When a great big zero is A+

On several occasions, I presented data here on this blog about the efforts of BIDMC to eliminate central line infections. You can now view those data on our hospital website.

Our community hospital, BID~Needham, operates under its own license and has a staff and Board highly committed to quality and safety improvements. It also chose to engage in a program to eliminate central line infections. The Needham effort had several components:

-- Develope guidelines for the prevention of blood stream infections;
-- Work with procurement to create a standardized supply kit;
-- Use a standardized protocol for maximum sterile barrier precautions;
-- Use Chlorhexidine-based antiseptic for skin preparation;
-- Use a standardized protocol for catheter hub and port disinfection; and
-- Educate both health care worker and patients.

Well, the results for this small hospital are pretty spectacular and are presented above. They have demonstrated that a sustained rate of zero is possible. I say that this is one case where zero warrants a grade of A+!

Cooley-Dickinson vanquishes VAP

About a year ago, I wrote about the great progress made by Cooley-Dickinson Hospital in Northhampton, MA with regard to eliminating ventilator associated pneumonia. I now hear from Daniel J. Barrieau, RRT, CPFT, Director of Respiratory Care Service, that "we are now counting our time between incidences of Ventilator Associated Pneumonia in YEARS instead of days. This week we passed the 2 year mark and took a moment to celebrate the milestone. Here is a pic of the cake. . ."

Congratulations!

Caller-Outer of the Month Award #9

Our Board of Directors awarded this month's caller-outer award to Tinea Simpson, Practice Representative in our GI department.

GI staffers on Tinea's floors are practicing a “Leaner” way to conduct their day to day business thanks to her call-out, and the resulting reorganization that came from her work with Resource Nurses Mary Ellen Johnson and Christine Hunt.

As you may know, there is a patient packet for every procedure that happens in a hospital. For the past several years BIDMC volunteers have assembled these packets covering the entire demand of our GI unit – over 100 procedures a day.

As medical practices are revised and forms become obsolete or go unused, the end result can be a tremendous waste of paper and money. These three women evaluated the situation, decided what forms were necessary and what were not, and with the help of Volunteer Services, took action to correct the packets and reduce the use of hundreds of forms.

They created a path of action to include creating new sample packets for volunteers to follow and purging forms that were no longer warranted. Congratulations to Tinea for demonstrating the concept that each person should feel encouraged and empowered to recognize and go about seeking solutions to inefficiency and waste that he or she sees in the workplace.

Caller-Outer of the Month Award #8

Continuing our series, David Mangan, shown here, received this month's Caller-Outer of the Month Award from our Board of Directors.

Sometimes a call-out is just a sign of initiative and caring. It might not result in a new process, but it might help confirm that something that has been put into place is working well. Such was the case here.

Dave is a pharmacist who helps nurses and other staff learn to use our sophisticated medication-delivery pumps. During a pump's testing phase, he will sometimes distribute a few pumps to people in training and then collect them before the full roll-out occurs.

He did this recently and found one pump was missing, having disappeared. Previously, finding one pump on the dozens of floors in the hospital would have taken forever, during which time it might have been misused or create other problems. Here, Dave immediately called Pam Dicapua in our clinical engineering department. That group had recently installed an RFID system and labeled hundreds of medication pumps. This particular lost pump was located within 37 minutes of Dave's query to Pam. It had traveled downstairs from one floor on our West Campus, across the street three blocks away, and then upstairs to a floor on our East Campus.

In short, good heads up thinking and initiative by Dave, and excellent follow-through by Pam at clinical engineering, using the latest systems put in place by her and her colleagues.

Dave says he has renamed RFID to mean "Really Finds Infusion Devices"!

Problem must be visible!

We recently hosted Mr. Hideshi Yokoi, president of the Toyota Production System Support Center in Erlanger, Kentucky, and Mark Reich, a general manager at TPSSC. This is part of our own orientation to Lean process improvement. Together, we visited gemba and observed several hospital processes in action, looking for ways to reduce waste and reorganize work. It was fascinating to have such experts here and see things through their eyes. Mr. Yokoi's thoughts and observations are very, very clear, notwithstanding a command of English that is still a work in progress.

The highlight? At one point, we pointed out a new information system that we were thinking of putting into place to monitor and control the flow of certain inventory. Mr. Yokoi's wise response, suggesting otherwise, was:

"When you put problem in computer, box hide answer. Problem must be visible!"

Caller-Outer of the Month Award #7

Continuing our series, our Board of Directors awarded this month's caller-out award to Marylou Conant, RN, who works in our PACU (i.e., post-op area.) Regular readers will recall that this award is presented by the Board to reinforce the underlying concept of BIDMC SPIRIT -- that each person should be encouraged to call out problems in the workplace and be recognized and appreciated for his or her contribution to safety, quality, efficiency, and a better work environment.

Marylou's call-out was related to the availability and location of Calstat hand cleansing pumps. She noticed that hand hygiene in the PACU was being impaired. Why? The issue is that patients in the PACU are in bays that are close together, and you approach the patient from the foot-end of the bed. The Calstat dispensers are mounted at the head of the bed, on the wall, a location that does not support ease of good hand hygiene. But each bed does have a mobile bedside table that you pass on your way to the patient. Marylou and her colleagues figured out that you could "set a location" for a Calstat dispenser on every mobile bedside stand. They came up with a simple but elegant solution that provides both a visual cue as well as a slip-proof location on the mobile table using simple magnetic strips.

Marylou received a congratulatory letter, plus second row dugout tickets to a Red Sox game of her choice.

Lean: Tortoise not Hare

Here's an update for those of you interested in our process improvement efforts at BIDMC and our preliminary thinking about the next stages. Back in March 2008, we rolled out our BIDMC SPIRIT program, our first formal experiment with staff-based call-outs based loosely on the Totoya Production System, aka "Lean." It has accomplished some good stuff, and we have learned from it. (Search "BIDMC SPIRIT"and "Caller-Outer" on this blog to see a collection of those items.)

From the very beginning, we said that BIDMC SPIRIT would itself evolve, and now we are at the latter stages of thinking through how to do it. This process included some in-depth training of several of our senior clinical and administrative leaders, a cadre of the next organizational level of directors, and several of our medical trainees. Beyond training us, those sessions served as test beds for the specific curricula developed by our staff, in cooperation with and building on materials from the Greater Boston Manufacturing Partnership. Meanwhile, too, Steve Spear invited several of our folks to audit his process improvement class at MIT, where they have had more advanced exposure to Steve's work but also healthy interactions with people from other industries.

