Really, the most significant?

Medscape Today has an article featuring "The Most Significant Medical Advances and Events in 2011."  The list includes things like some FDA drug warnings; the fact that the Supreme Court will review the health care reform law; some finding about cellular phone use and brain activity; withdrawal of propoxyphene from the market; and new listings of top hospitals.

To which I say, "Bah, humbug!"  Most of the things mentioned have had and will have little or no impact on you, me, our relatives and friends as we seek to get care or avoid care.

What are the most significant advances and events?  They are the ones that have occurred by communities, patients, and clinicians in their home towns or their home regions that demonstrate the potential for real improvement in clinical care.  These are the ones that save lives now.  These are the ones that empower patients to be true partners with their caregivers and vice versa.  These are the ones that have nothing to do whatsoever with government mandates, accreditation actions, and the like.

These are the ones that occur because, by strategy or opportunism, well intentioned and thoughtful people modestly work together to reorganize the work in hospitals and other settings.

Examples from this blog are:

1 -- A patient named Christian who persuaded a nurse to allow him to administer his own dialysis, and who then trained others, transforming care in a Swedish hospital.

2 -- Peter Pronovost and colleagues document that reducing central line infection rates in Michigan also lowered costs.

3 -- Glen Cove hospital achieves 1223 patient days without a central line infection.

4 -- The one million people of Saskatchewan allocate $5 million per year of government funds to establish and maintain a Health Quality Council, an independent agency that measures and reports on quality of care in Saskatchewan, promotes improvement, and engages its partners in building a better health system.

5 -- The University of Michigan Health System demonstrates the power of adopting a Lean process improvement philosophy and generously shares its experience with the world.

6 -- Jeroen Bosch Hospital in the Netherlands celebrates the opening of a new building by enthusiastically endorsing transparency of clinical outcomes.

7 -- Aided by the Vermont Oxford network, thousand of neonatologists create state consortia to to set statewide targets and objectives, compare best practices, and understand the variability in clinical practices across and within institutions. 

8 -- The SCAD ladies band together and influence the direction of medical research.

9 -- The Sepsis Alliance presses for greater awareness of this deathly clinical syndrome.

10 -- The Manukau District Health Board in New Zealand propounds the following philosophy: 

What we need to do if something goes wrong is pull back from the instinct to place blame and instead think more deeply about the contributing factors. We need to think about how the system got us to where we are and where the faults in it lie.

More on Lean from Michigan

I want to add a couple of more items to the post below about John Billi's MIT-sponsored webinar about Lean at the University of Michigan Health System.

When the Lean approach was first adopted at UMHS, there were some notable successes which I would term "projects."  For example, a rapid improvement event was held to redesign the carts used for blood draws, using the 5S approach that I have often referenced on this blog.  Here's the "before" view:

And here's the "after" view:

This is all good stuff, but it is not a full-fledged implementation of an organizational philosophy.  What UMHS found out  is that the cultural change inherent in Lean takes a long time to become embedded in the firm.  At BIDMC, we used to talk about "tortoise not hare" when we described that.  In essence, the process of adopting Lean becomes a Lean process itself.  It is one of modesty and constant learning.  Look, for example, at what John presented for the coming agenda for his institution.

The other point John made is when a map is constructed to enable all to all aspects of the value stream, "it's not the map that's valuable.  It the process of mapping, which produces a shared understanding of the value stream and which enables the front-line team to design improvement experiments together."

Lean progress at the University of Michigan

I just listened to an extraordinarily well done webinar from MIT, presented by Dr. John E. Billi, associate dean for clinical affairs at the University of Michigan Medical School and associate vice president for medical affairs at the University of Michigan. John leads the Michigan Quality System, the University of Michigan Health System’s business strategy to transform clinical, academic, and administrative functions through development and deployment of a uniform quality improvement philosophy.

As noted in the webinar summary, the University of Michigan Health System (UMHS) has been on the lean journey for the past six years, creating the Michigan Quality System. UMHS has 20,000 faculty, staff, and trainees. The goal is to create 20,000 problem solvers who are finding and fixing root causes of problems they face daily. Dr. Billi described UMHS’ initial approach, results of early experiments, what leaders learned, and how they adjusted. The discussion covered the transition from scattered projects led by coaches to an integrated approach that incorporates people development and process improvement.

John's presentation was one of the best I have heard on this topic.  His slides, too, were clear and descriptive.  I'd like to show you all of them, but let me pick a few.  The thing I liked best was the modesty and transparency demonstrated.  Even after years of doing this work, John felt comfortable starting with this slide, showing where is system still needs work:

That he would feel the need to do so is even more striking when you look at some of the successes.  Here are some results from cardiac surgery:

I liked the story about increasing mobility of ICU patients.  Here's the summary chart:

But even better than the substantive results was the fact the Lean approach resulted in pull-based authority.  Having achieved a broad consensus on objectives and experiments, the front-line team was able to exercise their discretion in how to carry out the improvement.  You see them here accompanied by the grandson of a patient, another key participant.

John summarized other key lessons.  The first is about how authority must devolve to make Lean work.  "Leaders have to show respect, which means trusting people to solve their own problems if they are given the tools."

Finally, to reach the goal of having 20,000 problem solvers, you need to design brilliant processes, based on creating standard work.

I have some more observations in the post above.

When is a protocol not a protocol?

Answer:  When people don't follow it?  Better answer:  When people don't think they should follow it?  Still better answer:  When people don't follow it and people are harmed.

