On June 30, I told you about our plans to solve the pump problem using the principles of BIDMC SPIRIT. We decided to document this problem-solving process with a home-made video. Here's the first of these videos, which presents a pretty good description of some of the problems and the perspectives of a lot of people working here. I am betting that those of you who work in other hospitals will watch this and think we filmed it at your place! Stay tuned as we work through this.
Wednesday, July 30, 2008
Wednesday, July 9, 2008
SPIRIT list
I know this might not seem as serious as the posts below about wrong-side surgery, but we have made good progress with a lot of call-outs through BIDMC SPIRIT. Some of these may seem somewhat trivial to you, but please remember that fixing even a "minor" item that takes up the time of a nurse or other caregiver creates more time to actually be with patients, improving the quality of care and reducing the chance of errors -- not to mention improving the work environment for that person and many others, too. Remember, too, that these resulted from real people on the floors calling out problems that previously would have resulted in perpetual work-arounds. I think this is good stuff.
So, here's just a running a list from the last several weeks:
The abandoned bikes outside the Farr building have been removed, freeing up spaces for employees to leave their bikes.
It is now easier to find precaution gowns in the ED.
BIDMC’s evening shuttle has expanded its service to provide transportation to Ruggles Station upon request between 9pm and 11:30pm.
The many incorrectly functioning aspects of the mobile computing unit used in the Trauma SICU have been fixed.
Several new documents have been posted to the SPIRIT site to assist with discussions about SPIRIT and its best use. Take a look under “Reference Documents.”
Chair alarms on Farr 9 are easier to track.
CC6A no longer runs out of menus for patients.
Surgical residents can respond to trauma team pages more quickly now by exiting the Palmer and Baker call rooms through doors previously locked at night.
Clinical staff no longer need to hunt around as much for missing suction set-ups on 11 Reisman.
A bathroom on Palmer 2 has reappeared (actually, just the sign had disappeared, but some staff did not know there was a bathroom there).
Nurses and respiratory therapists in the MICU 7 no longer have to tend to ventilator false alarms as often; an equipment default has been fixed.
Patient confidentiality is better assured in certain Dermatology exam rooms now that shredders have been placed in them.
Omnicell restocking on Farr 5 happens at a time more convenient for nurses and for distribution of morning meds.
There is a new process for completing updates to the OMR dictionary—new medications will be recognized more frequently.
CVICU staff no longer have to hunt around for a wheelchair; there is a designated wheelchair and space to store it.
Inpatient RNs have read access to webOMR.
The SPIRIT log has a built-in search function; please use it to gain insight into call-outs that might bear similarities to yours.
The Patient Profile on POE now lists the need for an interpreter when necessary so all care providers are aware of it.
The Farr 7 breakroom no longer receives calls for Psychiatry.
Incorrect instructions for patients scheduled for ambulatory surgery have been updated to include correct check-in location.
There is now a streamlined system for repairing patient call lights promptly on Farr 9.
Patients requiring an MRI or CT are no longer delayed by IV access needs.
New measures are in place to help prevent inadvertent activation of the code center disaster recording.
New signage is helping visitors to the Trauma SICU find the correct waiting room and prompt assistance much more easily.
Patients miss far fewer nuclear bone scan appointments because they now receive appointment reminders.
Patient phone jacks no longer get pulled from the wall on Reisman 11.
Staff in the ED now spend less time looking for tubes to send to the Blood Bank or STAT Lab.
Laptops on Farr 6 no longer need to be rebooted before use.
West Campus MRI techs are more easily and reliably reached via pager.
Vital sign log sheets will now be reinforced to prevent ripping and loss.
Sharps bins on Shapiro 9 and the PACU are being emptied on a schedule more aligned with their actual use.
The Deaconess 2 house staff lounge now has a speaker for broadcasting Code Blue signals.
Lunch is ready for ED patients when they need it.
Nurses on Farr 7 can find a pulse oximeter when they need one.
On 12 Reisman, blood pressure cuffs and parts are better organized and stored.
East Campus CT Techs now have a printer in their immediate workspace.
A better plan is now in place to supply the SICU A&B with enough pillows.
Employees should no longer receive a bill for care following an occupational exposure.
The Dermatology Unit now has a new system to maintain adequate supplies of essential medical items.
