Learning to get the SPIRIT

More in our continuing series on BIDMC SPIRIT, our effort to enhance the work environment for staff throughout the hospital. Here are additional comments from people who have just gone through the train-the trainers training program. You can get a feel for both the excitement and the nervousness.

I really liked seeing how other areas of the hospital worked. It was nice having a hands on view of the hospital. It was a long day. The information was great, and you have to go over the material before you go out to try it but it is a long day and a lot to digest.

The process [for problem solving] is a plus. Being able to step back from the daily rush and think through an effective process. What’s needed is even more disciplines in this group.

What was great was learning how one problem can have implications in many other areas, something I never would have imagined. An issue is that a think we will need a little bit of handholding in our own areas, once this starts … help working through some problems until we are used to it.

Loved the trainers. They knew their subject. They were knowledgeable. I am not clinical and it was so interesting to see the work on the floors.

My worry is about the areas that are the suppliers to many areas. They are very gung ho right now but even in training they are getting lots of calls and I worry about them being overwhelmed. We need to develop supports for them from Day 1. Even now they are joking that “It’s 2:00 – SPIRIT training time – so my pager is about to go off.” We don’t want them to burn out … [Later in conversation same participant offered the following idea …] It would be helpful if some of the observation visits could take place in those supply departments. I think it would send two messages. The first is that it would help them be prepared to respond more effectively to calls re: real time root cause problem solving. Second, it would send the message that this is about you, too. And that’s important.

The positive was that we went out and did real problem solving on the floor. It was insightful. It was nice to see challenges that other areas face. It was a long day.

Getting out was great. We have never done that in our other trainings. Great. I need the bibliography that was mentioned – this is just a total shift for us – plus that list of tools / helpful hints for working with staff on real time problems. My barrier or worry is that problems that need to go to other areas [for investigation / solution development ] may take time, and may hit barriers. We may need to get back together once we start and look at how well that is working and revisit our efforts there.

I’m coming away from this today with real good tools to attack problems. The trainers were great. It’s good subject matter. It’s a long day but you probably have to do it in one day. Actually using the tools was great.

It was great. The best for me was being on my own floor and getting to use the tools from the AM in the afternoon. It helped me see things I was seeing differently, in a way the staff could see and feel as well … very helpful. It did help me to think about the roots of things, about why the problems I am seeing are occurring. To improve it, I would send ahead more background on change management coming in, and make sure we had more tools going out.

I liked having no choice about where I observed. Given my experience here, I wouldn’t have picked to go back to peri-op because I assumed I knew how everything worked. When I got back there of course I realized I didn’t know how it really worked.

What was great was that it was experiential. It fundamentally changes training. Great. Giving everyone one way to think about problem solving would be huge. As awesome a task as it sounds, it is totally worth undertaking. The negative was the eight hours is not enough to equip a manager to do it effectively. We need a log for the process of implementation itself. A place that issues and struggles can be called out and learning shared. A kind of help chain support for how to be better at it.

The diversity of this group was a huge plus. We need more prerequisites coming in. It’s a little loose at the end. Coming out of these trainings the managers are saying “Oh my G-d.” If we think about it, we could come out of the trainings with a clear sense of next steps that may help everyone come out feeling more positively.

This is really exciting. I didn’t know what to expect on the floor. It was easy to identify problems. If we do it, it will be incredible. If we can make it a way of life. The question is how to do this. One key thing we identified today was the issue of when managers are called [in the help chain] and they haven’t been trained yet, it can be worrisome. They might say they know “who” may have messed up and you want to rush to say “ no, no we’re looking for a system issue” … so that’s an issue and it’s hard to create safety in the moment.

The basic tenet of safety is key. Once established they (participants in problem solving) were much more forthcoming.

I was struck that doing this on a busy unit at a busy time, seemed overwhelming. But the more we circled back to staff as they were able to give us a minute the more things did move along. Seemed more possible.