Lola Butcher (could we have picked a better teaser of a last name?) writes in Hospital and Health Networks that, according to the head of The Joint Commission, "surgeries on the wrong side of the body, the wrong site or even the wrong patient continue to occur an estimated 40 times every week."  She notes that the JC "first highlighted the problem of wrong-site surgery in 1998."  Further:

The Joint Commission already requires accredited hospitals and surgery facilities to use a universal protocol that covers preoperative verification, marking of the surgical site and taking a time-out by all members of the surgical team immediately before the procedure begins. The extent to which the protocol is followed varies widely.

While things sounds like a prima facie case of failure on the part of the accreditation body, it is more than that.  The clinical director of the Pennsylvania Safety Authority notes that  there have been some successes in the country, but:

"When you subtract out the 50 facilities that have been in those collaborations, we don't see any change at all in the remaining facilities," Clarke says. "We do think we have made a difference, but it's only when hospitals actually make a commitment to change their systems.""

The simple truth is that many doctors don't buy in to this.  I've heard of some anesthesia writings that cite the statistics indicating the errors continue as evidence that the checklist protocol does not work!  These observers completely ignored whether the protocol was actually being followed or not.

Let's go back to The Joint Commission.  As I have discussed, failure to pay for such "never" events is not effective.  While I am not keen on regulatory interventions, it is possible to use a light, but effective hand that could make a difference.  How about starting by publicizing all cases on the public JC website, with the name of the hospital?  Keep them in the public eye until a root cause analysis has been done and a remediation plan put in place.  Then, share those success stories widely, as opposed to hiding them behind the JC paywall.  

If that approach doesn't start to get results, adopt a policy of putting the hospital on probation, in terms of its accreditation, until a root cause analysis has been done and a remediation plan put in place.

A final toast to IHI

Just when I thought it was safe to eat the oatmeal, I discovered problems with the bagels!  Readers from last year's IHI National Forum may recall my series of articles about the non-Lean system used to serve oatmeal at the conference facility.  That was a four-part series.  And remember, too, this Lean conference in Springfield, MA, where they had a problem serving the toast.

So, now, look at this set-up.  I first saw the potential for a problem when I came downstairs and noticed a really, really large number of bagels and one four-slice toaster per station.  I guessed that this would create backlogs.

And, voila!  When the people came to eat, sure enough.  Not enough toasters for the flow of traffic.  We had introduced a blocking batch process in what should have been a cleaner continuous process.  This creates waste, in the form of unnecessary time spent.

One of the hotel staff people saw me taking the pictures, and we started joking about the problem.  S/he said, "We used to have another toaster at each station, but the electrical circuitry in each socket got overloaded, so we had to remove one.  This back-up always happens."

This demonstrates that in a facility, Lean starts in the design.  The architect and electrical planner for this conference center did not have a full understanding of how the building would be used.  Waste built in is waste that lasts forever.  Another lesson to those in health care.

Cooley Dickinson KOs C. diff

Cooley-Dickinson Hospital in Northhampton, MA, has had an exemplary record for infection control, knocking out central line infections for an extended period, but they have just reached some new heights.  They used a high intensity, pulsing ultraviolet light to kill Clostridium difficile and MRSA (methicillin-resistant Staphylococcus aureus) bugs in patient rooms and elsewhere.  C. diff, a bacteria that can cause diarrhea and when severe can cause sepsis and death, is a difficult organism to kill: Its spores lay dormant but potent on surfaces of patient rooms (e.g., walls and bed rails).  Bleach is the most effective cleaning agent, but it is hard to know if all areas have been properly cleaned.

The technique is to use the Xenex system to have 120 flashes per minute for seven minutes in each patient room, and each bathroom, and each OR after discharge and each emergency department space every day.  This was all added to aggressive previous approaches like MRSA screening before admitting patients, and using precautions.

During the application period, the UV light bounces all over the room, on all surfaces and into cracks that might otherwise be missed.  The results were extraordinary:

Or to put it in the technical terms of a recent poster presented by Joanne Levin, MD; Linda Riley, RN; Christine Parrish, RN; and Daniel English:

Methods. During January 2011, the use of two PPX-UV devices to disinfect patient rooms was phased in. Rooms and bathrooms were terminally cleaned as usual with a chlorine- based product, followed by the use of PPX-UV, usually for three, seven-minute exposures (once in the bathroom, twice in the bedroom). The overall room turnover time was extended by about 15 minutes. When a device was not being used for terminal cleaning of patient rooms, it was also used in the operating suites, emergency department, and other areas. Surveillance for HA-CDI using SHEA definitions continued as per routine. No other new infection prevention interventions were instituted during this time.

Results: CDI cases were found for a rate of 3.18/10,000 patient days (pd). This compares favorably with the rate of 9.5/10,000 pd for all of 2010. We also compared Q1-Q3 data for the previous three years. The combined Q1-Q3 rate for 2008-2010 was 9.77/10,000 pd compared to 3.18 for Q1-Q3 2011 when PPX-UV was used, resulting in a 67% decline (p=0.017). In addition, to date there have been no HA-CDI–related deaths or colectomies since the institution of PPX-UV. 

I wonder if this will become the disinfection routine of choice over time.

Poster session at IHI

Each years, dozens of people present posters at the IHI National Forum.  Here's a sampling from today's presentations.