Discharge medication lists are now simpler and easier to understand.
Accounts Payable has a new mailbox for invoices to streamline processing.
Monday, July 7, 2008
A lesson from Tom
I have received many thoughtful comments below about our wrong-side surgical error, but there is one that deserves some special attention. It is from Tom Botts from Royal Dutch Shell, and I repeat it in its entirety here:
Paul: thanks for having the courage and commitment as a senior leader of a large organisation to role model open and honest dialogue when a mistake is made. Surely that is the best way to ensure learning takes place and improve the chances that the same mistake will not be made in the future.
I am a senior executive in the oil and gas industry, and we work incredibly hard to ensure our operations are safe, every day. But sometimes mistakes are made and we have to be aware of systems and behaviours that discourage open and honest dialogue (people fearing there is more to lose than gain by being open). The short term result of transparency is often a lot of second-guessing and finger pointing. But it's important we break through those barriers, as you are doing, and decide to stay focused on the longer term goal of learning and preventing future mistakes.
In my business, we had a tragic incident several years ago where two men lost their lives. We decided to be as open and transparent about the incident as possible and went through a Deep Learning journey, involving hundreds of people, that examined in detail all the root causes that contributed to the accident, and to get a clear picture of the system that produced the fatalities. Even though the two men that were killed could have made better decisions, my senior leadership team and I could find places where we “owned” the system that lead to the tragedy.
It was a defining moment for us when we, as senior leaders, were finally able to identify our own decisions and our own part in the system (however well intended) that contributed to the fatalities. That gave license to others deeper in the organisation to go through the same reflection and find their own part in the system, even though they weren’t directly involved in the incident.
Once you take that step of committing to transparency and learning, it sets a high bar and it is very hard (probably impossible) to take it back. This approach has helped make us stronger and more aware of the impact of our daily decisions. I wish you full success in your learning journey and encourage you to stick with it!
While I really appreciate Tom's point about having the courage to disclose errors, he may overstate the fortitude needed to do that. In fact, one could argue that in today's media environment, it has become more or less standard "crisis management" practice to disclose corporate errors. Admittedly, the medicine and the hospital world is slow to adopt that approach, but it is likely to do so more and more.
The real courage is the one shown by Tom and his team: When we, as senior leaders, were finally able to identify our own decisions and our own part in the system (however well intended) that contributed to the fatalities. Please understand the personal context for him, as explained by our mutual friend Jessica Lipnack:
As head of Shell's UK operations at the time, Tom staked his reputation on safety in this very dangerous industry. A massive campaign ensued. You couldn't walk through a vestibule in any of the facilities without seeing a video about safety. There were signs everywhere. From the largest areas of risk - on the rigs - to the smallest - walking down the hall with a hot cup of coffee without a lid on it, people were encouraged to help one another be more safe. I can recall being reprimanded (in a helpful way) a number of times for not holding onto a railing while climbing stairs, this on dry land in a completely stable building, not even on a seaborne vessel.
Then, unbelievably, two young men died on a rig. They'd gone down into what is called a "leg" of the rig without the proper safety equipment. One was 22, the other, perhaps 30 or so. Very young. Completely unnecessary. Despite everything Tom and his safety group had done, despite training, equipment, and extensive conversation.
The one thing I recall Tom saying is this: He was most surprised by his own faulty thinking, that everything he believed about how something like this could happen was plain wrong, that he had false beliefs about learning, and that he couldn't believe that he'd gotten to that point in his life and been so dead wrong. And this is a person who thinks deeply about organizations and how to change them.
I don't believe we have yet gotten to that point here at BIDMC. Sure, we believe in disclosure and transparency. Sure, we have established superb goals for patient quality and safety. Sure, we have instituted an important program to improve the work place and reinforce the value of every person working here. But these are baby steps along this journey.
When I say "we", I mean myself, our clinical Chiefs, and our senior management team. I don't think we are sufficiently self-reflective yet to question our own underlying assumptions and frameworks about how people learn, how bad habits are erased, and how flexible and thoughtful good work habits are created. The standard to which we should be held accountable by our Boards is whether we will grow to learn the lesson presented by Tom and his colleagues. And will we do it fast enough to avoid unnecessary tragedy in this hospital.
