More Thanksgiving thoughts

This post is prompted by the following note from one of our chiefs to his staff:

You can't fail to hear from most everyone that Thanksgiving is "my favorite holiday." No exceptions here. Among other things it is a stimulus for me to reach out, express awe and appreciation for the exemplary jobs you do in fulfilling our collective mission. This is not easy work, but the rewards are beyond measure. Thanks to you on behalf of our patients and this medical center.

I have the good fortune to work in a marvelous place like BIDMC, surrounded by well-meaning people who spend their time helping others deal with illness and disease and the real dramas faced by families as they go through difficult times. There are happy times here, too, when people are cured of their illnesses, and the happiest of all, when babies are born and new life arrives -- literally in rooms just a few floors above my office.

While there are daily challenges in the hospital environment, it is the underlying good will of people in these places that is the dominant characteristic. As teenagers in the 1960's, my classmates and I were inspired by John and Robert Kennedy and Martin Luther King, Jr., to enter careers of public service. In our self-centered way, we used to think of our generation as special in that way. But in this place, I see people in their 20's through their 90's who are devoting their lives to alleviating human suffering caused by disease. It is a marvelous commonality of purpose that binds us -- people of all ages, nationalities, religions, and races.

Before I worked here, I wondered (along with many of my friends) if people who worked in hospitals cared anymore. Much of what you hear about hospitals from the outside is related to complaints about insurance rules, difficult working conditions, burnt-out doctors, harried nurses, and rude front-desk staff. I have learned and want to assure my readers that the folks in hospitals do care and care deeply, but the health care environment is often not well suited to bring out the best in people. (By the way, I have learned through my travels that this is not just a US problem.)

Beth Israel Deaconess is characterized by a kind of warmth, compassion, and respect that is legendary, but even it can be a tough and tiring place to work. I view my job as CEO as trying to create a workplace that reflects the deep underlying values of our staff, working to minimize those aspects that inhibit or impair their ability to carry out their heartfelt mission. In this, I am warmly and strongly supported by our lay leaders, members of the community who volunteer to serve on our boards and have the ultimate governance and fiduciary responsibility for this institution. Not many of us are given the privilege of heading up an organization like BIDMC, so I am trying to use my tenure here to make a positive difference for the people who work here.

Last week, I sent the following email to our staff along these lines. Like other things I have shared with you about BIDMC, I am sharing this one. Those of you who are new to this blog might find it surprising that I do so. Regular readers will not be surprised. A hallmark of this administration is transparency -- even when such openness is awkward or embarrassing -- because holding ourselves publicly accountable is the best way for us to improve.

I will also keep you informed of our progress as we move through implementing the program outlined in email. I do so because I think we will learn a lot about ourselves and about the path towards process improvement. I am very confident we will flub up aspects of this as we move along. There may well be those out there who will be quick to judge when we do. But as an academic medical center, one of our jobs is to share what we learn so that it might be helpful to others here in Boston and throughout the world.

----

Dear BIDMC,

What's the most important activity at our hospital? Providing patient-centered care?

Right!

But what do we spend most of our time doing? Patient care??

Wrong. It is fetching. As in spending time trying to find a piece of equipment, a certain paper form, or some other supply. Or it’s re-doing work. As in writing the same piece of information in 3 different places.

Admit it. If you are a nurse on the floor or the OR or the PACU, a respiratory therapist in the ICU, a person cleaning surgical instruments in CPD, or a practice assistant in a clinic, think of how much time you spend fetching instead of actually taking care of a patient or doing the job you’ve been hired to do to support patient care – whether that’s running lab tests, preparing food in our kitchen, or repairing a broken piece of equipment. How much of your day is spent in these ways versus face-to-face time with patients or in doing something tied directly to patient care and the support of that care? If you are a typical person here, it is way over 50% and more like 80%.

But I don't have to tell you that, do I?