As you have seen, one of them is from Atrius Health, a Massachusetts multi-specialty practice.  Here's a nice graphic showing attendance at the Leadership Academy discussed in the video.

If you cannot see the video, click here.

North Shore-LIJ invests in continued excellence

Another notable moment at the IHI Exhibition Hall was an encounter with two of the quality and safety mavens from the North Shore-LIJ Health System.  Karen Nelson, RN, is Vice President for Clinical Excellence and Quality, and Dr. Jeremy Boal is Chief Medical Officer.

Regular readers of this blog may remember my post from August in which I praised the leadership of CEO Michael J. Dowling and congratulated him for receiving the National Center for Healthcare Leadership (NCHL) 2011 Gail L. Warden Leadership Excellence Award for bringing innovation and accountability to health care and contributing significant and lasting improvements to the field.  Well, a leader like that attracts talent like Karen and Jeremy, who make real differences in the lives of patients, family, and staff.

The group has also created the "Center for Learning and Innovation," the largest corporate university in the health care industry.  The mission of this organization is to "promote a culture dedicated to excellence, innovation, teamwork, and continuous change."  The agenda: "Through continuous learning opportunities, employees are assisted in the development of knowledge, attitude, and skills necessary to support the North Shore-LIJ Health System's strategic and business goals."

As Mr. Dowling notes:  "To advance an organization's strategic and business goals, its leadership must foster growth and continuous learning among it employees."

I have no doubt that they are well on their way and will set an example that will be noticed far and wide.

Don’t wait for Washington

Brent arriving at the IHI Annual Forum

With these words, Brent James began his keynote address to the attendees at the Vermont Oxford Network meeting this morning.  Noting that the recent legislation in Washington focused mainly on providing insurance to a portion of the 46 million Americans without coverage, he reminded the audience that the law had very little to say about the issue of rising health care costs in the country.  He warned them that “our profession is in the midst of profound change” because the cost pressures would wend their way to affect doctors and hospitals over the coming years.  “If you feel like you have a target on your forehead, you are right.”  Paradoxically, though, he left the audience eventually with the thought, “This is a glorious time to be in medicine.”

“What’s up?” you might ask.  What’s up in Brent’s view is the fact that more and more doctors, nurses, and administrators have started to adopt an approach to clinical care based on reducing variation and on weeding out inefficiencies and waste.  “Quality costs less, “ is his watchword, dating this philosophy back to the work of W. E. Deming.

Brent went through the evolution of this approach at Intermountain Health, hearkening to the initial work done in 1991 by Dr. Alan Morris at LDS Hospital.  Undertaking an NIH-funded randomized clinical trial in treatment of pulmonary disease, Morris’ team of eight intensivists discovered a large degree of variation in ventilator settings, not only among themselves, but even between daytime and nighttime with the same doctor and the same patient.  Morris, looking at the work of Jim Womack documenting Toyota’s Lean process improvement in The Machine that Changed the World, realized that he needed to create a protocol among all the doctors to standardize the care being given.  Only by have enough standardization could there be the possibility of evaluating the “pre” and “post” of the clinical trial.

But Morris noted, “I had no validation data” for the best protocol.  So, the team assembled and designed a protocol based on the literature of the day, but then they applied Lean principles to the use of the protocol.  Physicians were instructed to vary from the protocol if they judged it in the best interest of a patient.  Each time this happened, though, the case would be discussed among the group.  Over time the protocol was modified when there was a scientific basis for doing so, and over time variation from the protocol diminished.

During the following years, this process was expanded to other clinical arenas in the Intermountain system.  The concept of “shared baselines” came to rule:

1 -- Select a high priority clinical process;
2 -- Create evidence-based best practice guidelines;
3 -- Build the guidelines into the flow of clinical work;
4 -- Use the guidelines as a shared baseline, with doctors free to vary them based on individual patient needs;
5 -- Meanwhile, learn from and (over time) eliminate variation arising from the professionals, while retain variation arising from patients.

Note that this approach demands that doctors modify shared protocols on the basis of patient needs.  The aim is not to step between doctors and their patients.  This is very different from the free form of patient care that exists generally in medicine.  Notes Brent, “We pay for our personal autonomy with the lives of our patients.  This is indefensible.”  The approach used at Intermountain values variation based on the patient, not the physician.

Brent is optimistic because he has seen this philosophy of learning how to improve patient care extend to more and more doctors and hospitals around the country.  He views it as providing the answer to the rising cost of care, and he is excited about the potential.  He concludes that this is a “glorious time” to be in medicine because it is the “first time in 100 years” that doctors have a chance to institute fundamental change in the practice of medicine.

We left the VON meeting together and flew off to Orlando, where we are now attending the IHI Annual National Forum.

State collaboratives save babies' lives

A number of state perinatal quality collaboratives take advantage of the Annual Meeting and Quality Congress of the Vermont Oxford Network to get together and compare notes.   Some of these collaboratives have existed since 2006 or so; others are more recently created.  The idea is for people in neonatal intensive care units (NICUs) in each state to set statewide targets and objectives, compare best practices, and understand the variability in clinical practices across and within institutions.  This is not a government-ordered process:  It originates with practitioners in each state.

I sat in on the session today and was greatly impressed by the scope and scale of work going on in a number of states.  In Michigan, for example, 17 centers get together and have produced a 46% reduction in nosocomial infections between 2008 and 2010 among level III (the most vulnerable) babies in their NICUs (from 298 cases per thousand patient days to 127.)  It was reported that trust across the centers assisted in the shared learning that made this possible.  Also, transparency across centers identified factors contirbuting to the variability in infection rates across the centers.

