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.

Thursday, May 29, 2008

Central Line Infection Update

I have been writing for many months about our efforts to eliminate central line infections, starting with this post in December of 2006, and then giving periodic updates on this blog. Now, there is a regular feature on the BIDMC website where people can check in on this and other clinical indicators.

But we received a report yesterday that I have to share in this forum again. The chart above shows the year-by-year number of central line infections at BIDMC, as measured in cases per 1000 patient days in our intensive care units. Clear and steady progress over the last several years is evident, and I have to admit that I am really proud of our folks -- nurses, doctors, residents, and others -- in our ICUs.

What does this mean in real terms? Well, in a typical month, there might be 1500 patient days in our ICUs. With a drop in our infection rate from over 4.0 to under 1.0, it means that more than 4 people per month (.003 x 1500) did not get a central line infection. With a mortality rate of, say, 20% among those getting such infections, it means we are saving the equivalent of roughly one life per month.

This also saves lots of dollars, mainly for the insurance companies and governments who pay for the extended stays that result from infections. It also frees up scarce ICU capacity for seriously ill patients who show up in our Emergency Department or are otherwise admitted to the hospital.

What's left? What does it take to get to zero? Frankly, we are not sure. There is no distinct pattern of causality among the cases we still see -- and we evaluate each and every one. I'd love to hear from others out there who have also been successful on this front if they want to offer comments on anything we might want to consider to achieve our ultimate goal of a sustained "zero".

Friday, May 16, 2008

Lessons learned from switching sides

An email letter from a staff member to me. Many, many helpful suggestions that we will work on.

Paul – I have unfortunately have had the experience over the past several months to switch sides from supporting MDs provide care to patients to that of becoming the loved one of a patient. My mom was admitted here on 12/29/08 with what was thought to be a stroke. After five weeks of treatment and the inability to control seizures that she was having every three minutes, it was discovered that it was not a stroke, but instead a Grade IV Glioblastoma.

Since my mom’s first admission, she has been readmitted four other times. In total, I think my mom was an inpatient at BIDMC, 10 out of the past 14 weeks. For family reasons, coordination of her care has fallen to me. We have many supportive family and friends, but at the end of the day it’s just the two of us. Her prognosis is not good. They say less than three months. I never thought I would get to the point where I am o.k. with her passing, but life is not for existing, but living. She is now in long term care and luckily, has only had a few episodes of pain. Anyway, I have written and re-written this email in my head a million times, but seeing your (May 7 SPIRIT update) email today has prompted me to sit down and send you a few of my observations over the last ten weeks. I am sorry this is so long, but each bullet reflects an important point I wish to emphasize.

Here they are:

-- The nurses are phenomenal!!! Time after time, I have been impressed that here is this woman who they only know through my description (one of the results of the tumor and subsequent seizures is that she cannot speak) and the nurses are so dedicated, caring and empathetic. My mom has gone from a woman who walked seven days per week, took down her own fence this past summer and cared for my children to a woman who can’t talk, walk, wears a diaper and has to be fed. They somehow without even trying have time after time preserved her dignity.

-- The coworkers (patient care technicians) are also phenomenal. They do not receive near enough credit. Their jobs are very hard. They lift, roll, clean, feed patients constantly and do so quietly and patiently. They must go home exhausted every night.

-- Communication, communication, communication. If we could find a way to better communicate w/ families, our Press Ganey scores would exceed 90% instantly. I have worked here for 12 years and at times was so frustrated with my inability to find out what was going on. I had instant access to my mom’s oncologist and neurologist, but in most cases, families have to go through residents. The residents are so busy and they usually see the patients first thing in the morning prior to a family member coming. In addition, once you get to know one, they switch services and you have to start all over again. The same thing with medical students. One day over a weekend, I waited eight hours in my mom’s room to speak to a resident. No family member should have to do that. I at least would go into my mom’s record to read the notes (with her permission of course), but people that do not work her do not have that opportunity. If there was a way to block certain sections of OMR (online medical record), but provide families access to others or develop a summary page for family members that would be great.

