The value of standard work

"The most important thing we can teach our residents and trainees is the value of standard work."

Imagine if that were the philosophy in every academic medical center. It is the philosophy at the Mayo Clinic, according to Dr. Stephen Swensen, Director for Quality. Dr. Swensen commented on these matters during last week's IHI Annual Forum. I was not able to attend his session, but a colleague did go and reported back to me.

For years, I have been hearing about the quality of care given at Mayo and was having trouble learning what distinguishes the place. I should have figured it out. The simple summary of process improvement is that you cannot design and implement improvement if there is too much variability in your process. Why? First, you cannot design an experiment for change unless you are confident that your change is being applied to a relatively uniform "prior." Second, you cannot measure improvement compared to a base case if there is not base case.
Dr. Swensen talks a lot about the "cottage industry" and "farmers' market" approaches to medicine, as opposed to the Mayo way of standard work, decision support, and forced protocolization. Mayo has a Clinic Clinical Practice Committee that has the authority to set practice standards and methods across the organization. When improvements are discovered, there is rapid diffusion of learning.

When it comes to residents, they must be bronze-certified through Mayo Quality Academy before treating patients. This includes training on simulators before being allowed to practice procedures (like central lines) on patients.

Dr. Swensen also discussed four conflicts in academic medical centers that prevent truly patient centered care:

• Physician Autonomy - As mentioned, a high variation environment is inherently unsafe.
• Financial conflicts - Some care receives higher payments; there are financial conflicts between the doctors and the hospital; and fee-for-service creates conflicts of interest.
• Research - The well-intentioned focus on the mission that "we're here to advance knowledge" can interfere with care.
• Education - The well-intentioned view that "we're here to provide training opportunities" lets trainees practice on patients and causes care to be organized around the training program, rather than vice versa.

As I heard this, I thought about our place. While we have instituted some standard practices, it is clear that we have not gone as far as we might. On the financial front, we have started to move away from fee-for-service, but there is not a uniform payment system across all of our payors. And his comments about research and teaching are often likely to be valid.

I will state immodestly that we are viewed as one of the leaders among academic medical centers with regard to quality, safety, and process improvement. If we still have so far to go, after several years of concerted effort, the academic medical sector as a whole has miles to travel.

Dr. Vollmer and his team continue to tell all

Transparency of clinical outcomes has now become part of the culture at BIDMC, and that is nowhere as evident as in our outcomes for pancreatic resection surgery. These are difficult procedures, where surgical skill matters, but where use of a standardized plan of care (or clinical pathway) makes a large difference.

Our website contains a clear exposition of the results in our hospital. As noted by Doctor Charles Vollmer in our Department of Surgery,

"This summary reflects our initiative for total transparency of the real outcomes from our practice which are available to anyone through our institutional website. We believe this is a unique approach in our specialized field of pancreas surgery, and I would even contend it is rare to see anything like this for any general surgical domains around the country."

Credit for this approach also clearly goes to Dr. Mark Callery, chief of our general surgery division, and also a major practitioner in this particular field.

You can find the website here. The new numbers are about to be posted. Here is a sneak preview, showing the changes from 2007 through 2010.

Volume of Procedures: 82; 73; 86; 89
Mortality Rate: 1.2%; 0%; 3.5%; 1.1%
Length of Stay (Median): 7.5 days; 8 days; 8 days; 7 days
% of Patients Requiring Admission to an ICU: 8.5%; 12.3%; 17.4%; 11.2%
Blood Loss During Surgery (Median): 300ml; 300 ml; 275 ml; 200 ml
% of Patients Requiring Post-Op Blood Transfusions: 14.6%; 26%; 12.9%; 19.1%
Reoperation Rate (within 3 Months): 6.0%; 6.8%; 7%; 3.4%
Readmission to Hospital (within 90 days) Rate: 13.4%; 25%; 29%; 11.2%
Central Venous Line Infection Rate: 0%; 0%; 1.2%; 1.1%
% of Patients Receiving Immunizations Prior to Discharge (for Splenectomy): 100% (all years)

As I have said previously with regard to another topic, if we can post these rates for BIDMC, why can't people from other hospitals? Why can't the insurance companies post them? Where are the public health advocates on this topic? The data are collected regularly by all hospitals. We must get past a culture of blame and litigation and persuade people that transparency works: Real-time public disclosure of key indicators like this (not the untimely publication of "process" metrics) can be mutually instructive and can help provide an incentive to all of us to do better.

Some people have argued that transparency will lead to doctors trying to avoid the high risk cases. I know from personal knowledge of some of their patients that such is certainly not the case with Dr. Vollmer and his colleagues. Note, too, that they make no attempt to risk-adjust the metrics above. These are all-in figures.

No such thing as random failure

Joseph Gavin, Jr., who died in November, was an aeronautic engineer who was intimately involved in the design of the first manned craft to land on the moon. He was also a key player in the rescue of the Apollo 13 astronauts. He was a remarkable fellow, and I had a chance to hear a tribute to him during this past week's meeting of the MIT Corporation. (He was in the class of 1941.)

One of the quotes ascribed to him during the presentation was, "There is no such thing as a random failure."