In Mississippi, where the group has just formed, they have set targets for reductions of central line associated bloodstream infections (CLABSI), reduction of bronchopulmonary dysplasia (BPD); increases in the use of human milk for very low body weight (VLBW) babies; and the like.  In North Carolina, with one of the longest running collaboratives, documented progress on an number of metrics has persuaded the state's largest insurer to give preferential rate treatment to those centers that are part of the collaborative.  In Ohio, with a long-running collaborative, CLABSI problems have significantly diminished.

I was especially pleased to learn that back in my home state of Massachusetts, the 9-center collaborative decided several years ago to share all data from their NICUs with one another, attaching the name of each hospital to the data as part of the process.  This was at the urging of Jonathan Cronin, unit chief of neonatology at Massachusetts General Hospital, who reportedly said that if the collaborative was to be serious about meeting higher standards of care, such transparency of clinical metrics was essential.  So the group regularly shares information on rates of retinopathy of prematurity, chronic lung disease, necrotizing enterocolitis, infections, and the like.

In summary, this was an inspiring session with lots of important examples and lessons for adult care, as well.  And good for the Vermont Oxford Network to facilitate the collaborative process.

Things are cooking at Cook's

As a kind of warmup to this week's IHI Annual National Forum, I am currently at the Annual Meeting and Quality Congress of the Vermont Oxford Network, a group of over 1000 neonatal doctors and other professionals who gather together to share stories of patient care advancement.  I was asked to give a keynote address, but as usual, I learned more than I imparted.  Here is a great story told by Tammy Hoff, RN, from Cook Children's Medical Center in Fort Worth, Texas (seen here with BIDMC's John Zupancic).  They made a concerted effort to reduce the rate of central line infections in their level III-C NICU (750 admissions per year, average census 55).  They used methods from the Institute for Healthcare Improvement and Pediatrix medical group and have been a rate of zero for many months.  Here are the key slides:

What were the costs to the hospital?

Tammy noted:

In order to establish the line team, we had to give up two nursing positions.

Since the establishment of this team and with the success of the program, we have since been able to get those two nursing positions back and filled.

The overall greatest expense in this process is in the risk of taking the first step:  To hire a dedicated team that can focus on nothing but infections and the development of best practice.

Since the inception of this team an expense, but one that we are willing to accept, is the travel to different conferences and programs around the country to share out story.

Here are the benefits, more generally, for society, using Peter Pronovost's CLABSI Opportunity Estimator tool:

Good study. Bad access.

The AHRQ Patient Safety Network is a great site for keeping up to date on research in the field.  Here is an example of an article of interest, "Medication errors during patient transitions into nursing homes: characteristics and association with patient harm."

Here's a portion of the abstract:

This study analyzed medication errors reported by North Carolina nursing homes to describe specific errors that occurred during patient transitions to nursing homes. Of the nearly 30,000 individual medication errors reported, 11% involved a care transition. Notably, the transition-related errors were also associated with higher odds of patient harm. Contributing factors to the transition-related reports included problems with staff communication, order transcription, medication availability, and pharmacy issues. The authors highlight the opportunities for medication safety during this high-risk transition period for patients.

Unfortunately, like so many others, The American Journal of Geriatric Pharmacotherapy will not permit you to read the article without a subscription or paying for the single article ($31.50),  and the AHRQ can't get you past that paywall from their site.  A shame.  I bet it has some useful things to say that would be of broad interest to hospital case managers and others involved in transition of care issues.

Buena suerte, hospitales de Madrid. Lean es mejor.

Speaking of Lean process improvement, it appears that the folks running hospitals in Madrid could use some help. Check out this article on smartplanet, entitled, "Madrid hospitals look to free beds." The lede:

Spanish hospitals are looking to speed up check in and check out processes, without cutting patient care.

So, officials from sixteen hospitals in the city are getting together to share ideas. The article notes that most hospitals do have programs and objectives geared towards greater efficiency, but that they are “siloed” from department to department and problems often feel a “domino effect.”

As everywhere, there are some cultural problems that can complicate the situation:

[B]esides emergencies, Spanish hospitals shut down Friday afternoon until the busiest time of Monday morning, often keeping patients there two days longer than necessary. After congestive heart failure, the most popular cause of a longer length of hospital stay is simply the fact they were admitted on a Friday.

The medical director of the private Madrid Hospital Moncloa, Carlos Zarco described some services of hospitals functioning on the weekends as a great idea, but essentially “imposible” and very expensive in Spain. He said that profitability would go down, but he does think departments like radiology should be open on weekends.

Claro, imposible. I think this is an example of focusing on the hardest solution, rather than redesigning every day work flows to eliminate waste and inefficiency. Instead of bringing administrators together to analyze the problems from on high, it is time for them to go to gemba and watch the obstacles and work-arounds that the front line staff face every day.

Uncool and unLean taxi batching at Logan Airport

One of the things you learn from Lean is that batch processing is often inefficient and wasteful compared to continuous flow processes.  I have sometimes used this blog to illustrate this phenomenon, like at this bakery and, ironically, even at the food service line of a Lean conference.

I saw another example when I arrived at Logan Airport late at night this past week and was waiting for a taxi.  Here's the scene behind me.  Counting those in front of me, at least 50 people were in line at Terminal B, with more showing up every minute.

