BIDMC SPIRIT update

An email I sent to the BIDMC community:

Dear BIDMC,

Back in chilly days of winter, I wrote you about the beginning of BIDMC SPIRIT, and it is time to present a status report. Since starting the program, we have held training sessions for about 600 managers and others. Many of the rest of you, too, have patiently participated in those training sessions when the groups arrived on your floors! Many of you have called out problems, and we have discovered solutions to some of those problems. You can check the portal for a scrolling summary of a sample of those, or you can look at the SPIRIT Problem Solving Log for more detailed descriptions.

As I stated at the outset, we did not expect a revolutionary change from SPIRIT, but we did hope to introduce a new way to solve those daily problems that get in your way when you are trying to do your job. So far, so good. Some of you really are engaged in this and like the program. Some of you view it as background noise or a minor part of your life. Some of you consider it a bother. Wherever you are on that spectrum, please keep an open mind and keep trying to use this approach, as we have seen that it can produces real improvements.

We have not solved all the problems that have been called out, but we knew that would be the case. After all, you can't undo decades of practice and systems in just a few months. There have been about 700 call-outs logged thus far. Of these, about 400 had enough information provided by the caller-outer to enable a follow-up. Of those, about 180 have been formally resolved and closed. This is about what we would have expected for this stage of the program.

Through SPIRIT, we have also discovered some very big, very pervasive problems in the Medical Center that need a special effort to solve. I am going to present a summary of these below. Let's see how we do on these. Stay tuned.

Meanwhile, though, some of you have submitted questions to me about the program. Here they are, with answers:

What made you decide to ask us to take this on? Why now? Why this approach?

I got tired of seeing our people get frustrated with the amount of fetching and work-arounds they have to do. We studied various models that highly effective companies have used to solve this problem, modified them, and came up with SPIRIT. Even now, as we get comments from you, we continue to make modifications to the program to make it work better.

My problem is so big! Is it worth calling it out even if I think that no one can fix it?

No problem is too big or small! Give it a try.

People use SPIRIT Log as a complaint board. It could be disruptive and builds distrust. How can we stop them?

This is bound to happen sometimes. When we see it being used that way, we post a message on the Log to help people learn the right way. If a Log entry is particularly offensive, we delete it.

People are afraid of retribution so they either post problems anonymously or don't use the Log at all. What can we do to make people feel safe to use the Log?

Time and results will be the key. Also, the way in which managers treat people who post problems will either send a positive signal about participation or be really discouraging. We hope that managers will help create positive reinforcement by the way in which they respond.

I think this process is wonderful! Will the research community have a call-out pathway with the contacts list available?

You already do! Try it.

I have many frustrations about how my work is set up, but since my work is purely administrative, none of them relate directly to patient care. Is it still OK to call them out? Will they be addressed with as much priority?

Yes, SPIRIT is not just about patient care. Please call out administrative problems as well.

I have told my manager about these things so many times before and nothing ever gets done. What will make this problem log call out any different?

While not all problems will be solved, managers have been asked to give priority to those items called out through SPIRIT.

Managers already have too much on their plate. They don't have the time to train their staff about SPIRIT. What tools can we offer to support the managers?

Ironically, managers have a lot on their plate because they see the same problems over and over again, and they don't get solved. Over time, SPIRIT will be seen by managers as a more effective way to use their time. In response to suggestions, we are preparing a set of tools that can be used by managers and others to help introduce and implement the SPIRIT process more broadly.

We know Sr. Management reads the Log and perhaps judges our performance based on the log entries. However, we have to juggle SPIRIT issues with other daily priorities. What is Sr. Management's expectation?

No one is judging anyone's performance based on SPIRIT call-outs or the Log. SPIRIT issues are not meant to be separate issues from your daily priorities. They are supposed to be things that get in the way of your priorities. Don't view SPIRIT as an add-on. View it as a way to help solve the problems that matter to you.

How will we know when we get "there" and what will "there" look like?

When every BIDMC staff member to be able to answer these questions with a resounding "Yes!" every day:

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?

We know we are not there yet!

Now here are the big problems that were pointed out in SPIRIT call-outs, and what we are doing about them. For all four of these, updates will be provided regularly on the "Project Updates" page on the SPIRIT home page (under "Lists" on the left hand menu). The updates will include links to video footage documenting the current state, the process, the solution and its implementation. There will also be links to my blog postings, with things we have learned from the process.