In this discussion board, a commenter says, with regard to that quote, "Amazing when you look at things now, that in the avionics industry of the time 'random' failures were acceptable! As he says, there is (almost) no such thing as a random failure... Everything has a cause, and in a safety critical system (or one-shot system like this), every failure cause has to be designed out..."

It strikes me that there is a parallel with medical care. I have discussed the problem of "These things happen" that often characterizes the delivery of care. I noted:

Several years ago, we had that attitude in our hospital with regard to certain types of medical outcomes. For example, we were content with our level of central line infections because we were below the national average. After all, these things happen. Then our chiefs of medicine and surgery said, "No, they don't have to happen. When they happen, people die. We are going to insist that we achieve zero central line infections." And then they got to work. As I have noted below, it is not an easy problem to solve, but it is worth the effort, and you can improve.

The science of process improvement can be applied to the delivery of care, as it has been to other high performance service and manufacturing industries. I hope my readers will excuse the degree to which I focus on this topic, but I cannot imagine a more important subject to cover.

This week, several thousand people will be attending the IHI Annual Forum to learn and trade information and stories along the theme of Taking Care. Maybe, if we learn well enough, we can say that "these things" no longer happen.

Here's Ethel Merman, to make the point in her own way. (If you cannot see the video, click here.)

Enthusiastic Transparency

The State of Washington posts a variety of information about hospital infection rates. The latest addition to this is the publication of surgical infection rates. The website provides data on infections following three important types of surgeries: cardiac, orthopaedic, and hysterectomies. The Washington State Legislature required the data to be collected and made public in House Bill 1106 in 2007 and House Bill 2828 in 2010. Here is a section of the press release from the Washington State Hospital Association:

“Washington’s hospitals are enthusiastic participants in providing this new information about surgical infection rates,” said Carol Wagner, vice president for patient safety at the Washington State Hospital Association. “We believe that public reporting helps hospitals improve, assists consumers in making good decisions about hospital care, and creates collaboration between hospitals and quality experts.”

“Hospitals are dedicated to the care and comfort of our patients. In most cases, the data show good results, though there are also areas for improvement. Our member hospitals are working hard to implement changes to stop surgical infections, and we expect the results to get better and better,” concluded Wagner.

Washington State’s infection reporting program is considered a national leader. The National Conference of State Legislatures highlighted Washington, along with nine other states, in its recent report, "Lessons from the Pioneers: Reporting Healthcare-Associated Infections."

Note, too, the publication of central line infection rates and ventilator pneumonia infections.

I like the sound of that: enthusiastic participants. Congratulations to the WSHA for their part in helping bring this about and to the Washington legislature for their leadership.

Two stories about transparency

Here are a couple of stories about transparency of clinical outcomes. I present them for your review and comment.

The first is one from the Los Angeles Times, entitled "'Error-free' hospitals scrutinized." Here are some excerpts:

California public health officials are scrutinizing hospitals that claim to be error-free, questioning whether nearly 90 facilities have gone more than three years without any significant mistakes in care.

Eighty-seven hospitals — more than 20% of the 418 hospitals covered under a law that took effect in 2007 — have made no reports of medical errors, according to the California Department of Public Health.

The high percentage has raised concerns that errors have gone unreported. Some patient advocates say it is an indication that hospitals are unwilling to police themselves. State officials have given hospitals until Tuesday to verify their records as error-free or to report errors, as required by law.

Next, a report from The Health Foundation in the United Kingdom. Martin Marshall, Clinical Director and Director of Research and Development, and the late Vin McLoughlin, Director of Quality Performance and Analysis, have published a paper called, "How might patients use information comparing the performance of health service providers?" It is on the BMJ website. They note:

There is a growing body of evidence . . . describing what happens when comparative information about the quality of care and the performance of health services is placed in the public domain. The findings from research conducted over the last 20 years in a number of different countries are reasonably consistent and provide little support for the belief that most patients behave in a consumerist fashion as far as their health is concerned. Whilst patients are clear that they want information to be made publicly available, they rarely search for it, often do not understand or trust it, and the vast majority of people are unlikely to use it in a rational way to choose ‘the best provider’. The evidence suggests that the public reporting of comparative data does seem to play a limited role in improving quality but the underlying mechanism is reputational concern on the part of providers, rather than direct market-based competition driven by service users.

. . . How should policy makers, managers and clinicians respond to these findings? Some might be tempted to suggest that we should focus only on those who work in the health service and discount patients as important stakeholders. We believe that this would be wrong. The public has a clear right to know how well their health system is working, irrespective of whether they want to use the information in an instrumentalist way. Improving the relevance and accessibility of the data should be seen as a good thing in its own right and may start to engage a large number of people in the future.

. . . That patients might want to view health as something other than a commodity presents a conceptual as well as a practical challenge to those responsible for designing and producing comparative performance information. We suggest that for the foreseeable future presenting high quality information to patients should be seen as having the softer and longer term benefit of creating a new dynamic between patients and providers, rather than one with the concrete and more immediate outcome of directly driving improvements in quality of care.

Sign congestion

Sometimes, with "new eyes," you see things you walk by every day. As I went to visit a sick friend yesterday, not as the hospital CEO but just a visitor, here was the scene I found at the elevator in one of our main lobbies.