As the graphic above displays, we view ourselves at the very beginning of a long journey to full implementation of Lean principles in our hospital. Others, exemplified by Gary Kaplan and his colleagues at Virginia Mason Medical Center in Seattle, and John Tuissaint at Thedacare, started earlier and are further along.

As I was discussing with Jim Womack the other day, it is an interesting paradox that while an important part of the Lean philosophy is the concept of standardizing work (to avoid waste and unnecessary variation), when it comes to implementation of Lean, each organization is essentially sui generis. That is, the plan for diffusing the concepts of Lean in an institution like ours has to be cognizant of the people and the culture of the place, an environment that has evolved over decades.

The idea here is to be slow and steady -- "Tortoise not Hare" -- in both planning for implementation and executing the plan. I present, for your viewing, a simplified chart of the roll-out proposal we are currently thinking about and will be sharing with our leadership groups and staff. You can click on that chart and expand it. You might not get all the points, but you can see the major themes: Lots of training; application by the trainees of what they have learned; focus on broad system work across the hospital, but also specific project work in high priority areas; and a small, nimble governance structure to keep track of things and make mid-course corrections.

I hope, by presenting these materials here, to encourage others of you who have been through this kind of transformation to submit comments to share your experiences, and to encourage those who are thinking about doing this to reach out to others who are in mid-stream. As the US considers its options with regard to health care reform, the real action will remain in each hospital and physician group. Public policy instruments are blunt and imprecise. Unless we take charge of the manner in which we do our work, the broad general policies being considered in Washington, DC will make very little difference in the quality of care and the efficiency with which it is delivered.

Canadian Lean is bakin'

My virtual and occasionally in-person friend, Farhan Merali, (Harvard Medical School MD 2011 and Harvard Business School MBA 2011), sent along this link to an excellent introductory article from Healthcare Quarterly about application of Lean principles in the Canadian health care environment. It was prepared by Dr. Dante Morra and associates from the University of Toronto and Toronto General Hospital. As you will see, Lean principles and philosophy are independent of geographic setting.

What the CEO cannot do

This is what leadership looks like. It comes in the form of an email from Michael D. Howell, MD, MPH, our Director of Critical Care Quality and Associate Director of Medical Critical Care, to the ICU nurses, house staff, fellows, pharmacists, respiratory therapists, and attending physicians. Without these kind of champions throughout the hospital, the CEO's job is impossible.

All –

Fifty days. No splashes in any of the nine adult ICUs.

For those I haven’t met (welcome, new interns and fellows!), I’m the Director of Critical Care Quality and one of the ICU docs. In the past, I’ve written about our work to improve patient safety (90% reduction in central line infections, etc), speed delivery of critical medications to our patients (70% reduction in time-to-first-dose antibiotics), and more recently about work we’re doing to improve the experience for patients and families in critical care. Today, though, I’m writing about your safety.

Most of you will have noticed the box in the upper right corner of the Portal [note: our intranet home page] that lists the number of days since an employee injury. You’ve probably noticed that it’s always zero, meaning that one of our colleagues is hurt every day. I’ve been sort of agitated by that, and a few months ago we set it as one of the major improvement priorities for critical care.

As our first target for improvement, we sought the elimination of exposure to bloodborne pathogens by splashes. If you or a friend has ever gotten blood in your eye, you know it’s unpleasant, shocking, and scary. Some of our colleagues have, in fact, even been exposed to HIV and hepatitis this way. We know that nearly all exposures from splashes should be preventable by using personal protective equipment. And yet, before we started our work, someone got splashed about every week or two in our ICUs.

Many of you have participated as we began to try to figure out how to prevent these. Here are a few things we learned:

· ABGs and accessing arterial lines are especially risky procedures. In January alone we had *five* splashes from this mechanism.

· Glasses don’t offer adequate protection. Many people have gotten blood in their eyes (or mouth) while wearing their own eyeglasses.

· Splashes happen at unexpected times: disconnecting a Foley, flushing a PICC line, suctioning an ET tube, and being in the room while someone else was doing as ABG – people have been splashed in all of these ways.

Yesterday, though, we crossed an important threshold -- it has been fifty days since our last splash exposure in any of our nine adult ICUs. That’s definite, meaningful progress. Distribution tells us we’ve more than doubled our mask usage, and in some cases they have even had trouble keeping up with demand. That’s because of your work.

From my own practice, I know that it can be irritating and sometimes challenging to put on a mask and visor every time you’re doing something with a patient. But look at it this way: If we’d done things like we used to, we would have expected three to five more of our colleagues to have gotten blood splashed in their eyes during this time period. Instead, no one did.

I want to make a special request of those of you who are more senior, with lots of ICU experience: Please watch out for your junior colleagues, and if they are forgetting to wear a mask with visor, please remind them. Remember also that you set an extraordinarily powerful example with your own practice. By not wearing a mask, you may unconsciously be training your more junior colleagues to put themselves at risk.

Finally, I want to say ‘thanks’ to everyone who is helping with this, and particularly to Sabrina Cannistraro who is helping to lead the project, analyze the data, and coordinate the work. We will keep focused on splashes for the next several months, and once we’ve convincingly eliminated them we’ll begin to focus on needlesticks, lift injuries, and other challenges to our own safety.

As always, feel free to send comments, questions, and rebuttals directly to me, and please forward to anyone I’ve omitted.

Thanks,

- michael

Interns learn Lean -- They get it in two days!

With medical education focused so heavily on the cause of disease, diagnoses, and therapies, an area that is usually neglected relates to the science of care delivery and process improvement. We're trying to make some inroads here. I told you about one below, and here's another.

Three of our interns (Maryanne Kazanis, Nina Nandy, and Paul Bailey) are participating in a pilot educational experience in quality improvement. As noted by Dr. Julius Yang, who is coordinating the effort, "This is not yet standardized for all new interns, as we are trying to learn from these three whether this is worth expanding to a larger group in the future. The pilot experience is an outgrowth from our participation in the ACGME Educational Innnovation Project, where we are attempting to incorporate continuous health systems improvement skills in the standard training for all our residents."

Julius reports about the first two days: After a whirlwind morning introduction to the field of health care quality and “lean practice” (facilitated by a video that features making toast in a less wasteful way), this group spent an afternoon with clipboards and stopwatches (on day 1 of internship) to observe our current discharge process – using their “uncommitted eyes” to watch the process from the perspective of both nursing and physician workflow. They then spent the next day generating a “future state” concept of what attributes would comprise the ideal discharge process, complete with very near-usable “checklists” (one for the patient, one for the physicians) to help standardize the process.

To give you a sense of the perspicacity of our new doctors, here are just a few excerpts from their observations (some of which paralleled our senior management visit to gemba). Not bad for two days on the job!