At the start, so many things will be identified. For the first month, how should we prioritize? I am worried we are about to open Pandora’s box here.

One idea I had today that you may hear about is to once a year have a BIDMC Spirit Award. Something really meaningful. And done in a way that doesn’t convey the message that only this SPIRIT achievement counts and yours doesn’t matter …

It’s the issue of training that keeps me up at night. I don’t want to do this [act as trainer] until we are ready for prime time. We may need more support for a longer period from the people who’ve done this during their whole career.

This is my second time [training to be a trainer]. Last Thursday, my worry was the sense our staff have of handing over problems to you to be solved. Today, we scared several people. It was definitely not our intent. It’s just that people who have not yet been to orientation respond in the old way, as if “I did something wrong.” We are really going to have to work on that.

I am worried about tomorrow on my unit. I will talk to them about this experience today. I am not sure they are going to wait until March 1 to call out. It’s a good thing, I know. As they become more used to identifying problems, it will be a real burden to try to keep up and make this work.

There are tremendous tensions building up in the system about how we are going to be able to do this. Stating the obvious to people about these things is really, really important for leaders to do.

I was struck by how important it is to get the managers involved to work the staff, to not “jump the help chain” straight to the staff level. It’s what’s going to make sustainable solutions possible.

True safety comes in the moment, through the work itself. But can we prepare the culture? Can we have the managers understanding that they are important, they are vital, to work toward sustainable solutions?

Trainees report back and train trainers

As promised, I want to keep you up to date on our experiences as we implement BIDMC SPIRIT, our process improvement program of the sort described by Steve Spear. We are now at the stage of orienting people and training the trainers, the people on our staff who will train over 600 staff members in the techniques of calling out problems and pulling together help teams to solve them. We are assisted by some folks from a firm called Value Capture, which was founded by Paul O'Neill based on his experience at Alcoa.

After the first session, as part of an effort to improve the orientation and training sessions themselves, the group leader asked:

“Tell me one thing that was great or positive about today/SPIRIT so far … and one thing that was negative or is worrying you.”

Here are the replies:

Great: The observations, the real time problem solving and action plan development. The wonderful openness of Donna (director) and her team. Some of the role plays. Today was an incredibly useful exercise. The train the trainer approach is the right one. Scary to think about doing the training, but workable. As valuable as the Value Capture people are it’s important that we show we really own this in as many ways as we can. What was bad or am I worried about? It’s a long day! The chairs were bad. The room. We are training several hundred people, but only a small portion by March 1st. I am worried we will not have enough people ready with the language and the tools. But somehow I think it will work out. We need to manage expectations and the anxiety. We need to tell people we will not be great at this at first … but it will be a start.

Ditto to everything above. Great was the observation and work on the areas we went to – that was the highlight. We called out that the PACU role play should be further simplified (told as a simple story, holding discussion until end). I also agree about changing the room.

I came in with skepticism … a lot of skepticism … and I am leaving feeling a lot better, less skeptical. Going through this was transformative. My worry is that there are still 1,000 things to learn … will we be ready? Should we cut our teeth by piloting this in a few units first?

Great: The observation and the hands on problem solving. The willingness of the staff to participate! They were really ready. They knew about SPIRIT from Paul’s messages. My worry is the same. Do we really have the readiness to train? Will management be ready. Should we ramp up from a pilot?

Great: I was pleased to see the staff’s wariness melt and the problem solving process become fun! I worry that we have to get it deep enough down to the front line staff level. Use the code team example – have an outsider who wears the lanyard who can come and help – objective eyes in an observer – together with maintaining the transparency. Those are the keys to make it safe.

I see that this could be so incredible. But I worry there on the same count. Will we be able to be fully engaged and work staff through the barriers … to really get this rolling. I am somewhat overwhelmed by the number of problems. I don’t want to let staff down. We want it to work for them.

