Continuing in our series on the roll-out of BIDMC SPIRIT, here are comments made by participants in the most recent training session in response to these questions posed by Dr. Ken Sands, our SVP for Health Care Quality:

“What about SPIRIT and the training works? What needs to work better? What should BIDMC do differently?”

One of the things that works best about is having other disciplines see what other disciplines do. The old saying “walk a mile in another person’s shoes.” I think a lot of us are coming away with a lot of renewed respect for what other people do around here. And it’s ok that it’s managers doing it, but it would be key for front line staff to do too.

I’d like to see more MD involvement. I know some have been coming through. Is there a plan to accelerate?

Do you have a place where everyone who has been through training is listed?

How do we encourage front line staff to use this? Managers and supervisors are familiar with it. We had staff meetings and talked about it but I’m not sure it’s gotten out there enough.

I haven’t seen much of this in the area where I work. Pre-SPIRIT, I was told how to reach out for some guidance on making improvements. One time, it was very successful. Another time, with another kind of problem, I had someone in my office two days later yelling at me. I’m not sure there’s a clear enough structure for this yet where I work so I hope it can continue to be strengthened.

Is there a way for the log to drop an e-mail to a manager who’s been named in the help chain?

We have been problem solving in our area, but not following through to enter on the log. But we’ll follow through and log it now that I’m reminded of the value to others.

We have noticed that when you are on the screen of one of the problems, the number is not visible. You have to go back out of the problem and then find it again, which can be hard (require a search or scrolling if it’s not one of the newest problems). It would be very helpful if the number could be displayed on the problem screen.

I found this concept so affirming. I have been a staff member for 15 years. I can’t tell you how many thousands of times I have become vaguely aware of how frustrated I was getting, but I had absolutely no way of doing anything about it. I want to tell you how moved I am that the institution wants to do this for us. It’s basically about how our day is. How do you mobilize people to do this, like you were asking? Tell them this if for us! I am the kind of person who has to process things, so I’ll have to return to the materials, but some of the tools that are shared like the activities and pathway principles – those are news to me. I’ll use them in my own life. They don’t teach you that in nursing school!

SPIRIT video

Here is a short video about a potential patient safety problem with code carts that was called out by a nurse as part of BIDMC SPIRIT and how it was handled. It will give you a sense of the steps involved. Worth watching all the way to the end. And a clear contrast with the definition below!

We want to listen. Are we good at it?

Although we are always listed among the "most wired" hospitals in America, with lots of clinical applications for both providers and patients, we still depend on people both inside and outside of the hospital to tell us how our information systems can be improved -- from the user's point of view.

I have mentioned how useful our PatientSite program is for patients, allowing them access to medical records, appointments, prescriptions, and the like. This is a very good system, but one of our patients sent in the following suggestion:

For the wish list: This might be a substantial change but I ask that you put it into the hopper for a someday rethink. I ask that you (BIDMC) begin to define an appointment from the patient's point of view, or at least offer us a view that serves us. For me, the "appointment" object is a trip to the hospital that may have a one-to-many relationship with several sub-objects that are of interest only to the hospital, for whom each person is a schedulable resource. Right now, I have one trip to BIDMC scheduled for Monday 6/9. To me that's one appointment, one trip, and patients would be better served if we had visibility into more appointments. To you it's appointments (resource bookings) for three separate objects (people). Bottom line, I'm appealing to the hospital to consider presenting things appropriately to the POV of the individual stakeholder. You might say that it does me very little good to offer me visibility into YOUR view of the resources, when that isn't the information that *I* need.

The reply from the tech support person:

Our programmer has checked the code again. You are correct, as just 5 appointments can be displayed on the Home page at one time. There is a finite number of appointments that will display. If you have a long list of appointments, the (later) appointment with Dr. X will display after some of the others have passed.

After this reply, the patient bumped it up to me:

This is way below your radar but I want you too to be aware of this as a thought. Here's something I just submitted to the PatientSite support team, to put onto the wish list.

