Lean Speech

For some reason, I have been invited to give lots of speeches and classes lately, mainly on the topic of how to achieve process improvement in hospitals to improve quality and safety. I view this as a bit odd since I am just learning this stuff myself. Maybe people like to hear about the process in mid-stream. Anyway, I enjoy these sessions, getting to know new folks who are interested in the topic, but, as often as not, learning more from them than they do from me.

I tend to accept almost all invitations from colleges, non-profits, civic organizations, and also local businesses -- as my part of the educational mission of BIDMC. If I think they can afford it, I ask for a small honorarium to support programs in our hospital. I also get requests from those companies that organize expensive one- or two-day seminars for business people who want to travel. In those cases, I ask for a very, very large fee -- a large multiple of what they charge their attendees -- and then they usually find someone else!

Today's group was the Lean Educator's Conference, organized jointly by Professor Earll M. Murman at the Educational Network of MIT's Lean Advancement Initiative and another university group called LEAN. LEAN is affiliated with Jim Womack's Lean Enterprise Institute -- Jim is flanked in the picture above by Prof. Joe Sussman of MIT's Department of Civil and Environmental Engineering and Prof. Judy Hoffer Gittell of Brandeis University's Heller School. The invitation came because Earll had heard me talk last October at the National Academy of Engineering on "Adapting Process Improvement Techniques to Academic Medical Centers."

Since there may have been repeat listeners, I had to find some new jokes . . .

Flash! SPIRIT lowers high blood pressure!

What's one of the most common things a nurse does upon entering a patient's room? Check the blood pressure. So just imagine the work-arounds that were happening over and over again before this problem was called out as part of BIDMC SPIRIT. I post the results from the problem log.

Type of Problem -- Save Time; Improve Patient Care
Campus -- East
Setting -- Inpatient Ward
Location of Problem -- 12 Reisman
Problem -- Many of the patient rooms missing blood pressure cuffs and/or parts.
Person Describing Problem -- AnnMarie Grillo, RN

Root Cause
Many of the nursing staff unaware of storage location of BP cuff and extra parts (kept in a closet at the end of the hall). Because of this, missing cuffs and parts not getting replaced.

Solution (after investigation)
Change storage location to more central area.

Action Plan (who, what, by when)
1) Immediately -- room rounds done and all missing cuffs and parts replaced. (Done by AnnMarie Grillo and Gina Murray.)

2) Moved storage location of BP cuffs and parts to a drawer in the medication room at the nurses' station. Labeled drawer and notified the staff. (Done by AnnMarie Grillo and Gina Murray.)

3) Obtained current list of BP cuffs and supplies from Bill Pyne in Distribution. Posted this list in medication room above BP supply drawer for staff to make re-ordering easy. (Done by Kerri Petraitis and Gina Murphy.)

Investigation -- Closed (Complete w/ root cause, solution, action plan complete)

Busywork is not your job!

A SPIRIT Story:

On March 25, a SPIRIT training team visited the MICU 6. During the 25-minute observation, Pat Boykins, a Unit Coordinator, attempted to order copies of a patient consent form from the Web site of Office Depot Web, which has a contract to print all of BIDMC’s forms. When she entered the BIDMC code for the form (MC1793) she received an error message saying that the SKU – the product number Office Depot associates with the form – was incorrect. There was no other information, and thus Pat could not order the form.

Pat then spent 5-7 minutes making phone calls to hunt down the correct code. She eventually found it: MR1793. When asked at the end of the 25-minute observation if she encountered any problems in her job during that time, Pat said “No.” Why? Because this type of hunting and fetching has become a routine part of her job – a job she does with as much efficiency as possible. When prompted by the SPIRIT team to think of a way to improve the form-ordering process, however, she did make a suggestion that she said would save her a lot of time: find a way for the Office Depot site to provide the correct SKU for an expired or changed form code.

Here’s what happened next:

Pat reached out to her Help Chain Contact, Kristin Russell, Nurse Manager of MICU 6. Kristin spoke with Paula French, Contract Manager, who handles the Office Depot account. Paula said the proposed functionality of the Office Depot database does exist, and that the SKU never changes for a given form, even if its BIDMC code changes. She referred Kristin to Michelle Micale, Project Manager in Health Information Management, the department that handles all forms.

