But take a look anyway, if you have an interest in process improvement in hospitals. This is a collection of my best posts on this topic.

Sunday, December 21, 2008

What if?

Just thinking, along the lines of a New Year's resolution. What if all of the hospitals in the Boston metropolitan area -- academic medical centers and community hospitals -- decided as a group to eliminate certain kinds of hospital-acquired infections and other kinds of preventable harm? And what if they all committed to share their best practices with one another and to engage in joint training and case reviews in these arena? And what if they all agreed to publicly post their progress on a single website for the world to see?

Let's start simply. My candidates:

1 -- Eliminating central line infections (Metric: The number of CLIs, as defined by the CDC. Goal = 0)
2 -- Adopting the IHI bundle to help avoid ventilator associated pneumonia (Metric: Percent compliance with the bundle. Goal = 100%)
3 -- Adopting the WHO protocol developed by Brigham and Women's Hospital's Atul Gawande for surgical procedures (Metric: Percent of surgical cases in which the pre-op, time-out, post-op checklist has been followed. Goal = 100%)

The medical community in Boston likes to boast about the medical care here, but we don't do a very good job holding ourselves accountable. This would be a terrific way to prove that we are serious about reducing harm to patients and that we can cooperate across hospital lines for the greater good.

Thursday, December 18, 2008

Caller-outer award of the month

A key part of BIDMC SPIRIT is the idea that everybody in the organization is encouraged to call out problems they see in the workplace, problems of safety, efficiency, or anything else.

A few weeks ago, when holding their retreat, our Board decided to create new monthly award. Instead of honoring someone who had solved a problem, they would honor someone who had called out a problem. The idea was to provide further encouragement through the organization to those who notice and mention problems.

The first award has now been presented, to Gloria Martinez (in picture), who called out the problem with the delivery of specimens from the GI department to the pathology laboratory. This led to a complete revision of that delivery process, which later spread to other areas as well, as noted below.

Gloria received a congratulatory letter, plus two super tickets to a Red Sox game of her choice next spring.

Spreading the story of discovery

Several weeks ago, I told you the story of how we had improved the process for getting GI specimens to the laboratory for analysis. But part of BIDMC SPIRIT is to transfer the lessons learned in one setting to another.

I received a report last month that the process that was developed to improve specimen pick-up and transport in the GI department was successfully implemented in all other interventional procedural areas in the medical center. Our folks note, "This process was designed to provide a timely and safe transport of specimens bound for the departments of Pathology and Cytology. (These types of specimens are especially sensitive in nature due to the fact that they are often un-recollectable.)"

"This new process, developed by a multi-disciplinary team of staff from all levels, ensures that specimens are signed out in a timely manner while also providing full reconciliation at the point of intake. It improves the process for employees preparing the specimens for transport, those providing transport and those receiving the specimens in pathology, while minimizing the chance that any specimens will be misplaced or misassigned."

Tuesday, December 9, 2008

The 5S's + 1

Here's more about the CPD Lean rapid improvement event discussed below. It is in the form of report to the entire OR community from the director of that area, Elena Canacari:

Last week we completed a 5S Rapid Improvement Event in the West CPD decontamination room and in the OR core tech room. We spent much of our time on sorting out unneeded items (S1) and continued through each of the other 5 “S’s.” We even decided to add a sixth “S” for SAFETY because our team identified many opportunities to improve the safety of the staff who do the work. We accomplished a lot this week, and this improvement process will continue.

Let’s take a closer look at the 6 S’s:

1. Red tags and "sorting things out"

Clutter clogs up physical and mental flow of material and information. We went around the CPD and OR areas and looked for things that were broken, dirty, homeless, over stocked or no longer needed. We used 5S red tags to identify all of these items and we placed them in a “red tag holding area” so we could decide what was really needed and what was not. Once this was done, we realized how much space all of the unused items were taking up and how much space we could now use for the items we actually need!

2. Why is it necessary to set locations?

Set locations is another name for smart placement. Organization is the first step in rearranging work flow and we want to avoid reaching, bending and searching to use the items we need. Like items are now co-located and commonly used items are at eye-level, so no one needs to bend over or use a stool to reach items. In addition, there is no need to search for items now that we gave them all clearly defined homes as well. We want to create good flow with no barriers.