Each one of these signs was likely added for good reason. But, in combination, they are problematic -- too cluttered.

Also, they are not culturally competent. The blue sign on the left has several languages. None of the others do.

Perhaps it is time for a Lean rapid improvement event about our signs.

En route to True North

"True North" is a key concept in Lean process improvement. It might be viewed as a mission statement, a reflection of the purpose of the organization, and the foundation of a strategic plan.

Here are illustrative thoughts from two observers:

The "ideal vision" or "True North" is not metrics so much as a sense of an ideal process to strive for. It sets a direction, and provides a way to focus discussion on how to solve the problems vs. whether to try.

If we don't know where we're going, we will never get there. "True North" expresses business needs that must be achieved and exerts a magnetic pull. True North is a contract, a bond, and not merely a wish list.

Lean is inherently the most democratic of work place philosophies, relying on empowerment of front-line staff to call out problems. The definition of True North, however, does not rely on that same democratic approach. Instead, it is established by the leadership of the organization.

At BIDMC, we have been engaged in a slow and steady approach to adoption of Lean. Our actions have been intentionally characterized by "Tortoise not Hare," as we methodically train one another, carry out rapid improvement events, and integrate the Lean philosophy into our design of work. As you have seen on this blog, staff members have come to embrace Lean and have used it in a variety of clinical and administrative settings.

(For more examples, enter "Lean" in the search box above. I have been presenting them here for some time in the hope that they would be useful to those in other hospitals who are thinking of adopting this approach.)

We have intentionally not, until now, tried to define True North, but things have now progressed sufficiently in terms of our application of the Lean philosophy that the organization is crying out for it. This is just as we had hoped. Establishment of True North before this time, i.e., without an understanding of its role, would not have been as useful in our hospital.

So, the clinical and administrative leaders recently met to try to nail this down. The process is not over. Indeed, our Board of Directors has yet to pitch in and offer their thoughts. But, we are far enough along that I thought you would enjoy seeing the draft.

Here it is:

BIDMC will care for patients the way we want members of our own families to be treated, while advancing humanity's ability to alleviate human suffering caused by disease. We will provide the right care in the right environment and at the right time, eliminating waste and maximizing value.

Here is some commentary to help you interpret and deconstruct this. The first sentence is based on the long-standing tradition of our two antecedent institutions, the New England Deaconess Hospital and the Beth Israel Deaconess hospital. The late doctor Richard Gaintner used to refer to the Deaconess as, "A place where science and kindliness unite in combating disease." That could just as well have been applied to the BI. As an academic medical center, our public service mission of clinical care is enhanced by -- and enhances -- our research and education programs. Our mission is to help humanity, not just the people who live in our catchment area.

The second sentence is offered in realization that the Ptolemaic view of tertiary hospitals as the center of the universe is no longer apt (if it ever was!) We need to view ourselves as being in service to primary care doctors, community hospitals, and other community-based parts of the health care delivery system.

On another level, it is also reflective of the fact that society expects us to be more efficient both within our own walls and in cooperation with our clinical partners, adopting approaches to work that do not waste societal resources.

In contradistinction to what I just said about this not being a democratically established statement, I offer our draft to you -- both those within BIDMC and worldwide -- for your criticism and suggestions. I don't know of other places that engage in this form of crowd-sourcing with regard to True North, but readers of this blog are unusually informed about health care matters, and I welcome your observations.

Transparency arises in the South

Novant Health is a not-for-profit health care organization serving more than five million residents from Virginia to South Carolina. Their team recently decided to dramatically expand the degree of transparency they provide with regard to clinical outcomes.

Paul Wiles, Novant's President, said to me: "We are delighted that you are willing to let your readers know of our efforts to enhance the field with respect to transparency of clinical information."

If you go to this website and click through the various categories, you will see an honest and open exposition of how they are doing on central line infections, ventilator associated pneumonia, and other important items. They mean it when they say that they are "committed to providing clear, accurate and honest information about the quality of care we offer to all of our patients."

Here's the VAP chart, which is illustrative, too, of the presentation of quite recent data. Why wait two years for national numbers based on administrative data when virtually every hospital collects real-time data on actual clinical outcomes?


Paul continued, "Our latest quarter is now posted. We had some improvements, some the same and unfortunately some declines in our performance. With our results in the public domain we have a real incentive to make our results better."

This view is consistent with what I have said before:

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.

Congratulations to everyone at Novant for making this commitment. Do I detect a movement? Will the Boston hospitals join in?

Mungerson Lecture

I was honored to present the 2010 Mungerson Lecture at Advocate Illinois Masonic Medical Center today. The lecture is named for Gerald Mungerson, an inspiring leader and a passionate advocate for the health and wellness of the communities he served. This included Boston, where, prior to going to Chicago, he served with distinction as General Director of what is today is part of the Brigham and Women’s Hospital. (You see his son, Andy, and wife, Cynthia, in the accompanying picture.)

As explained to me by Susan Nordstrom Lopez, President, "Each year we select the Mungerson lecturer on the basis of his or her dedication to health care and record in improving a health institution, practice or community. Like Jerry, the Mungerson Lecture balances clinical rigor with the critical need to involve lay people in understanding, supporting and improving health care."