Michelle Micale was very helpful, and in the information she provided, the root cause of the problem was revealed. She confirmed that the form’s internal, BIDMC code had changed recently as part of an overall, ongoing process of reassigning more specific codes to forms to categorize them. Instead of all being Medical Center (MC) forms, they are being recoded as Medical Records (MR) forms, Learning Center (LC) forms, Human Resource (HR) forms, etc.

Michelle is working with Office Depot to ensure that both the old code and the new code for each form will always lead to the same SKU, beginning with the Medical Records forms. This process will take a while. In the meantime, she is available as a resource to provide the correct form number to anyone who needs one. Her e-mail and phone number are on the problem log. David Drew of Patient Care Services has sent this information to all Unit Coordinators.

Straight talk about SPIRIT

After each full-day training session for managers and others about BIDMC SPIRIT (almost 600 people now), there is a debriefing session. The comments that emerge are helpful to us in refining both the training program and our plans for calling out and solving problems throughout the hospital. To give you a sense of the issues raised, I am posting the comments from the last session. Remember, this is early in the process, not like at Toyota and other places where similar approaches have existed for decades. So, we are still feeling our way. I love that people are so open and clear about what they find reassuring and what they find troubling. That, in itself, is an important aspect of what we are trying to accomplish.

BIDMC Spirit Orientation
Participant Concluding Reflections
April 15, 2008
These reflections were invited by Ken Sands, our SVP for Health Care Quality. He started by saying, "We heard earlier today from a colleague about how logging of items about their unit had been used as a metric that wasn’t positive." Responses follow:

That was me. I did get a call from someone above me who said in effect, "There are a lot of call-outs in your area there must be some real problems there; what’s going on?" when it’s 4 out of 450 and I know we are trying to encourage call outs. I wanted to say that I’m a big supporter of this process, but it has been confusing regarding are we supposed to deal with things as they are called out and up "the help chain" or by getting calls from people above us or reacting to an e-mail from the log monitor? Are we supposed to scan it everyday? It’s not clear and it’s hard to know how to prioritize. We talked about it earlier today, and we discussed how we are all learning together including the leaders, but it’s important to be aware of this dynamic because it creates pressure and anxiety.

Thanks for saying that. The other day we had an issue and I ended up talking about it with the other manager by saying, "Maybe we can do a problem solving without logging it." And we actually had a phenomenal response; fastest ever. But there’s something about the log, it’s very visible, monitored, punitive potentially. It just feels like a difficult environment for me to call out in, at least at this stage.

The last five years have seen a great focus on greater accountability. We just don’t want to slip into blame.

I wanted to say that SPIRIT does empower us to deal in areas where we’ve struggled … it makes it much easier to engage on issues we’ve struggled with. I do have a suggestion about the training; make it easier to make a personal connection in the set-up, with phone numbers etc. Finding time was hard for me, so you send an email and you hope for a response but it’s not to anyone in particular.

I’ve been to a lot of trainings like this. The bigger challenge than training is how to keep it going. How does the organization reinforce this; how do we get reinforcement? Reflecting on today, I’m not sure I would have been as persistent and nice in working with the people involved. It’s a discipline. It needs to be reinforced/mentored. This is a cultural change!

My comment is about language. If we changed what we say from "problem" to "opportunity" it might help. Because that’s what they are – opportunities – and even the word problem seems to connote something negative.

It was inspiring to see people on the front line involved in solutions and being asked for their opinion, not just told. Being asked, "What do you think about this?" and "How would this idea come across to your peers if we rolled it out?" That was totally inspiring.

11 minutes of pleasure

A year ago, I wrote about our use of mystery shoppers to help guage whether we were meeting standards of customer quality in our clinics. We still do this and find it a good way to help the staff at the front desk staff do better and better for our patients. Here's a call, though, that shows exemplary service. (The call lasted 11 minutes. You can't rush quality.) Note the immediate feedback to the staff member from the secret shopper, too.