3. S3 is scrub, shine, and sweep

Before we could move ahead with our improvements, we cleaned the workplace to prepare it for new organization. This included mopping the floors, scraping off old labels, washing the walls, and shining counters and shelves. A clean workplace is a happy workplace!

4. Create standards

When you walk past CPD or go through the OR core tech room, you will notice parking places for trash and linen bins, color-coded signs to direct flow of instruments and kits, and taped areas to separate dirty areas from clean ones. Different colored shelves now help to set different levels of priority for turnover of dirty instrument trays and time tickets will be used as a new technique for visual communication. These are all methods for creating standards so that anyone who is involved in the process can have the right materials, in the right place, and at the right time.

5. We need to sustain the gains!

Everyone is an owner of the process and we should all be proud of our work. Building relationships between departments was an important part of the Lean journey, and in addition to teamwork between CPD and the OR, we now have friends in facilities, environmental services, housekeeping, and infection control. Practice makes permanence, and it is all of our jobs to communicate with other staff to share knowledge, highlight successes, and catch people doing the right thing.

6. Improving Safety in the Workplace

During our “waste walk” through both areas, many of the team members identified wastes that could impact the safety of the people doing the work. In keeping with the Lean principle of respecting people, the team decided that it was important to address safety issues. Some safety issues that the team addressed were marking off space in front of the fire extinguisher and hose, removing fabric materials from the decontamination rooms, marking off space in front of clean sinks, adding hand sanitizer and germicidal wipes, among many others. As important as it is to make process improvements, it is as important to ensure the safety of the process and the safety of those involved.

Feel free to stop by and provide feedback. Remember, this is a work in process. We are not waiting for perfection, but are going to make small incremental improvements that lead to big gains.

Should you have any questions, feel free to ask anyone on the event team, or speak to the management team. Thanks to the entire 5S event team: Ray Clarke, Heideman Zayas, Anderson Gray, Deborah Kravitz, Cheryl Wiggins, Kelly Cormier, Marti Cunningham, Jack Field, John Dzialo, and to the Lean team: Alice Lee, Bonnie Baker, Jenine Davignon, Kim Eng, Brandan Holbrook, and Samantha Ruokis.

Thank you to the Lean 5S Event Team. We look forward to your input and involvement. Elena

Don't stop. Don't stop. Don't stop.

Whenever we run a Lean rapid improvement event as part of BIDMC SPIRIT, we ask the participants to fill out a questionnaire. One question we ask is, "Was this a worthwhile experience, why?"

We had an event last week in one of our central processing divisions, the place where surgical instruments and supplies for the ORs are cleaned, sterilized, and maintained. The group comprised CPD folks and also nurses and surgery techs from the ORs. There are often tensions between these two groups, as misunderstandings arise in the stressful OR environment between the people in the two areas who are pursuing parallel parts of the same surgical processes. But, look at the answers to the question above after three days of very hard work together:

Yes, I feel like I was exposed to so many other departments and learned so much about the amount of time it takes to accomplish what you would think of as simple goals and tasks.

Yes, this event uncovered and exposed the process issues between OR/CPD. I feel that this is a good beginning, but will have to continue with other Lean projects to prove process and standardization.

Yes, I think it shows people how changes can be made and they can be effective and well received. Don't stop. Don't stop. Don't stop.

This was a worthwhile experience. I was able to learn more about the facilitation of good communication. I was able to learn more about effectively engaging others. Issues that affect both productivity and employee satisfaction were clearly revealed.

Yes, because the safer we are the better the Department is.

Yes, finally the staff sees that this whole process was not just lip service. Everyone in CPD and the OR has gotten involved.

This was more than a worthwhile experience. It shows how much can be accomplished when people put their ideas together and work as a team.

Yes, it involved multiple team members from different departments working on a common goal. Everyone's input was valued.

I was able to learn more about my co-workers' ideas, talents, and values. I found that particularly rewarding. The process provides many tool for creating change.