I was asked to expand on a topic covered on this blog, "On Purpose," with a particular emphasis on the role of quality, safety, transparency, process improvement, and patient involvement in the new health care environment. Of course, this was a bit like preaching to the choir, as Advocate Illinois Masonic Medical Center does an excellent job on these fronts. Their commitment to transparency is exemplified in these posters on the various floors of the hospital, where staff, patient, and visitors can see progress on a variety of indicators and metrics.

The cath lab goes Lean

I had a chance yesterday to get a presentation on the use of Lean process improvement techniques and philosophy in our catheterization lab. This is a very busy place where diagnostic and interventional cardiologists string catheters through people's blood vessels to evaluate the extent of cardiovascular disease, open up blockages, and extend lives.

Tech Kenny Lee and nurse Eric Harrington, along with Kimberly Eng from our Business Transformation group, led me through the analysis that has been done of the current state and the proposed future state. There will be dramatic improvements in the quality of people's work day as a result. In addition, staff and patient safety in and around radiation-rich areas will be enhanced. There have already been substantial improvements in inventory control, too, leading to major cost reductions. The renovations of the space and continued reorganization of supplies and equipment designed during the Lean process will take place in the coming weeks.

Here's a video tour. If you cannot see the video, click here.

Joint Commission Report

Representatives from the Joint Commission visited us last week for their periodic survey. I post below today's email from me to our staff. As noted, the actual report is available for all to see. We view that as an essential way to make sure all people here can benefit from this appraisal of our clinical quality.

Beyond the report and the email below, I want to mention an important item for your consideration. Many readers here will recall our dedication to transparency about a wrong-side surgery event several years ago. With full staff participation, we then devised a new pre-surgical protocol.

During this survey, this protocol was viewed in actual surgical settings by one of the surveyors, who said, "That is the finest time-out I’ve ever seen." The JC surveyors said they would recommend it as a "best practice" to be shared with other hospitals throughout the country.

I view this as yet another validation of the use of transparency to help obtain process improvement.

Here's the email:

Dear BIDMC,
As many of you know, we recently had a visit from the Joint Commission, the organization that accredits all of the hospitals in America. The surveyors from the Joint Commission spent several days here in intense review of our physical facilities, our information systems, and -- most importantly -- our actual delivery of care to patients.

As is the current practice, this was an unannounced visit, with the surveyors showing up on a Monday morning with just a few hours notice. The people who came were excellent, thoughtful, and comprehensive. There were six surveyors who spent a total of 24 surveyors days with us. In all, they talked with almost 300 of our staff members and visited 49 unique sites on and off campus.

They found some things that needed improvement, but they also had many compliments for the hospital in general and for many, many of you in particular.

My favorite quotes from them during the week were, “The team is impressive – it’s a privilege to be a witness to the care being provided;” and "They are completely committed to what they do -- inspirational."

Consistent with our practice, we want you to have the advantage of their work product, so we have posted it on our website. Please read it.

With gratitude and appreciation,

Paul

Fishbones

To follow up on yesterday's post about the CC6 Lean team, I had a few minutes today to drop by just as the group was getting engaged in fishbone diagrams. These are used to brainstorm in more detail the nature of major problems, looking at their components and then asking the "five why's" to conduct a root cause analysis.

As I walked into the room during a break, a couple of people mentioned to me that the morning session had been a lot tougher, emotionally, than yesterday's current state analysis. This is a common stage in the Lean process. It is relatively easy to map out the current state. When you start talking about why it exists, it is hard not to blame someone else in the room or someone who is not in the room. "If [name] only did this differently, we could solve the problem," is the common refrain I have seen in other rapid improvement events.

But, the idea of Lean is to focus on the problem and not the person. This is not about blame. It is about a workplace environment that has evolved over the years -- full of work-arounds and inefficiency and waste. By the time I left, the group was again smiling a bit more and collaborating on how to analyze the situation. Later, they will invent countermeasures to help undo the waste, setting goals and targets and timelines for the next steps.

Here is a short video about fishbones to give you a sense of the concept and how it progresses. Jenine Davignon from our business transformation group is leading the class. If you can't view the video, click here.

Wow, they work hard!

The roll-out of Lean at BIDMC continues throughout the hospital. A current project is to redesign the work flow on "CC6," one of our busiest medical/surgical floors. Although the staff has been working on this for several months, it can be difficult to find time during the workday to make improvements when nurses, patient care technicians, and others have full patient assignments. So, this week, we have taken two days aside for an improvement event, during which the staff will have dedicated time to look at their processes and experiment with improvements.

I dropped by for a short time today to watch people outline the "current state" of their work flow. A person in each job category prepared a step-by-step itemization of their daily routine. I offer a videotape of sections of this below. In order, you will see Stacey Adamson, physical therapist; Dawn Castro, resource nurse; Mike Crowley, unit assistant; and Laurie Phillips, case manager. You will also briefly see Jenine Davignon, a management engineer from our Business Transformation office, and Allison Wang, a college co-op student in that office. And finally Oscar Juarez and Sandra Espinosa, being reminded to post lunch breaks as part of a busy day in the work flow of a patient care technician.