Taxis were arriving in groups of three to five as they were sent over from the parking lot at which they are required to wait.  In between, the dispatcher required all passengers to wait behind a chain.  (By the way, note the signage!)

Then the taxis arrived and parked at the curb. 

Only then would the dispatcher allow the batch of three to five passengers groups past the chain.  It would take them about a minute to reach their cabs, load their luggage, and sit inside.  Since the cab at the front of the line was furthest from the chain, its passenger would have the longest distance to walk and take the most time to load. 

Only after that first cab was filled and ready to leave could any of the ones behind it proceed to leave.

In between batches, the dispatcher had nothing to do. He even had time to visit a passing MassPort supervisor driving by in his SUV.

I was about number 40 in line when I arrived at the scene.  It took me over a half hour to get into a cab using this approach.  Each batch had three to five cabs, arriving every three to five minutes.  Loading took a minute for each batch.  I had to wait for eight to ten batches. 

Imagine a simple improvement to this system.  Assuming the taxis have to come over in batches from their parking lot, why not have the dispatcher get people ready to load by standing at pre-marked spots along the sidewalk, ready to load luggage and hop in as soon as a car pulled up.

But imagine a further enhancement.  I asked my cab driver, "Did you have to wait a long time at the remote parking lot before being freed up?"  "No," he said, "only about 15 minutes."  I was stunned that this could be the case on a very busy night, with unmet demand at each terminal.

Apparently the overall dispatcher at the parking lot sends a clump of cabs to each terminal, in sequence, when it is a busy night.  With five terminal locations, every fifth group will show up at any given terminal, always in a batch.  That batch takes time to exit the parking lot, and then the next group moves up the line from their parking places.  What if, instead, the dispatcher at the parking lot sent each single cab, on a continuous basis, to the next terminal in sequence?  A steady flow of individual cabs would arrive at each terminal, separated by less than a minute, to be entered by a waiting passenger at the curb.

I'll let our process flow engineers do the math, but I guarantee this approach would have reduced waiting times considerably, both for cab drivers trying to make a living by getting as many trips as possible and for passengers trying to get home as quickly as possible.

Mr. Ness, everybody knows where the booze is.

A quality-driven MD colleague writes with frustration about two problems in his academic medical center.  I often hear similar comments from nurses and doctors, and so I present the examples for your consideration.

This hospital has a poor record with regard to hand hygiene (in the 30% range), and my colleague suggested at an infection control meeting suggested that the rates be publicly posted in the hospital to provide an impetus for improvement.  "I suggested that instead of being embarrassed, maybe we should OWN the data." This, of course, is a standard and accepted approach in quality improvement.  S/he was told that the "the lawyers will not let us do this."  S/he wonders, "Who, exactly, is our primary concern?"

At another meeting, the chief nursing officer asked why there had not been more progress made with regard to central line infections in the ICUs.  It turned out that there had been meetings with  the bedside staff which identified a number of problematic workarounds they had created. However, the team was limited in what they could do because decisions about equipment and kits are made based on cost, away from the bedside. The CNO was upset because the local folks had not shared with her what they had already done and wanted to know why they hadn't told her about these problems – while acknowledging she couldn't do anything about them.

My friend summarized: 

I explained that if she wanted to find out what was going on – she need only walk onto the unit and ask.

This all reminds me of the scene in The Untouchables. Elliot Ness talks about busting Al Capone if only he knew where he was making his booze. Sean Connery's character (Jimmy Malone) takes him to a post office across from the police station.  Ness can't believe the booze is there. Malone says, "Mr. Ness, everybody knows where the booze is. The problem isn't finding it, the problem is who wants to cross Capone."

The problem isn't knowing HOW to fix this problem. It's doing what it takes to accomplish that -- over-ruling the lawyers and accountants and doing the hard-work to change the culture. This can't happen if the C-suite leads from meeting rooms.

These stories exemplify the huge cultural schism in the country between the minority, those institutions that have taken on the quality and safety agenda and internalized it into their decision-making and process improvement efforts, and the majority, the ones that have not.  Each year at the IHI Annual Forum, I hear from nurse managers and young doctors asking, "What can I do to get my CEO/CFO/CNO/Board of Trustees to support us in what we know must be done?"

I want to state this as clearly as possible:  The leaders of academic medical centers and medical schools are failing to be the leaders the country needs at this time. In their failure, they sow the seeds of burdensome governmental and regulatory requirements, for those in policy positions will see the vacuum and will fill it. In their failure, they persist in accepting the view that "these things happen," and are personally -- yes, personally -- responsible for thousands of preventable deaths and injuries each year.  This is the most significant ethical issue facing the profession, and they simply fail to accept responsibility.

Bravo to Brent James

Dr. Brent James last week was awarded Columbia Business School’s W. Edwards Deming Center for Quality, Productivity and Competitiveness. As described in the press release:

The Deming Cup grew from the center’s drive to highlight the achievements of business practitioners who adhere to and promote excellence in operations – the Deming Center’s area of focus. This award is given annually to an individual who has made outstanding contributions in the area of operations and has established a culture of continuous improvement within their respective organization.

Dr. James was recognized for his pioneering work in applying quality improvement techniques that were originally developed by W. Edwards Deming and others, in order to help create and implement a “system” model at Intermountain, in which physicians study process and outcomes data to determine the types of care that are most effective.