GI Specimen Reconciliation

Description:

On May 13th, 2008 a Transporter made a call-out regarding the length of time it takes for her to reconcile specimens in the GI Lab. The immediate problem has existed for quite some time but has recently been amplified since the GI labs from East and West combined and moved to Stoneman 3. This process currently takes about 1 minute per specimen. The number of specimens “per pick up” varies throughout the day with 90-100 patients per day as an average.

Contributing causes:

Currently, the labels in the specimen log book are put in order by procedure time; however, the arrival of the specimens for reconciliation does not happen in that order. Transporters do rounds, and the specimens arrive in batches.
In addition, physicians might have different times of the day that they are involved, possibly creating another instance of batching.
As a result, when the transporter arrives at GI, he/she has to flip through pages and pages of the specimen log book to look for a label with an account number or name that can be reconciled with the specimen label.
This pathway redesign presents an opportunity for decreasing the time spent by the transporter and may decrease the turn-around time of the specimens.

Current status:

Observations of the nursing node of this pathway have been conducted and an observation of the Pathology node was conducted this Wednesday (June 25). The anticipated time to implementation of a solution should be about 4 weeks.

Patient Mode of Transport

Description:

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).

Contributing causes

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.)\

Current status:

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.

Medication pumps

Description:

Medication pumps are not always available for patient care when needed. (Focus first on the West Campus)

Contributing causes:

There is no clearly defined pathway.
There is no single, known place where pumps can always be found.
Calls for a pump interrupt the resupply process, thus causing more disruptions .
There is no clearly defined signaling between the customer (nurse) and the supplier. When does one call? When one is out of pumps? When one is down to just a couple?
Because of the sense of scarcity, the supply is based more on a perception of need than on the actual need.

Current state:

Several observations have been conducted in the PACU, on the nursing side, of the resupply efforts. We are developing measures for the time involved in hunting and fetching and the delay of transfer from the PACU to the floor. Eventually, we will have a way to figure out the average amount of time to get a pump when needed. A team has already been put together to work on this project. The anticipated time to implementation of a solution is about 10-12 weeks.

Patient Belongings

Description:

Patient belongings and valuables are getting lost. This is happening to patients across the medical center. Staff spend a lot of time hunting down patient belongings, and the medical center spends tens of thousands of dollars in reimbursement payments to patients.

Contributing causes:

Patients move from their originating location to one or several others, but their belongings don’t follow. Or, if they do, there is a delay (of several hours or several days).
There is no systematic process for collecting and handing off patient belongings.
There is inconsistent or nonexistent documentation.
There is no absolute responsibility, i.e. no one is charged with being responsible for patient belongings.

Current status:

We are beginning with a focus on the ED. There is currently a thorough effort in place to collect measurements of the current state, including:

How long it takes to search for items
How many items are searched for
The response time to a call
The time it takes to return an item to a patient.
Once the baseline data are gathered and the current state established, the plan is to pilot a more centralized approach to storing/retrieving patient valuables and belongings which involves the introduction of a primary owner of the overall process.


Thanks for your ongoing support, participation, and patience.

Sincerely,

Paul

Paul F. Levy
President and CEO
Beth Israel Deaconess Medical Center

Double header

A twofer: Watch this program on Sunday to see BIDMC SPIRIT in action. But first, read the comments from the same training session (below) to get a preview!

(From our media relations office) BIDMC’s SPIRIT program will be featured on “Sunday with Liz Walker” this Sunday, June 22nd at 11 a.m. on WBZ-TV, Channel 4. Walker observed a SPIRIT training session in BIDMC’s Neonatal Intensive Care Unit this week. The SPIRIT trainees shadowed Cathy Young, RN, and Nina Koyama, RRT, to identify work-arounds, time-wasters and barriers to patient care with the goal of implementing solutions as close to real time as possible. The trainees, who included, Susan Young, NICU, Denise Arena and Steve Maynard, Pharmacy, Elaine Mahon and Emi Rizik, Food Services, Heidi Jay, Healthcare Quality and Manny Alves, Pathology, then gathered with trainer Diana Richardson, Director of Support Business Services, to call-out a problem surrounding the turnaround time to clean equipment. BIDMC President and CEO Paul Levy was also interviewed separately about the purpose and goals of SPIRIT.

(And, now, some of the participant feedback comments from that same June 18 SPIRIT Orientation.)

