Lean leaves well-oiled gears

Remember when I told the story about using Lean process improvement techniques to enhance the service in our orthopaedic clinic? That was over a year ago.

Here's a note from a recent patient, a local student:

I just had to share this with you because it was such a neat feeling at the time. I saw Dr. Gebhardt yesterday (my orthopaedic surgeon) and there there was no wait for anything at all. Checking in was a breeze. I saw Dr. Gebhardt exactly on time. Afterwards, I was worried about getting the x-rays because the whole waiting room was full, but again, there was no wait. I've read about lean, SPIRIT, and process improvement on your blog, so it was such a neat feeling to experience and also to know what was behind my no wait experience! I think it provides a whole new meaning to patient-centered care. The only thing that was odd was that the front desk never asked me to pay...but I was so happy with my visit that I actually offered to pay my copay (and this is coming from a poor graduate student).

We will work on the payment part next!

Dear Interns

As each new class of interns arrives at the hospital, it is important to provide a context for their experience. Most of their advice and training comes from their clinical leaders, but the CEO has a role, too. Here are excerpts from one of my notes to the current class:

Dear Interns,

I'd like to turn to some important matters facing BIDMC and explain your role in helping us achieve some very important goals. The context is this: While you as doctors -- along with others who have come before you -- have received excellent training in biology, disease, diagnostics, and treatment, there is a growing part of clinical care that requires all of us to expand our scope and consider the manner in which we actually deliver care and how we might improve that. Our hospital has decided to be a leader in the science of care delivery, reviewing and enhancing our overall system of care to reduce harm to patients.

Several months ago, our Board of Directors voted to set an audacious goal for BIDMC, to eliminate preventable harm over the next four years. See these entries on my blog for more details. Our chiefs of service are fully in support of this goal and are now engaged in many measures to make it happen. We know of no other hospital in Boston that has taken on this challenge, and there are likely very few throughout the country. It is a bit daunting. But we believe that we have a lot to learn and a lot to teach by making the effort.

Part of the context for setting this goal is to hold ourselves accountable to the public and ourselves. We have been the leaders in this region in transparency of our clinical outcomes, for we believe that self-reporting of medical errors and process improvement is a sure statement of our commitment to progress in this arena.

We have also established an overall process improvement program called BIDMC SPIRIT, in which you will be trained after your arrival. Here's the introductory message about this program. The concept is simple -- to encourage people throughout the organization to call out problems as they see them and to solve them to root cause -- rather than creating work-arounds that just add layers of poorly designed process in the organization. Here are a couple of examples to give you the idea.

I look forward to having you join us as we invent and implement these programs and eliminate preventable harm for our patients.

Sincerely,

Paul

Midcourse lessons from SPIRIT

Here are some comments made after today's BIDMC SPIRIT training session (see some of the participants above). We are now winding down on training the first 600 people. As you can see, people quickly get to the core issues, problems, and opportunities. This is about where we expected to be at this point in the process. After all, we are introducing new concepts of empowerment, problem identification, and problem solving -- and sometimes people are confused or nervous. The suggestions from these trainees are exceedingly helpful. But look, too, at the last comment: Key messages are starting to come through. Then, see a bit of my analysis after the comments.

We noticed when logging our issue that you see “SPIRIT problems.” We think it would be better to look at “SPIRIT opportunities.” One idea we had was to change the language.

On the issue of what are appropriate call outs, several of us were talking earlier today that there seems to be some confusion out there about what it’s OK to call out and who can do it. At the beginning, it seemed that it could be about anything and everything and the staff would be empowered … then there seemed to be a reassessment and it became in some areas there are some things you can call out and some you can’t … that you have to go through the manager and the body language suggests whether this is going to go forward or not … and I think there are varied answers to these things depending on who’s speaking from the help chain.

How to fix this? I think just a reaffirmation of the goals and key principles to the entire leadership team, so that it is not interpreted in various ways by various leaders. In some places, staff aren’t allowed to touch the log without talking to the manager. We know we are trying to find our way and it’s early.