-- Another issue is communication between specialties. My mom was part of the Neurology Service. She started on Stroke, moved to Epilepsy, then to Neuro. Oncology, then back to Epilepsy and now is back on Neuro. Onc. Did you follow that? I have come to learn that Neurologists are highly specialized. You can’t ask a Neuro Oncologist about your mom’s seizure meds. You have to go to her Epilepsy Neurologist. Depending on what floor you are on, the quarterback varies. My mom was transferred from one floor to another and she ended up with a whole new attending that I had never met. What made it worse was she had one for the weekend and then a new one starting the following Monday because it was a new month. Again, I work here so I knew who to call, but imagine the 80 year old man trying to take care of his wife. Lack of information is so frustrating. There needs to be a better way to communicate with families and patients.

-- Add-on surgical procedures need to be better coordinated. My mom’s biopsy was an add on for a Friday. Room Service forgot to bring her dinner on Thursday night so her last meal was lunch at around 12 noon that day. Pre-op did not come to pick my mom up until Friday at 6:30 pm. We then waiting there for three hours. She did not go into her biopsy until 9:30pm. The surgeon was ready for her at 9 pm, but we had to wait 30 minutes for her Halo to be delivered for the procedure. The surgeon, nurse and anesthesiologist sat there waiting. My mom’s roommate was an add-on for Monday. Her last meal was Sunday at 6 pm. She got bumped on Monday and not taken until 10 am on Tuesday. She did not eat for almost two days.

-- Patient Satisfaction Surveys – Did you know that you receive one for every admission? That means we have received four. I filled out one. There has to be a savings there. Her experience did not change that much between each admission to warrant four separate surveys.

-- We need better discharge planning. I found three medication errors during each discharge and I am not a doctor. I can only imagine the poor family member that does not speak English. On the day of my mom’s last discharge, the intern kindly called me at home and told me she would be discharged by 1 PM to a long term care facility in Hingham. I got there at around 3 PM and was surprised she was not there. I set up her room and waited. I asked the unit coordinator at the front desk about it and she said she would be in the same room and there must be traffic. I went back and waited. I finally called thr floor at the hosital where I was put on hold for about five minutes. Finally, the nurse got on and said she had her all ready to go at 1 pm and they told her she was not being discharged and did not know why. I then asked to speak to who did know and the intern got on, apologized for not calling me and said it would not be until Monday due to the antibiotics that they could not give to her at the rehab. The following Monday, I was on my way to meet her there when I received a page from the case manager that they had to move her to yet another facility because Hingham would not take her. Luckily, I am happy with where she is, but what a fiasco.

-- MDs need to learn how to give options to families. Her Oncologist has recommended no further treatment with hospice. That was a big pill for me to swallow. Our family does not give up. Once I was able to process that I felt pressured by him to sign off on a DNR and agree to “his” recommendation. After I really thought about it, I realized that in fact that there was no decision to make because she was not even eligible for treatment given her low counts. I had to really push back with him. I’m not sure most families would feel comfortable doing that.

-- Case Managers need to meet with families more. When selecting a rehab., I was given a photocopy of a book with rehabs in our area. The case manager had never been to one of them and recommended I go to visit. I have three children, another family member needing support, a husband, a mother with a brain tumor and full time job. When was I going to do that? This was going to be the place my mom would probably die. I wanted it to be excellent. It would have been helpful if she or another case manager could provide me with some information on the facilities, i.e. the DPH report, testimonials from other patients, etc.

-- Families need to understand the financial implications of recommended treatments and care. Her doctor recommended long term care with hospice. What he neglected to say is that although hospice is covered, long term care room and board is not. This means that if she is not eligible for nursing care or rehab. we have to pay room and board of over $300/day. Luckily, my mom has savings for this, but I was not made aware of this until I sat down with the Head Nurse at the long term care facility.

Thank you for listening.

Tuesday, May 13, 2008

SPIRIT can shred red tape

A recent report on the SPIRIT log shows that process improvement can show up in unexpected ways. Nice to see residents using it, too! We prefer that they spend time with patients rather than dealing with red tape. With an organization of our size and history, we can expect bureaucratic glitches to show up a lot.

Location of Problem: Employee Health & Emergency Department

Problem: I was recently splashed in the operating room and directed by employee health to have my labs drawn in the ED since it was 4:30pm. In the ED, my vitals were taken and my blood was drawn by an RN. The triage nurse of the ED confirmed that obviously there would be no bill sent, yet about 2 weeks later I received a bill from both the ED Department and the ED Physician for almost $600. After speaking with employee health, I was told this happens "all the time" and I can expect to receive another bill or two but they would work on getting the charges reversed - but it would not be immediate.