GOALS:
To highlight the less efficient aspects of the patient discharge process from a nursing perspective.
To provide a standardized patient discharge protocol for the nursing staff.
To explain why the recommendations implemented in a more standardized discharge protocol would lead to a more efficient discharge process overall.

ASPECTS REQUIRING IMPROVEMENT:
Waiting:
Discharge orders are often entered by the MD at a time that is later than ideal for the nursing staff. This especially contributes to a less efficient overall process when nurses have multiple discharges to complete at once, and when the patients to be discharged are particularly complicated and require more time/teaching by the nursing staff.

Another issue that arises with later discharge order entry is that patients are left to wait 8 hours or more from the time they are told about discharge in the morning to when they are actually free to leave the hospital. This leads to increased questions by the patients to the nursing staff, pages to the MD, potentially displeased patients, and fewer beds available for new patients awaiting admission from the ED.

Forms:
The completion of online forms at this time is redundant with nurses cutting and pasting much of the same information into the patient’s copy of the discharge summary that the MD completed for the permanent medical record. In addition, some online forms include default information that is not relevant to all patients and require frequent deletion by the nursing staff.

Medication reconciliation:
At the time of admission, ED physicians are not consistently completing the handwritten carbon-copy version of the medication reconciliation form and filing it in the patient’s chart. As a result, nurses are required to transcribe by hand this information onto the carbon-copy form which can be quite time consuming.

Obtaining and recording vital signs, removing IVs, and completing medication reconciliation:
At the current time, nurses are often making multiple trips back and forth to the patient’s room to do these items at separately. This leads to inefficient use of time walking back and forth, and may potentially lead to errors in excluding an important part of the discharge protocol.

Front row syndrome

Here is a picture of our entering class of residents at their orientation session. What, you don't see anybody? Well, it is because these are the rows at the front of the auditorium. There seems to be some kind of Darwinian imperative -- perhaps based on their experience in undergraduate medical education -- for trainees to sit in the back rows. If you go back a few rows, you can find people, like these three new Emergency Department residents, seen with Dr. Sean Kelly, head of our graduate medical education program.

Notwithstanding their seating proclivities, this is a great group of trainees, and we are happy to have them with us for the coming years. My major points of advice to them? Wear bicycle helmets. And, help us eliminate preventable harm in the hospital by being vigilant caller-outers.

Pig -- Part 1

One of the lessons of Lean is that if you standardize work, you not only reduce variation, but you improve the quality of the product or service. This is known to be true in the delivery of medical care, but it is often not practiced in hospitals. Instead, hospitals remain cottage industries, with each craftsperson (doctor) plying his or her craft (clinical care) on the basis of experience, intellect, and creativity rather than on the basis of scientific evidence. This leads, nationwide, to extension variation in practice patterns (and cost). More locally, it leads to greater potential for harm. What we need, instead, is a greater reliance on standardized practices in those portions of medical care than can and should be standardized -- still leaving to doctors their ability, creativity, and craftsmanship for those circumstances that truly demand those attributes.

This pig game demonstrates the value of standard work flows. It's fun and illustrative of the concept. Find some friends on whom you can experiment. We'll start with this posting in round one, and then rounds two and three follow below. First, prepare standard size pieces of paper with the grid shown above -- one per participant. (If you click on the picture of the grid, you will get an enlarged version you can print out on paper.)

Now, read the following instructions to your friends: You'll probably have to repeat the instructions.

1) Draw the side profile of a pig, centered on the page.
2) Make sure the pig's head is facing left.
3) The pig should be drawn large enough so that a piece of it is in every box EXCEPT the top right.
4) You have 2 minutes to draw your pig.

Now, have everyone show their pig drawing to everyone else. OK, go to round two, below.

Pig -- Part 2

Now we turn to round 2 of the pig game. This time, hand out the instructions above, along with another copy of the grid, and ask people to draw another pig. Again, have everyone compare their results. Now go to the next step, below.

Pig -- Part 3

And, finally round three of the pig game. Hand out this set of instructions, along with another grid. Now, compare the results of the participants.

I'm guessing you will see higher quality pictures and more uniformity. All right, I know this is not a clinical procedure, with all of its potential complications, but the lesson is nonetheless powerful. After our residents took their Lean training course, several of them said this was the most powerful lesson they learned. They now apply it in clinical settings, looking for "pigs" to standardize their work where appropriate.

Remember, we are not trying here to standardize those parts of patient care that should not be standardized; but we are trying to do so for those elements of care than can be and, most importantly, should be to reduce and eliminate harm. In our hospital, we have done so in the following arenas among others. This has saved lives and reduced other harm, plus making life better for staff and patients:

Clinical pathways -- obstructive sleep apnea; Whipples;
Central line infections;
Ventilator associated pneumonia;
Rapid response teams;
Surgical time-outs.

Caller-Outer of the Month Award #6

Speaking of residents, our Board of Directors today presented this month's Caller-Outer of the Month Award to Adam Fein, MD, a second year medical resident. Regular readers will recall that this award is presented by the Board to reinforce the underlying concept of BIDMC SPIRIT -- that each person should be encouraged to call out problems in the workplace and be recognized and appreciated for his or her contribution to safety, quality, efficiency, and a better work environment.

One of the annoying things about leaving a hospital is that the discharge process often takes a long time, leading to frustration for both patients and families. Adam diagnosed a source of those delays: The residents who were arranging follow-up appointments with hospital-based specialists were calling each specialist's office one at a time. This discharge step was often the lowest priority for residents: After all, patients who were still sick and needed care would instead get their attention. Meanwhile, the healthier patients waiting to be discharged would, in fact, be waiting for the resident to make those follow-up appointments.

As it turns out, we have a service for referring physicians in the community who need to make appointments with our specialists. They send in their request to a centralized referral command center ("RefComm"), where a nurse acts as the liaison in setting up appointments and communicating with all parties. As a result of Adam's call-out, the RefComm service center was also made available to the residents. Instead of making all the follow-up arrangements themselves, they simply send an electronic request to the folks at RefComm, who take care of things. This frees up the residents to carry out their doctoring duties and accelerates the discharge planning process.

Adam received a congratulatory letter, plus second row dugout tickets to a Red Sox game of his choice.

Gemba meets GME

Our senior executive Lean training program always has a visit to gemba as part of the day's session. This time, we went to one of the clinical floors to watch the process of work rounds. The purpose was mainly for us to practice using Lean tools to gather baseline data and identify variation in the work process.