Paul: thanks for having the courage and commitment as a senior leader of a large organisation to role model open and honest dialogue when a mistake is made. Surely that is the best way to ensure learning takes place and improve the chances that the same mistake will not be made in the future.
I am a senior executive in the oil and gas industry, and we work incredibly hard to ensure our operations are safe, every day. But sometimes mistakes are made and we have to be aware of systems and behaviours that discourage open and honest dialogue (people fearing there is more to lose than gain by being open). The short term result of transparency is often a lot of second-guessing and finger pointing. But it's important we break through those barriers, as you are doing, and decide to stay focused on the longer term goal of learning and preventing future mistakes.
In my business, we had a tragic incident several years ago where two men lost their lives. We decided to be as open and transparent about the incident as possible and went through a Deep Learning journey, involving hundreds of people, that examined in detail all the root causes that contributed to the accident, and to get a clear picture of the system that produced the fatalities. Even though the two men that were killed could have made better decisions, my senior leadership team and I could find places where we “owned” the system that lead to the tragedy.
It was a defining moment for us when we, as senior leaders, were finally able to identify our own decisions and our own part in the system (however well intended) that contributed to the fatalities. That gave license to others deeper in the organisation to go through the same reflection and find their own part in the system, even though they weren’t directly involved in the incident.
Once you take that step of committing to transparency and learning, it sets a high bar and it is very hard (probably impossible) to take it back. This approach has helped make us stronger and more aware of the impact of our daily decisions. I wish you full success in your learning journey and encourage you to stick with it!
While I really appreciate Tom's point about having the courage to disclose errors, he may overstate the fortitude needed to do that. In fact, one could argue that in today's media environment, it has become more or less standard "crisis management" practice to disclose corporate errors. Admittedly, the medicine and the hospital world is slow to adopt that approach, but it is likely to do so more and more.
The real courage is the one shown by Tom and his team: When we, as senior leaders, were finally able to identify our own decisions and our own part in the system (however well intended) that contributed to the fatalities. Please understand the personal context for him, as explained by our mutual friend Jessica Lipnack:
As head of Shell's UK operations at the time, Tom staked his reputation on safety in this very dangerous industry. A massive campaign ensued. You couldn't walk through a vestibule in any of the facilities without seeing a video about safety. There were signs everywhere. From the largest areas of risk - on the rigs - to the smallest - walking down the hall with a hot cup of coffee without a lid on it, people were encouraged to help one another be more safe. I can recall being reprimanded (in a helpful way) a number of times for not holding onto a railing while climbing stairs, this on dry land in a completely stable building, not even on a seaborne vessel.
Then, unbelievably, two young men died on a rig. They'd gone down into what is called a "leg" of the rig without the proper safety equipment. One was 22, the other, perhaps 30 or so. Very young. Completely unnecessary. Despite everything Tom and his safety group had done, despite training, equipment, and extensive conversation.
The one thing I recall Tom saying is this: He was most surprised by his own faulty thinking, that everything he believed about how something like this could happen was plain wrong, that he had false beliefs about learning, and that he couldn't believe that he'd gotten to that point in his life and been so dead wrong. And this is a person who thinks deeply about organizations and how to change them.
I don't believe we have yet gotten to that point here at BIDMC. Sure, we believe in disclosure and transparency. Sure, we have established superb goals for patient quality and safety. Sure, we have instituted an important program to improve the work place and reinforce the value of every person working here. But these are baby steps along this journey.
When I say "we", I mean myself, our clinical Chiefs, and our senior management team. I don't think we are sufficiently self-reflective yet to question our own underlying assumptions and frameworks about how people learn, how bad habits are erased, and how flexible and thoughtful good work habits are created. The standard to which we should be held accountable by our Boards is whether we will grow to learn the lesson presented by Tom and his colleagues. And will we do it fast enough to avoid unnecessary tragedy in this hospital.
Saturday, July 5, 2008
The message you hope never to send
An email sent out on Thursday morning. My commentary follows.
Dear BIDMC Community,
This week at BIDMC, a patient was harmed when something happened that never should happen: A procedure was performed on the wrong body part. With the support of all our Chiefs of service, we are sharing this information with the whole organization because there are lessons here for all of us.