I have been involved before this training, as a supervisor getting a SPIRIT call, vaguely knowing what it was about but then getting the call and really feeling on the hot seat. Not anything that was said, just the fact of suddenly doing a big problem solving while in a crisis. It happened twice in a week. So I was thinking this SPIRIT thing is a problem. I wasn’t looking forward to today. I feel like I was turned around a little by today. I can see the benefits. It helps you look at things differently. I was pleased to see that. But as the person getting the call, knowing you may be in a crisis, it can put a kink in your day!

I liked the day because it’s structured how you have to approach problems. It gave a process to do so, and then expanded on the process to show you how to get to root. The patient safety reports we have we are expected to get to root as well but I don’t think we ever got a tool to do it. This gave me the tools, and also the insight to see that I might not have been getting there in my patient safety reports.

I was trained more in systems. It was great to see how this goes hand in hand with systems work. They are not mutually exclusive.

The facilitators were great in emphasizing safety with us and all the folks out there. They were very professional about it and I just wanted to say thanks.

People do get defensive. That will change over time. The best part about this is it takes the finger pointing out of it.

I enjoy the log. It’s like my Boston Globe in the morning! I want to see the latest activity. I also use it to find out about problems others have had that can help me. For example, one of my staff came to me and said, "our old copier is broken again and we just have to throw it out the window and get a new one." It was constant. But I looked on the log and saw that a tech had helped fix another copier by showing how a certain piece jams. When I read that, I got in touch and asked if we could freeze the drawer we print on since we only use one size paper and that would take that piece that jams totally out of the picture. He said yes, we did it and guess what? The copier works perfectly. No more problems.

I work in research off site. To see the clinical side, the compassion, the excellence is very exciting. I feel more connected to the mission after my experience. I got a lot out of the day beyond SPIRIT itself. It was something much deeper for me.

I like the role playing. It really prepared us. My first experience with SPIRIT was coming into my area and seeing 20 SPIRIT folks training and thinking “Oh my G-d what is this?” It was interesting seeing pharmacy have to do lots with paper when I would have thought it would have been more automatic.

I thought we had a solution in place, but I learned we have lots of systems but they don’t talk to each other or no one gets the information in so that we must rely on the person and word of mouth to get the allergy and put it in the record … and a similar issue with a medication timing issue.

In our group we were all afraid to ask a doctor to explain something to us but then A. was bold and helped us ask one and it worked out very, very well.

Where are the pumps? Part 1.

I have provided several examples of how BIDMC SPIRIT has been employed to solve some small and annoying work-arounds and other process problems in the hospital. But, it has also permitted us to discover some pervasive issues that can really affect the lives of our staff and the quality of care given our patients. We are about to do a full-court press on several of these, and I am going to give you the play-by-play as these proceed, i.e., in real time -- telling you what we learn, how we learn it, and how we work as a team to fix the system.

Remember, the concept of SPIRIT, which is borrowed from the process improvement programs of the best firms in other industries, is to empower and encourage all members of the staff to call out problems they see in the work environment; "swarm" around that problem and solve it to root cause; and then spread the story of the discovery throughout the organization. This is not easy to do. First, you have to develop a blame-free culture, so that the person calling out the problem is shown gratitude and appreciation for having done so. You also have to train people to see problems as problems, as opposed to the normal flow of work. Then, you need to get good at analyzing problems to their root. This often involves engaging people from other divisions or departments because the cause of most problems is usually multi-jurisdictional. Then, you need to discover and implement the solution and make sure it is sustainable.

The problem I'd like to present today has to do with medication delivery pumps. If there is one pervasive problem in the hospital, as pointed out to us by the nurses, it is making sure that a functioning pump is available and accessible at the time it is needed at a patient's bedside, whether in the surgical post-op area (PACU), a medical/surgical floor, or the emergency department. But, as anybody in any hospital will tell you, there is often a frustrating amount of fetching going on when a pump is needed. Please note that the problem is not an actual physical shortage of pumps: It is making sure that they are functioning and where the should be when they are needed.

Without further ado, I present here the first set of notes coming out of our group that is "swarming" to solve this problem. This is just the beginning. Stay tuned over the coming days as we work through this together. (By the way, the picture above is a diagram of the morning pump collection/supply cycle on our West Campus, showing the different supply paths taken by our devoted distribution staff as they try to meet patient needs -- indeed, as they try hard to reduce the burden on the nurses and other caregivers! I think you can see evidence of the some of the problems noted below.)