I was impressed by the complexity of each person's job. I also began to see, as they presented their daily work, opportunities for reducing waste and improving the work environment and patient care. The team will undoubtedly find many more of those opportunities during this two-day session. If I can drop by tomorrow, I will report back to you.

If you cannot see the video, click here.

College student cleans up

Continuing our short series about summer student projects, here you see Aviva Hamavid, a college student intern, participating in our freecycling program. This is based on the idea of a swap shop. You bring in office materials you don't need, and other people take them.

“The idea is to take existing supplies which, for one reason or another, are not being used and give them a new life where they can be used,” says Aviva's supervisor, BIDMC’s Sustainability Coordinator Amy Lipman. “Sharing these items keeps them out of landfills and helps save money throughout the medical center.” We do this twice a year, and the events have made paper, hanging folders, file folders, binders, unused toner cartridges, envelopes, labels, desk organizers and other useful office items available for free to all staff. (Regular readers will remember that I also ran my own version of this last year.)

You see Aviva and Amy in action in the video below, where they have set up the freecycle station in a corner of our cafeteria.

If you cannot view the video, click here.

Point-Counterpoint

A recent Boston Globe op-ed by Suzanne Gordon argues in favor of state-mandated nurse staffing ratios for hospitals. A response to this was submitted as a letter to the editor by our chief nursing officer. Here are her thoughts:

We can all agree that more nursing time spent directly with patients results in better patient outcomes. But mandated nurse to patient ratios, which Suzanne Gordon advocates in her Aug. 5 op-ed “Critical care,’’ are the wrong way to achieve this goal.

Those of us applying proven improvement methods in health care, such as Lean and Six Sigma, have learned what the manufacturing world has long known. We need to free nurses from the administrative burdens, inefficient activities, and wasted steps that do not directly add value for patient care.

In an environment of rapidly expanding health care costs, legislatively mandated nurse to patient ratios are unsustainable.

Yes, we need more nursing time spent directly with patients. But we must achieve this by aggressively applying improvement techniques to remove waste from our workflow. This is the only sustainable way to both control costs and improve patient safety.

Marsha L. MaurerSenior vice president, Patient Care ServicesChief nursing officerLois E. Silverman Department of NursingBeth Israel Deaconess Medical CenterBoston

AARP confirms value of mystery shoppers

I have written here once or twice about our mystery shoppers. Here's a new article in the AARP Bulletin on this topic.

As noted in this story, we continue to find this a very important way of meeting our patients' expectations:

Sherry Calderon, manager of ambulatory services at Beth Israel, says: “I really feel like this kind of regular checking has driven change here that nothing else has.”

Toussaint and Gerard tell us how to get on the mend

John Toussaint and Roger Gerard have published a book entitled On the Mend: Revolutionizing Healthcare to Save Lives and Transform the Industry. Ordinarily, you would be well advised to be skeptical of anyone promising revolution and transformation, but not here.

Here's an excerpt from the introduction:

With few exceptions, [government policy] debaters assume that healthcare costs are fixed, that America's proud history of medical care and innovation comes with a staggering bill.

We know different.

Governments can tweak payment systems and probably get some temporary fiscal relief. But until we focus reform efforts on where most of the money goes, which is healthcare delivery, we will remain stuck in a revolving door of near disaster and narrow escapes. To get to the point where all people have access to high-quality healthcare, affordably, we must focus our attention on how the healthcare delivery system determines costs and quality. Then we need to change that delivery model entirely.

In fact, hospitals, physicians, and nurses -- all of healthcare -- must change. First, we must emphasize the science of medicine over the art. This means turning to evidence-based medicine, which is already underway in some sectors. But we are also talking about evidence-based delivery, work that has barely begun.

And then, they go on and explain how to do this.

You can get a sense of the message in this video produced by the Lean Enterprise Institute, which also published the book. If you can't see the video, click here.

Lean is for bakeries, too

There is a problem once you learn the Lean philosophy and techniques: Every setting prompts you to imagine how much better it could be if these principles were adopted.

Earlier this week, a friend gave me a sample of some marvelous cranberry bread from a new bakery in Wellfleet, PB Boulangerie. She warned, though, that the place has long lines and that I should be prepared to wait, unless I arrived at the 7am opening time. I arrived at 7:05 and found a line of 20 people. Here is a picture of the ones behind me after I had been there ten minutes.

Now, it is summer on Cape Cod, and who really cares if you have to wait? You meet people from all over and compare notes about beaches, restaurants, and the like. But, then we noticed that the line was scarcely moving. Earlier customers set up their coffee and pastries at a nearby table, and they were practically finished eating by the time I approached the front door.

Once inside, the problem was made evident. There were plenty of serving people (four), but the bakery was rife with batch processes. Two people were in charge of taking orders for bread and pastries; one person was in charge of coffee orders; and one person was the cashier. After the bread person took your order and put it carefully in bags, s/he would place the order on a low shelf, under the counter near the cashier. Meanwhile, the coffee person would hand you your coffee directly.

By the time you got to the cashier, she had become a bottleneck. She would reach under the counter and grab the closest order, and lift it up and place it on the counter and say, "Did you have two baguettes?" and you would say, "No, I had the brioches," and she would bend down and replace the first order with your order. Meanwhile, some independent process would be going on for the coffee.