Talking about the “chain of command” has a connotation of fear in some places. Where we were, these were perhaps more junior nurses than in the PACU and they didn’t want to identify anything as a problem … it seemed they were fearful. For us, residents, it can be hard to call something out. We need an environment where all are equal and our insights are encouraged.

We’ve trained all the managers and supervisors and not the front line in this way because that would be overwhelming but perhaps we could do an in-service DVD that just lays out the key principles that this is all about. Staff are reading about this on the web, they are hearing things second hand, but if you (Paul Levy) could deliver the message it might help with the consistency of the message as well.

A big thing is … just because it happens all the time doesn’t mean it should. We see all of these problems. 10 minutes here. 20 minutes here. People think they are little. But they add up quickly. For those of us who are out there, they add up quickly to patients’ lives. 1 life. 2 lives. They may seem small but they aren’t. They matter. People need to understand that.

We started our journey toward eliminating hunting and fetching for every BIDMC staff member 8 weeks ago. We are consciously following the path trod by other large organizations in other fields (Toyota, Alcoa, US Navy submarine corps) that seem to do what their peers do to far superior results, in terms of staff satisfaction, quality, and business performance. The core of our approach is empowering everyone at BIDMC to call out when they hit a glitch in their work (see the problem) and participate in understanding the problem and developing solutions. We are learning how to provide the right level of help to them right away (swarm the problem), then how to share improvement stories transparently throughout the hospital.

Overall, we stand about where I expected, but some of the particular challenges we have are interesting.

We have plenty of evidence that it is right to involve each employee more deeply in problem solving, every day. Story after story has surfaced about how the people who do the work have pointed to the solution that could work – and is more likely to endure. Just last week, the housekeepers and unit staff in an ICU developed a solution to a chronic shortage of pillows needed to prop up their patients that has been driving them crazy for years.

We also are seeing the value of immediately investigating specific instances of problems, while the details are fresh. Using the observed details of what just actually happened keep us on the right track in a way that far-off committee meetings of folks who may not actually do the tasks being discussed may not.

And while we are still in the infancy of learning how to share effectively, people are picking up not only specific solutions from the SPIRIT log, but also insights on how to solve problems.

And people are paying attention. The SPIRIT log is often viewed more than 1,000 times a day, and my reports from SPIRIT here on this blog are being tracked by people around the world eager to learn with us.

So that is good, but we are still far from where we want to be in the breadth and quality of problem solving that will really make life as good as it could be for our staff. That’s what we expected at this stage of things, but it underlines how much work we have to do. What are the challenges on which we should focus at this starting stage?

First, the quantity of hunting and fetching investigation and solution attempts we are seeing is not even a small fraction of the challenges we know staff face on a daily basis. This is not a numbers game, but we do want to see much more high quality problem solving occur. Every person at BIDMC has something to offer (and gain) to understand this dynamic in their own areas, but here are some of the forces at work.

(1) It’s clear that in many places, it doesn’t feel “safe” for staff and managers to have problems in our areas being called and worked in the transparent light of SPIRIT. This sense is critical to overcome. When people feel more comfortable to bring opportunities to the surface and work them in plain sight, we will make the most rapid progress. It is the areas where I am not seeing any SPIRIT call outs that I worry about the most at this point.

(2) Some of us are so used to working around problems that we don’t even recognize that there is an opportunity to make the work easier. Some managers are countering this by actually walking next to staff as they do their work and helping them see what may be a “work around” and where there is opportunity. That works and can be helpful in these initial stages.

(3) Many people don’t really believe their boss wants to hear about their next hunting and fetching episode “in real time.” People have been implicitly rewarded in the past for solving impediments by brute force, and they think their leaders may not welcome reports of a “small” problem. After all, the managers are busy, too. We need to reaffirm that the responsibility rests with supervisors to actively encourage those who look to them for leadership to begin calling out opportunities to them in person. Of course, we won’t be able to work on every problem in real time until we get a lot better and faster at this, but we need to start.