---

The Pump Opportunity – SPIRIT call-out #691

We can’t thank Julie Kelly in the West PACU enough. Because she chose to call out that they had run short of pumps needed by patients, causing stress and strain for all involved, a huge opportunity to strengthen the system and make life better for an awful lot of committed BIDMC staff has come into view. As Mary Gryzbinski, the PACU shift leader who helped Julie enter the call-out, said in first providing details about the situation, “we knew the people in Distribution were doing everything they could to find the pumps for us … we knew we all just needed some help.”

Prompted by the call-out, an effort has begun to deeply understand how the process works today, the first step of a rigorous collaborative and transparent effort to create a system capable of providing pumps exactly when needed, every time.

Key Learnings So Far:

1) There is nothing more powerful than “going and seeing” how the process actually works, through the eyes of the people who do the work. Staff and leaders we talked to noted how “the pump problem” has been known and debated in meetings for over a decade at BIDMC. Yet in just a few hours of directly observing how the process works by walking the paths of pumps and observing nurses as they encounter a need for pumps and other key nodes of the system, the core reasons the present design fails everyone involved became clear.

2) Everyone involved in the system – from the nurses who need pumps to the amazingly hard working distribution team that gathers and supplies them to the clinical engineers who maintain them – are working with great effort and dedication to meet the need. Like his peers, Mr. Cecil Whyte – the Materials Handler who does the pump resupply run and several other duties on the West Campus during the day shift – is acutely aware of how much is riding on his ability to find and supply enough pumps over the course of a day. Mr. Whyte’s physical effort matches his dedication. He walks so much every day in his search for pumps that he buys a new pair of shoes every three months!

3) This is not just a PACU need. For the most part, pumps circulate with patients across the hospital and so – not surprisingly – this opportunity involves a huge cross section of units, departments and BIDMC staff. This is not a problem that can be solved by one unit or one department; it’s going to take everyone.

4) The pump supply system on the West has some core strengths – especially the people! But it does not embed all of the core principles that a complex system like this requires in order to meet needs perfectly. With the people who do the work, we will be exploring some of those key ideas in order to design and achieve a stronger system. Those ideas include:

• The way pumps are supplied and replenished should be simple and direct. Our pump system has some of these features, but in a critical aspect or two embeds “loops” – forcing people in the process have to retrace steps in scattershot fashion – and a “fork” or two – where two parallel processes are used to meet very similar needs in a way that confuses customers.

• The system should be based on clear and unambiguous “yes / no” signals between pump customers and suppliers, but the signals in our system are more variable and vague, leading to stress, rework and missed needs.

• The activities each person performs should be highly specified, including their content, timing, and expected outcome. Unfortunately, aspects of our pump supply system make it virtually impossible for our suppliers to stay on track!

• We will also be exploring how problems can be solved quickly in the system, so that it can stay stable and constantly improve. We don’t want to have 10 more years of frustration! The people involved care too much, and deserve to succeed.

Time was also spent today to begin to appreciate the current state on the East Campus as well. Many thanks to Aurelio Gende, Supervisor, and Pedro Perez, Materials Handler, both in Materials Management; Michele Boucher, Clinical Nurse Specialist, PACU; and their colleagues for introducing us to the current processes.

The "secrets" behind central line improvements

A self-explanatory note from one of our doctors and great teachers, which I am happy to share, in that it gives you a sense of lots of good things.

Hello Mr. Levy,
I missed your blog from Thursday, but Dave Fobert from the Shapiro Institute and the Simulation Center recently pointed it out to me. I'm thrilled to hear that we've been able to reduce our central line infection rate, and more thrilled to hear that we've been able to maintain (and even further reduce) the infection rate over the last year! I've had the privilege of working with a number of colleagues who have helped make the reduction in central line infections possible, and have been impressed with the thoughtful dedication and effort of all of them. I would like to take a moment to point out two projects that I hope have helped contribute to the reduction in central line infections, and, more importantly, highlight the many individuals who helped make these projects possible.

The first is the Department of Medicine procedure service. While many residency programs have begun to develop similar programs, ours was the first of the kind. The AHRQ recently asked Dr. Grace Huang and I to write a perspective piece detailing a variety of issues related to the creation of this service. At the bottom of this e-mail I've included a link to the article, but wanted to share with you a comment from the article and acknowledge some of those involved in the creation of this service.