We might have the latest in cutting edge technology to take care of our patients and the finest doctors, but in a big institution like BIDMC -- like in most hospitals -- the organization of our work is based on patterns and systems that might as well be 100 years old.

The practice of medicine in academic medical centers like ours is a cottage industry. While other fields and industries have progressed in terms of process improvement, ours remains woefully behind.

Every day, thousands of you undertake "work-arounds" to solve the problems you face in delivering care. And you do solve those problems -- by dint of personal commitment, hard work, and good will. As a result, our patients get extraordinary care.

But, because we all invent work-arounds, we often don’t solve the underlying work process problems that pervade every aspect of what we do. And you go home feeling really tired and wondering how you really spent your day.

Over the next several months, we are going to start a program to work on these problems. Our goal is simple. We want to improve the quality of the time you spend here at BIDMC so you can focus on the things that matter instead of working around problems you encounter.

While the goal is simple, the solution is not. We want a solution that will identify and start to solve problems on the floors as they occur. We want a solution that will uncover and fix underlying problems, not result in yet another set of work-arounds.

We have been studying other efforts around the country and have come up with an approach that we think makes sense for BIDMC.

Recently, we had a chance to spend some time with people from a group called Value Capture. They relayed the content of speech by former Secretary of the Treasury Paul O'Neill at the Harvard Business School. He outlined the three questions every employee should be able to answer with a resounding "Yes!" every day in order for an organization to have the potential for greatness:

Am I treated with dignity and respect by everyone I encounter, regardless of role or rank in the organization?

Am I given the knowledge, tools and support that I need in order to make a contribution to my organization and that adds meaning to my life?

Did somebody notice I did it, i.e., am I recognized for my contribution?

Does that sound right to you? It feels right to me. The Value Capture folks, who have done this in some other places, are going to help us design the program for BIDMC.

Let’s be honest. We can’t all answer "Yes!" to these questions today, and, in fact, in many instances we don’t even come close. But our goal is to get there. If this works, we will set a new standard for staff satisfaction and participation in the operation of an academic medical center.

The program will involve some training and new approaches to our work. Most of all, it will involve you. Don't worry. It will not be painful. It may actually -- dare I say this? -- be fun! And in the long run, we won’t see this as a "program", but rather just as the way we constantly improve work and care at BIDMC.

Have I got you curious? I hope so. Stay tuned for more details this winter.

In the meantime, though, I need help. Every program has to have a name. What should we call this one? I am hoping for something decidedly unbureaucratic -- and maybe even with a sense of humor. Please write back with your ideas.

Best wishes to you and your family for a lovely holiday!

Paul

Reply from one of our doctors

People often ask me how our doctors feel about the things I post on this blog. The answer, of course, is as varied as our faculty, and -- trust me -- our faculty is not the least bit shy about letting me know how they feel. After I wrote a post on safety and quality a couple of weeks ago, one of our doctors wrote me the following note. I'd like to share it with you to get your reactions. Please understand that this is a world class clinician who is beloved by his patients and who has an exemplary record in safety and quality. So he is not saying we shouldn't be good at that, but he is saying something about how he thinks the hospital marketplace really works and what I should be emphasizing in public statements.

No one in their right mind could want anything but the safest possible hospital. But complex human organizations are inherently frail in the infallibility department. So while we have to work on this continually, we should not confuse that with "quality".

In the marketplace, people want the "best doctor". You will never hear anyone saying that they picked their doctor because the hospital he practiced at had a better safety record.

While we have to be excellent at safety, quality in the minds of the public is related to whether they think that the care they are getting from their doctor is the best. By this they mean, is the doctor practicing at the very highest level, making the right diagnosis, giving them access to the cutting edge and best therapies. Quality is not how many falls we have, because even though you and I know that the falls are dangerous and kill people, no one comes into the hospital thinking that they are going to fall.