Suggested Solution: Better coordination between employee health and ED billing. First, the billing for an occupational exposure should not occur, but if it does, the reversal of charges should be immediate. I shouldn't have to waste my time and continue to follow up through a cycle of bills. I should be able to contact the billing department and have a zero balance as soon as the report of the error occurring.

Person Describing Problem: Vijay Saluja (Anesthesiology Resident)

Root Cause: Vijay, thank you for calling this out. I can address the BIDMC ED charging issue. You are correct that the charges should not have been billed to you for an occupational exposure. There are provisions for covering those cases. Thanks to your call out we have identified a system bug that caused the BIDMC charges to be billed to you and to others in error, and the inconvenience caused is regretted. Martina Comiskey, Revenue Cycle Systems and Training.

Solution (after investigation): Billing system configuration issue causing BIDMC charges to bill to patients instead of Workers Comp Coverage. Needs to be resolved to prevent future incidences. Retroactive report of all impacted patients needed. All accounts need to be corrected and the charges appropriately redirected.

Action Plan (who, what, by when)
WHO: Revenue Cycle Systems team

1) BIDMC billing system bug fix - completed 5/8/08
2) Retroactive reporting will be completed 5/9/08
3) All patient accounts will be corrected by 5/12/08
4) Monitor monthly to ensure that process is working as intended.

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

Surgical workaround

A note from one of our surgeons:


I'm writing this out of frustration. The door C334 to the male locker room in the Shapiro OR has been dysfunctional for weeks. You need an access card to open it. The mechanism is faulty and each morning for some time now surgeons, techs etc have had to battle to get in the room and change for the OR.

Efforts have been made to 'repair' the mechanism but nothing has worked.

Please forward this to the appropriate person and have them leave the door unlocked till such time as it can work effectively. People have had to force the door open at times which is causing more damage ( to the door and shoulders).

I just don't know who is in charge of this kind of thing but am sure you can forward it to the appropriate authority.

Response from our head of maintenance a few hours later:

Dan Kendall from our offices was approached on this issue directly and has already both assessed the problem and rectified it. In essence, a staff member had taken it upon himself to tape (surgical tape) the latching mechanism so as to avoid having to use his swipe card for access to the locker room. Some of the adhesive residue remained within the moving parts of the mechanism even after the tape was removed.

Dan was able to locate the individual who admitted to taping the mechanism and agreed not to bypass this (or any other) security measures again. Dan was also successful in removing all remaining sticky residue, and the latching mechanism is once again fully functional.

Note to self: Teach surgeons how to use BIDMC SPIRIT to reduce blood pressure.

Monday, May 12, 2008

Triggers happy

A year ago or so, I wrote about the introduction of our Triggers Program, a rapid response team approach to patients on medical floors who might soon decompensate or have other serious changes in their condition. The program has been incredibly successful in reducing mortality and morbidity. In fact the number of "codes" on our floors has gone down so dramatically that residents now need to practice emergency resuscitation mainly in the simulation center because so few actual patients need it.

I recently asked a couple of our folks who were deeply engaged in the design and
implementation of this program -- Dr. Michael Howell and Patricia Folcarelli, RN, Ph.D. -- to tell me what lessons have come out of the last year's experience with Triggers. Here is what they sent me. I offer it in the spirit of sharing information with people in other hospitals.

In the year after implementation of the Triggers program, one of the major focuses of our reviews was on patients who had major adverse events happen in spite of the Triggers program. When these adverse events occurred, we tried to understand the factors that contributed to them even being possible in our organization. A few months after Triggers began, we began to notice some patterns. Here are some examples of the things we learned.

Oxygen is not a utility

Patients in the hospital sometimes need extra oxygen. Low oxygen levels in the blood can be due to pneumonia, heart failure, or a number of other problems. Surprisingly, extra oxygen usually does not help with the feeling of shortness of breath, but rather prevents further problems from not getting enough oxygen to vital organs. We found that, in many cases, providers often treated oxygen as a utility -- like the water that comes out of the sink – rather than as a drug used to support a feeling organ system. (The members of our Triggers Steering Committee had worked in about twenty other hospitals total, and we all felt it was the same in every hospital in which we’d ever worked.)