I see the positive culture change here. I loved the value of outside eyes for problem solving. We need to add the additional helpful hints, watch outs, useful phrases to help managers approach this w/employees in real time.

This is transformative. In the middle of doing the work on the floor today it hit me. Earlier in the day, I was hung up on the connection between the log and problem solving, and then it hit me – Is this a tool or is it about a new process and way of thinking about problems. It’s the latter.

Great: It’s simple steps … we laid it out easily and we followed it. Not easy to do but still good. It’s easy to understand (the method). What worries me? We have different skill levels in the organization. I worry about will it be used at a level that it will be used well? I’m worried about time. I worried that we’ll be able to take time away from other things, especially when it’s patient care. I need more tools as a trainer. I’d like more exposure to the help chain; we didn’t have to use it in our problem.

The observation opportunity was fantastic. We struck gold with our group and problem and the staff we worked with. What’s positive is we are pushing decision-making closer to the people who do the work. I worry about training. I need more problem solving exercises to feel comfortable as a potential trainer. Also, I think this is OK/great in departments with a participatory culture, but in departments with different norms if not implemented and supported well it could be quite harmful to the people. We need to think about the involvement of coaches/outside eyes.

I went from being skeptical on the (problem solving) log to feeling it could be very useful … and applied to all kinds of problems. The last module on the log was very useful.

In terms of worries: We have not been good enough messaging that this process is for hunting and fetching problems. We’ve got to be clear about what this is for. And also for the other systems that we are preserving.

Keep in mind, it’s hard when a few things are still blurry. But consider how this is being designed as a process to improve as improvements are suggested. It’s already been improved and will continue to do so.

Have Paul continue to message directly to the staff on this. They hear him. He is such a popular figure. He is clear. They also listen because he doesn’t fill up our e-mail with too many things.

I’d like another review session, to help prepare as a trainer (in addition to the planned development sequence – just a couple hours to go over the design, etc).

More on fetching and work-arounds

Some colleagues and I had a chance today to spend some time with Steven Spear, from MIT and the Institute for Healthcare Improvement, who is an expert on the kind of process improvement program we are trying to carry out at BIDMC. That he had terrific and useful insights was no surprise to those of us who have read some of his work.

Steve also made mention of research carried out by Anita Tucker, from Harvard Business School, in which she spent many hours observing nurses in hospitals. (I did not find this particular study, but here is one that summarizes it.) Her conclusions were consistent with my own observations and the points I made in my staff email back in November -- and many comments I received from our staff after that email. Professor Tucker found that nurses who encounter problems or impediments on the hospital floors generally will invent a quick work-around to solve those problems. This makes sense. First of all, they are really busy and just need to get the problem solved. Secondly, most organizations do not provide a way to call out problems and have them solved in a timely or effective fashion. Unfortunately, this pragmatic approach to problem-solving leaves systemic problems untreated and, indeed, aggravated by an additional layer of work-arounds.

As Steve has written in his studies of Toyota and reviews of other high performance organizations, the common characteristic of these organizations is not in their ability to design perfect and complex production or service delivery systems. Rather, it is their ability to discover great systems. They do this by managing their work flow to encourage people at all levels to call out problems; to "swarm" together to solve those problems; to share this process of discovery with others in the organization so that the solutions are diffused widely; and to cultivate the skills of people throughout the organization to be involved in this kind of constant improvement.

It was heartening to hear this reinforcement for the kind of program we are beginning at our hospital, which was named BIDMC Spirit in our own election campaign. I feel like we are on the right track. Now comes the simple (hah!) part -- doing it. Our first training session was held today. Stay tuned for further developments.

Ready Resolve at NYU

Here is a really neat program at NYU's Tisch Hospital. Employee volunteers (each one serves for one hour per day for one week every other month) visit patient rooms and conduct a quick on-the-spot survey of patient needs and follow up to solve a series of common problems -- do the phone and TV work properly; are the room and bathroom clean; did you get the meal you ordered. The Ready Resolvers either fix or call in any problems imediately. The responding departments are responsible for resolving the problems within two hours. If they cannot fix the problem right away, they send a staff member to visit the patient to explain in person.