(4) Some people don’t yet know how to “call out” in the most productive way. We need specific reports of specific problems, without blame. We need people to stick to the facts. And we need reports made in person to the immediate supervisor, not entered directly on the log unless no one is available to help.

Second, I see lots of opportunity to deepen our solutions, so that we are not only solving the immediate problem, but also applying the lessons to similar situations. For example, if CT radiology residents didn’t have an easy way to realize they were sometimes presenting their technologists with protocols that conflicted with the original physician orders (a “connection” problem), how many similar situations exist across our clinical services? We plan to begin pushing on these issues as we progress.

Third, though we are pleased with the orientation and training we have provided to almost 600 managers, staff have told us that they need more direct exposure to the SPIRIT principles and tools. We will expand efforts in this area shortly.

Teamwork on central line infections

I received this wonderful report from Blanche Murphy, Nurse Coordinator for the Central Line Service, who knows of my interest in eliminating central line infections. Be sure to check out the site she mentions for an excellent educational tool.

Dear Paul,

I want to share with you a very positive recent experience that I have had at the medical center. Knowing how much you believe in team spirit, I feel that my story is a wonderful example of many people from several areas of the medical center coming together to produce a resource enabling our patients to have safer and knowledge based care. Although many of the functions were done independently, it took all people I mention to produce the outcome.

Three years ago I had an idea to develop a pictorial index on-line allowing staff to correctly identify central venous lines and their appropriate care. It would also serve as an educational tool providing diagrams and pictures to further enhance understanding of central venous access. At the time of this idea, I also initiated a practice change reducing the concentration of heparin we give our patients that would effect the information being given but also entailed major changes to our on-line pharmacy ordering system . On April 16th we went live with a very involved change in the POE system and the debut of the central venous line educational tool.

From the start there were many people who provided their expertise to make this goal achievable. Rich Stroshane from Operations took all of the pictures and Davin Janicki from Healthy Care Quality/ Process Improvement worked endless hours helping put the images into an on-line format. Andy Mackler P.E.V.A. Consultant from Venous Access contributed all the information in regards to PICC lines. Karen Smethers from Pharmacy worked several hours with me establishing a correct ordering system with generated flushing orders for the multiple number of lines we place in our patients. Steve Maynard, Jean Beach, David Feinbloom MD, Jean Hurley from IS, and Kim Sulmonte from Patient Care Services also gave much of their time. Media services' Christophere Ruhle (no longer employed here) and Oran Barber assisted in putting on the final touches to obtain a professional system . Lynn Darrah and Justine Carr were major catalysts for bringing the project to a successful completion with an effective roll out. Although each member of this team developed contributions on their own, it was only when each part worked to together with a team spirit for the final product that the launching could happen.

At http://home.caregroup.org/centralLineTraining/ you can see for yourself how wonderful the outcome was. By selecting a picture you will be able to view more in-depth information with a link to flushing guidelines insuring a quick reference for staff immediately available. The POE ordering under IV Therapy/IV Access orders also provides not only the correct flush orders for multiple lines but also another way to link to the educational tool.

As I said this was an idea I had three years ago, and if not for the tremendous team work and support from various areas across the medical center it would have never been successfully carried out.

Sincerely,
Blanche Murphy

Lean Speech

For some reason, I have been invited to give lots of speeches and classes lately, mainly on the topic of how to achieve process improvement in hospitals to improve quality and safety. I view this as a bit odd since I am just learning this stuff myself. Maybe people like to hear about the process in mid-stream. Anyway, I enjoy these sessions, getting to know new folks who are interested in the topic, but, as often as not, learning more from them than they do from me.

I tend to accept almost all invitations from colleges, non-profits, civic organizations, and also local businesses -- as my part of the educational mission of BIDMC. If I think they can afford it, I ask for a small honorarium to support programs in our hospital. I also get requests from those companies that organize expensive one- or two-day seminars for business people who want to travel. In those cases, I ask for a very, very large fee -- a large multiple of what they charge their attendees -- and then they usually find someone else!

