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, June 25, 2009

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!

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.

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.

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.

Tuesday, June 23, 2009

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.

Monday, June 22, 2009

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.

Wednesday, June 17, 2009

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.

Tuesday, June 9, 2009

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.

Thursday, June 4, 2009

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.

Wednesday, June 3, 2009

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.

Monday, June 1, 2009

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.