Thursday, December 4, 2008

Short story: Good news

While you can go to our website to follow our overall progress on eliminating central line infections in our ICUs, here's something more: Although we have frequently had months where there were no hospital-acquired central line-associated bloodstream infections in our ICUs, October was the first month ever in which we had no such infections in the ICUs or in any other unit.

I want to extend thanks and appreciation to those who do the work and deserve the credit: Lots of nurses everywhere, MDs, PEVAs, our IV team, radiology, and others who place and care for the lines.

This time, it's about us!

A message I just sent out to people in our hospital. Thanks to Paul O'Neill, former CEO of Alcoa, for his advice and inspiration on this front. If this can be done in a mining and manufacturing environment, we surely should be able to do it in a hospital.


We have now been engaged in BIDMC SPIRIT for over six months, and we have accomplished a lot. But, we have also learned a lot about how to make it work better. I’ll talk about that below, but first this.

When I first introduced SPIRIT to you, I emphasized how we wanted to reduce hunting and fetching and improve the work environment in that way.

Now, we need a new focus.

It’s time to crank things up, but in a new direction.

Last year, there were 891 on-the-job injuries of BIDMC staff members – more than two a day! Almost one hundred of our colleagues were injured to the extent that they were unable to work for five or more work days.

You probably know that we have set ourselves a goal of eliminating preventable harm to our patients. It is time to do the same for us!

I have told our vice presidents that I personally want to receive a report of every employee injury in the hospital within 48 hours of its occurrence. I want a description of the injury, what caused it, and what we are going to do to help avoid that kind of injury in the future. Over time, we will uncover patterns and trends and make this a safer place to work.

We will soon have a running total of staff injuries on our portal. We will have a graphic showing how long it has been since the last injury. Right now, that is measured in hours. We’d like to change the interval to days, weeks, and eventually months. Whether slips and falls, exposures to blood and body fluids, injuries from patient handling, our goal is to drive the number of cases down to zero.

I need your help, though. There is something you can do right now to help jumpstart our safety efforts: Do a SPIRIT call-out.

1. Identify safety hazards or near misses you have experienced or look around your work place to identify potential harm.
2. Call out the problem to your manager/shift leader.
3. Work together to identify the root cause of the problem immediately and solve it as soon as possible.
4. If you and your manager can’t solve it locally, your manager can use the Help Chain to reach beyond your unit/department.

Remember: Call-outs that point to a bigger, medical center-wide problem will go up the Help Chain to the leaders of BIDMC.

We have seen some incredible successes with SPIRIT, but we have also learned from you comments and suggestions that there were some problems with our initial approach. Through it all, we have confirmed that the basic principle of SPIRIT is strong – the people closest to the work are the best problem-solvers.

Your feedback told us:
• There is uncertainty about what to use SPIRIT for – hunting and fetching? Patient care problems only? Big problems? Little problems?
• It was unclear when to do a call-out instead of a regular operational response to a problem, like calling Service Response.
• Using the SPIRIT log was frustrating and it was unclear whom on the help chain to contact. Entries were often made – sometimes anonymously – without a constructive way to act on them.
• There is confusion about how SPIRIT, Lean and other quality improvement efforts are related. The short answer is that they are all different ways of solving problems and improving quality – SPIRIT through staff call-outs; Lean through a trained team of specialists that works side-by-side with staff; and Healthcare Quality and other staff through a wide range of activities, from incident reporting to Joint Commission preparation.
• You need more resources to understand and use the SPIRIT principles – and more practice.

When we started SPIRIT, we expected that our first try would probably need some improvement. We fully intended to improve SPIRIT itself over time, just as we are trying to improve our work environment.

So here's what will change:
• As noted above, the second year of SPIRIT is beginning with a focus on a specific topic – safety in the work place.
• We will more actively use our formal patient and staff incident reporting systems to identify problems.
• More training and coaching through actual problem solving efforts – for all staff, managers and physicians – in person and through easier access to materials and tools.

Here’s what will remain:
• Those of you who are engaged and using SPIRIT principles are encouraged to keep it up and let us know about your work.
• We will continue to share with you stories about how SPIRIT, Lean and quality improvement projects are working.