Today's group was the Lean Educator's Conference, organized jointly by Professor Earll M. Murman at the Educational Network of MIT's Lean Advancement Initiative and another university group called LEAN. LEAN is affiliated with Jim Womack's Lean Enterprise Institute -- Jim is flanked in the picture above by Prof. Joe Sussman of MIT's Department of Civil and Environmental Engineering and Prof. Judy Hoffer Gittell of Brandeis University's Heller School. The invitation came because Earll had heard me talk last October at the National Academy of Engineering on "Adapting Process Improvement Techniques to Academic Medical Centers."

Since there may have been repeat listeners, I had to find some new jokes . . .

Flash! SPIRIT lowers high blood pressure!

What's one of the most common things a nurse does upon entering a patient's room? Check the blood pressure. So just imagine the work-arounds that were happening over and over again before this problem was called out as part of BIDMC SPIRIT. I post the results from the problem log.

Type of Problem -- Save Time; Improve Patient Care
Campus -- East
Setting -- Inpatient Ward
Location of Problem -- 12 Reisman
Problem -- Many of the patient rooms missing blood pressure cuffs and/or parts.
Person Describing Problem -- AnnMarie Grillo, RN

Root Cause
Many of the nursing staff unaware of storage location of BP cuff and extra parts (kept in a closet at the end of the hall). Because of this, missing cuffs and parts not getting replaced.

Solution (after investigation)
Change storage location to more central area.

Action Plan (who, what, by when)
1) Immediately -- room rounds done and all missing cuffs and parts replaced. (Done by AnnMarie Grillo and Gina Murray.)

2) Moved storage location of BP cuffs and parts to a drawer in the medication room at the nurses' station. Labeled drawer and notified the staff. (Done by AnnMarie Grillo and Gina Murray.)

3) Obtained current list of BP cuffs and supplies from Bill Pyne in Distribution. Posted this list in medication room above BP supply drawer for staff to make re-ordering easy. (Done by Kerri Petraitis and Gina Murphy.)

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

Busywork is not your job!

A SPIRIT Story:

On March 25, a SPIRIT training team visited the MICU 6. During the 25-minute observation, Pat Boykins, a Unit Coordinator, attempted to order copies of a patient consent form from the Web site of Office Depot Web, which has a contract to print all of BIDMC’s forms. When she entered the BIDMC code for the form (MC1793) she received an error message saying that the SKU – the product number Office Depot associates with the form – was incorrect. There was no other information, and thus Pat could not order the form.

Pat then spent 5-7 minutes making phone calls to hunt down the correct code. She eventually found it: MR1793. When asked at the end of the 25-minute observation if she encountered any problems in her job during that time, Pat said “No.” Why? Because this type of hunting and fetching has become a routine part of her job – a job she does with as much efficiency as possible. When prompted by the SPIRIT team to think of a way to improve the form-ordering process, however, she did make a suggestion that she said would save her a lot of time: find a way for the Office Depot site to provide the correct SKU for an expired or changed form code.

Here’s what happened next:

Pat reached out to her Help Chain Contact, Kristin Russell, Nurse Manager of MICU 6. Kristin spoke with Paula French, Contract Manager, who handles the Office Depot account. Paula said the proposed functionality of the Office Depot database does exist, and that the SKU never changes for a given form, even if its BIDMC code changes. She referred Kristin to Michelle Micale, Project Manager in Health Information Management, the department that handles all forms.

Michelle Micale was very helpful, and in the information she provided, the root cause of the problem was revealed. She confirmed that the form’s internal, BIDMC code had changed recently as part of an overall, ongoing process of reassigning more specific codes to forms to categorize them. Instead of all being Medical Center (MC) forms, they are being recoded as Medical Records (MR) forms, Learning Center (LC) forms, Human Resource (HR) forms, etc.

Michelle is working with Office Depot to ensure that both the old code and the new code for each form will always lead to the same SKU, beginning with the Medical Records forms. This process will take a while. In the meantime, she is available as a resource to provide the correct form number to anyone who needs one. Her e-mail and phone number are on the problem log. David Drew of Patient Care Services has sent this information to all Unit Coordinators.