Nephrology
After one ring, Kerry Falvey answered my call by enthusiastically stating the name of the practice, her own name, and asking, "How can I help you?" I explained that I needed to make an appointment, but I had never seen a Nephrologist before. I had seen a Urologist recently because of recurrent UTIs who said I had high creatinine levels. My PCP and this Urologist both suggested I see a Nephrologist. Kerry said that she could definitely help me with scheduling an appointment, and asked for my name and date of birth. She confirmed that I had never been to BIDMC then explained that as a new patient, she would need to start a profile for me. She then collected all of my demographic information and confirmed that my PCP was the referring physician. She also asked if there was a particular doctor I'd be interested in seeing, and I said there was not. Kerry then explained that she would check for the first available appointment. She mentioned that their new patient policy was to provide an appointment within seven business days. The first appointment she found for me was for Tuesday, February 26th (6 days) at 10:30a with Dr. Walter Mutter, whose name she spelled for me. She confirmed that this appointment date and time would work with my schedule and confirmed that the reason for my appointment was because of high creatinine. Kerry then explained that she would check if I needed a referral. She clearly explained that depending on my insurance and PCP, I may not need a referral because of certain agreements between BIDMC and certain insurance companies. She explained that since I had Harvard Pilgrim insurance and my PCP was a BIDPO doctor, I would not need to obtain a referral. She then explained that she would check if they could access my PCP's records. Since she discovered that they could not electronically access the records, she said that they would contact my PCP, with my permission, to obtain any pertinent notes. Kerry asked if I knew where their office was located, and I said I did not. She explained that there would be a letter coming in the mail with details on directions, parking, etc, but that she would give me the location anyways. She provided me with the address, name of the building, and floor on which I could find Medical Specialties, which is where their practice is located. She asked if I needed directions to the medical center, and I said I should be fine. Kerry then repeated the date, time, and doctor I would be seeing for my appointment. She provided me with the practice phone number and explained that I could call with any questions and that any of their three staff could help me. She asked if she could help me with anything else before transferring me to registration.

Kerry's facilitation of my call was nothing less than exemplary. I mentioned to her that her tone of voice was very pleasant, and she was easy to speak with, making for an enjoyable conversation. I also commended her clear explanations throughout the call, including why she needed to collect my information, the fact that she would schedule me an appointment then transfer me to registration, and her description of the referral exception which my insurance allowed. I also thought she was very accommodating, since she was able to check right then and there whether I needed to call my PCP for a referral and since she offered to obtain the medical notes from my PCP. I also mentioned to Kerry how helpful it was that she repeated the reason for my appointment, indicating she understood my request, and that she repeated my appointment date, time, and doctor at the end of the call. I also mentioned to Kerry that it seemed like she provided me with all the information I needed and asked all the questions she should have. The only suggestion I could think of for Kerry was for her to mention something about parking along with the location of the practice.

It was very uplifting speaking with Kerry, even for something as mundane as scheduling a doctor appointment. Even on this Friday afternoon, Kerry's spirits were still high, which certainly lifted my own mood. This call truly sets the bar for the customer service that all of our schedulers should aspire to reach. Kerry received a 5 (excellent) out of 5 for this call.

Save Time; Improve Patient Care; Improve Work Life

Direct and unedited from our problem log, a great example of a call-out and problem solving from BIDMC SPIRIT:

Type of Problem -- Save Time; Improve Patient Care; Improve Work Life
Campus -- West
Setting -- Inpatient Ward
Location of Problem --Farr 7

Problem
I could not find a pulse oximeter to check my patient's oxygen saturation. There were none in the equipment cubby which is a section of our breakroom remote from patient care rooms. I wasted a lot of time going from patient room to room until I found one.
Suggested Solution -- Define a specific location that is more convenient to the nurses' and pcts' work flow
Person Describing Problem -- Beth Morrison

Root Cause
Why were none available? It is not a supply issue, there are 7 pulse oximeters for the floor. Why could Beth not find a pulse oximeter? None were in the storage area. Why are the oximeters not returned to the storage area? It is in an inconvenient location. Why when the oximeters are used are they not returned to the storage area? In the past we had a locked equipment room that was centrally located. On our new floor Farr 7, we do not have an equipment storage room and have designated a small cubby hole in the staff breakdown to store equipment. It is inconvenient in relation to the work area. Also, it is in the breakroom so sometimes it is difficult to move past staff who are sitting eating a meal.

