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.

Wednesday, August 25, 2010

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.

Wednesday, August 18, 2010


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. Maurer
Senior vice president, Patient Care ServicesChief nursing officerLois E. Silverman Department of NursingBeth Israel Deaconess Medical CenterBoston

Tuesday, August 17, 2010

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.”

Thursday, August 12, 2010

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.

Saturday, August 7, 2010

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!

Wednesday, August 4, 2010

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)
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!
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)
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.
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)
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)
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)

Tuesday, August 3, 2010

On purpose

An email I sent to our staff last night:


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.