then, why don’t we??”

I think the whole discussion of the idea of SPIRIT ratcheted things up for him to say, “Wait a second, I don’t have to live with no pillows, I can actually call for more and I think I will.”

Kind of a silly example, but I think the program will have this power.

That’s it, just sharing! I think it is very exciting.

Early SPIRIT success

Sometimes the little successes mean a lot. Here is a short story of a call-out and a solution during the first official day of BIDMC SPIRIT. This did not take a lot of work and really only involved a short investigation and the realization that a simple phone call could solve a problem. (Not all will be this easy.)

The story is told by Betsy, a manager in the Radiology Department, to the Techs and Associates in her department. The problem being called out was that Techs arriving to administer a portable chest image for patients on the cardiology floor would often find a patient missing. A wasted trip, and frustrating for these very busy people, who then also would wonder why the patient couldn't just have been sent to the Radiology floor to have the imaging done there.

Our first BIDMC Spirit call out was entered yesterday for portable chest ordered on Farr 6 when patients are off the unit. As many of you may have encountered arriving for a portable on Farr 6 - to find the patient is off the floor (usually in dialysis). So the SPIRIT was looking at why this was happening and what could be done. We learned a couple of things:
* This is a cardiology set-down unit.
* The person entering the order does not know the patient's schedule for the day.
* These patients have telemetry - so when they leave the unit they must be accompanied by a nurse. This takes a nurse off the unit, so they try to limit the time away - hence the portable order.

Solution - call the unit first to see if the patient will be there. The unit will be happy to help!

Thanks to everyone who was involved looking into this …see, there was a reason for the patient to be portable and a reasonable solution!

Betsy

The SPIRIT arises

(Email yesterday to the BIDMC Community, formally kicking off this adventure.)

Dear BIDMC,

Today we begin BIDMC SPIRIT across the medical center. Don’t expect flag-waving, speeches or any fanfare like that. This week is about first steps.

Why do we need to do this? Please read the following situations from some of our SPIRIT training sessions over the past few weeks:

The lights are too bright over my telemetry work station so it’s hard for me to read my screen, but if I turn off the switch it is too dark for the nurses at the rest of the nursing station.

When I mail a prescription to a patient and drop it in the BIDMC outgoing mail box it can take up to 10 days to get to the patient. We have resorted to buying our own stamps, hand-addressing the envelopes and dropping them in a US mailbox.

We are looking for a patient to bring down to angio. We have already searched in the day care unit and on the inpatient unit where we thought he was – but we found out that he went home yesterday!

I needed an IV pump in my recovery bay and I searched all over for one before I found out that we had none.

Think back to your first day of working here: Was it your goal to deal with situations like these? Probably not! But we all acknowledge that it happens every day. No matter where you work at BIDMC, you probably spend a chunk of your time hunting for things, tracking down something or someone you need, and fetching materials. You are well-intentioned, hard-working, creative and industrious. You have found ways to provide excellent patient care or support for patient care in spite of the challenges. Often you create “work-arounds” to simply get your work done. The problem with work-arounds, though, is that underlying systemic problems don’t get fixed. Now, with BIDMC SPIRIT, we aim to fix them.

My hope is to have us improve the quality of the time you spend here so you can focus on the things that matter instead of working around the problems you encounter. We know from other places that this can happen. They key is to empower every single person to call out problems, participate in solutions, and be appreciated for his or her contributions.

I will promise you one thing, though. During the first few weeks of SPIRIT, activities may feel clumsy – and perhaps chaotic. The number of problems called out will certainly exceed the number that can be worked on in real time. Not all of our managers have been formally trained, but we can’t wait for the timing to be perfect. We have to get started. So be please patient with each other – and especially me! -- as we get this going.

You probably have lots of questions. To learn more about how SPIRIT works, please read this Q and A (Note: This linked to the document below.). There are posters and flyers around in four languages so we can make sure that staff who don’t use computers or those for whom English is a second language are involved.

I also ask you to visit the general portal and click on the BIDMC SPIRIT logo some time this week. You’ll find a problem log up-and-running. Real-life, BIDMC problems and solutions from the first SPIRIT trainings are already there for everyone to see and learn from. It’s a great way to see what SPIRIT is.

You will be hearing much, much more about BIDMC SPIRIT in the coming weeks and months through e-mails, newsletters and the BIDMC SPIRIT site on the portal. Also, I will be documenting our progress for the world to see on my personal blog, www.runningahospital.blogspot.com.

Finally, many thanks to Andrew French, Research Administrator, who came up with our program’s name, BIDMC SPIRIT: Solutions Promoting Improvement, Respect, Integrity and Teamwork.

Sincerely,

Paul

----

And here is the Q&A that is referenced in the message above:

Frequently Asked Questions

The lights are too bright over my telemetry work station so it’s hard for me to read my screen, but if I turn off the switch it is too dark for the nurses at the rest of the nursing station. On…off…on… off. It doesn’t make sense. We need help!

When I mail a prescription to a patient and drop it in the BIDMC outgoing mail box it can take up to 10 days to get to the patient. We have resorted to buying our own stamps and dropping the envelopes in a US mailbox. Is this extra hassle really doing any good? We need help!

We are looking for a patient to bring down to angio. We have already searched in the day care unit and on the inpatient unit where we thought he was – but we found out that he went home yesterday! What a waste of time! We need help!

I needed an IV pump in my recovery bay and I searched all over for one before I found out that we had none! There has got to be a better way to do this! We need help!

What do these scenarios have in common?
They are all “call-outs” – BIDMC staff declaring that something is keeping them from doing their jobs in the best way possible. The call-outs above are real situations that came up in the first wave of manager training sessions for BIDMC SPIRIT.

