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