We saw a pattern in which providers would repeatedly increase the amount of extra oxygen that was being provided to patients. We often monitor the oxygen level in the blood through a noninvasive device -- as his number was normal, providers felt reassured – not taking into account the fact that the patient was needing higher and higher levels of artificial support to keep this number at the “right” level.

In fact, interns would sometimes round in the morning and would find their patients on oxygen with no explanation, and the patient had been breathing room air the night before. Sometimes, neither the nurse nor the intern knew why the patient got put on oxygen; it had happened overnight and was viewed as an unimportant event.

As a result of this we conducted a Failure Mode Effects and Criticality Analysis, a tool used in the military and industry to understand points at which complex systems are likely to fail, and implemented substantial changes in the ways that we order oxygen, in a way that patients are monitored from a respiratory standpoint. We also introduced physician, nurse, and patient care technician education on this matter.

Aspiration risk

We also learned that aspiration was a bigger threat to patient safety than was usually appreciated. When physicians and nurses talk about "aspiration" they are talking about when a patient swallows something the wrong way. This can be the person's own saliva and secretions or, more commonly, can occur when they try to eat or drink something. Since the mouth is usually full of bacteria, this can lead to pneumonia; sometimes, the person actually swallows his or her stomach acid in the lungs, which can lead to very severe chemical injury to the lungs. In some cases, aspiration leads to death. For this reason, when we think that someone is at high risk for aspiration, we put them on “aspiration precautions." This means that nurses, patient care technicians, and physicians are all alerted to the increased risk of this problem. In addition, we put a sign up on the patients at the patient's bedside to warn visitors and those providers who may be seeing the patient before seeing the chart.

As we dug a little deeper into some of these cases, we learned that patients sometimes aspirated food that their families brought in. Family members obviously did this out of love, but it sometimes led to very severe consequences for their loved one. When we tried to figure out why this happened, we found that our warning signs depended heavily on written English, rather than on easily interpretable symbols. This meant that if family members came to visit and English was not their first language, or if they had trouble reading English, we might not convey the right information to them. In coordination with a provider education campaign about the risks of aspiration, we therefore redesigned our signage to overcome these barriers – by using multiple languages and universal symbols (think Mr. Yuck!) that were likely to be interpretable even if the family member was unable to read the sign -- see above.

Who does what?

As inpatient medical care has become more complex, more people are needed to provide it. For example, our nurses do a number of safety checks as they're preparing various medications because these medications have inherent risks. There is also substantial amount of documentation that nurses have to do for safety, compliance, and legal reasons. This means that nurses need extra manpower to get work done. Most hospitals, therefore, have a group of providers who are variously known as nursing assistants, nurse’s aides, or patient care technicians. These providers are trained by the hospital, and sometimes by external schools, but are not licensed in the same way that nurses and physicians are. Patient care technicians may check vital signs, help with turning patients, assist with toileting, etc. In our hospital, for example, many of the routine vital signs are taken by patient care technicians. The Triggers program taught us a few things about patient care technicians and their relationships with our other existing systems of care. In particular, when we did our initial education for the Triggers roll out, we forgot to include patient care technicians in the educational campaign. This was a huge oversight, which we quickly learned when we would see patients who did not Trigger even though they had abnormal vital signs. Why didn't they Trigger? They didn't Trigger because we forgot to provide education to this very important a set of providers in our institution. Once we had included them in the educational campaign, this mechanism of Trigger failure essentially vanished.

We also learned that what patient care technicians do on any given floor is extremely variable. We therefore began a program to help standardize the scope of practice for patient care technicians at BIDMC.

Unintended consequences of improving patient satisfaction

A few years ago, as we tried to improve patient satisfaction, we changed the way that patients order their hospital food. The program was called “At Your Request" and let patients call up to order their meals from a menu of options – at essentially anytime they wanted to eat. (From a practical standpoint, this works a lot like room service: you call and order your meal, and it shows up half an hour later.)