Here's a picture of intern Elena Resnick reporting to resident Lauren Fishbein. Our doctors in training do an excellent job, but we noticed many opportunities for better integration of their activities with those of other departments in the hospital (e.g., radiology, pathology, and case management). However, that would require a massive shift in the mode and purpose of work rounds, attributes which have been in place for decades as part of the design of the medical education process.

We'll come back to this problem some day in the future. For now it was an illustration of the degree of complexity of an academic medical center, where the delivery of clinical care is intimately -- and often inefficiently -- connected to the delivery of undergraduate educational services to medical students and graduate medical education to residents.

5S gets you organized to be Lean

As our merry band of senior executives and clinical leaders continued our course in Lean philosophy and techniques today, we were reminded of the foundational power of the 5S, often called the first step in workplace improvement: Sort, set in order, shine, standardize, sustain. The storyboards above give some examples of the applications of these from clinical locations at BIDMC as we have proceeded with BIDMC SPIRIT over the last several months. As you look at them, they seem common-sensical and easy, but it takes practice and training to notice the opportunities and implement this kind of improvement.

Who's waiting?

E-patient Dave referred me to this article in USA Today, entitled "Wait times to see doctor getting longer." The title says it all, but here's an excerpt:

The survey found that, on average, wait times have increased by 8.6 days per city. Boston had the longest wait, averaging 49.6 days.

But, now look at this marvelous contrast in our hospital, where we have made a concerted effort to reduce wait times. Over one year, the average wait time for all of our medicine clinics has dropped from 13 days to 4.4 days. (The figures are based on a sample of mystery shopping calls.)

Our goal is for all clinics to be under three days. Right now, 6 have been meeting that goal. Another six are in the 3-5 day range. Two are in the 5-10 day range, and one is greater than that. In these last three cases, the reason is that we have doctor vacancies that are being filled in July.

This kind of success takes coordination across multiple areas, constant review of our procedures, use of mystery shoppers to evaluate the patient experience, and transparency of the results both to ourselves and our patients. Speaking of mystery shoppers, our customer service ratings for these clinics had an average of 4.5, on a scale of 1 (poor) to 5 (excellent). We're still shooting for better -- a goal of 4.8.

The WIHI chat room

A picture of Madge Kaplan from the set of the WIHI webcast below, along with some comments from the chat room. The topic was mainly this blog. While some comments were directed to me, others were going back and forth among the listeners. There was not time to reply to all questions, but to hear my answers and the whole thing, check the podcast available here sometime on Friday.

Moulay Alaoui: In this era of transparency in health care and trend of patient demand, it is very relevant. However, it is very courageous of you to use this medium.

Denise Vincent: Oh gosh yes, the EPA makes water treatment plants send an annual report to all customers.

Cristina Wilhelm: The blog makes me think of the Wizard of OZ...the curtain has opened and everyone can look in. Kudos to you for opening the curtain yourself.

Pamela Ressler: Communication is essential in healthcare, but often we are afraid of it -- and it does take courage and vulnerability to put yourself out there, as Paul has done so well through his blog.

Mary Ann Bone: Has your legal department responded to your blog?

Sandra Snider: I've been afraid to blog too much about work for fear of getting in trouble.

Brian Yanofchick: Apart from a legal department's predictable issues, how have other staff, such as physician, nurses, others responded?

Maureen Watchmaker: I am a nurse case manager who has been at BIDMC before and after Mr. Levy's arrival (since 1999). To answer Mr. Yanofchick's question, from listening to colleagues, the overall response (including my own) started as suspicion, moved to incredulousness tinged with hope and now has become an attitude of "of course this is should how a CEO should behave." Now, as times become tough, most of us feel hopeful with Mr. Levy at the helm. With the SEIU circling our hospital, I think that his transparency has been one of the factors that have kept them out.

Brian Yanofchick: Thanks for that response. Very helpful. I'm not surprised by the initial worry, but heartened that staff have begun to see it as a plus.

Shawna Willcox: Maureen, what is the SEIU?

Maureen Watchmaker: Shawna-It is a very aggressive union that has targeted BIDMC.

Lawrence Van Rossum: Question: Do you think Hospitals need to take a serious look at the Process of Patient Care and Clinician work flow in order to achieve a better level of service and harm less patients?

Charles Lee: You mentioned medicine is a "cottage industry". Is this changing with government, hospital corps, PPOs, HMOs, etc. becoming more and more the norm?

Aline Gonsalves: Unless you learn to blog and be more open in all communications (whether clinical or other), as long as privacy laws are not violated, it is crucial this type of blogging become part of organizations' daily running or our teenagers will make it so in the near future. It's crucial CEO's learn how to do this as soon as possible before they are forced to. Blogging and internet network are tools for enabling, not destroying.

Moulay Alaoui: Great point! Healthcare provision quality is central and it is mainly about processes not persons. Standardization is an ultimate goal of this industry, especially within a system (a conglomerate of providers).

Ann Bailey: How have patients/community responded to the blog and outcomes data? Are you getting any feedback? Some organizations report that patients/potential patients may not understand what the data says or how they might use.

Dave Weinstock: Do physicians need to be salaried and work for the hospital to help standardize (as an organization versus a collaboration of individual contractors)?

Doug Bonacum: Have you had any malpractice allegations brought against BID where Blog / Website information was used against you?

Brian Yanofchick: Communication methods like this are a great opportunity to positively change a culture from one of paternalism to one of true accountability.

Sandra Snider: I'd rather post our outcomes data than have Healthgrades post data that is years old.

Daniel Grigg: I'm wondering how much time it takes to do the blog each day. Once you begin, it's a pretty serious commitment to keep up with it.

Madeleine Girard: If an organization is truly transparent, the "need to know" attitude disappears. And all the fears and worries that come along with it.

Daniel Roy: In dealing with healthcare professionals, the mentality has always been that they are behind the times...presumably because of the fear of change and risk of increasing liability. I applaud you for taking a leap to change that perception.

Madeleine Girard: I agree with you Daniel. A huge culture change is happening in my workplace with a new CEO at the helm. His style reflects Mr. Levy's though he is not yet blogging... Something to suggest at our next meeting.

Sandra Snider: If the public knows you use mistakes in a positive way to improve care and prevent future events, they will be more likely to forgive us our mistakes.

Nick Dawson: Is there something unique about healthcare that lends itself to "social media" - its a topic that is much hotter than social media in other industries from John Lockhart to All Participants:I am a hospital board member studying the new IRS form 990. Will you discuss executive compensation issues on your blog ?

J Zuercher: Healthcare impacts everyone!

Aline Gonsalves: It's about connecting as people.

Pamela Ressler: And communication allows for more effective collaboration -- provider/patient, leadership/staff.

