Straight talk about SPIRIT

After each full-day training session for managers and others about BIDMC SPIRIT (almost 600 people now), there is a debriefing session. The comments that emerge are helpful to us in refining both the training program and our plans for calling out and solving problems throughout the hospital. To give you a sense of the issues raised, I am posting the comments from the last session. Remember, this is early in the process, not like at Toyota and other places where similar approaches have existed for decades. So, we are still feeling our way. I love that people are so open and clear about what they find reassuring and what they find troubling. That, in itself, is an important aspect of what we are trying to accomplish.

BIDMC Spirit Orientation
Participant Concluding Reflections
April 15, 2008
These reflections were invited by Ken Sands, our SVP for Health Care Quality. He started by saying, "We heard earlier today from a colleague about how logging of items about their unit had been used as a metric that wasn’t positive." Responses follow:

That was me. I did get a call from someone above me who said in effect, "There are a lot of call-outs in your area there must be some real problems there; what’s going on?" when it’s 4 out of 450 and I know we are trying to encourage call outs. I wanted to say that I’m a big supporter of this process, but it has been confusing regarding are we supposed to deal with things as they are called out and up "the help chain" or by getting calls from people above us or reacting to an e-mail from the log monitor? Are we supposed to scan it everyday? It’s not clear and it’s hard to know how to prioritize. We talked about it earlier today, and we discussed how we are all learning together including the leaders, but it’s important to be aware of this dynamic because it creates pressure and anxiety.

Thanks for saying that. The other day we had an issue and I ended up talking about it with the other manager by saying, "Maybe we can do a problem solving without logging it." And we actually had a phenomenal response; fastest ever. But there’s something about the log, it’s very visible, monitored, punitive potentially. It just feels like a difficult environment for me to call out in, at least at this stage.

The last five years have seen a great focus on greater accountability. We just don’t want to slip into blame.

I wanted to say that SPIRIT does empower us to deal in areas where we’ve struggled … it makes it much easier to engage on issues we’ve struggled with. I do have a suggestion about the training; make it easier to make a personal connection in the set-up, with phone numbers etc. Finding time was hard for me, so you send an email and you hope for a response but it’s not to anyone in particular.

I’ve been to a lot of trainings like this. The bigger challenge than training is how to keep it going. How does the organization reinforce this; how do we get reinforcement? Reflecting on today, I’m not sure I would have been as persistent and nice in working with the people involved. It’s a discipline. It needs to be reinforced/mentored. This is a cultural change!

My comment is about language. If we changed what we say from "problem" to "opportunity" it might help. Because that’s what they are – opportunities – and even the word problem seems to connote something negative.

It was inspiring to see people on the front line involved in solutions and being asked for their opinion, not just told. Being asked, "What do you think about this?" and "How would this idea come across to your peers if we rolled it out?" That was totally inspiring.

11 minutes of pleasure

A year ago, I wrote about our use of mystery shoppers to help guage whether we were meeting standards of customer quality in our clinics. We still do this and find it a good way to help the staff at the front desk staff do better and better for our patients. Here's a call, though, that shows exemplary service. (The call lasted 11 minutes. You can't rush quality.) Note the immediate feedback to the staff member from the secret shopper, too.

Nephrology
After one ring, Kerry Falvey answered my call by enthusiastically stating the name of the practice, her own name, and asking, "How can I help you?" I explained that I needed to make an appointment, but I had never seen a Nephrologist before. I had seen a Urologist recently because of recurrent UTIs who said I had high creatinine levels. My PCP and this Urologist both suggested I see a Nephrologist. Kerry said that she could definitely help me with scheduling an appointment, and asked for my name and date of birth. She confirmed that I had never been to BIDMC then explained that as a new patient, she would need to start a profile for me. She then collected all of my demographic information and confirmed that my PCP was the referring physician. She also asked if there was a particular doctor I'd be interested in seeing, and I said there was not. Kerry then explained that she would check for the first available appointment. She mentioned that their new patient policy was to provide an appointment within seven business days. The first appointment she found for me was for Tuesday, February 26th (6 days) at 10:30a with Dr. Walter Mutter, whose name she spelled for me. She confirmed that this appointment date and time would work with my schedule and confirmed that the reason for my appointment was because of high creatinine. Kerry then explained that she would check if I needed a referral. She clearly explained that depending on my insurance and PCP, I may not need a referral because of certain agreements between BIDMC and certain insurance companies. She explained that since I had Harvard Pilgrim insurance and my PCP was a BIDPO doctor, I would not need to obtain a referral. She then explained that she would check if they could access my PCP's records. Since she discovered that they could not electronically access the records, she said that they would contact my PCP, with my permission, to obtain any pertinent notes. Kerry asked if I knew where their office was located, and I said I did not. She explained that there would be a letter coming in the mail with details on directions, parking, etc, but that she would give me the location anyways. She provided me with the address, name of the building, and floor on which I could find Medical Specialties, which is where their practice is located. She asked if I needed directions to the medical center, and I said I should be fine. Kerry then repeated the date, time, and doctor I would be seeing for my appointment. She provided me with the practice phone number and explained that I could call with any questions and that any of their three staff could help me. She asked if she could help me with anything else before transferring me to registration.