What is SPIRIT?
SPIRIT stands for Solutions Promoting Improvement, Respect, Integrity &Teamwork.

You probably remember the e-mail from Paul Levy around Thanksgiving in which he challenged each member of the BIDMC community to be part of a new way to consistently identify barriers to care and implement system-wide solutions as close to real time as possible.

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

The goal of SPIRIT is to make the work lives of all of our staff easier and more gratifying. To begin, we must all see and think about what we do every day in a new light. Chances are we all have work-arounds that we do every day without thinking. Or we waste time fetching and hunting for materials or resources we need and we may not even notice.

Once you identify a problem, the basic steps are:
-- Call out a problem to your manager/shift leader.
-- Work together to identify the root cause of the problem and solve it as soon as possible – in real time.
-- Log it. (see below)
-- Use the Help Chain, if necessary. (see below)

Less time hunting and fetching can mean more time spent on patient care – which will have a major impact on our goals of higher patient satisfaction and improved safety.

When and how will we start?
We intend to launch the BIDMC SPIRIT program the first week of March.
We have been busy orienting supervisors, managers, directors and vice presidents to the basic concepts of real time problem solving. We are working with a group of consultants from a company called Value Capture. They have experience in leading system wide change at the international manufacturer Alcoa and leading similar change initiatives at several academic hospitals.

How will it work?
All employees will be asked to participate by “calling out” to their local manager/shift leader to report a problem related to hunting and fetching activities that are causing you to do work-arounds. Your manager/shift supervisor will help you to meet immediate patient needs as soon as possible. We call this “restoring the system.” Together, you will then log the problem into an electronic SPIRIT problem log (click on the SPIRIT logo on the general portal.) Your manager/shift leader will use real time problem solving strategies to facilitate a solution for the problem. Because you are the one who knows your work the best, you will be involved in the steps of finding a solution whenever possible. The goal for us is to have these call-outs addressed within 24 hours. The solutions will also be logged in the SPIRIT problem log.

I do most of my work in a patient care area, but I report to another department. To whom should I call out a problem?
You have two choices:
a) The unit’s nurse manager
b) Your departmental supervisor

When you call out a problem, ask yourself who makes the most sense to provide help. (You don’t need to spend too much time deciding this – there’s no ‘wrong’ answer.) Here is some guidance:

Is the problem related to patient care or work done on the unit? Call the unit’s nurse manager.
Example: While seeing a patient on Farr 7, a Case Manager finds that discharge paperwork isn’t ready at the right time. After solving the problem for the immediate patient, she calls out the problem to the Farr 7 nurse manager – because this problem involves the Farr 7 doctors, nurses and physical therapists and makes sense as part of the Farr 7 Unit Team.

Is the problem specific to your work, but not to the unit you’re working on? Call your usual supervisor.
Example: While seeing a patient on Farr 7, a Case Manager notices a serious bug in the case management software. It doesn’t make sense to call the Farr 7 nurse manager as part of the help chain for this problem, so she calls her supervisor in case management.

What is the SPIRIT problem log?
The SPIRIT problem log is a click away on the portal – just click on the SPIRIT logo on the top of the general portal. It provides a public space for you and your manager to log your “call-outs” and for us to track the various “call-outs” across the medical center. The SPIRIT log is not a notification system. Problems and work-arounds should be called out in person to your manager/shift supervisor whenever possible. At times when no one is available (night shift for example), go ahead and log it into the system anyway. Your manager will get back to you to involve you in problem solving if time allows. The SPIRIT log is visible from any public work station on the portal. The log will also track solutions. This will give us an opportunity to share the knowledge about fixes in one area that may be easily adapted for another area.

For patient safety reports or any report that requires the use of specific patient information, please continue to use the Patient Safety Reporting or Adverse Drug Alert or Adverse Event Management systems. The SPIRIT problem log does not provide the privacy protection needed when reporting patient related events.

What is the HELP CHAIN?
Every department is specifying the components of its HELP CHAIN. The chain flows from the local manager to the director to the VP to the President’s office and then to the Board of Directors of the medical center. We are creating a comprehensive list of departmental manager HELP CHAIN contacts so that your manager will know the name of a manager in another department who can be called when the problem “call-out” and subsequent root cause and solution involve more than your home department. We imagine that this is going to be the case for many of the “call-outs.”

How will I know how it’s going?
Information will be updated on the SPIRIT section of the portal. There will be weekly Friday e-mail updates about SPIRIT with a focus on stories about staff who are doing the work.

What about people who don’t use computers?
For staff who don’t use computers, the preferred way to call out problems is still to talk to their managers/shift leaders. If a manager isn’t available, there is a special SPIRIT phone number, (66)7-7474, for staff to call in a fetching or hunting problem. Information from the weekly Friday e-mails will be collected and put into to a print newsletter.

What about staff for whom English is a second language?
For staff whose primary language is not English, the preferred way to call out problems is still to talk to their managers/shift leaders. If a manager isn’t available, the special SPIRIT phone number, (66)7-7474, allows staff who speak Spanish, Portuguese or Haitian Creole to leave a detailed message in their first language. Staff from Interpreter Services will transcribe the messages and pass them on for the SPIRIT log. The print newsletter will also be translated into Spanish, Portuguese and French/Haitian Creole.

How can we possibly solve all of the problems called out?
We know that this is not going to be perfect on day one! We are all going to learn this together. There will probably be many more problems called out than can be solved in real time. Having said this, the important thing is that we begin by trying to solve some – everyday. This is the main priority for our work this year. Solving more problems in real time and involving those closest to the work will result in smarter solutions and less formal problem solving meetings over time. Remember, to reach our potential for greatness, every employee should be able to answer the following questions with a resounding “YES!”

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

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

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