Maureen Bisognano: In this day and age, leaders need to use all methods of communication to reach the many audiences they need to connect with...we are in a time of "continuous partial attention" (Tom Friedman), and we know that people learn and contribute in many ways. You reach them all!

Aline Gonsalves: As a business consultant in healthcare, it's important to realize it's crucial impact on accountability frameworks within healthcare. It helps surface assumptions that exist in healthcare. With the "accuracy" of internet medical information, assumptions are made that can result in wrong decisions. Blogging and internet networking can clarify misconceptions.

Ron Ferrand: Is there a recording of this webex available?

Jesse McCall: Recording available at: http://www.ihi.org/IHI/Programs/AudioAndWebPrograms/WIHI.htm?TabId=14 by tomorrow.

Making it easier at Gemba

A repetitive theme of our Lean training is that many of the best ideas are easy to implement, but they would never get management's attention absent a clear commitment to listen to the front-line staff. Here's one example that some of our senior management team learned during our visit to gemba, this time at the Hematology laboratory.

The manager of the lab took the initiative a few months ago to set up a very easy system for getting staff suggestions. It took the form of a single card on which any person could make a suggestion, give the reasons for it, and offer his or her opinion as to why it would be helpful. OK, that's just like a suggestion box, right? But the difference here was a daily staff huddle at which the crew would discuss each idea and vote on it. If it was approved, it would be implemented. (As a reward, the suggester's picture would be added to the card and it would be posted on the wall.)

When we asked Nicole Burston (shown here) what was the best idea to come along so far, she said it was an extra label printer (also shown here). Huh? Well, it turns out that some blood separation "spins" need to be "double-tubed." Each tube needs an identifying label. The old way: Walk across the lab to the area where the original tube was labeled; bother the team whose people are busy putting on the original labels by asking them to do extra work, disturbing their sequence; and then walk back across the lab. Do this dozens of times per day.

The alternative, print out a new label on the printer located at the place it is needed.

Manager Gina McCormack (shown here) was asked, "Was this a new idea that had never been raised before?" Nope, but it always got put off for other priorities and reasons. "Did you have to come up with money for this and therefore postpone another project?" Nope, I just called the IS department and told them it was part of a Lean improvement event, and they ordered it and paid for it out of their budget.

Noted SVP Walter Armstrong, "Organizations often suffer from a sense of resignation. You don't ask because you assume you will not get what you need." The Lean process helps break through that bottleneck.

Clicking through Lean

An aspect of the Lean process improvement that is reinforced often in our training sessions is to learn to identify and eliminate "the 7 wastes" that are found in production and service organizations. Here is a handy pen that clicks through the forms of waste to help you remember them: defects, waiting, motion, inventory, processing, transportation, and overproduction. Thanks to Greater Boston Manufacturing Partnership for the memory tool.

McAllen, Texas = Boston, Massachusetts

Thoughts as I go through the night prepping for my regular colonoscopy (OK, more than you want to know!) which allows me to be up even earlier than usual and make some observations. I can't yet blame the soon-to-be administered Demerol for any incomprehensible wanderings, and I promise not to write the next post until that wears off.

Atul Gawande has yet another beautifully written article in the New Yorker about health care costs, this time focusing on a particular city in Texas that has remarkably high costs compared to the rest of the country. Of course, he need not have travelled so far. The points he raises have been published for years by our colleagues at Dartmouth, and have been discussed by Brent James and others. And the kinds of numbers he cites, although perhaps not as extreme, also typify health care costs here in Massachusetts.

Brent summarized some of these issues in a talk he gave here about a year ago:

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

While Atul focuses on national policy in his article, let me bring the discussion back to strategic planning for hospitals in general and academic medical centers in particular. It seems to me that there are three overwhelming public policy trends in America:

1) A desire to set an annual budget per person for health care;
2) A desire to limit the growth of that annual budget to a rate equal to or less than the overall rate of inflation; and
3) A desire to reduce the amount of harm caused to patients during hospitalizations.

The successful hospitals (and their associated physicians) will be those who learn to live within these broad formulations, and the most successful with be those who wholeheartedly embrace them. Further, they will need to create integrated networks of care -- whether by ownership or strategic alliances -- with people in other parts of the health care delivery system who have similar beliefs. Finally, they will need to engage in process improvement of the type discussed by Steven Spear to squeeze waste out of the system on the "factory floor."

In Massachusetts, there is only one integrated delivery system characterized by ownership of enough entities to engage in this kind of strategic approach, but that system has not yet demonstrated an ability to deliver care at a lower cost. Indeed, just the opposite. For a place like BIDMC, we will have to rely on finding multi-specialty groups, community hospitals, and others who share our vision of success through improving the quality and efficiency of our service, delivering care in the most appropriate settings, and constantly striving to be "the best at getting better."

Many of you have watched our progress here on this blog and on our corporate website as we feel our way along this path. One of our management techniques is transparency. It is based on a philosophy that you can't get better and you can't hold yourself accountable unless you are exceptionally public about what you do wrong, as well as what you do right. As I have noted elsewhere:

Transparency's major societal and strategic imperative is to provide creative tension within hospitals so that they hold themselves accountable. This accountability is what will drive doctors, nurses, and administrators to seek constant improvements in the quality and safety of patient care.

In this sense, transparency is a necessary but not sufficient element in bringing about transformational change in an organization. But the actual implementation is not easy. You've seen our stories about BIDMC SPIRIT and Lean process improvement here. We view ourselves as babes in the woods in these arenas, but we view part of our role as an academic medical center to share what we have learned with others. We will also ruthlessly borrow good ideas from others in our quest to do better for our patients but also for ourselves as an organization facing the three policy imperatives set forth above.

Luy and Ethel discover gemba

Lean training for our senior executive group continued apace this week. As always, a segment was a return to gemba, the place where work happens and value is created for the customer. Here, SVP for Health Care Quality Ken Sands visits with radiology staff members Michael Hogan and Caitlin Buchsteiner to learn about what visual signals exist in the workplace that give a sense of the status of the pace of diagnostic radiology exams. One part of the Lean theory is that it should be easy for staff members to get at-a-glance information on the status of a given work flow or process.

The classic example of a system in which the workers are disconnected from the upstream aspects of production system is found in this episode from the I Love Lucy show. How many examples of this can be found in your hospital? We find them all over. As always, this is not a case of ill-intentioned people working in a bad environment: Rather it is the all-to-common case of really good people working in an environment that has not been designed to reduce waste. The result is work-arounds, wasted effort, errors, and staff who go home more tired each day than they really need to.