Imagine that, improving clinical care is consistent with efficiency in the health care system.  This has to be another lie, just like that stuff about Pronovost saving lives and reducing costs by reducing the rate of central line associated bloodstream infections.  Or assertions by that trio of fraud, Spear, Toussaint, and Kaplan.

This stuff can't be true.  If it were everybody would be doing it.  Right?

Back on January 15, 2009, I published a post entitled "What does it take?", in which I expressed frustration with the slow pace of process improvement in hospitals.  What followed in the comments was a virtual seminar by some of the country's leaders in the field.  They are still worth checking out.  Brent offered his point of view:

Paul, you have put your finger on what I regard as THE core task of the present generation of the healing professions. It is very clear that we are in the midst of a transition. The term of art that is usually used to describe the present state – and which Don Berwick so eloquently explained (at least, at the level that an individual physician would experience it) – is “the craft of medicine.” It’s the idea that every physician (or nurse, or technician, or administrator, etc.) is a personal expert, relying primarily on their personal commitment to excellence. In a very real sense, every physician occupies his/her own universe, with its own reality, truths, physical constants. As a physician I might say to a colleague, “What works for you, works for you. What works for me, works for me. Let’s both stay focused on the patient – our core fiduciary commitment to put the patient first in all things – and that will guarantee the best possible results.”

David Eddy said it most eloquently: This core assumption of the craft of medicine is scientifically untenable.

As a direct result of some solid research around this fact, the healing professions are in the midst of a major sea-change, a once-in-a-century shift: We’re moving from “medicine practiced as individual heroism” to “medicine as a team sport.” The kinds of tools you’re talking about make perfect sense in a team setting, but almost no sense within the craft of medicine.

Don is right in calling it culture change. However, we are well past the tipping point. There is strong evidence that the professions have committed to a new course and are actively moving. It’s the difference between 5% of the profession “getting it” (where we are now), and moving to a point where it is standard, accepted, background business essentially all of the time.

The key change concept was perhaps best expressed by Winston Churchill: “People like to change; they just don’t like to be changed.”

I am also deeply impressed by Roger’s classic text on change: Diffusion of Innovation. He describes bottom-up change, by sharing results (both data and word of mouth) from initial thought leaders (his “early adopters”). That has worked very well for us, and makes the change fun – rather than something that a bunch of external “know nothings” are trying to do to you.

Ohio steps backward on transparency

After expressing enthusiastic support for many quality initiatives by hospitals in Ohio, I must report with disappointment an action by their trade association to dismantle the state's hospital transparency website.  This article summarizes:

The Ohio Hospital Association (OHA) is backing a piece of recently introduced legislation that would free hospitals from the requirement to report performance data such as measures of heart and surgical care, infection rates and patient satisfaction.

The reason?  Alleged duplication of effort with the CMS Hospital Compare website.  According to an OHA spokesperson:

The time and effort spent on reporting the data to the state as well as the federal government reduces the resources Ohio hospitals can devote to patient care.

To which I reply, "Bull twaddle!" (This is a family blog, or I would use stronger terms.)

First, let's acknowledge that the data presented in the the CMS site is old, very old.  It accomplishes little or nothing with regard to transparency.  As I have noted:

While you cannot manage what you do not measure, trying to manage with data that are a year or two or more older is like trying to drive viewing the road through a rearview mirror. The principles of Lean process improvement and other such systems suggest that real time "visual cues" of how the organization is doing are essential. Why? Because that kind of data is indicative of the state of the organization right now, not what existed months or years ago.

Second, let's be real about the amount of time this state-run site "takes away" from delivering patient care.  This data would be collected regularly by hospitals, as part of delivering patient care, even if there were no federal or state reporting requirements.  It is not an incremental responsibility.

Next, the Ohio Department of Health says:  “It was an unfunded mandate for ODH to collect the information and make it public."

To which, I can only repeat the above, "Bull twaddle!"

Since when does a state agency get to complain about unfunded mandates from the legislature that supervises it?  (You only get to complain about unfunded mandates if a higher level of government imposes a cost on a lower level of government.)  The staff of the agency get funded every day they work there.  This is a matter of priorities.  In any event, this is a gross overstatement of the amount of effort needed for this task.

I am willing to bet that a graduate student or health care club at OSU, Case Western, or one of the other fine schools in Ohio would gladly set up and maintain a voluntary website for the Ohio hospitals.  Each hospital could enter through a password-protected portal to enter real-time data about the metrics that are of value in pursuing important quality and safety goals.  At virtually no cost.  It would take seconds, not even minutes or hours, to enter it once a month or once a quarter.  As I have noted:

Such data are collected in hospitals on a current basis. If their main purpose is to support process improvement, they do not need external validation or auditing to be made transparent in real time.

Come on, Ohio.  Don't step backward.

Congratulations to Peter Pronovost

Peter Pronovost has been elected to the Institute of Medicine.  Bravo!  This is so well deserved.  Here's a summary of his work from Newswise.

A professor of anesthesiology and critical care medicine and surgery at the Johns Hopkins University School of Medicine, Peter J. Pronovost directs the Armstrong Institute for Patient Safety and Quality at Hopkins and is senior vice president for patient safety and quality for Johns Hopkins Medicine, where he has transformed the way hospitals around the world think about bloodstream infections.