If you make patient safety your acid test, you are not going to attract the kind of patients you need to stay in business. The difference, in the mind of the public, between quality and safety is huge. Quality means the medical care expectations. Safety is merely expected…until something goes wrong.

So, from my point of view, the emphasis at BIDMC has to be on quality, as in finding things that we are simply the best in the world at, and riding that wave.

Teamwork wins against VAP

Back in March, I gave an update on our efforts to eliminate ventilator associated pneumonia in our ICUs. This requires implementing a five-part "bundle" of steps every day with every patient. You measure compliance in this program by the percentage of time you do all five steps. There is no partial credit.

An additional item is to perform dental hygiene on patients every four hours. The bugs that can cause pneumonia often originate in the mouth.

The goal is to reduce the number of cases of VAP, which statistically have a 30% mortality rate.

We report on this item on our company website, but I wanted to give you a secret advanced preview. The charts above show our improvement with the bundle and with dental hygiene.

I don't want to brag too much -- well, actually I do! -- because these results are spectacular. They are the result of terrific teamwork among several departments of nurses, doctors, and other health care professionals. Our best estimate is that the reduction in VAP from these efforts is amounting to about 320 cases per year at BIDMC. While it is risky to extrapolate to relatively small numbers by applying broad statistics, if the 30% mortality figure is applied to this number of cases, it means that our folks saved 96 lives per year.

For those interested in costs, a case of VAP is estimated to increase hospital costs by about $40,000 per patient. Once again, applying this broad average figure to our specific number of avoided cases (320) means cost savings to the hospital of about $12 million. Hmm, saving lives and saving money by teamwork and rigorous attention to detail. Any lessons here?

Outpatient clinic of innovation

An interesting idea from Ulleval University Hospital in Oslo. (There are some similar concepts that I know of from the US, like MIT´s Center for Biomedical Innovation and Entrepreneurship Center, but this one has its own unique features.) Here´s a summary from Andreas Moan, Director of Research and Education:

The Clinic of Innovation is run like any traditional out-patient clinic with one major difference: The purpose of this Clinic is to facilitate the conversion of ideas from research and medical practice into new services or products to the benefit of both patients and society. We also want to offer the same kind of service to ideas generated outside the hospital, offering our medical and research expertise. The Clinic of Innovation is organized as any other out-patient clinic, offering diagnostic work-ups, treatment and follow-up.

It is a joint venture between the Ulleval University Hospital and Medinnova, a Technology Transfer Office with 20 years of experience in innovation. The Clinic has two main customers: First, people working within the health system with new ideas on how services, treatment, organization or products can be improved or developed. Secondly, the Clinic acts as a bridge into the health system for people, commercial parties, biotech and other research-intensive businesses who may be looking for an initial point of contact to the public health sector.

Culture and language is quite different in the public health system and in private enterprise, and our goal is that the Clinic of Innovation may serve as a meeting point and as translators. Our employees have experience from both the private and public sectors.

Although this Clinic is organized as any other out-patient clinic, there is one major difference: To this Clinic you can refer yourself – please see below.

The Clinic of Innovation offers:

Diagnostic work-ups entailing evaluating your idea’s potential in both research and commercial context, or calling external competence as needed to do so. Depending on the diagnosis, the idea (and its owner) will be offered treatment that may entail
- direct problem solving
- development as a joint venture/active project
- establishment of contact with new networks that we believe will help develop the idea
- referral to group therapy with other innovators facing similar problems

Follow-up means seeing you and your idea back for follow-up and additional referral or problems solving as the idea evolves.

The Clinic of Innovation is also a tool to inform about the importance, possible economical impact and sheer pleasure of innovation. The tools for this activity include media coverage, advertising and visiting relevant people and communities inside and outside of the hospital.

How do you find the Clinic of Innovation?

Physically located at the Ulleval University Hospital in Oslo, Norway.