However, this turned out to be another way that patients who were at high risk for aspiration (see above) could get food that was unsafe for them to eat. A patient on aspiration precautions, for example, could literally call and order a hamburger, which would generally be delivered, warm and tasty, a half hour later. When we saw events related to this, we redesigned the process by which food was delivered, creating an electronic Diet Dashboard and directing the delivery of all food for patients on aspiration precautions to the nursing station. (Sometimes, patients at high risk for aspiration just need help eating food safely, which we can now provide.)

If the nurse is worried, you should be worried too.

This is an example where our analysis confirmed something we already believed to be true.

The Triggers Program has various specific criteria mandating a response from providers. For example, if the pulse rate is acutely greater than 130 beats per minute, a Trigger is called and the team responds. However, we have one criterion which is much more subjective: "marked nursing concern." When we implemented the Triggers program, many physicians were very nervous about giving this criterion. They were afraid that they might be called in the middle of the night for things that weren't really important, and that nurses might use this as a weapon if they did not like the physician or if they disagreed with the plan of care.

Well, it turns out that nurses use this Trigger quite judiciously – only 15% of our Triggers are called only for nursing concern. (In another 27% of cases, nurses express “marked concern” but the patient also meets other criteria simultaneously.) It also turns out that if nurse has “marked nursing concern,” it means you’re really sick. The in-hospital mortality rate for a patient who has a Trigger called for “marked nursing concern” is 10.7%.

This is roughly twice as bad as showing up to the Emergency Department with a heart attack. Literally.

Friday, May 9, 2008

Lean leaves well-oiled gears

Remember when I told the story about using Lean process improvement techniques to enhance the service in our orthopaedic clinic? That was over a year ago.

Here's a note from a recent patient, a local student:

I just had to share this with you because it was such a neat feeling at the time. I saw Dr. Gebhardt yesterday (my orthopaedic surgeon) and there there was no wait for anything at all. Checking in was a breeze. I saw Dr. Gebhardt exactly on time. Afterwards, I was worried about getting the x-rays because the whole waiting room was full, but again, there was no wait. I've read about lean, SPIRIT, and process improvement on your blog, so it was such a neat feeling to experience and also to know what was behind my no wait experience! I think it provides a whole new meaning to patient-centered care. The only thing that was odd was that the front desk never asked me to pay...but I was so happy with my visit that I actually offered to pay my copay (and this is coming from a poor graduate student).

We will work on the payment part next!

Dear Interns

As each new class of interns arrives at the hospital, it is important to provide a context for their experience. Most of their advice and training comes from their clinical leaders, but the CEO has a role, too. Here are excerpts from one of my notes to the current class:

Dear Interns,

I'd like to turn to some important matters facing BIDMC and explain your role in helping us achieve some very important goals. The context is this: While you as doctors -- along with others who have come before you -- have received excellent training in biology, disease, diagnostics, and treatment, there is a growing part of clinical care that requires all of us to expand our scope and consider the manner in which we actually deliver care and how we might improve that. Our hospital has decided to be a leader in the science of care delivery, reviewing and enhancing our overall system of care to reduce harm to patients.

Several months ago, our Board of Directors voted to set an audacious goal for BIDMC, to eliminate preventable harm over the next four years. See these entries on my blog for more details. Our chiefs of service are fully in support of this goal and are now engaged in many measures to make it happen. We know of no other hospital in Boston that has taken on this challenge, and there are likely very few throughout the country. It is a bit daunting. But we believe that we have a lot to learn and a lot to teach by making the effort.

Part of the context for setting this goal is to hold ourselves accountable to the public and ourselves. We have been the leaders in this region in transparency of our clinical outcomes, for we believe that self-reporting of medical errors and process improvement is a sure statement of our commitment to progress in this arena.

We have also established an overall process improvement program called BIDMC SPIRIT, in which you will be trained after your arrival. Here's the introductory message about this program. The concept is simple -- to encourage people throughout the organization to call out problems as they see them and to solve them to root cause -- rather than creating work-arounds that just add layers of poorly designed process in the organization. Here are a couple of examples to give you the idea.

I look forward to having you join us as we invent and implement these programs and eliminate preventable harm for our patients.