And from me to the relevant Vice President, who wrote to the relevant IS folks:

Can we have patient site display more than 6 appointments at a time; i.e., longer out in the timeline? Please me know.

The reply:

I'm not sure what would be involved in changing this, but we will follow up with the team and get back to you.

A few days later, the follow-up:

I reviewed with the team, and it would be possible for us to increase the number of appointments and other events that display in MyEvents in PatientSite. I have attached a screenshot for your reference.
There are three options:
1. Raise the limit of future appointments from 5 to some higher value.
2. Show all appointments that fall within a specified date range, e.g., the next six months.
3. Show all future appointments regardless of date.
All three options are technically feasible. Approaches 2 and 3 would seem to better address the patient's request that we adopt a patient's point of view in the display.
Let me know if you would prefer one of these options over the others, and we can proceed from there.

VP replies:

I think we should do option 2 or 3. Either let patient give the time frame they want to see or all appointments. I will leave that to you , but it needs to be option 2 or 3.

IS replies:

Patients can now view all future appointments on their PatientSite Home page. If the list is longer than 6 appointments, a scroll bar will appear so they can scroll down. I have emailed the patient who originally made the enhancement request.

Summary:

The good news is that we listened to this excellent idea from a patient and implemented it without a lot of fuss. The not-so-good news is that the patient felt he had to send me a note on this issue to get it done. Now, it might have made it on its own through the system, or it might not have. So, the next step for me is to find out from the VP involved how patient suggestions that are made to tech support get reported and prioritized by the IS team. In other words, this now becomes a BIDMC SPIRIT call-out from the CEO's office....

Central Line Infection Update

I have been writing for many months about our efforts to eliminate central line infections, starting with this post in December of 2006, and then giving periodic updates on this blog. Now, there is a regular feature on the BIDMC website where people can check in on this and other clinical indicators.

But we received a report yesterday that I have to share in this forum again. The chart above shows the year-by-year number of central line infections at BIDMC, as measured in cases per 1000 patient days in our intensive care units. Clear and steady progress over the last several years is evident, and I have to admit that I am really proud of our folks -- nurses, doctors, residents, and others -- in our ICUs.

What does this mean in real terms? Well, in a typical month, there might be 1500 patient days in our ICUs. With a drop in our infection rate from over 4.0 to under 1.0, it means that more than 4 people per month (.003 x 1500) did not get a central line infection. With a mortality rate of, say, 20% among those getting such infections, it means we are saving the equivalent of roughly one life per month.

This also saves lots of dollars, mainly for the insurance companies and governments who pay for the extended stays that result from infections. It also frees up scarce ICU capacity for seriously ill patients who show up in our Emergency Department or are otherwise admitted to the hospital.

What's left? What does it take to get to zero? Frankly, we are not sure. There is no distinct pattern of causality among the cases we still see -- and we evaluate each and every one. I'd love to hear from others out there who have also been successful on this front if they want to offer comments on anything we might want to consider to achieve our ultimate goal of a sustained "zero".

Lessons learned from switching sides

An email letter from a staff member to me. Many, many helpful suggestions that we will work on.

Paul – I have unfortunately have had the experience over the past several months to switch sides from supporting MDs provide care to patients to that of becoming the loved one of a patient. My mom was admitted here on 12/29/08 with what was thought to be a stroke. After five weeks of treatment and the inability to control seizures that she was having every three minutes, it was discovered that it was not a stroke, but instead a Grade IV Glioblastoma.

Since my mom’s first admission, she has been readmitted four other times. In total, I think my mom was an inpatient at BIDMC, 10 out of the past 14 weeks. For family reasons, coordination of her care has fallen to me. We have many supportive family and friends, but at the end of the day it’s just the two of us. Her prognosis is not good. They say less than three months. I never thought I would get to the point where I am o.k. with her passing, but life is not for existing, but living. She is now in long term care and luckily, has only had a few episodes of pain. Anyway, I have written and re-written this email in my head a million times, but seeing your (May 7 SPIRIT update) email today has prompted me to sit down and send you a few of my observations over the last ten weeks. I am sorry this is so long, but each bullet reflects an important point I wish to emphasize.