Wednesday, December 3, 2008

Great progress to the west

OK, so not really that far west, but in Northampton, MA, at Cooley Dickinson Hospital. The press release follows. Congratulations to the entire group for a job well done!

NORTHAMPTON, Mass – It’s been one year and 28 days since a Cooley Dickinson Hospital ICU patient has become sick with ventilator-associated pneumonia, a serious infection that can occur in people who rely on ventilator machines to breathe.

“As of Nov. 29, that’s 393 days since the last ventilator-associated pneumonia infection,” Daniel J. Barrieau, director of respiratory care services says of an infection that in October topped a list of the most costly and common hospital-acquired infections.

According to the Centers for Disease Control’s National Healthcare Safety Network Report, Cooley Dickinson’s accomplishment of preventing Ventilator-Associated Pneumonia or VAP ranks the hospital’s performance in the top 10 percent of the nation’s medical/surgical intensive care units (ICUs).

VAP can occur in patients who, because of severity of illness or condition, require mechanical ventilation. When the ventilator tube that pumps life-saving air into vulnerable lungs becomes contaminated, the tube can act as a pathway for bacteria or secretions to enter the respiratory tract, paving the way for VAP. According to the Institute for Healthcare Improvement’s (IHI) website, VAP typically “afflicts up to 15 percent of those in ICUs so weakened by illness or trauma that they need mechanical help to breathe.”

Physicians and staff at Cooley Dickinson are working to eliminate VAP and have adopted a zero-VAP philosophy. Says Barrieau, “We are being aggressive about eliminating VAP, and our track record demonstrates our commitment to delivering the highest possible care to our patients.”

This aggressive approach is paying off. Barrieau says VAP infections in Cooley Dickinson’s intensive care unit have gone from 5 in 2007 to zero as of Nov. 29.

“Besides searching for clinical solutions to the VAP problem, we asked ourselves, ‘what could we change about our culture and our systems to improve our outcomes?’” says Barrieau.

This culture change began in 2005 when team of respiratory therapists, physicians, nurses, quality improvement staff and infection prevention specialists adopted a set of instructions from the Institute for Healthcare Improvement known as the IHI ventilator bundle. The IHI bundle offers a series of interventions determined to be the best evidence-based practices related to reducing the risk of VAP to patients.

Then, Barrieau explains, staff began to “push beyond the bundle of strategies to look for other ways to reduce the risk to patients and eliminate VAP altogether.”

They scrutinized the VAP cases to identify patterns and trends. For example, their analysis indicated that patients on ventilators for more than 19 days, those with difficult intubations and those who required transportation within the hospital were the most vulnerable.

Using an approach called clinical Microsystems, where front-line teams are empowered to make improvement decisions based on scientific data and best practices the team evaluated how each clinician relates their daily work and actions to VAP.

“Doing the minimum is not enough to achieve our zero-VAP philosophy,” states Barrieau. He says clinicians in a culture of zero VAP understand how their actions matter and that acting to reduce risk is part of the clinician’s standard practice.

In addition to preventing VAP infections in patients and providing best-practice care, there is a significant cost savings to the hospital. In 2007, based on Cooley Dickinson’s VAP prevention measures, the organization saved $200,000 by reducing or eliminating the occurrence of the infection and reducing the patient’s length of stay in the intensive care unit.

In 2006, the Institute for Healthcare Improvement named Cooley Dickinson a mentor hospital in three clinical areas including VAP. Since then, Barrieau and his colleagues have presented Cooley Dickinson’s VAP elimination strategies at professional conferences, and he has served on the Mass. Department of Public Health’s Healthcare Associated Infection Task Force.

In December 2007, Cooley Dickinson was one of three hospitals in Massachusetts to receive the Betsy Lehman Patient Safety Award for the organization’s work to eliminate hospital-associated infections including VAP.

In October 2008, Cooley Dickinson was featured in the Joint Commission Journal on Quality on Patient Safety and lauded for breaking new ground in quality improvement.

The five healthcare groups that contributed to the guide include the Healthcare Infection Control Practices Advisory Committee (HICPAC), the Society for Healthcare Epidemiology of American (SHEA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology, Inc. (APIC) and The Joint Commission.