Simply stated, the goal of Lean is to train people to see these examples and also to have the team learn how to address them in a comprehensive and thoughtful way. The idea is not to solve for the complete perfect solution all at once, but to be "very good at getting better."

Caller-Outer of the Month Award #5

Our Board of Directors yesterday presented this month's Caller-Outer of the Month Award to Susan Adams and Lora Morgan, whose near-miss call-out I have previously described. Susan was the ICU nurse mentioned in that story, and Lora was the clinical pharmacist. Please recall that this award is presented by the Board to reinforce the underlying concept of BIDMC SPIRIT -- that each person should be encouraged to call out problems in the workplace and be recognized and appreciated for his or her contribution to safety, quality, efficiency, and a better work environment.

Gemba calls again and again

The training sessions for the senior management in Lean philosophy and techniques continue, in an effort to integrate that approach with the ongoing BIDMC SPIRIT program. Each session involves a visit to a front-line process or clinical area. Here you see Suzanne Albright, a recruiter in our human resources department, explaining the steps in recruiting, screening, interviewing, and hiring to Mark Gebhardt, Chief of Orthopaedics.

Above, you also see the group at play, with a simulation of a meeting to discuss process improvement. Each person is labeled with a characteristic -- unknown to him or her -- that causes the other participants to treat him or her in a stereotypical fashion. The lesson is clear within just a few minutes: If you draw assumptions about your colleagues with regard to their ability to participate fully in process improvement, it is a self-fulfilling prophecy. The result is a diminution of the ability of the group and the organization to learn from one another and achieve the best results.

Returning to Gemba

You may recall that I discussed the Lean training program being taken by our senior management group. A second session was held this week, and we returned as a group to Gemba, the place where work happens, where value is created for consumers. Today's visit was to the pharmacy. SVP Jayne Sheehan, seen above in her "bunny suit", and I observed how things are done in the clean room.

We watched Rena Lithotomes (left), a trainee, and Rosmara Harvey (right), a pharmacist, as they carried out the incredibly precise and important work of preparing dosages of a wide variety of drugs used in clinical settings.

Later in the classroom setting, we compared notes to refine our observational skills and ability to see opportunities for reductions of muda, mura, and muri in our work areas. These concepts have often been used in other industries, but not so much yet in the health care industry. Probably the best example is Virginia Mason Medical Center in Seattle, where CEO Gary Kaplan has made this the hallmark of his administration for several years. We are earlier on the path to adoption of this philosophy in our hospital, merging it into our BIDMC SPIRIT program in a more systematic way over the coming months.

Going to Gemba

I have related below our efforts to spread the word about Lean techniques (aka Toyota Production System), for example to our residents, and apply them to the hospital setting. We're also conducting a similar set of training sessions for our senior management team.

For those not familiar with Lean, one of the concepts is "going to Gemba," where Gemba is the place that work is actually done, where value is created for the customer. By witnessing problems and work-arounds in real time, the team can have a better idea of how to solve problems to root cause and make incremental improvements in work flows. This is a critical part of a program of continuous process improvement, the theory behind BIDMC SPIRIT.

Here are (from top) Senior Vice Presidents Jayne Sheehan and Walter Armstrong following nurse Pam Moss, and Radiology Chief Jonny Kruskal following nurse Sarah DeCristoforo. The purpose of today's exercise was not actually to solve problems but to train our team in aspects of going to Gemba. As always, we all left with an enhanced appreciation for the dedication, outstanding work, and endurance of our nurses in the high-pressure environment of a medical-surgical floor.

Caller-Outer of the Month Award #4

Our Board of Directors met yesterday and presented their fourth Caller-Outer of the Month Award. There were two recipients, Holly Dowling and Susan Keefe, nurses in our hematology-oncology outpatient clinic.

As I have noted previously, the purpose of the award is not to recognize someone who has solved a problem, but rather to recognize someone on the staff who has noticed a problem and called it out. The idea is that call-outs lead to root cause analyses that enable us to fix problems systematically rather than engaging in work-arounds. Our Board of Directors created the award as part of our BIDMC SPIRIT program to encourage people to call out problems to make our hospital a better place to work. (Beyond the recognition, the award is accompanied by two really good tickets to a Red Sox game.)

The story here was that Susan, a new employee, noticed that the rubber gloves she was asked to wear in the unit were thinner than gloves she had worn in her previous place of employment. She called this out to Holly, her group leader, and Holly then proceeded to investigate. It turns out that the supplier had mistakenly sent the wrong kind of gloves. Although other people had noticed that their gloves had changed, no one else had thought to call out the issue.

The problem is that OSHA requires a heavier grade of gloves for people working with chemotherapy drugs because of the potency of those drugs. If the medication gets on skin, it can be absorbed. In a clinic like this, with a number of younger women nurses who might be pregnant or might be planning to get pregnant, this could be particularly dangerous. The attentiveness shown by Susan and Holly quickly resulted in a review of the situation, determination of the root cause, and fixing the problem.

DPH and CMS help out

While we are justly proud of many of our quality and safety initiatives at BIDMC, we have to acknowledge that we still fall short in a number of ways. The memo below, distributed to our staff yesterday, contains an example.

Just as we view transparency around our clinical outcomes as an important management tool, we view transparency about regulatory activities, findings, and requirements in the same way. If a regulatory agency finds that we are doing things wrong, why would you want to keep that conclusion secret from the staff? After all, the doctors, nurses, and others are the ones who ultimately must correct the problem, and we trust their ability to evaluate and act on legitimate criticisms received by us.

In a previous post about the Joint Commission, I stated: "If the Joint Commission did not exist, we would want to invent it. An objective outside review of this sort is extremely helpful to a hospital as it strives to provide better and better care to the public." Ditto for our state and federal regulators.

Here's the memo:

To: BIDMC Community

From: Ken Sands, MD
Senior Vice President,
Silverman Institute for Health Care Quality and Safety

DeWayne Pursley, MD, MPH
Neonatologist-in-Chief
Interim Chief, Obstetrics and Gynecology

Marsha Maurer
Vice President, Patient Care Services
Chief Nursing Officer

We are writing to share important information about some serious clinically related issues at BIDMC over the past few months. To begin, we will give you some background, and then we will fill you in on what happens next.

What Has Occurred
First, between last November and March, BIDMC experienced several occurrences or “clusters” of methicillin-resistant Staphylococcus aureus, or MRSA, infections that have affected some of our patients (19 newborns and 18 mothers) days to weeks after discharge from our obstetrics and newborn services. These infections have been, for the most part, superficial skin infections and breast infections. It is important to note that no babies in our Neonatal Intensive Care Unit have been affected.