Peter Pronovost has brought a scientifically rigorous yet common-sense approach to eliminating medical errors and unnecessary harm, shaping the national conversation about patient safety in the process. His biggest success so far: the much-heralded, cockpit-style, five-step checklist for doctors and nurses designed to prevent central-line associated bloodstream infections (CLABSIs). The simple checklist, coupled with a program that promotes a culture of safety, has transformed the way hospitals think about bloodstream infections, which kill more than 30,000 patients a year and sicken many thousands more. Thanks to Pronovost, these infections are no longer seen as a cost of doing business. They are preventable.

Pronovost and his team have dramatically reduced ICU bloodstream infections throughout the state of Michigan and exported that success to hospitals across the nation and the world. His program is now in place in 47 states, Puerto Rico, the District of Columbia and in many countries throughout the world. As he spreads the message that CLABSIs can be virtually eliminated, he is also using these strategies to prevent other harm, such as surgical-site infections and pneumonias contracted through the use of ventilators.

In 2008, Pronovost was awarded a MacArthur Fellowship, or “genius grant,” from the John D. and Catherine T. MacArthur Foundation for exhibiting exceptional creativity and showing the promise to make important future advances based on a track record of significant accomplishment. That same year, he was also named one of Time magazine’s “100 Most Influential People.”

He is the author of the book, “Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us Change Health Care from the Inside Out,” published in 2010. He is also author of more than 200 research articles.

The Lean dentist

The next speaker I am hearing at the "Made Lean in America" conference is Sami Bahri, DDS, author of Follow the Learner: The Role of a Leader in Creating a Lean Culture.  The book describes how this organization, the Bahri Dental Group, transformed its work and thinking from a traditional batch-and-queue approach to one focused directly on the needs of the patient, not on the needs of the practitioners.

Sami related how his practice in Jacksonville, Florida was growing unsustainably.  His solution to complexity was to "hire more people," but he soon realized this was not the answer.  "I wanted to get rid of the problem.  I needed to find a theory.   With a theory, you can make quick decisions."  He then became aware of the Lean philosophy and the work of Jim Womack and others.  Reading a number of books, he figured out how to apply Lean manufacturing ideas to his practice.

Sami summarized that Lean was an evolution over time of our collective thinking.  We started as craftsmen; then moved to the division of labor; but then, with more complex processes, we had quality problems; then time and motion studies of people led to improvement of functions; and then we learned to follow the product to improve efficiency and improving quality.

Sami said, "I went back and started learning how Toyota did it.  How did Ohno start?  'The TPS started when I challenged the system.' "

Sami noted, "It took him five years to produce a high quality car.  It took me nine years in our practice."

His conclusion after all this time:  "The most important ingredient is people.  Are they learning every day?  If you want them to learn and sustain the system, you need your people."

Speaking of his practice, he noted, "Set-ups stand in the way of one piece flow.  We eliminated these."

Sami defining "leveling" as balancing load and capacity.  The idea was to distribute procedures, according to TAKT time, evenly throughout the schedule.

He had to define "flow" in dentistry.  This resulted in a system of one appointment to see all providers.  The end was continuous treatment, with no delay between providers (just-in-time treatment).

His goal was that the patient's stay time would be equal to the treatment time, eliminating waits, optimizing use of the patient's time but also the providers' time.

The treatment the patient receives changes during the appointment, but the patient location stays the same.  Providers move to where they are needed.  Crossing the functional barriers was key.  The hygienists, whose lives improved dramatically under this approach, ultimately said, "Please don't give me my own room.  I'll go to whichever room the patient is located."

Sami reported on patient satisfaction surveys, showing a remarkable uptick in their views about his office and his staff.

All in all, this was a marvelous presentation by a thoughtful entrepreneur applying the theories of Lean to a new setting.

John Shook on "The big lie about outsourcing"

The keynote speaker at today's "Made Lean in America" conference, is John Shook, CEO of the Lean Enterprise Institute.  He is seen here with Lesa Nichols, whom John describes as a true TPS (Toyota Production System) expert with GBMP (Greater Boston Manufacturing Partnership).  His speech is entitled "The Big Lie About Outsourcing."  I'll try to pick up main points as he talks and relay them to you.

John related two recent conversations with CEOs of two American businesses, one medium sized and one large.  The CEOs at both had outsourced parts of their manufacturing processes, but had concluded, when thinking about the current recession, that they could do better by bringing things back from overseas.  Making things where you sell them seemed to make more sense, if you could do so in accordance with Lean principles.  Indeed, says Shook, outsourcing takes us far from the concept of effective value stream management.  It is not a matter of just the lowest piece price.  But even with a low piece price, it is not always cheaper to go abroad.  The lowest labor cost is not always indicative of total value.  The rush to outsource to garner economies often meant that we lost the core capabilities of our companies.

Value stream dynamics is a way to think about this. 

The ideal supply chain is one with the effectiveness and efficiency of vertical integration, but with the flexibility of looser networks of suppliers.  But that is very difficult to accomplish, and describing it that way can be interpreted as a "a solution to copy," without understanding the real purpose of the relationships.

The key is trust among all the participants in the value stream.  Within a company, TPS/Lean does this is a very specific way.  It is both a social system and a technical system.  When a person sees a problem, s/he calls it out; the manager responds in real time; a root-cause analysis is performed; and solutions are developed and implemented.  The philosophy is, "I'm going to trust the front-line worker to initiate this."

If this is true within a company, it also has to be true between the company and its suppliers.  We should not think of the supply chain (outsourcing) as series of discrete transactions.  Instead, it should be viewed as an opportunity for deep learning.  This creates deep adaptability as things change.  Instead of optimizing discrete transaction points, we want to create an adaptive learning system.