Kerry's facilitation of my call was nothing less than exemplary. I mentioned to her that her tone of voice was very pleasant, and she was easy to speak with, making for an enjoyable conversation. I also commended her clear explanations throughout the call, including why she needed to collect my information, the fact that she would schedule me an appointment then transfer me to registration, and her description of the referral exception which my insurance allowed. I also thought she was very accommodating, since she was able to check right then and there whether I needed to call my PCP for a referral and since she offered to obtain the medical notes from my PCP. I also mentioned to Kerry how helpful it was that she repeated the reason for my appointment, indicating she understood my request, and that she repeated my appointment date, time, and doctor at the end of the call. I also mentioned to Kerry that it seemed like she provided me with all the information I needed and asked all the questions she should have. The only suggestion I could think of for Kerry was for her to mention something about parking along with the location of the practice.

It was very uplifting speaking with Kerry, even for something as mundane as scheduling a doctor appointment. Even on this Friday afternoon, Kerry's spirits were still high, which certainly lifted my own mood. This call truly sets the bar for the customer service that all of our schedulers should aspire to reach. Kerry received a 5 (excellent) out of 5 for this call.

Save Time; Improve Patient Care; Improve Work Life

Direct and unedited from our problem log, a great example of a call-out and problem solving from BIDMC SPIRIT:

Type of Problem -- Save Time; Improve Patient Care; Improve Work Life
Campus -- West
Setting -- Inpatient Ward
Location of Problem --Farr 7

Problem
I could not find a pulse oximeter to check my patient's oxygen saturation. There were none in the equipment cubby which is a section of our breakroom remote from patient care rooms. I wasted a lot of time going from patient room to room until I found one.
Suggested Solution -- Define a specific location that is more convenient to the nurses' and pcts' work flow
Person Describing Problem -- Beth Morrison

Root Cause
Why were none available? It is not a supply issue, there are 7 pulse oximeters for the floor. Why could Beth not find a pulse oximeter? None were in the storage area. Why are the oximeters not returned to the storage area? It is in an inconvenient location. Why when the oximeters are used are they not returned to the storage area? In the past we had a locked equipment room that was centrally located. On our new floor Farr 7, we do not have an equipment storage room and have designated a small cubby hole in the staff breakdown to store equipment. It is inconvenient in relation to the work area. Also, it is in the breakroom so sometimes it is difficult to move past staff who are sitting eating a meal.

Solution (after investigation)
A cubby hole in the nurses's station is not being used. It's location in very convenient for small equipment storage. Electrical outlets and shelving need to be installed. Once that work is complete, I will apply LEAN principles and outline with black tape and label each area for the specific equipment.

Action Plan (who, what, by when)
1. Kathy Hussain met with staff to brainstorm new, convenient location. Complete.
2. Kathy worked with her Operations Coordinator Debbie McGrath to discuss needed work. Complete.
3. Kathy discussed renovation with her director Jane Foley. Approval given to move forth with project. Complete
4. Kathy and Debbie met with Brendon Raftery and Chris Kimball on March 17th to scope the work. Complete.
5. Electrician installed 20 electrical outlets. Complete
6. Carpentry measured and ordered required shelving.
Complete
7. Currently awaiting installation of shelving.
8. Once shelving installed- will outline placement of equipment so that each piece of equipment has a designated and corresponding location.