This began as a pilot in June on three units, with 27 volunteers. It was expanded in August to 4 additional units, with 63 volunteers.

Interesting, too, that the Ready Resolvers started to uncover problems that were systemic in nature, that require further hospital-wide work.

I like this idea. If you work in a hospital, here or elsewhere, do you?

Organizational Wiki

This is a request for advice. As I have noted below, we are engaged in a major process improvement and staff engagement process we now call BIDMC SPIRIT. We are designing a system that will enable staff people throughout the hospital to call out problems that they see while doing their everyday work, and then have help teams focus in on those problems, do root-cause analyses, and construct sensible solutions and diffuse them throughout the organization. This process, in part, relies on experience from Toyota, but it also uses some newer work done by other organizations.

Our folks are excited and intrigued by this and are starting to get engaged. Among other things, we plan to conduct formal training in the approach for about 600 people -- roughly 10% of our staff -- to create a core group from whom the process will spread.

Because this is a really new approach to things for an academic medical center of our size, one of my goals is to make sure that people feel they can also participate in the actual design and implementation. For example, I'd like for the training and communication process to be modified from suggestions of people as it proceeds, so that we refine it and keep things clear and relevant as we implement the program.

In essence, I want to create the organizational equivalent of a wiki -- a process that is organic during its implementation as a result of multiple and transparent contributions by the participants themselves. Think about that as allowing the people in the hospital to enhance the process improvement process itself even as that process is being rolled out. Think about it further as an incredibly and intentionally democratic design approach that puts great faith in the staff to know what will be most effective in teaching themselves about the program, for the benefit of one another. Now, add on to that characterization the fact that this needs to occur in a real-time manner and in multiple languages (English, Spanish, Creole, and others) and across multiple job categories so that all people feel confident that their points of view are heard and respected in a culturally sensitive manner.

We have some ways we are employing to do this, but I would love to hear from others -- whether in the medical field or elsewhere -- who might have tried this and can provide stories or references to their work. Please don't focus solely on computer information systems: Remember that lots of our people do not regularly look at a computer.

The votes are in!

Lots of you seem interested in the inside story on managing change in the hospital, and I am happy to share what we are doing on the chance it might be informative to those in other organizations. For those who are interested, here is a follow-up to my Thanksgiving staff email on our process improvement program for BIDMC. We conducted an election to name the program, with unlimited nominations "from the floor" and a preliminary ballot to narrow the field to seven finalists. Asking the staff to name the program is just the most visible part of encouraging their participation in its design and implementation. Here's today's email announcing the winner:

Subject: The votes are in! BIDMC SPIRIT takes first place!

Hi,

In an election that has set a national standard for voter turnout and lack of negative campaigning, and a full week before Super Tuesday, we have a winner in our naming contest for the new BIDMC process improvement program.

Almost 2000 votes were cast, and the run-away winner was:

BIDMC SPIRIT (Solutions Promoting Improvement Respect Integrity & Teamwork)

Please stay tuned over the coming weeks for more about this initiative -- further explanation, training, and experimenting. Remember, the goal of BIDMC SPIRIT is that we want every BIDMC staff member to be able to answer these questions with a resounding "Yes!" every day:

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?

I'll tell you right now that we are inventing something new here. Sometimes it will feel chaotic, inefficient, or downright dumb as we do this: You will probably question my judgment many times over for even trying it. But, let's give it a chance and see what we can do together with the right BIDMC SPIRIT!

(By the way, will the person who suggested this name please contact me?)