On the Internet: at www.ulleval.no “Idépoliklinikken” in our rather remote language and at www.medinnova.no

E-mail: idepoliklinkken@uus.noPhone: +47 23 02 70 23

Point of contact: Eli Margrethe Walseth

What can you expect?

New ideas are best submitted by a webform located here Medinnova or by email or phone.

The Clinic of Innovations has weekly intake meetings, so you can expect an answer within no more than two weeks. We may want to contact you ahead of the intake meeting to better understand your concept. Your referral is guaranteed full confidentiality, confirmed on the return receipt you get on our referral form. We will also sign a confidentiality agreement at the first appointment.

How we manage

I often get questions as to how we manage this place. I usually jokingly reply that we don't manage, we cope. But we really do try to have a close alignment between the medical and administrative staff in support of the overall goals that are adopted each year by our Board of Directors. Those goals, in turn, are guided by our overall mission and informed by the strategic plans that have been approved by the board for clinical care, research, and education.

I thought you might like to see excerpts of this year's annual operating plan to get a sense of what it contains. Those of you who have been reading this blog for a while will not be surprised by some of the items included. There are three main categories -- improvement in clinical results and patient safety; improvement in patient satisfaction; and improvement in the organization's financial results.

Please remember that I am not presenting the complete document. Also, things arise during the year that can cause a change in plans. But this does present an example of the kinds of issues that attract managerial attention at an academic medical center like ours. The plan is based on analysis and conversations among people in all parts of the medical center. To that extent it is "bottom-up." But then it is formally adopted by the senior managerial and clinical leadership and then by the Board of Directors and becomes a "top-down" document against all are held accountable. Of course, it is widely shared with the staff by being available on the hospital's website and in meetings with people throughout the organization.

Fiscal Year ’07 Annual Operating Plan
Each year our budget and related annual operating plan offer new challenges and opportunities for success, and this is especially true of fiscal 07. While our ‘07 AOP is built around the three key areas of quality, satisfaction and financial performance as in prior years, you will note a slight shift in emphasis reflecting the challenges in this year’s budget.

This year there is an increased emphasis in implementing a more rigorous approach to improving productivity, managing clinical resources, and developing clinical pathways and in monitoring and measuring the success of these efforts. Many of you will be asked to participate in these efforts, and we appreciate your support.

We remain committed to and focused on clinical quality and patient safety and satisfaction, as they remain the primary elements defining our institution and its role in the medical community. We have achieved major progress in our quality of care and patient safety and have developed a track record of innovation in these areas. We have likewise seen continuous improvement in our satisfaction scores. In addition, we have been successful in developing programs that support the growth and career development of our employees. In ’07, our goal is to hold these gains and selectively build on the successes in these areas.

As always, this plan is supported by detailed and specific tactics and measures that will ensure our ability to be successful and measure our progress. We will periodically provide updates on these more specific actions to our Board, physicians and staff. We ask for your support and welcome suggestions on how to achieve these goals in FY’07.

Goal 1: Promote Continuous Excellence in Clinical Quality and Patient Safety

a. Achieve the goals in our annual quality and safety plan adopted by the MEC [The faculty's Medical Executive Committee] and PCAC [The Board's Patient Care Assessment Committee], including:
1. Implementing programs for patient safety, environmental safety, and emergency/disaster preparedness that ensures BIDMC’s readiness for JCAHO survey;
2. Achieving top 10% ranking in all the JCAHO/CMS quality indicators;
3. Achieving target performance in hand hygiene in 80% of critical care units and demonstrated improvement in 80% of inpatient units;
4. Achieving further improvement beyond 2006 rate in ICU central line associated bloodstream infection rate and best practice standards for VAP prevention;
5. Achieving influenza immunization rate of 60% of direct care providers.

b. Full implementation of key IS projects in patient identification, OR specimen tracking, and POE [computerized provider order entry] for ambulatory chemotherapy patients.

c. Continue to develop coverage plans and facility plans to meet patient needs and accommodate volume growth.

d. Expand the roll out of the clinical trials patient registration tool to two additional high volume departments/divisions.

e. Develop and implement patient safety initiatives in the Shapiro Simulation and Skills Center including training in the placement of central venous lines and in triggers/crisis management.

f. Achieve higher rates of donor conversion and organs/donor than the national goals for organ donation.