Tuesday, May 6, 2008

Midcourse lessons from SPIRIT

Here are some comments made after today's BIDMC SPIRIT training session (see some of the participants above). We are now winding down on training the first 600 people. As you can see, people quickly get to the core issues, problems, and opportunities. This is about where we expected to be at this point in the process. After all, we are introducing new concepts of empowerment, problem identification, and problem solving -- and sometimes people are confused or nervous. The suggestions from these trainees are exceedingly helpful. But look, too, at the last comment: Key messages are starting to come through. Then, see a bit of my analysis after the comments.

We noticed when logging our issue that you see “SPIRIT problems.” We think it would be better to look at “SPIRIT opportunities.” One idea we had was to change the language.

On the issue of what are appropriate call outs, several of us were talking earlier today that there seems to be some confusion out there about what it’s OK to call out and who can do it. At the beginning, it seemed that it could be about anything and everything and the staff would be empowered … then there seemed to be a reassessment and it became in some areas there are some things you can call out and some you can’t … that you have to go through the manager and the body language suggests whether this is going to go forward or not … and I think there are varied answers to these things depending on who’s speaking from the help chain.

How to fix this? I think just a reaffirmation of the goals and key principles to the entire leadership team, so that it is not interpreted in various ways by various leaders. In some places, staff aren’t allowed to touch the log without talking to the manager. We know we are trying to find our way and it’s early.

Talking about the “chain of command” has a connotation of fear in some places. Where we were, these were perhaps more junior nurses than in the PACU and they didn’t want to identify anything as a problem … it seemed they were fearful. For us, residents, it can be hard to call something out. We need an environment where all are equal and our insights are encouraged.

We’ve trained all the managers and supervisors and not the front line in this way because that would be overwhelming but perhaps we could do an in-service DVD that just lays out the key principles that this is all about. Staff are reading about this on the web, they are hearing things second hand, but if you (Paul Levy) could deliver the message it might help with the consistency of the message as well.

A big thing is … just because it happens all the time doesn’t mean it should. We see all of these problems. 10 minutes here. 20 minutes here. People think they are little. But they add up quickly. For those of us who are out there, they add up quickly to patients’ lives. 1 life. 2 lives. They may seem small but they aren’t. They matter. People need to understand that.

We started our journey toward eliminating hunting and fetching for every BIDMC staff member 8 weeks ago. We are consciously following the path trod by other large organizations in other fields (Toyota, Alcoa, US Navy submarine corps) that seem to do what their peers do to far superior results, in terms of staff satisfaction, quality, and business performance. The core of our approach is empowering everyone at BIDMC to call out when they hit a glitch in their work (see the problem) and participate in understanding the problem and developing solutions. We are learning how to provide the right level of help to them right away (swarm the problem), then how to share improvement stories transparently throughout the hospital.

Overall, we stand about where I expected, but some of the particular challenges we have are interesting.

We have plenty of evidence that it is right to involve each employee more deeply in problem solving, every day. Story after story has surfaced about how the people who do the work have pointed to the solution that could work – and is more likely to endure. Just last week, the housekeepers and unit staff in an ICU developed a solution to a chronic shortage of pillows needed to prop up their patients that has been driving them crazy for years.

We also are seeing the value of immediately investigating specific instances of problems, while the details are fresh. Using the observed details of what just actually happened keep us on the right track in a way that far-off committee meetings of folks who may not actually do the tasks being discussed may not.

And while we are still in the infancy of learning how to share effectively, people are picking up not only specific solutions from the SPIRIT log, but also insights on how to solve problems.

And people are paying attention. The SPIRIT log is often viewed more than 1,000 times a day, and my reports from SPIRIT here on this blog are being tracked by people around the world eager to learn with us.

So that is good, but we are still far from where we want to be in the breadth and quality of problem solving that will really make life as good as it could be for our staff. That’s what we expected at this stage of things, but it underlines how much work we have to do. What are the challenges on which we should focus at this starting stage?

First, the quantity of hunting and fetching investigation and solution attempts we are seeing is not even a small fraction of the challenges we know staff face on a daily basis. This is not a numbers game, but we do want to see much more high quality problem solving occur. Every person at BIDMC has something to offer (and gain) to understand this dynamic in their own areas, but here are some of the forces at work.

