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.