Sincerely,

Paul

---

Wow, within minutes, I have already received the following comments back from the email:

Good morning, Excellent choice, that was my choice. Have a great day. Thank you.
--
Whoever named this did a great job....
--
Congratulations on running a great campaign
--
BRAVO!! Congratulations.....
--
wow.........I finally picked a winner....now if I could only make up my mind about the democratic primary..........
--
Junior Seau said this week over and over again the same thing you did -- "let's just give it a chance, everyone just needs a chance" -- and look where he is now!!!!! I voted for this one too!
--
I am very excited the BIDMC SPIRIT was selected! I had suggested it during the original polling process… but I am glad that so many people resonated with it!
--
I would love to have an active role in this campaign of BIDMC SPIRIT.
--
An abbreviation better than WMD.
--
Love the name.

---
And this really nice one later on:

Although I cannot take credit for the name or idea of this program, I think it is an important concept. I am happy to know that this is going to be implemented and feel as though everyone will benefit from it in the end (especially the patients). From my perspective, there is nothing more rewarding than taking care of individuals during a time of need. We will all experience this vulnerability at some point in our lives. The key (again in my opinion) is to deliver quality care in a supportive, nurturing environment. It is evident that happier employees ultimately equals a more positive work environment which in turn equals quality care.

Thank you for supporting this program and also for taking the time to recognize the individual who is responsible for creating the name. You send a powerful message and it sounds like you are getting a positive response.

Responses to our new goals

As promised below, I am sharing some of the responses I received from members of the staff and also outside observers after we announced our new goals for patient satisfaction and quality and safety. As you will see, there is a variety of opinion on the issue. This is not expected. I am going to divide them up by doctors, nurses and other staff, and outside folks who read the story or editorial in the newspaper or heard a radio interview.

I am not including my replies to these emails. You can offer your own replies in the comments!

Doctors

#1 -- How does BIDMC plan to determine if harm prevention measures are actually causing unintended harm? This isn't an idle question - we have bypassed much of the usual science of medicine when invoking quality improvement. We assume that if we force providers to don gloves and gowns before examining patients in an ICU that they will still go into the rooms just as much. We assume that the pass-off errors caused by resident work-hour changes won't exceed the benefits from reduced fatigue errors. We assume that the benefit of infections prevented by forms and checklists with central venous catheters makes up for the occasional delay in acute resuscitation. We assume that the benefits of medication reconciliation in the outpatient world will exceed the harm done by the loss of precious minutes spent actually talking with patients (my department can't even provide projected numbers on how long it should take the average MD to type in an average med list for our patients.) These are all measurable questions. Perhaps we assume too much? Auerbach's editorial on the question in the NEJM should have been a clarion call for us to redouble our efforts to evaluate change before declaring it beneficial.
---

#2 -- I am delighted to hear from your email of the Hospitals' re-affirmation to emphasizing patient satisfaction.
---

#3 -- (A) Makes me proud. I think that this is in part an ethics issue: there are few moral responsibilities we have as serious and widely acknowledged as the Hipprocratic admonition to “Do No Harm.”

(B) At our monthly Ethics Rounds (held in every ICU and 15-20 units total) we should consider moving from asking about “any cases of adverse events in the past month that you think weren’t disclosed/reported properly?” to “any cases in the past month where a patient was harmed by something we did that was preventable?”

(C) We could also encourage our individual Ethics Liaisons (designated by the chiefs of more than 50 clinical and administrative units) to think about ways they can help foster a culture in which we take moral responsibility for not harming patients, and constructive “preventive ethics” efforts not to do so in the future.