The person next to me was a process engineer, and so you can imagine the conversation we started to have. What if there had been a continuous process, with visual cues, all focused on the needs of the customers? The possibilities were endless.

In this case, though, the elapsed service time, start to finish, was 55 minutes.

But, here are the almond paste and raspberry brioches, along with the cheese bread and cranberry bread. Worth the wait!

Staff talk about purpose

Here are some responses I received to the staff email presented below. I never know how my messages will be received or what reactions they will provoke. I can always count, though, on thoughtful engagement and a reaffirmation of the underlying values of our hospital.

Excellent example of actualization of purpose versus a mission statement not so well actualized. (Radiology)
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I love it, thanks. I have always tried to live by, "Treat others as you would have them treat you" and have raised my children as my parents raised me. My daughter now works as fitness trainer working with the elderly (many of whom remind her of her now deceased grandparents) and my son found his passion working to integrate those with special needs. To know that I work for such a special organization makes coming to work even more enjoyable.

Working with women in OB/GYN, I try to treat each on as I would want my mother, sister, or daughter treated. It makes no difference to me when I am informed that a patient is a doctor or wife of one. No one gets special treatment, because I feel everyone that comes here gets SPECIAL treatment!
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I have always believed by giving some control back to the patient, it helps eliminate high anxiety and make the patient feel respect. Thank you for your thoughts. (Med/Surg)
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As a nurse on labor and delivery I just wanted to say that was a wonderfully put statement. As you know we on L&D form very strong emotional bonds with our patients and their families sometimes repeatedly with additional children . We form a certain kind of interdependence relying on each other in a way that is truly unique. Thanks for the "heads up." We appreciate it, and it made total sense. Also made me smile.
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Hi Paul...this is a great message from you, and I look forward to hearing more, as time goes on. You may remember several years ago when you hosted small groups for dinner, we spoke about treating patients as we would want our own families and loved ones to be treated. As part of my interviewing process, since I began in this position, I have always referenced that message. What I tell applicants (and anyone else who will listen to me!!) is, "I need people who treat everyone, but I will concentrate on patients now, as they would want to be treated or how they would want their families or loved ones to be treated." If we don't do this, then when our time or their time rolls around, and it does roll around for all of us sooner or later, we have no right to expect more than we've given. And even if it feels like it isn't happening, that's okay, do it anyway because it's the right thing to do!

Your statement, "It is very different from the training received by doctors, and even that received by many nurses. Beyond being respectful, empathetic, and compassionate, it requires us to be ever modest about our knowledge and in our demeanor."

This is key! Until and unless we all recognize and appreciate that we all need the next person in order to be successful, to make the clock tick, we will never rise to the level we otherwise might. The surgeon needs the housekeeper to clean the OR, the housekeeper needs the equipment to accomplish the work, the manager needs a strong staff, and on it goes. I have always believed that no one is more important than the next, and that, in medicine, patients must be listened to with great attention; if not, we've lost a great deal in the process and will never reach the heights that we are capable of reaching - together. The crush is on in health care, all around! (Gastroenterology)
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Thank you very much for sharing with us the airline industry story. it is so true that we can never forget what we are working at BIDMC for. We are here to carry a big mission in delivery -- the best and safe care for our patients and their families.

We should never forget how lucky we all are that we are not standing the other side in needing that care but using our skill and knowledge in helping the others. (Peri-Operative Services)
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I was thinking precisely the same things about airlines and customer service as I flew back to Boston on a crowded flight on Saturday. I always check Southwest first, not because they're necessarily cheaper, but because I like their ethic, and the tension on other airplanes due to carry-on baggage simply doesn't exist there.

Not too long ago, I asked a flight attendant at another airline how they coped with the increased carry-ons. She surprised me by saying that their cabin crew were not actually logged in as "at work" until the flight took off. Any arranging of bags and assisting of passengers before take-off was quite literally done on their own time. So, apparently, it's the customers and the staff who are suffering from the checked-bags policy.

Compare that with our ethic here at BIDMC - treating patients "as we would like ourselves and our families to be treated". This is so often the way to make the patient experience simpler, more efficient, and crucially - more welcoming. A motivated staff understand and agree with the reasons for doing what they do. That's a large part of what we Mystery Shoppers encourage among our terrific front-line BIDMC staff.

Thanks for a thought-provoking message. (Ambulatory Services)

On purpose

An email I sent to our staff last night:

Dear BIDMC,

Stick with me through some background that might seem irrelevant. Then, I hope you like where it leads!

A few weeks ago, I heard a talk by Roy Spence, the author of It's Not What You Sell, It's What You Stand For: Why Every Extraordinary Business Is Driven by Purpose. As suggested by the book's title, his proposition is that truly excellent organizations are those characterized by a common sense of purpose. This is different from having a mission statement or corporate objective, which state a business direction. It is more about having a desire to change the world for the better.