(1) It’s clear that in many places, it doesn’t feel “safe” for staff and managers to have problems in our areas being called and worked in the transparent light of SPIRIT. This sense is critical to overcome. When people feel more comfortable to bring opportunities to the surface and work them in plain sight, we will make the most rapid progress. It is the areas where I am not seeing any SPIRIT call outs that I worry about the most at this point.

(2) Some of us are so used to working around problems that we don’t even recognize that there is an opportunity to make the work easier. Some managers are countering this by actually walking next to staff as they do their work and helping them see what may be a “work around” and where there is opportunity. That works and can be helpful in these initial stages.

(3) Many people don’t really believe their boss wants to hear about their next hunting and fetching episode “in real time.” People have been implicitly rewarded in the past for solving impediments by brute force, and they think their leaders may not welcome reports of a “small” problem. After all, the managers are busy, too. We need to reaffirm that the responsibility rests with supervisors to actively encourage those who look to them for leadership to begin calling out opportunities to them in person. Of course, we won’t be able to work on every problem in real time until we get a lot better and faster at this, but we need to start.

(4) Some people don’t yet know how to “call out” in the most productive way. We need specific reports of specific problems, without blame. We need people to stick to the facts. And we need reports made in person to the immediate supervisor, not entered directly on the log unless no one is available to help.

Second, I see lots of opportunity to deepen our solutions, so that we are not only solving the immediate problem, but also applying the lessons to similar situations. For example, if CT radiology residents didn’t have an easy way to realize they were sometimes presenting their technologists with protocols that conflicted with the original physician orders (a “connection” problem), how many similar situations exist across our clinical services? We plan to begin pushing on these issues as we progress.

Third, though we are pleased with the orientation and training we have provided to almost 600 managers, staff have told us that they need more direct exposure to the SPIRIT principles and tools. We will expand efforts in this area shortly.

Monday, May 5, 2008

Teamwork on central line infections

I received this wonderful report from Blanche Murphy, Nurse Coordinator for the Central Line Service, who knows of my interest in eliminating central line infections. Be sure to check out the site she mentions for an excellent educational tool.

Dear Paul,

I want to share with you a very positive recent experience that I have had at the medical center. Knowing how much you believe in team spirit, I feel that my story is a wonderful example of many people from several areas of the medical center coming together to produce a resource enabling our patients to have safer and knowledge based care. Although many of the functions were done independently, it took all people I mention to produce the outcome.

Three years ago I had an idea to develop a pictorial index on-line allowing staff to correctly identify central venous lines and their appropriate care. It would also serve as an educational tool providing diagrams and pictures to further enhance understanding of central venous access. At the time of this idea, I also initiated a practice change reducing the concentration of heparin we give our patients that would effect the information being given but also entailed major changes to our on-line pharmacy ordering system . On April 16th we went live with a very involved change in the POE system and the debut of the central venous line educational tool.

From the start there were many people who provided their expertise to make this goal achievable. Rich Stroshane from Operations took all of the pictures and Davin Janicki from Healthy Care Quality/ Process Improvement worked endless hours helping put the images into an on-line format. Andy Mackler P.E.V.A. Consultant from Venous Access contributed all the information in regards to PICC lines. Karen Smethers from Pharmacy worked several hours with me establishing a correct ordering system with generated flushing orders for the multiple number of lines we place in our patients. Steve Maynard, Jean Beach, David Feinbloom MD, Jean Hurley from IS, and Kim Sulmonte from Patient Care Services also gave much of their time. Media services' Christophere Ruhle (no longer employed here) and Oran Barber assisted in putting on the final touches to obtain a professional system . Lynn Darrah and Justine Carr were major catalysts for bringing the project to a successful completion with an effective roll out. Although each member of this team developed contributions on their own, it was only when each part worked to together with a team spirit for the final product that the launching could happen.

At http://home.caregroup.org/centralLineTraining/ you can see for yourself how wonderful the outcome was. By selecting a picture you will be able to view more in-depth information with a link to flushing guidelines insuring a quick reference for staff immediately available. The POE ordering under IV Therapy/IV Access orders also provides not only the correct flush orders for multiple lines but also another way to link to the educational tool.

As I said this was an idea I had three years ago, and if not for the tremendous team work and support from various areas across the medical center it would have never been successfully carried out.

Blanche Murphy