While respecting the confidentiality of both the patient and caregivers, here are the key facts: It was an elective procedure, involving an excellent team of providers. It was a hectic day, as many are. Just beforehand, the physician was distracted by thoughts of how best to approach the case, and the team was busily addressing last-minute details. In the midst of all this, two things happened: First, no one noticed that the wrong side was being prepared for the procedure. Second, the procedure began without performing a "time out," that last-minute check when the whole team confirms "right patient, right procedure, right side." The procedure went ahead. The error was not detected until after the procedure was completed. When it was, our patient safety division was notified immediately, and they in turn took all appropriate steps including investigation, reporting and corrective action. The physician discussed the error with the patient at the first opportunity, and made a full apology. The patient is now recovering at home from the injury, which is not life-threatening.
What a horrifying story. What important lessons. We learned that when teams are busy and distracted, it makes it easier to overlook something. We learned that key safety steps, like the "time out," need to occur every single time, since even one failure can be serious. We learned that serious events rarely relate to the performance of any single person. We learned that we have vulnerabilities that we were not even aware of, and that there are surely others out there.
Actually, we re-learned all these things, because none of these observations are new and all of them apply to the entire work place. We have already made improvements in our process for side/site marking and procedural time outs; what can you do to apply these lessons to your work?
The strength of an organization is measured not by counting the number of successes, but by its response to failure. We have made an institutional commitment to eliminating harm, and that requires sharing information about cases such as this so that we all have a chance to learn from it. We still have more to learn from this case, and changes that need to be made, and so will be providing more information in the future.
Sincerely,
Kenneth Sands, MD, MPH
Senior Vice President, Health Care Quality
Paul Levy
President and CEO
----
Before I start, I want to refer you to an excellent story summarizing the case written by Stephen Smith at the Boston Globe.
So, here are a few things you might want to know. The things that went wrong are summarized above and simply should not have happened. The test for our place is to figure out how to make the right things happen 100% of the time. As we work on that, I'll keep you informed.
While I feel incredibly badly about the event, I feel good about the actions taken by individuals and groups right afterward. Here are a few things that went right. (1) The surgeon immediately notified me and his chief of service when he realized that the error had happened. This permitted our Health Care Quality staff to quickly and efficiently interview everyone who was in the OR, while memories were fresh, so we could piece together all the relevant events. (2) The surgeon and others apologized promptly and openly to the patient and explained the nature of the error. (3) When all of our Chiefs of service met to review the case, they unanimously agreed that the case was serious enough that the email above should be sent to all of the thousands of people working in the hospital.
I could not say with any certainty that all three of these things would have happened even three years ago, when people would have been a lot more protective and skittish about this kind of disclosure. But the focus of our hospital on improving quality and safety and our emphasis on eliminating preventable harm and on transparency of our clinical results has taken hold in a very strong way. This is a cooperative effort of the clinical and administrative and lay leadership -- and it takes all three groups to make it happen.
On this particular case, though, one of our Board members put it exactly right: "Protocols are meant to make procedures insensitive to distraction and busy days. These are inadequate and embarrassing excuses. The 'culture of safety' has not permeated the front lines. Culture of safety training, and application of advances in safety science, I believe, are critical to preventing the type of complex harm that occurs in hospitals. Not just for new staff. For everyone who wears a BIDMC badge, or is affiliated as a physician to the hospital. I know that this is a new science, and a new way of doing business, but this event might just give that leverage needed for change."
While we explore lots of ideas, one already in my mind and that of this Board member would be to make a video with the actual people -- doctors, nurses, surgical techs -- who were in the OR at the time to explain what they saw and felt and what they learned from the experience. While they might be in too much distress to do this right now, they might agree over time, and their doing so would create a powerful message at every orientation, at nurses and departmental meetings, and conferences. Of course, if the patient would agree to participate, that would lend even more power to the story.
As noted by the Board member, "The video could pepper in the stories of near misses and other incidents to keep the lesson broad. The narration would guide the audience to consider challenges and accomplishments -- and work ahead. It could be a 20-minute masterpiece, shown at every orientation, nurses meeting, discussed by chiefs, shared at conferences. Transparency as opportunity, social marketing. It would get people talking, and thinking."
Your thoughts and suggestions?
Dear BIDMC Community,
This week at BIDMC, a patient was harmed when something happened that never should happen: A procedure was performed on the wrong body part. With the support of all our Chiefs of service, we are sharing this information with the whole organization because there are lessons here for all of us.