An example Roy gave was Southwest Airlines, who purpose is to give people the freedom to fly. You could probably quote the tag line: “You are now free to move about the country.” I listened as he talked about the airline’s actualization of this sense of purpose. One example occurred when the entire airline industry decided to start charging for baggage. Southwest was advised by its financial people that doing the same would save millions of dollars and make millions of dollars. The company decided, though, that charging people for luggage would conflict with its purpose and so -- contrary to all advice -- not only decided not to charge for luggage but to begin a now famous Bags Fly Free advertising campaign. “We love bags!” proclaimed actual baggage handlers on the tarmac.

Sure enough, the company did not save or make millions of dollars from this decision. It made billions of dollars, as the public responded by shifting gobs of business from other carriers.

I hadn’t thought about this much until today, when I got on an American Airlines flight and noticed virtually every passenger board a full flight with a “rollerboard” style suitcase to put in the overhead bins. They were all trying to avoid the $25 fee for checking their bags.

The tension was palpable among the passengers and the flight attendants. Passenger who boarded later peered ahead in the aisle wondering when the next open spot would be for their bags. Flight attendants were alternating between repacking each overhead bin to maximize its carrying capacity and hurrying passengers along so we could have an “on-time departure.”

The result: Airline employees were devoting all of their emotional energy to the baggage. If you had questions about anything else, they could not make eye contact because they were scanning the bins for empty spaces.

Another result: Passengers’ relative comfort with the flight had already been diminished, and we hadn’t even taken off yet. Categories were created between the “have’s” and “have not’s”. Those of us who arrived earlier (because of “priority access”) felt the calm superiority of secure overhead bag placement, while those who arrived after felt like they had missed something. One person actually asked me how I had managed to get on board before her.

To think, this all started with a different sense of purpose. For Southwest’s staff, everything is about wanting to give us the freedom to fly, and because of that, the airline’s customers never have a doubt.

I realized that I’d be hard-pressed to know American Airlines’ purpose. I opened up the magazine in the seat pocket to see if I could find it. There is a letter from the CEO which says something about “all my AA colleagues all over the world who put their hearts and souls into taking you wheresoever you want to go in the world.” At first blush, you might say that is the same thing Southwest says, but it is not quite the same. The AA line is about their doing something for you, not your doing something for yourself. It is not liberating: It is creating a dependence.

Let’s switch to medicine and hospitals now. As you all know, at BIDMC, we have a long-standing purpose. It is not a business objective in our strategic plan or mission statement, but it is deeply held: “To treat patients and their families as we would want members of our own family treated.” Achieving this purpose is a full time endeavor for all of us who work here -- including those involved in research and teaching as well as clinical care.

In the last eight years, we have accomplished a financial turn-around, successfully implemented a strategic plan and gained market share, dramatically enhanced patient quality and safety, come together as a community during economic hard times to save jobs and to protect our most vulnerable staff members, and begun an approach to process improvement (Lean) that is highly respectful of one another.

And, through it all, we took great care of patients and their families.

Notwithstanding these great successes, we have begun to learn that we cannot satisfy our purpose if we make all the decisions for patients and their families. In the ICUs and elsewhere we have established patient and family advisory councils that bring in the wisdom of our clients in logistics, space planning, and even clinical protocols. Several months ago, I wrote about one such effort in our ICUs that actually received international recognition.

Of all the lessons we have learned here at BIDMC, this may be the hardest. It is very different from the training received by doctors, and even that received by many nurses. Beyond being respectful, empathetic, and compassionate, it requires us to be ever modest about our knowledge and in our demeanor.

This kind of approach is most successful when it is a partnership, where dependence in one direction is transformed into bidirectional interdependence. I'm not writing today to provide lots of details, but to give you a heads up: Over the coming months, look for an expansion in our engagement with these advisory councils and other outreach to our patients and their families. We also plan to work with the Institute for Healthcare Improvement to encourage and enhance the activities of patient-run organizations in Boston and beyond.

If we can learn to be full partners with our patients in carrying out our purpose, the sky’s the limit.

Thanks, as always, for your involvement, support, ideas, passion, and encouragement.

Sincerely,

Paul

Timidity in Massachusetts

Over three years ago, while posting our rate of central infections, I asked the following questions:

If I can post these rates for BIDMC, why can't people from other hospitals? ... Why can't the insurance companies? ... Why can't the state of Massachusetts? ... 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.

Well, Massachusetts is getting passed by on this front. Here is a presentation showing the rate of central line infections for all of the hospitals in Illinois for 2009. If you sort on the column "infections per 1,000 central line days" by clicking on that header, you will find 50 hospitals with zero infections, and 31 more with fewer than one per 1,000.

This kind of presentation does not require state action. The Massachusetts hospitals could together decide to do this voluntarily. We all collect the data for our own hospitals. It would impose no administrative burden to forward it for publication to a collective website. (Look here to see BIDMC's figure, posted every quarter.)

What more persuasive way to demonstrate to the public and to legislators that we collectively are serious about eliminating one important form of hospital acquired infection? That we are willing to be held individually and collectively accountable to a standard of care to reduce harm to patients? That we likewise are willing to be held to a standard of care that also saves dollars for an overburdened health care system?

Look at this related story in the Chicago Tribune. An excerpt:

Ten years ago, Dr. Bob Chase would have laughed if someone had told him common infections could be eliminated in hospitals' intensive care units.

"I would have said that's ridiculous, not possible," he said. "As a physician, I was trained to believe bad things just happen."