We need to work towards the concept of total system efficiency, not just low piece costs.  How can we synchronize things through this system?  The same kind of trust needed within a company must exist across the corporate relationship, too.  This is very different from what we have seen over the last several years.

We have a great opportunity: To reconfigure value streams, both with and between companies, and make them as rational as possible.

Toasted at the Lean Conference

I'm in Springfield, MA, to attend the "Made Lean in America" conference organized by the GBMP (Greater Boston Manufacturing Partnership), a not-for-profit group whose mission is to sustain a strong and vibrant regional economy by improving the operational profitability and competitiveness of existing and emerging organizations, large and small, through training in Lean and continuous improvement principles.

This promises to be an engaging two days, and I encourage even late arrivals to head over to hear the speakers and shmooze with other Leaners.

We'll start, though, with a humorous, light touch.  GBMP's Bruce Hamilton (seen here) is famous for a short video, entitled Toast, in which he demonstrates the basic principles of Lean process improvement.  How fitting, then that the bagel toasting process at the convention center is anything but Lean!  A batch process, with poorly designed flows, leaves people waiting in line, unsure of what to do next.  Even the toaster itself is in an unstable setting, almost falling off the table!

Some of you may recall my "oatmeal chronicles," from last year's IHI Annual Forum, where the convention center in Florida likewise inadvertently provided a wonderful display of a poor service process.  Perhaps this kind of thing is intended at these kind of conferences, to offer real-time examples of how not to do things, so the attendees can think more clearly about how to do them right.

High standards in evidence at Duke

Here's the counter-example to the folks at Parkland Memorial Hospital, in terms of transparency and taking ownership for failure.  After bouncing around the scientific world, the story regarding a Duke University School of Medicine researcher padding his resume went worldwide last year, but there were also questions raised about the methodology behind the three clinical trials.  This kind of thing is an embarrassment to any institution, and the manner in which it is handled is indicative of the kind of leadership in place.

Hunt Willard, the Director of the Institute for Genome Sciences & Policy, has issued a letter to the community that makes clear he is the exemplar of what you would hope for.  Here are the key excerpts:

These events represent a teachable moment for all of us, and I want you to hear directly from me about what I think it means for us.

It is very clear now that we were too slow to recognize and acknowledge flaws in the underlying data, insufficiently attentive to the need to carefully track versions of both data and software, and inadequately responsive to external publications and communications that pointed out errors in the underlying data. All of these indicate a need for a tighter process, and I recognize all of this as a failure of leadership and a failure of oversight, failures for which, as director of the IGSP, I feel a level of responsibility.

In accepting responsibility for these failures, I underscore my deep commitment to the responsible conduct of research and to setting standards for accountability at all levels of our organization. I welcome your thoughts in this area, as well as any concerns you may have throughout the coming year.

Really, what more could you ever want from a leader?  But there is more, a lesson in the nature and values of the profession:

Bravo to Dr. Willard and his colleagues.

Good catches are catching on

For every adverse event that is reported in a hospital, there are likely 100 or maybe 1000 near misses that often go unreported.  Those close calls contain a wealth of information regarding systemic problems within a hospital.  Some hospitals have expanded their computerized reporting system to catch these problems.  For example, Children's Hospital in Denver did this.  After an electronic, web-based, secure, anonymous reporting system for anesthesiologists was put in place, a total of 150 incidents were reported in the first 3 months of operation, compared to four entered in the same time period a year previous.  "This . . . provided data to target and drive quality and process improvement."

Johns Hopkins uses another approach, a Good Catch Award. As noted in this paper presented to the Maryland Patient Safety Center last year:

The Good Catch Award creates positive incentives for providers and staff to report patient safety events. At the institutional level, the Good Catch Award encourages individuals to identify and report adverse events, near-misses, or other medical errors. The program rewards individuals who contribute and has been received positively by many providers and staff. The pilot phase of this program focused on identifying defects in the perioperative environment and devising a partial solution. The current phase of the Good Catch Award program shifts its focus to sustainability and strategies to maintain the implemented systems changes that resulted from the 13 Good Catch Awards given in the past two and a half years. This includes an educational component for providers, one of the original steps in the Good Catch Award process, to ensure better dissemination of information and implementation of systems improvements throughout the ACCM department. The program is ongoing in its effort to identify defects, formulate solutions, and recognize those who actively work to create a safer environment.

Here's a summary chart of the results:

This kind of program also exists at the University of Connecticut Health Center.  As noted:

John Dempsey Hospital's goal is to change any negative perceptions healthcare providers and others may have about reporting errors. Staff is encouraged to report near misses. It helps to identify areas where patients’ quality of care and safety might be improved. Reporting a near miss is considered a “good catch” and comes with rewards:

• Good Catch award certificate.
• Good Catch lapel pin.
• Special recognition within the Health Center community.
• A copy of the award certificate in Human Resources personnel file.
• Sincere thanks for dedication to patient safety and personal satisfaction.
• Reviews of all good catches to determine if additional safety measures should be implemented.

At our hospital, we had a Caller-Outer of the Month Award, similar in concept.  Instead of honoring someone who had solved a problem, our Board decided they would honor someone who had called out a problem. The idea was to provide further encouragement through the organization to those who notice and mention problems. 

These are all variations on the theme. All approaches lead to much good and are worth a look to be considered for emulation elsewhere.