Investigation -- Closed (Complete w/ root cause, solution, action plan complete)

Comments
Beth- thank you so much for calling out this problem. Your willingness to discuss this has lead to more efficiency and less wasted time. As a side benefit, the relocation of the equipment will allow us to recapture space in the breakroom, relieving the crowding and giving the Farr 7 staff a more pleasant breakroom.- Kathy

More from Brent James

Another part of the Silverman Institute's inaugural event was a grand rounds presentation by Brent James for our medical staff. When I saw the title of yesterday's talk -- Quality health care for the 21st century: A new outlook for humanity -- I said, "Wow, that's pretty expansive!" As it turned out, it was an accurate description of the talk. Let me try to provide some highlights.

First, we were grounded by the fact that the main determinants of health (in terms of how long we will live) are:
-- 40% Behavior (tobacco, alcohol, and obesity)
-- 30% Genetics
-- 20% Environment and Public Health
-- and only 10% Health Care Delivery (hospitals and clinics).

In 2006, the US spent $7100 per person, or 16% of GNP, on the last category. The trend in this cost is dramatically upward. What do we get for all that money?

Much of the US system is based on the rapid response aspects of health care. In contrast to other countries, where the emphasis is on primary care, we spend a lot on treating those problems. We provide better access to specialists and to technology, and we do not ration these services as they do elsewhere. Accordingly, the US mortality rate for heart attack and trauma, for example, is well below Europe. But the impact on overall mortality of our progress in these secondary care arenas is overwhelmed by the impact of a strong primary care emphasis in other countries.

James cites "the rule of rescue" as a reason for this. This is defined as "the imperative people feel to rescue identifiable individuals facing suffering or death." (Jonson, 1986 -- Sorry, I don't have the full cite and can't find it.) Our health care delivery system is skewed in this direction.

Ironically, other countries are now finding an increased demand for rescue care and so are seeing large financial pressures emerge in that segment of their own systems. (See my post below on Tuscany's desire to expand emergency services.)

After this overview, James turned to the problems in our system. As he notes, these actually emerged as a result of the design of the medical system through the 1900's, and he quoted Albert Einstein as saying, "Today's problems are often yesterday's solutions." Here are the problems:

-- Well-documented massive variation in practice based on local medical myths.
-- High rates of inappropriate care.
-- Unacceptable rates of preventable care-associated patient injury and death. (Hospitals are actually the #4 or #5 major public health problem in this regard!)
-- A striking inability to "do what we know works".
-- Huge amounts of waster and spiraling prices that limit access.

Why have these problems emerged? We continue to rely on the "craft of medicine", in which each physician practices as an independent expert -- in the face of huge clinical uncertainty (lack of clinical knowledge; rapidly increasing amount of medical knowledge; continued reliance on subjective judgment; and limitations of the expert mind when making complex decisions.).

We can begin to overcome these problems by practicing medicine with a "Shared Baseline" approach (a form of LEAN production) in which you measure, learn from, and (over time) eliminate variation arising from the professionals -- while retaining the variation that arises from the patients. He terms this "mass customization." This will assisted by full use of electronic medical record capability, and it will need to be done to make full use of EMRs. Finally, care needs to be organized around the team of caregivers, and not the individual practitioners.

Silverman Institute Inaugural Event

I just returned from celebrating the inaugural event of BIDMC's Silverman Institute for Health Care Quality and Safety. The Institute was created by a generous donation from our Board Chair Lois Silverman and her late husband Norman, and is the focal point for our quality and safety programs, as well as academic programs in that field. The event was also the inauguration of a new lecture series, entitled the Michael F. Epstein, MD Lectureship on Clinical Quality and Patient Safety, generously funded by numerous donors in honor of the hospital's previous chief operating officer.

Our speaker was Dr. Brent James, from InterMountain Health Care. He had a lot of useful things to say about the quality improvements in his system, but the focus of the talk was "Doing Well by Doing Good: The Business Case for Quality."