Goal 2: Ensure Outstanding Patient, Physician, and Employee Satisfaction and Loyalty

a. Achieve 95th percentile for patient satisfaction in inpatient, ambulatory surgery, and ambulatory visits and 90th percentile for the emergency department.

b. Complete the roll out of customer satisfaction training and job reclassification in all patient care areas.

c. Implement key recommendations from Referring Physician Survey including formal outreach to first time referrers and identifying selected enhancements to discharge fax for referring physicians.

d. Develop and implement a plan for assessment of core residency program performance in attracting and training residents.

e. Continue to foster open communication between employees and management through Town Halls, Executive Walk Rounds, and Management Roundtables.

f. Create and implement programs to recruit and retain an outstanding and diverse workforce including competitive benefits and compensation programs, career development programs, and leadership development programs to enhance the strength and capabilities of our managers.

Goal 3: Sustain Financial Strength through achievement of our inpatient and outpatient volume goals and increased focused on productivity targets

a. Achieve 3% operating margin

b. Support growth to achieve budgeted inpatient and ambulatory volumes.

c. Completing the Facility Master Plan and developing list of recommended multi-year facility actions required to ensure adequate capacity for ambulatory visits, surgical cases, and inpatient admissions.

d. Achieve significant productivity improvements required to reach the 07 budgeted cost/case and cost/visit and to prepare for FY08 budget by:
1. Implementing LEAN initiatives in 5 key areas with a focus on reducing costs and enhancing revenue;
2. Strengthening clinical resource management around high cost services in the OR and procedural areas;
3. Developing clinical pathways in partnership with physician program leaders to reduce variability in high volume/high cost DRG’s;
4. Continuing to identify and carry out projects to reduce energy utilization.

Online with real clinical results

Here's an email I sent to our staff today. Also picked up by the Globe. Please check out the site and let us know what you think. Now I can stop posting infection rates on this blog . . . .

Today we start a new experiment, a web site directed to the public called "The facts at BIDMC: We're putting ourselves under a microscope." You can find it on the external BIDMC web site at www.bidmc.harvard.edu/thefacts .

What's this all about? It is our belief that the public deserves timely and accurate information about the quality of care at hospitals. There are other web sites that provide some information; however, most of what is available is not current and is often based on administrative data like insurance claims, rather than on clinical data.

So, we decided to create our own. On this web site, you can see how we rate on certain "process metrics" – for example, how closely BIDMC is following recommended guidelines for treatment of heart attack and heart failure. You can also see how well we are doing in reducing harm to patients – such as our progress in eliminating central line infections. We also show how many times we have done certain kinds of procedures, like bariatric surgery, heart bypass surgery and others.

We show the latest numbers we have for all these metrics. Where national comparisons or benchmarks exist, we compare ourselves to them. Where national standards do not exist or where we think they are not adequate, we show our own goals and how we are reaching them. Where we are not doing as well as we would like (such as with hand hygiene), we show that too.

For each item we post, we try to explain how to interpret and use the numbers. Over time, we plan to add more categories of medical services.

As I noted, this is an experiment, so we also provide a page for reviews and comments. I recognize that this is a new experience for all of us – to have our work so starkly laid out and measured for all to see. I hope you all see this as a valuable tool that helps each of us do our jobs better every day. So please take a look and send us your thoughts.

More on mystery shoppers

Several months ago, I wrote a post on our use of mystery shoppers to evaluate and improve customer service. Today Liz Kowalczyk at the Boston Globe covers the story in more depth (and with better writing!) I also find it really interesting to see the different perspective on this technique across the city's hospitals.