But Chase, vice president of quality at Norwegian American Hospital in Chicago, doesn't think that anymore. A growing body of research has convinced him that many infections can be prevented if proper procedures are rigorously followed — evidence he's using to reduce higher-than-expected infection rates at his own institution.

The research is prompting a wave of improvements in hospital ICUs, and patients are starting to benefit: At many hospitals, the rates of some common infections have been cut in half or more, saving lives and money and preventing medical complications.
Why are the health care leaders in Massachusetts so timid on this issue?

Not enough, AHA

The American Hospital Association does excellent work in representing the views and interests of hospitals across America, and it genuinely seeks to help frame medical and hospital issues in a way that serves the public interest.

But because it is a membership-based organization, it can be hard to be as aggressive on some issues as the times call for. One such discussion is going on right now. The Association is considering a number of strategic performance commitments, one of which is to "advance a health care delivery system that improves health and health care."

I can't argue against that goal, but the manner in which it would be pursued and quantified is weak. See the slide above. It is the draft of what is being discussed by hospital associations across the country.

The first two items are certainly worthy, but the manner in which they are measured is problematic. The metric is a three-year running average produced by CMS and published a year after the year is over. Accordingly, no one will know if the 2012 target is met until 2014.

Why rely on administrative data collected by CMS when every hospital has its own data in real time? Why use a three-year rolling average when we are trying to demonstrate progress over the coming year or two?

The third goal, to achieve improvements in central line infection rates, is simply inadequate on its face. The idea of taking three years to move from the 2009 baseline of 5 cases per thousand patient days to a new target of 1 in 2012 does not reflect the deadliness of hospital acquired infections nor the progress that any hospital can make to reduce them in just in a few months.

The target for central line infections should be zero. That is the only intellectually compelling goal. The time period for doing this should be much, much shorter.

Non-zero sum

Let's face it. Health care is an odd field. Costs are unknown or indecipherable. Prices for the services offered are hidden from consumers. Likewise, the value (efficacy, quality, safety) of the services received is hidden from consumers. In no sense does it represent other markets, in which transparency of these elements reigns and which therefore have a better chance of reaching the "efficient market" described by economists.

In such an environment, growth in market share by one participant is usually solely at the expense of another: a zero sum game. But even in the dysfunctional world of hospitals and physician marketplaces, such transactions can add value to society. In that case, the result is a non-zero sum game. But only if the "winners" actually do add value.

The business strategy of our hospital is remarkably straightforward. We hope to be the high quality, low cost provider among academic medical centers in our region. We look for community-based partners -- hospitals and physician practices -- for whom we can respectfully help to deliver coordinated care. You have read numerous examples on this blog about how we are trying to do this.

But this is more than a business strategy. It is a matter of values and mission. You won't find this mission statement written in our formal documents or in any strategic plan. Its strength lies in the fact that it is a deeply held belief.

I never told you this story, but when Gloria Martinez, one of our transporters, won our first caller-outer-of-the-month award, she first graciously accepted the award on behalf of herself and the other transporters. Then, with no coaching or prompting whatsoever, she said that she and her colleagues viewed their job as "trying to provide the kind of care we would want members of our own family to receive."

I know I do not violate confidences when I tell you that this simple statement from Gloria left tears in the eyes of our Board members. That a person who pushes beds and wheelchairs and delivers specimens -- who in another institution might be anonymous and ignored -- could simply and elegantly express the community purpose of our hospital was a very moving moment.

We fully engage clinical transparency because we view openness in such matters as the best way to hold ourselves accountable to the standard of care we -- the Board, the clinical leaders, and the administrative leaders -- have set for ourselves. We do not do this for competitive purposes, but if the health care marketplace recognizes our progress and rewards us with a growing market share, we are happy to contribute to a non-zero sum result for society.

Progress in the ICUs

Our Medical Executive Committee recently received a report from our Critical Care Committee. I cannot be more proud of our staff and the progress they have made to reduce harm and improve quality of care in our ICUs. I include two of the charts.

Let me translate the implications of the reduction in Ventilator Associated Pneumonia (VAP). Preventing 744 cases over three years -- at a treatment cost of about $20,000 per case -- translates into a societal savings of $14.9 million during this period.

The rate of central line infections also dropped from 4.14 to 0.52 cases per 1000 patient days between FY2003 and FY2009, a reduction of 83%.

This probably reflects lost revenue for the hospital under the fee-for-service reimbursement system. So why do we do it? First, because it is the right thing to do and saves lives.

Hundreds of lives.

On the business front, it has contributed to a reduction in length of stay in our ICUs. We were able to avoid the multi-million dollar capital cost of expanding our ICU capacity. Indeed, we were able to create capacity out of the existing facilities and improve throughput.

I hope that those who argue that global payments (i.e., capitation) are a necessary condition to create societal cost savings and improve patient care will read this. I do not deny that such a payment methodology may be worth implementing for other reasons, but there is a lot that can and should be done under the current payment system.

While the state debate goes on about cost control, why can't we get all of the hospitals in Boston to release information like this about their quality improvement efforts to provide the public and public officials with a sense of confidence that we care about these matters and are willing to be held accountable.