"As with any new program or intervention that affects an entire department, the success of this program depends on the collaboration and cooperation of many. The willingness to dedicate the resources and faculty support to an untested endeavor was a direct reflection of the institutional spirit and dedication to providing the best possible care for our patients and education for our students and residents."

"Acknowledgment: The authors owe special thanks to those who showed an uncommon foresight and dedication to make the Medical Procedure Service at Beth Israel Deaconess Medical Center successful, including Drs. Moellering, Weinberger, Zeidel, Strewler, Weiss, Reynolds, Feller-Kopman, Gordon, Ernst, Aronson, Clardy, and Weingart."

The second project is our use of simulation to more effectively teach central line insertion. For last year and a half we have brought interns to the simulation center on the first day of their ICU rotation to provide them a comprehensive education of central line insertion in a safe environment. In addition, we have created a validated assessment tool to help determine competency at these procedures (believe it or not, such a tool hasn't existed until now) and are investigating how much our simulation education improved the resident's skill and whether it has resulted in improved patient outcomes. In the meantime we only have the anecdotal reports from our housestaff. Below is an e-mail from Dr. Arash Mostaghimi (a HMS graduate and now one of our outstanding interns) who recently put in a central line while rotating at the Dana Farber Cancer Institute:

From: Mostaghimi,Arash (BIDMC - Medicine)
Sent: Saturday, May 24, 2008 4:34 PM
To: Smith,Christopher (HMFP - Health Care Associates)
Subject: central lines

Hi Chris,
I wanted to let you know that I put a semi-emergent IJ in yesterday on one of my patients at the DF in less than 10 minutes, which was fairly impressive to my BWH colleagues. They were especially surprised to hear that I've only put in 5 central lines before. I think the key was the training that I had with the simulator earlier in the year--even though that was a subclavian line, just becoming comfortable with the equipment and having been able to practice it a couple of times (during the session and later during the testing session) was of great benefit.
So thanks for the teaching! I hope it's standard for our new interns.
Arash
--
Arash Mostaghimi, MD MPA
Internal Medicine/Dermatology PGY-1

As with the procedure service, the success of this simulation project is due to the efforts of many, including Dave Fobert (who sent the e-mail below); Dr. Grace Huang (Shapiro Institute and co-investigator of procedure service and simulation projects); Lori Newman (co-director of the Rabkin Fellowship and co-investigator of the simulation project); Drs. Ennaceril, Cho, Miller, Cobb and Leder (all 5 are senior fellows who helped with the simulation teaching over the last year); Drs. Clardy and Weiss (who have supported these project and have allowing interns to leave their ICU rotations for this training); Drs. Zeidel, Strewler, Schwartzstein, Aronson and Reynolds (for their continued support of these projects).

Not infrequently I have colleagues from other institutions inquire about our procedure work. What impresses them most is the degree of collaboration and cooperation that exists among colleagues at BIDMC!
Best wishes,
Chris Smith

The "secrets" behind central line improvements

A self-explanatory note from one of our doctors and great teachers, which I am happy to share, in that it gives you a sense of lots of good things.

Hello Mr. Levy,
I missed your blog from Thursday, but Dave Fobert from the Shapiro Institute and the Simulation Center recently pointed it out to me. I'm thrilled to hear that we've been able to reduce our central line infection rate, and more thrilled to hear that we've been able to maintain (and even further reduce) the infection rate over the last year! I've had the privilege of working with a number of colleagues who have helped make the reduction in central line infections possible, and have been impressed with the thoughtful dedication and effort of all of them. I would like to take a moment to point out two projects that I hope have helped contribute to the reduction in central line infections, and, more importantly, highlight the many individuals who helped make these projects possible.

The first is the Department of Medicine procedure service. While many residency programs have begun to develop similar programs, ours was the first of the kind. The AHRQ recently asked Dr. Grace Huang and I to write a perspective piece detailing a variety of issues related to the creation of this service. At the bottom of this e-mail I've included a link to the article, but wanted to share with you a comment from the article and acknowledge some of those involved in the creation of this service.

"As with any new program or intervention that affects an entire department, the success of this program depends on the collaboration and cooperation of many. The willingness to dedicate the resources and faculty support to an untested endeavor was a direct reflection of the institutional spirit and dedication to providing the best possible care for our patients and education for our students and residents."

"Acknowledgment: The authors owe special thanks to those who showed an uncommon foresight and dedication to make the Medical Procedure Service at Beth Israel Deaconess Medical Center successful, including Drs. Moellering, Weinberger, Zeidel, Strewler, Weiss, Reynolds, Feller-Kopman, Gordon, Ernst, Aronson, Clardy, and Weingart."