We have found our many Ethics Rounds a useful tool in the past for exploring in a BIDMC-wide way the views or experiences of front-line clinical staff about ethical aspects of issues such as a possible VIP unit. Our Ethics Liaisons Program is already proving it has great potential for engaging a large group of individuals across multiple departments.
---

#4 -- (Reply comment from another doctor:) RE "C", I would emphasize even more strongly that the moral responsibility is to learn as much as possible from every episode of harm in order to prevent that harm from recurring. We need to remain clear that competent and well intentioned providers may find themselves part of an event in which there is harm, and foster the culture where people see these as learning opportunities to prevent future harm.
---

#5 -- This is good, and it is clear that goal number one can be published because it only provides a measuring stick (new for BIDMC) for something we have already been doing. But goal number two: How does the hospital elegantly air this goal without the fear of being criticized for not having been doing this all along? Perhaps a better wording would be to emulate the wording of the first goal and say that we will establish new measures to ensure that our preventive measures work, so that we can fix them if they don't.
---

#6 -- I really liked your very thoughtful and important words on public radio this morning.
---

# 7 -- I am concerned about the wording of the second goal- there is a problem when you set an unobtainable goal, only to publicly show that you couldn't achieve it. Here is the unobtainable goal:

"BIDMC will eliminate all preventable harm by January 1, 2012."

This cannot be done, because it is stated in absolute terms. Eliminating "all preventable harm" is a noble ideal, but it is unrealistic given the complexity of delivering health care by multiple layers of teams and individuals. The best that any hospital can do is to develop mechanisms to reduce preventable harm, not to guarantee that all harm will be prevented. Any preventable harm, even if it was humanly impossible to foresee it, and even if no other hospital could prevent it, will be held against us as a failure to achieve what we promised.

I suggest that this second goal be revised as follows:

BIDMC will continue to create an environment that reduces preventable harm to the fullest extent possible. To this end, by January 1, 2012 we will be recognized as a national leader in the field of patient safety. We will accomplish this by continually monitoring all preventable and non-preventable occurrences of harm, and continuously improving our systems to allow the greatest opportunity to reduce harm.

This is also a noble goal, but it has the merit of being achievable....
---

#8 -- This is great, and the report in yesterday’s Globe has a lot of people elsewhere talking about it, and very favorably. May I suggest that the next step, given your interest and ability to be well ahead of the curve, would be – where the specific data permits such granularity – to know and report whether results were similar or different segmented by race, ethnicity, age group and gender. It would be fabulous to be able to say, with respect to various indices of care, that there was no difference at BIDMC when examined by race, ethnicity, gender and age group.

Nurses and other staff

#1 -- I treasure my place here and I imagine it will be a very long time before I will look elsewhere. I love this safety and quality initiative and I even love the naming exercise for the "thing"!!! Thanks for being who you are- it makes it possible for us to be who we are as well.
---

#2 -- Thank you for taking the lead in making and returning BIDMC a wonderful place for patients. I hope to contribute to the attainment of this goal as a clinical nurse.
---

#3 -- I am a nurse working at [a specified floor], and was just wondering if this meeting was in response to latest news that medical insurance will not be reimbursing hospitals for preventable occurrences (aside from the obvious that we care and value patient safety and prove that we are one if not the BEST hospital in Boston)?
---

#4 -- Take the leaps...set the goals...Count Me In!
---

#5 -- These are goals we can certainly reach. Over the last two years, we've made great strides creating performance measures in the Department of Medicine's divisions. After many meetings with our colleagues and data collection, it feels good to see the improvements based on our results.
---

#6 -- You have my support...please let me know what I can do to attain the goals you have set.
This is an awesome hospital....and I'd like to help make the patient experience even better.
---

#7 -- Although the initiatives you are describing relate to patient care, I believe that all subjects in research studies are patients as well. Please do not hesitate to contact me if I can lend my support and experience to any committees under development or in any way you see fit.
---

#8 -- WOW!
---

#9 -- These initiatives are terrific. I appreciate them both as an employee but more importantly, I appreciate it as a patient. Should I, or my family, be so sick that we need to be hospitalized, I want to feel confident, when we are most vulnerable, that we will be cared for safely. While we have not ever been hospitalized, we have utilized the outpatient services and have run up against some significant gaps in quality care. I've raised those issues with the appropriate managers and in both cases they responded quickly and appropriately. We have a way to go at all levels. You can count on me to help work toward these goals.
---

#10 -- I appreciate your and the Board's "raising the bar" at BIDMC and BID-Needham. I am looking forward to doing my part.