We are thankful that all identified infections have been successfully treated, in most cases with antibiotic cream or pills. We are working to identify any other patients who may have been affected. It appears that these clusters of infection have not impacted other parts of the hospital.

As with other hospitals and institutions that have experienced similar groups of MRSA infection, it is often impossible to identify a singular source or explanation. We have determined the bacteria to be the most common type of “community-associated” MRSA, meaning that the origin of the bacteria is most likely outside BIDMC. Despite extensive investigation, we have been unable to determine how it has spread. However, we have taken many steps within our obstetrics and newborn services to address this situation, including testing our employees and patients and strengthening our efforts on hand hygiene and sterilization.

We promptly reported these occurrences to the Massachusetts Department of Public Health (DPH) and the Boston Public Health Commission (BPHC) and continue to work closely with them. In addition, to help us with this ongoing challenge, we are working with the national Centers for Disease Control and Prevention (CDC), and we welcome their expertise and knowledge of similar situations. Our outreach has included communications with affected patients, patients who we believe have not been affected but were here at the same time as the affected patients, pediatricians and current patients in our obstetric units.

Second, during the course of a DPH visit regarding the MRSA matter on behalf of the federal Centers for Medicare and Medicaid Services (CMS), investigators observed instances when our infection control practices failed to meet our own standards. In addition, they had concerns about our system for reporting infection clusters to leadership bodies within the hospital.

What Happens Next
We have received the official CMS report and are putting together what is called a Plan of Correction to show how we will correct any and all deficiencies that were identified. We will make both their full report and our response available to the BIDMC community when they are filed within a couple of days. But as a result of the findings, a more vigorous, hospital wide survey by CMS will be coming to BIDMC in the near future for their own review and inspection of our policies and procedures. Every physician and employee must be prepared to welcome the CMS surveyors and show them the good work that we know BIDMC staff are doing every day.

Some Observations
We take the report on our lapses and the expected CMS visit very seriously. When we make this report available to all, you may find reading the report makes you uncomfortable. It is difficult for a group of expert and dedicated staff like our colleagues in Obstetrics and Newborn services to go through this process. They have worked extremely hard over the past few months to battle these MRSA infections and to re-dedicate themselves to the most rigorous infection control processes.

Yet the truth is any one of us at any time could be subjected to the same scrutiny and observation and we each need to ask ourselves how we would fare in this situation. This is an important learning experience for every one of us as we deal with the patients and family members who put their trust in us.

There is much to be proud of at BIDMC with our efforts to control infections. We have virtually eliminated central line infections and ventilator associated pneumonia over the past few years by implementing and standardizing major new processes. Each year, the outstanding clinicians at BIDMC provide quality care with exceptional outcomes to tens of thousands of patients.

The serious nature of the initial survey does not change those facts. But it does require that we continue to commit ourselves to providing the highest quality care to every patient who counts on us for their health care needs. Ultimately we believe the changes we will put in place as a result of this experience will make us stronger and better caregivers.

Residents learn Lean, too

Part of BIDMC SPIRIT is to infuse many of the LEAN process improvement principles throughout the hospital. A key constituency in this effort are the residents who, after all, spend as much time on the patient care floors as anybody. So, we have begun a training program for this group, and the first sessions were held this week.

Shown here is Alice Lee, our LEAN guru, er, sensei, conducting a class. Also, you see a couple of the students on the floors, quietly observing things and learning how to look for waste and opportunities for efficiency improvements.

The waste patrol at work, all 6000+ of them!

I love that people throughout the hospital are now involved in ferreting out waste. And I like it even better that they are calling out problems they see. And I like it even better when our managers treat these comments politely and respectfully, even when they sometimes have to explain why suggestions might not always be the best possible idea. Here's an email chain from today between one of our nurses, me, one of the vice presidents, and then another who had been copied. (I have changed the nurse's name for privacy purposes.)

Saturday, 9:14am
Hi Paul,
I was frustrated this morning when I came into the West Campus front entrance to find a new dispenser of complimentary umbrella bags for visitors. Why would we be purchasing something so unnecessary as this when we are being forced to give up [other things]? I really felt this was inappropriate.
-Mary

Saturday, 9:23am
News to me, Mary, although I could imagine that we do it to keep wet umbrellas from dripping all over our floors, which would then have to be cleaned up. I'll inquire around. Diana?
Paul

Saturday, 10:37am
Mary,
Thanks for your note-I know it is frustrating in these times to see something that looks like waste!

As you probably know, we've been doing a lot of work on employee safety through the Spirit initiatives. There have been literally hundreds of employee slips and falls in the last several months. Besides the pain of these incidents for the employee, slips and falls result in a major cost to the medical center in claims and lost productivity.

When the slips and falls committee, chaired by Jayne Sheehan and Michael Kennedy, investigated the root cause of these events, they discovered a significant number occur in lobbies when employees (and patients) slip on water that has dripped off of umbrellas. The umbrella bags are an inexpensive solution to help keep our employees and patients safe. (And eliminating just one claim from a bad fall will more than cover the cost of the bags!)

Please feel free to contact me if you would like more information. Thank you again for your note!
Diana

Saturday, 10:47am
Thanks, Diana and Mary,
Yes, Michael and I spent a lot of time investigating real time slips during inclement weather. It was clear the dripping umbrellas caused a wake of slips for not only our employees but our patients, particularly on the slick terrazzo floors and vct floors. We immediately looked into solutions to allow folks to keep their umbrellas, but leave a safe path behind them. Michael found a great solution, used in many other environments, and thought bringing it to the health care environment would serve the same purpose.

Important to note, is that the expense of all umbrella trees and the bags came to 1/10th of the cost of one employee injury where an employee may be then out for one or two days of leave. I felt it is well worth the minimal dollars to keep our staff who hurry a lot from campus to campus and our patients and their families safe.

Thank you, as always, for your thoughts and concerns during this fiscally challenging environment.
Jayne Sheehan

Saturday, 12:20pm
OK, thank you all for your responses. That certainly sounds reasonable and well thought out.
Mary

Caller-Outer of the Month Award #3

Today was the monthly meeting of our Board of Directors, along with another chance to present our Caller-Outer of the Month Award. It was given to Deborah Kravitz, seen here, who works in our Central Processing Division (CPD).

The purpose of the award is not to recognize someone who has solved a problem, but rather to recognize someone on the staff who has noticed a problem and called it out. The idea is that call-outs lead to root cause analyses that enable us to fix problems systematically rather than engaging in work-arounds. Our Board of Directors created the award as part of our BIDMC SPIRIT program to encourage people to call out problems to make our hospital a better place to work. (Beyond the recognition, the award is accompanied by two really good tickets to a Red Sox game.)