While respecting the confidentiality of both the patient and caregivers, here are the key facts: It was an elective procedure, involving an excellent team of providers. It was a hectic day, as many are. Just beforehand, the physician was distracted by thoughts of how best to approach the case, and the team was busily addressing last-minute details. In the midst of all this, two things happened: First, no one noticed that the wrong side was being prepared for the procedure. Second, the procedure began without performing a "time out," that last-minute check when the whole team confirms "right patient, right procedure, right side." The procedure went ahead. The error was not detected until after the procedure was completed. When it was, our patient safety division was notified immediately, and they in turn took all appropriate steps including investigation, reporting and corrective action. The physician discussed the error with the patient at the first opportunity, and made a full apology. The patient is now recovering at home from the injury, which is not life-threatening.
What a horrifying story. What important lessons. We learned that when teams are busy and distracted, it makes it easier to overlook something. We learned that key safety steps, like the "time out," need to occur every single time, since even one failure can be serious. We learned that serious events rarely relate to the performance of any single person. We learned that we have vulnerabilities that we were not even aware of, and that there are surely others out there.
Actually, we re-learned all these things, because none of these observations are new and all of them apply to the entire work place. We have already made improvements in our process for side/site marking and procedural time outs; what can you do to apply these lessons to your work?
The strength of an organization is measured not by counting the number of successes, but by its response to failure. We have made an institutional commitment to eliminating harm, and that requires sharing information about cases such as this so that we all have a chance to learn from it. We still have more to learn from this case, and changes that need to be made, and so will be providing more information in the future.
Sincerely,
Kenneth Sands, MD, MPH
Senior Vice President, Health Care Quality
Paul Levy
President and CEO
----
Before I start, I want to refer you to an excellent story summarizing the case written by Stephen Smith at the Boston Globe.
So, here are a few things you might want to know. The things that went wrong are summarized above and simply should not have happened. The test for our place is to figure out how to make the right things happen 100% of the time. As we work on that, I'll keep you informed.
While I feel incredibly badly about the event, I feel good about the actions taken by individuals and groups right afterward. Here are a few things that went right. (1) The surgeon immediately notified me and his chief of service when he realized that the error had happened. This permitted our Health Care Quality staff to quickly and efficiently interview everyone who was in the OR, while memories were fresh, so we could piece together all the relevant events. (2) The surgeon and others apologized promptly and openly to the patient and explained the nature of the error. (3) When all of our Chiefs of service met to review the case, they unanimously agreed that the case was serious enough that the email above should be sent to all of the thousands of people working in the hospital.
I could not say with any certainty that all three of these things would have happened even three years ago, when people would have been a lot more protective and skittish about this kind of disclosure. But the focus of our hospital on improving quality and safety and our emphasis on eliminating preventable harm and on transparency of our clinical results has taken hold in a very strong way. This is a cooperative effort of the clinical and administrative and lay leadership -- and it takes all three groups to make it happen.
On this particular case, though, one of our Board members put it exactly right: "Protocols are meant to make procedures insensitive to distraction and busy days. These are inadequate and embarrassing excuses. The 'culture of safety' has not permeated the front lines. Culture of safety training, and application of advances in safety science, I believe, are critical to preventing the type of complex harm that occurs in hospitals. Not just for new staff. For everyone who wears a BIDMC badge, or is affiliated as a physician to the hospital. I know that this is a new science, and a new way of doing business, but this event might just give that leverage needed for change."
While we explore lots of ideas, one already in my mind and that of this Board member would be to make a video with the actual people -- doctors, nurses, surgical techs -- who were in the OR at the time to explain what they saw and felt and what they learned from the experience. While they might be in too much distress to do this right now, they might agree over time, and their doing so would create a powerful message at every orientation, at nurses and departmental meetings, and conferences. Of course, if the patient would agree to participate, that would lend even more power to the story.
As noted by the Board member, "The video could pepper in the stories of near misses and other incidents to keep the lesson broad. The narration would guide the audience to consider challenges and accomplishments -- and work ahead. It could be a 20-minute masterpiece, shown at every orientation, nurses meeting, discussed by chiefs, shared at conferences. Transparency as opportunity, social marketing. It would get people talking, and thinking."
Your thoughts and suggestions?
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