My main take-away: Within a very few years, we will face a hockey stick pattern of unfunded shortfalls in medical costs paid by the federal government. At that point, there will be four main options: (1) raise taxes; (2) decrease Medicare benefits; (3) shift funds from other programs, like education and national defense; and (4) reduce payments to providers. Which of the four do you think is most likely to be preferred by elected politicians? Number (4), of course. "The money is not going to be there. The business strategy of providers has to be based on managing the cost structure of clinical care." Improving the quality and safety of care is the most efficacious way of doing that.

So, quality improvement has to be a core business strategy for hospitals. Now is a good time to start and learn how to do this. As Brent notes, "It was not raining when Noah built the ark."

Dear hospital colleagues: Do we really need this reason, also, to reduce harm in our hospitals? Well, it can't hurt to be reminded that there is a financial case to be made, in parallel to the humanitarian aspects. Early adopters will do better when the rain starts to fall.

When SPIRIT helps patients

For those of you following my stories about BIDMC SPIRIT, you know that our main purpose in starting this process improvement program was to enhance the quality of the work environment for our staff, those involved in direct patient care as well as in other hospital functions. But we also believed there would be spill-over benefits in improving the quality of patient care -- in ways that are not necessarily related to specific programmatic areas like reducing central line infections or ventilator associated pneumonia.

Here are two recent examples along those lines. I am going to present the log reports in "hospital-speak", i.e., as written by the staff, so please accept my apologies if not all the terms are familiar to lay readers; but I think you will get the picture. I think you will also get a feel for how complex the patient care environment is in a large academic medical center. The first case involves treatment of psychiatric patients entering the Emergency Department. There is a general shortage of psychiatric beds in Massachusetts -- having mainly to do with grossly inadequate reimbursement rates for these patients and also a failure of the state to properly care of patients who should be under its care -- and this shortage spills over in hospitals in the way described in this case. We can't solve those broader societal issues, so you will see how the staff cobbled together an appropriate solution to this particular issue. (Note, for example, how the materials on the "Expressive Cart" have to be carefully chosen so the patient cannot intentionally harm himself or herself.)

On March 5, an Emergency Department nurse called out a serious concern: that patients presenting to the Emergency Department (ED) for psychiatric evaluation are often held in the ED for a number of days while a bed search takes place. During that time, the patient is held in seclusion, without the benefit of therapeutic or diversional material.

On March 10, Michelle McCool, Director of Ambulatory and Emergency Operations; Karen Lottatore, ED Practice Manager; and Kathy Fanning, ED Nurse Manager, had a plan in place to purchase some activity materials by March 17, and to have a physician in Psychiatry approve them within five days. In the meantime, Michelle McCool updated the SPIRIT Problem Log, mentioning that long-term solutions are currently under discussion on a governmental level as well as on an internal, interdisciplinary level between the ED team and Psychiatry leadership.

On March 13, Michelle McCool and five others (Mary Anne Badaracco, MD, Chief of Psychiatry; Dyanna Domilici, MD, Psychiatry; Jonathan Florman, MD, HMFP Psychiatry; Tina Gosselin, RN, Psychiatry Nurse Manager; and Sandi Leitao, Administrative Director of Psychiatry) met to discuss improvements in the care of psychiatry patients with extended stays in the ED. They agreed on an extensive action plan that includes the following:

One crank hospital bed will be available to those patients uncomfortable on stretchers;
Michelle McCool will communicate with Central Processing on this.Patients will be offered items from an “Expressive Cart” which will include cordless radio head sets, non-toxic art supplies, books and other items.
After the acute evaluation is complete, if approved by Psychiatry, patients will be offered more comfortable clothing. (Michelle McCool to obtain a supply.)
A daily team meeting will occur, including Nursing and Psychiatry at a minimum. The team will develop a treatment plan which will be documented daily.
Consider other types of consults – possibly Nutrition, Physical Therapy and Occupational Therapy – for patients who have been in the ED for more than 24 hours.
Possible assignment of a case manager to patients requiring disposition. Marsha Maurer, RN, Vice President of Patient Care Services is considering this.

The second case is more typical of a large hospital. Capacity or staffing or continuity of care problems on one floor that require coordination with several other units to resolve.