You may recall reading about the LEAN rapid improvement event we ran in the CPD recently. Well, Deborah got the whole thing started many months ago when she invited me for a tour of CPD, and I was able to see the terrible working conditions facing her and her colleagues as they try to carry out their job of sterilizing all of the surgical instruments used in the hospital's ORs. After some delay, Deborah nudged me again a few months later and pointed out that nothing had improved. So, we got to work on the problem and with the help of the CPD staff, are now on the path to a much healthier, safer, and efficient work environment.

By the way, Deborah is also a talented artist. Check out a sample of her work here.

Good and bad news about infection control

I have been writing for some time about our efforts to eliminate central line infections in our hospital, and we have been totally transparent about our progress in that regard. While I know you can always look these things up, I want to make it easier for you and give you some advance news -- especially in light of the most recent results.

During the first four months of this fiscal year, a period covering about 7000 patient days, we had only one CLI in our intensive care units. This represents a tremendous effort by dozens and dozens of staff people.

In early 2006, our hospital's rate of infections was about 2 per thousand ICU patient days. At that old rate, there would have been 14 infections during this same four-month period. Given a 12 to 25 percent mortality rate associated with such infections, 2 or 3 people would have died unnecessarily.

Do we need a better reason to engage in these programs?

Two years ago, I raised a question: "If I can post these rates for BIDMC, why can't people from other hospitals? ... I am seeking no competitive advantage here. This is an attempt to get past a culture of blame and litigation and persuade people that transparency works: Real-time public disclosure of key indicators like this ... can be mutually instructive and can help provide an incentive to all of us to do better."

Then, a short while ago, I asked the question in a more direct way, posing a challenge to all the Boston area hospitals to jointly engage in a program to eliminate these kinds of infections and share their progress with the public.

The response to my public and private entreaties in this realm has been silence -- from hospital professionals, from insurance executives who care about a transformation of this industry, and, indeed, from public advocacy groups who care about access to care and the quality of care delivered. Some observers attribute the medical profession's lack of engagement to an underlying fear of transparency. And yesterday, a world expert in this field, whose wisdom and advice I treasure, told me that he has come to accept gradual progress in quality and safety improvement, citing the kind of training doctors get, which does not emphasize these areas. That such a person has become content with gradual changes in the status quo is an indication of what it must be like to beat your head against this wall of recalcitrance for several decades.

My advantage, being without medical training and having had but a short tenure in this field, is that I retain a sense of outrage. Our collective failure to approach this problem using well established methods of process improvement -- including publication of current performance results -- represents a moral and ethical lapse by the clinical and administrative leadership of the medical establishment in this city. Why? Simply put, a profession that takes an oath to do no harm is, by inaction or incomplete action, doing harm. We are causing people to die who should not die. What would we call that if we saw it happening in other sectors of society?

How was your visit?

A couple of years ago, I wrote about our use of mystery shoppers to evaluate how well we provide service in our ambulatory clinics. (You can also read more about it in this Boston Globe story by Liz Kowalczyk.)

Now, we are going the next step, not only conducting surveys of patients about their experiences in our clinics, but posting the survey results in those very same clinics. A portion of the survey is shown above. You will see three particular questions highlighted (just here, not on the actual survey). Those are the ones about which we receive the most complaints.

You also see above a mock-up of the kind of poster that will be prominently displayed in each waiting room, showing the performance results of that clinic for all to see. We believe this is part of "putting ourselves under the microscope." We have aspirations, not only to have an incredibly safe hospital, but also to rank highest in patient satisfaction in the country. We believe that you cannot achieve aspirations like this unless you hold yourself accountable by being transparent with regard to your progress.

I'd love to get comments from others out there, whether in hospitals or other businesses, as to whether you have tried this and what you have learned from it.

P.S. The mystery shoppers are still at work. We never stop learning from them.

The fear of transparency clouds all

I have been worried lately that I may have adopted radical views on quality and safety in hospitals, that I may be out of the mainstream of American life when I suggest that we should jointly determine to eliminate certain types of infections or engage in protocols to enhance patient safety. I was also worried that my insistence on the importance of transparency with regard to these issues was just too outlandish for people to absorb and accept.

Imagine my relief then, to read this editorial in USA Today. Hardly a radical journal, the editors write:

Too many Americans go into hospitals for treatment and end up getting sicker....

A greater sense of urgency is needed....

Why are infections so widespread? In part, of course, because hospitals are full of sick people and germs. But medical professionals, hospital administrators and government regulators are failing to demand adherence to actions they already know will protect patients....

Secrecy allows the problem to fester. Although 23 states require hospitals to report infections to one of four unlinked federal databases, reporting is so scattershot that there's no way to determine whether the problem has been getting better or worse.

On the comments under the post below, some of the world's experts on quality and safety offer their perspectives on this issue. What is it about the medical community that makes it so hard for these views to be accepted? A close colleague writes to me saying, "I imagine the fear of transparency clouds all."

Look at the numbers in the editorial: Tens of thousands of deaths from often preventable infections. We -- and I mean the academic medical centers in general -- rely too much on our reputations. It is beyond time to hold ourselves to a higher standard. As I have said before, if we fail to do so, it will be done for us and to us by legislative and regulatory action, and such action is bound to be less accurate and helpful than the kind of self-reporting I have advocated here.

Caller-Outer of the Month Award #2

It was time last night for the second Caller-Outer of the Month Award, given by our Board of Directors to an employee who exemplified the principles of BIDMC SPIRIT in pointing out a problem that was interfering with the staff's ability to do their jobs. This one went to Sharon O'Donoghue, clinical specialist in the medical intensive care units, seen above.

Here's the story. Last spring, based on observations from several ICU nurses, Sharon called out a frustrating problem: Inpatient nurses were unable to read many consult notes or follow up on tests because they did not have access to webOMR. WebOMR displays results and provides access to notes and other documentation. Instead, the nurses had to waste time searching in different locations for labs, imaging and plans of care.

Why? Because the original version of webOMR was optimized for outpatient workflows and was initially rolled out to outpatient providers. It had never been offered to the inpatient nurses or authorized to them as part of their information system log-in credentials. In fact these nurses first learned about the existence of the system when they happened to look over the shoulders of some doctors! Absent this access, the nurses had to use older programs that were not as complete, were not web-based, and were not as easy to use. This situation had existed for years.

Within a couple of days, Larry Markson, MD, Vice President, Clinical Information Systems, provided a simple way to give read access to webOMR to the inpatient RN staff, fitting the inpatient workflow. The result was enhanced patient care and improvement in the day-to-day lives of our 1400 nurses.

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