Solution (after investigation)
A cubby hole in the nurses's station is not being used. It's location in very convenient for small equipment storage. Electrical outlets and shelving need to be installed. Once that work is complete, I will apply LEAN principles and outline with black tape and label each area for the specific equipment.

Action Plan (who, what, by when)
1. Kathy Hussain met with staff to brainstorm new, convenient location. Complete.
2. Kathy worked with her Operations Coordinator Debbie McGrath to discuss needed work. Complete.
3. Kathy discussed renovation with her director Jane Foley. Approval given to move forth with project. Complete
4. Kathy and Debbie met with Brendon Raftery and Chris Kimball on March 17th to scope the work. Complete.
5. Electrician installed 20 electrical outlets. Complete
6. Carpentry measured and ordered required shelving.
Complete
7. Currently awaiting installation of shelving.
8. Once shelving installed- will outline placement of equipment so that each piece of equipment has a designated and corresponding location.

Investigation -- Closed (Complete w/ root cause, solution, action plan complete)

Comments
Beth- thank you so much for calling out this problem. Your willingness to discuss this has lead to more efficiency and less wasted time. As a side benefit, the relocation of the equipment will allow us to recapture space in the breakroom, relieving the crowding and giving the Farr 7 staff a more pleasant breakroom.- Kathy

More from Brent James

Another part of the Silverman Institute's inaugural event was a grand rounds presentation by Brent James for our medical staff. When I saw the title of yesterday's talk -- Quality health care for the 21st century: A new outlook for humanity -- I said, "Wow, that's pretty expansive!" As it turned out, it was an accurate description of the talk. Let me try to provide some highlights.

First, we were grounded by the fact that the main determinants of health (in terms of how long we will live) are:
-- 40% Behavior (tobacco, alcohol, and obesity)
-- 30% Genetics
-- 20% Environment and Public Health
-- and only 10% Health Care Delivery (hospitals and clinics).

In 2006, the US spent $7100 per person, or 16% of GNP, on the last category. The trend in this cost is dramatically upward. What do we get for all that money?

Much of the US system is based on the rapid response aspects of health care. In contrast to other countries, where the emphasis is on primary care, we spend a lot on treating those problems. We provide better access to specialists and to technology, and we do not ration these services as they do elsewhere. Accordingly, the US mortality rate for heart attack and trauma, for example, is well below Europe. But the impact on overall mortality of our progress in these secondary care arenas is overwhelmed by the impact of a strong primary care emphasis in other countries.

James cites "the rule of rescue" as a reason for this. This is defined as "the imperative people feel to rescue identifiable individuals facing suffering or death." (Jonson, 1986 -- Sorry, I don't have the full cite and can't find it.) Our health care delivery system is skewed in this direction.

Ironically, other countries are now finding an increased demand for rescue care and so are seeing large financial pressures emerge in that segment of their own systems. (See my post below on Tuscany's desire to expand emergency services.)

After this overview, James turned to the problems in our system. As he notes, these actually emerged as a result of the design of the medical system through the 1900's, and he quoted Albert Einstein as saying, "Today's problems are often yesterday's solutions." Here are the problems:

-- Well-documented massive variation in practice based on local medical myths.
-- High rates of inappropriate care.
-- Unacceptable rates of preventable care-associated patient injury and death. (Hospitals are actually the #4 or #5 major public health problem in this regard!)
-- A striking inability to "do what we know works".
-- Huge amounts of waster and spiraling prices that limit access.

Why have these problems emerged? We continue to rely on the "craft of medicine", in which each physician practices as an independent expert -- in the face of huge clinical uncertainty (lack of clinical knowledge; rapidly increasing amount of medical knowledge; continued reliance on subjective judgment; and limitations of the expert mind when making complex decisions.).

We can begin to overcome these problems by practicing medicine with a "Shared Baseline" approach (a form of LEAN production) in which you measure, learn from, and (over time) eliminate variation arising from the professionals -- while retaining the variation that arises from the patients. He terms this "mass customization." This will assisted by full use of electronic medical record capability, and it will need to be done to make full use of EMRs. Finally, care needs to be organized around the team of caregivers, and not the individual practitioners.