Problem: At 8:30 a.m. a staff nurse (Lucy Miller, RN) on Farr 9 needed to page the medical house staff with a question about a patient admitted overnight from the Emergency Department (patient arrived on floor between 3:30 and 4:00 a.m.). The nurse paged the resident listed as covering, but that beeper was forwarded to another resident who stated he was not covering. That resident instructed the nurse to call another resident who also stated she was not covering. The nurse paged the attending physician of record who gave the nurse two additional options to page. At this point, John Ryan, RN, Nurse Manager on Farr 9, became involved and paged the Chief Medical Resident for help in determining coverage.In addition, coverage for the SIRS firm, which often covered medical patients on Farr 9, was not easily identifiable through the online paging system like other medical firms such as MERIT or Blumgart. The nurse had to get the SIRS on call resident information by calling page operator.

Person(s) Describing Problem: Lucy Miller, CN2, Farr 9, and John Ryan, RN, Nurse Manager, Farr 9.

Help Chain Contact: Jane Foley, RN, Director of Clinical Operations.

Root Cause: There were a higher number of medical admissions than usual overnight. The patient was assigned to a different medical firm (team of residents, interns, medical students and attending physicians) than the SIRS firm that usually covers Farr 9 patients. The POE order set did not indicate the correct firm coverage. Why? Until recently, Farr 9 had been primarily an inpatient surgical unit. In early February we moved several surgeons that had been admitting to Farr 9 to the east campus. This left available capacity on Farr 9. Additionally we had a couple of surgeons still operating on the west on vacation and high Emergency Department medical volume – thus Farr 9's population shifted to 40-50% medical service patients. Why? The overall increase in medical patients house wide and particularly on Farr 9 led to some coverage issues for the medical firms. Why? In order to safely spread medical firm coverage, patients on Farr 9 were getting assigned to teams other than the SIRS firm which usually covered F9 medical patients.

Solution After Investigation: The immediate issue was fixed and the correct team assignment was notified, but it took 30-45 minutes. On March 5, Jane Foley contacted Sandra Denekamp, Telecommunications, about adding SIRS on call to the online paging system. Completed.

Action Plan: Julius Yang, MD, Hospitalist, and Todd Pollack, MD, Chief Medical Resident, worked on solutions with Nurse Manager John Ryan, RN, to prevent issue from occurring again:

· Medical firms reassigned to support increased medical volume on Farr 9. (completed by Yang/Pollack)
· Farr 9 RN staff educated about medical staff coverage – virtual pager for Robinson/Kurland Firm; page #s posted on unit and staff educated on how to find medical call schedule on portal. (completed by J Ryan)· Medical house staff will up date POE order set to accurately reflect team coverage. (completed by Yang/Pollack)
· As a back up, if POE order set is not up-to-date, medical house staff will either evaluate patient if critical issue is occurring or locate correct coverage as opposed to giving RN another intern/resident to page. (completed by Yang/ Pollack)
· On call paging system updated to list SIRS firm by name. (completed by Sandra Denekamp)· Automated paging system (generates an automated page to medical admitting resident once bed assigned for patient admitted via ED) updated to reflect new admitting scheme – (completed by Yang/Pollack/Larry Nathanson, MD, Emergency Department)

Democratization 2.0

I heard a great talk last week by Andrew McAfee, a professor at Harvard Business School, about Web 2.0 and, as he terms it, Enterprise 2.0. This expanded into a discussion of the inherent democratization that occurs in the 2.0 environment, from which Andy rhetorically raised the question of how reliable and accurate this kind of approach is. Of course, my immediate response was, "Compared to what?" He then reminded us about the "contest" in 2005 that was held comparing Wikipedia to the Encyclopedia Britannica. The two sources were found to be equally accurate, until several hours later, when the mistakes on Wikipedia had been corrected!

This reminded me of a post I wrote several weeks ago about my hope to create the organizational equivalent of a wiki. And, of course, it relates to all the stuff I have been boring you with about BIDMC SPIRIT. The underlying premise is that a democratic approach to problem identification and problem solving is what makes it possible for a complex organization to discover ways to improve. As Steven Spear notes, the alternative method -- trying to design the perfect complex system in advance using the traditional business hierarchical approach -- is unlikely to produce a sustainable and efficacious solution, especially in an environment characterized by structural change.

Can health care institutions learn this approach to adaptation and improvement? The jury is still out.