The second project is our use of simulation to more effectively teach central line insertion. For last year and a half we have brought interns to the simulation center on the first day of their ICU rotation to provide them a comprehensive education of central line insertion in a safe environment. In addition, we have created a validated assessment tool to help determine competency at these procedures (believe it or not, such a tool hasn't existed until now) and are investigating how much our simulation education improved the resident's skill and whether it has resulted in improved patient outcomes. In the meantime we only have the anecdotal reports from our housestaff. Below is an e-mail from Dr. Arash Mostaghimi (a HMS graduate and now one of our outstanding interns) who recently put in a central line while rotating at the Dana Farber Cancer Institute:

From: Mostaghimi,Arash (BIDMC - Medicine)
Sent: Saturday, May 24, 2008 4:34 PM
To: Smith,Christopher (HMFP - Health Care Associates)
Subject: central lines

Hi Chris,
I wanted to let you know that I put a semi-emergent IJ in yesterday on one of my patients at the DF in less than 10 minutes, which was fairly impressive to my BWH colleagues. They were especially surprised to hear that I've only put in 5 central lines before. I think the key was the training that I had with the simulator earlier in the year--even though that was a subclavian line, just becoming comfortable with the equipment and having been able to practice it a couple of times (during the session and later during the testing session) was of great benefit.
So thanks for the teaching! I hope it's standard for our new interns.
Arash
--
Arash Mostaghimi, MD MPA
Internal Medicine/Dermatology PGY-1

As with the procedure service, the success of this simulation project is due to the efforts of many, including Dave Fobert (who sent the e-mail below); Dr. Grace Huang (Shapiro Institute and co-investigator of procedure service and simulation projects); Lori Newman (co-director of the Rabkin Fellowship and co-investigator of the simulation project); Drs. Ennaceril, Cho, Miller, Cobb and Leder (all 5 are senior fellows who helped with the simulation teaching over the last year); Drs. Clardy and Weiss (who have supported these project and have allowing interns to leave their ICU rotations for this training); Drs. Zeidel, Strewler, Schwartzstein, Aronson and Reynolds (for their continued support of these projects).

Not infrequently I have colleagues from other institutions inquire about our procedure work. What impresses them most is the degree of collaboration and cooperation that exists among colleagues at BIDMC!
Best wishes,
Chris Smith

http://www.webmm.ahrq.gov/perspective.aspx?perspectiveID=56

--

From: Fobert,David V. (BIDMC - Res Academic Affairs)
Sent: Friday, May 30, 2008 5:31 PM
To: Smith,Christopher (HMFP - Health Care Associates)
Subject: Central Line
Chris,
Just a quick question. Is Paul Levy aware of the central line simulations done in the simulation center? I noticed his blog entry from earlier. Given that it looks like we'll be able to do the training as part of the rotation for next year, I hope it can help to bring the infection rate even lower!
Anyway, saw his post and wanted to mention it. Have a great weekend!
Dave
David V. Fobert
Administrative Manager for Operations, IT
Carl J. Shapiro Simulation and Skills Center at
Harvard Medical School and Beth Israel Deaconess Medical Center

Continuing in our series on the roll-out of BIDMC SPIRIT, here are comments made by participants in the most recent training session in response to these questions posed by Dr. Ken Sands, our SVP for Health Care Quality:

“What about SPIRIT and the training works? What needs to work better? What should BIDMC do differently?”

One of the things that works best about is having other disciplines see what other disciplines do. The old saying “walk a mile in another person’s shoes.” I think a lot of us are coming away with a lot of renewed respect for what other people do around here. And it’s ok that it’s managers doing it, but it would be key for front line staff to do too.

I’d like to see more MD involvement. I know some have been coming through. Is there a plan to accelerate?

Do you have a place where everyone who has been through training is listed?

How do we encourage front line staff to use this? Managers and supervisors are familiar with it. We had staff meetings and talked about it but I’m not sure it’s gotten out there enough.

I haven’t seen much of this in the area where I work. Pre-SPIRIT, I was told how to reach out for some guidance on making improvements. One time, it was very successful. Another time, with another kind of problem, I had someone in my office two days later yelling at me. I’m not sure there’s a clear enough structure for this yet where I work so I hope it can continue to be strengthened.