I want to make sure you're aware of something I saw at the FDA website. I imagine you are aware of it but since it appears to be right in line with the announced aspirations and "The Thing" I felt I should take a chance at being redundant. The title of the FDA program is "AHRQ Releases Toolkits to Help Providers and Patients Implement Safer HealthCare Practices" and here is the link.
---

#11 -- A thought about patient feedback: The several times I have been hospitalized, the efforts of staff to go beyond courtesy to make me feel taken care of and cared about have always stayed with me more than anything else about a hospital stay. And of course, apathy, lassitude or grumpiness has made an equally strong impression on me. There were times when I felt mistreated by “bad apples” (not at BIDMC). At the time, I wished I had had the opportunity to give feedback to the hospital. However, in the weakened state of illness, patients do not have the physical or mental energy to seek recourse on their own. If patients were given feedback cards (as often happens in restaurants) when they are admitted (not on leaving, when the memory is less accurate), this would help in more ways than one: the patient would feel he/she had recourse, and would thus leave feeling the hospital cared, even if the “bad apple” didn’t appear to, and 2) if they know patients have this forum, bad apples are likely to take more care how they treat patients.

Question regarding the phrase in your email: “We will measure ourselves based on national benchmarks”: I was just wondering if national benchmarks include a measure of staff satisfaction, since patient satisfaction depends daily on the way they are treated.

Outside folks

#1 -- I can say that after my experiences @ BI & my husband's experiences at an unnamed hospital, you are well ahead in the process & examples.
---

#2 -- Bravo!
---

#3 -- Bravo! I will follow with great interest.
---

#4 -- Reading today's Globe, I was once again struck by how very proud I am to be associated with Beth Israel Deaconess Medical Center. Not only do I appreciate your forward thinking but am amazed at your goal to not only be first, but to do right.

Congratulations. This is a great day.
---

#5 -- Congratulations to both of you and your Boards for this outstanding initiative.
---

#6 -- Hearty congratulations and a bold and positive step!
---

#7 -- First rate and I am sure will be supported by all of us.

One issue to think about over time. You can make the hospital experience great and are doing that. However, with the advent of out patient care and day surgery, much of the experience takes place in the doctor's office. Some are not so great at continuing the great feeling one gets at the hospital.

As a lawyer I represent many banks. I am acutely aware that how I treat the bank's customer in documenting the transaction reflects back at the bank.

I hope you can (or can continue to) foster that feeling in your doctors.

Regards and with continuing admiration for what you are doing.
---

#8 -- Congratulations on your quality goals. Nice to see someone put a stake in the ground and focus on what this business is really about.
---

#9 -- Impressive move by you and your board. That's the way to push the envelope. Let's hope others take up the challenge as well.
---

#10 -- Great Globe Editorial today! I’m so proud to now be a BI patient!
---

#11 -- Good luck with the initiative. It’s a big undertaking.
---

#12 -- I am really delighted that you have chosen to meet this head on. Obtaining accurate data and putting the CARE back into healthcare will continue to keep us in the forefront both in Boston and nationally.
---

#13 -- I can’t tell you how excited I am by your commitment to avoid all preventable harm to patients. It is simply the right thing to do. In a similar vein, I first learned of Ascension Health’s commitment to “no preventable deaths by 2008” in the fall of 2004. I have known Dr. Sandy Tolchin for many years and have had the opportunity to learn of his efforts, initially at Borgess Health Alliance in Kalamazoo and now as VP Clinical Excellence in collaboration with David Prior and others at Ascension Health. When I last spoke with him in the late fall, he said, “We have now demonstrated that flawless care is achievable.”