Is there a way for the log to drop an e-mail to a manager who’s been named in the help chain?

We have been problem solving in our area, but not following through to enter on the log. But we’ll follow through and log it now that I’m reminded of the value to others.

We have noticed that when you are on the screen of one of the problems, the number is not visible. You have to go back out of the problem and then find it again, which can be hard (require a search or scrolling if it’s not one of the newest problems). It would be very helpful if the number could be displayed on the problem screen.

I found this concept so affirming. I have been a staff member for 15 years. I can’t tell you how many thousands of times I have become vaguely aware of how frustrated I was getting, but I had absolutely no way of doing anything about it. I want to tell you how moved I am that the institution wants to do this for us. It’s basically about how our day is. How do you mobilize people to do this, like you were asking? Tell them this if for us! I am the kind of person who has to process things, so I’ll have to return to the materials, but some of the tools that are shared like the activities and pathway principles – those are news to me. I’ll use them in my own life. They don’t teach you that in nursing school!

SPIRIT video

Here is a short video about a potential patient safety problem with code carts that was called out by a nurse as part of BIDMC SPIRIT and how it was handled. It will give you a sense of the steps involved. Worth watching all the way to the end. And a clear contrast with the definition below!

We want to listen. Are we good at it?

Although we are always listed among the "most wired" hospitals in America, with lots of clinical applications for both providers and patients, we still depend on people both inside and outside of the hospital to tell us how our information systems can be improved -- from the user's point of view.

I have mentioned how useful our PatientSite program is for patients, allowing them access to medical records, appointments, prescriptions, and the like. This is a very good system, but one of our patients sent in the following suggestion:

For the wish list: This might be a substantial change but I ask that you put it into the hopper for a someday rethink. I ask that you (BIDMC) begin to define an appointment from the patient's point of view, or at least offer us a view that serves us. For me, the "appointment" object is a trip to the hospital that may have a one-to-many relationship with several sub-objects that are of interest only to the hospital, for whom each person is a schedulable resource. Right now, I have one trip to BIDMC scheduled for Monday 6/9. To me that's one appointment, one trip, and patients would be better served if we had visibility into more appointments. To you it's appointments (resource bookings) for three separate objects (people). Bottom line, I'm appealing to the hospital to consider presenting things appropriately to the POV of the individual stakeholder. You might say that it does me very little good to offer me visibility into YOUR view of the resources, when that isn't the information that *I* need.

The reply from the tech support person:

Our programmer has checked the code again. You are correct, as just 5 appointments can be displayed on the Home page at one time. There is a finite number of appointments that will display. If you have a long list of appointments, the (later) appointment with Dr. X will display after some of the others have passed.

After this reply, the patient bumped it up to me:

This is way below your radar but I want you too to be aware of this as a thought. Here's something I just submitted to the PatientSite support team, to put onto the wish list.

And from me to the relevant Vice President, who wrote to the relevant IS folks:

Can we have patient site display more than 6 appointments at a time; i.e., longer out in the timeline? Please me know.

The reply:

I'm not sure what would be involved in changing this, but we will follow up with the team and get back to you.

A few days later, the follow-up:

I reviewed with the team, and it would be possible for us to increase the number of appointments and other events that display in MyEvents in PatientSite. I have attached a screenshot for your reference.
There are three options:
1. Raise the limit of future appointments from 5 to some higher value.
2. Show all appointments that fall within a specified date range, e.g., the next six months.
3. Show all future appointments regardless of date.
All three options are technically feasible. Approaches 2 and 3 would seem to better address the patient's request that we adopt a patient's point of view in the display.
Let me know if you would prefer one of these options over the others, and we can proceed from there.

VP replies:

I think we should do option 2 or 3. Either let patient give the time frame they want to see or all appointments. I will leave that to you , but it needs to be option 2 or 3.

IS replies:

Patients can now view all future appointments on their PatientSite Home page. If the list is longer than 6 appointments, a scroll bar will appear so they can scroll down. I have emailed the patient who originally made the enhancement request.

Summary:

The good news is that we listened to this excellent idea from a patient and implemented it without a lot of fuss. The not-so-good news is that the patient felt he had to send me a note on this issue to get it done. Now, it might have made it on its own through the system, or it might not have. So, the next step for me is to find out from the VP involved how patient suggestions that are made to tech support get reported and prioritized by the IS team. In other words, this now becomes a BIDMC SPIRIT call-out from the CEO's office....