Here they are:

-- The nurses are phenomenal!!! Time after time, I have been impressed that here is this woman who they only know through my description (one of the results of the tumor and subsequent seizures is that she cannot speak) and the nurses are so dedicated, caring and empathetic. My mom has gone from a woman who walked seven days per week, took down her own fence this past summer and cared for my children to a woman who can’t talk, walk, wears a diaper and has to be fed. They somehow without even trying have time after time preserved her dignity.

-- The coworkers (patient care technicians) are also phenomenal. They do not receive near enough credit. Their jobs are very hard. They lift, roll, clean, feed patients constantly and do so quietly and patiently. They must go home exhausted every night.

-- Communication, communication, communication. If we could find a way to better communicate w/ families, our Press Ganey scores would exceed 90% instantly. I have worked here for 12 years and at times was so frustrated with my inability to find out what was going on. I had instant access to my mom’s oncologist and neurologist, but in most cases, families have to go through residents. The residents are so busy and they usually see the patients first thing in the morning prior to a family member coming. In addition, once you get to know one, they switch services and you have to start all over again. The same thing with medical students. One day over a weekend, I waited eight hours in my mom’s room to speak to a resident. No family member should have to do that. I at least would go into my mom’s record to read the notes (with her permission of course), but people that do not work her do not have that opportunity. If there was a way to block certain sections of OMR (online medical record), but provide families access to others or develop a summary page for family members that would be great.

-- Another issue is communication between specialties. My mom was part of the Neurology Service. She started on Stroke, moved to Epilepsy, then to Neuro. Oncology, then back to Epilepsy and now is back on Neuro. Onc. Did you follow that? I have come to learn that Neurologists are highly specialized. You can’t ask a Neuro Oncologist about your mom’s seizure meds. You have to go to her Epilepsy Neurologist. Depending on what floor you are on, the quarterback varies. My mom was transferred from one floor to another and she ended up with a whole new attending that I had never met. What made it worse was she had one for the weekend and then a new one starting the following Monday because it was a new month. Again, I work here so I knew who to call, but imagine the 80 year old man trying to take care of his wife. Lack of information is so frustrating. There needs to be a better way to communicate with families and patients.

-- Add-on surgical procedures need to be better coordinated. My mom’s biopsy was an add on for a Friday. Room Service forgot to bring her dinner on Thursday night so her last meal was lunch at around 12 noon that day. Pre-op did not come to pick my mom up until Friday at 6:30 pm. We then waiting there for three hours. She did not go into her biopsy until 9:30pm. The surgeon was ready for her at 9 pm, but we had to wait 30 minutes for her Halo to be delivered for the procedure. The surgeon, nurse and anesthesiologist sat there waiting. My mom’s roommate was an add-on for Monday. Her last meal was Sunday at 6 pm. She got bumped on Monday and not taken until 10 am on Tuesday. She did not eat for almost two days.

-- Patient Satisfaction Surveys – Did you know that you receive one for every admission? That means we have received four. I filled out one. There has to be a savings there. Her experience did not change that much between each admission to warrant four separate surveys.

-- We need better discharge planning. I found three medication errors during each discharge and I am not a doctor. I can only imagine the poor family member that does not speak English. On the day of my mom’s last discharge, the intern kindly called me at home and told me she would be discharged by 1 PM to a long term care facility in Hingham. I got there at around 3 PM and was surprised she was not there. I set up her room and waited. I asked the unit coordinator at the front desk about it and she said she would be in the same room and there must be traffic. I went back and waited. I finally called thr floor at the hosital where I was put on hold for about five minutes. Finally, the nurse got on and said she had her all ready to go at 1 pm and they told her she was not being discharged and did not know why. I then asked to speak to who did know and the intern got on, apologized for not calling me and said it would not be until Monday due to the antibiotics that they could not give to her at the rehab. The following Monday, I was on my way to meet her there when I received a page from the case manager that they had to move her to yet another facility because Hingham would not take her. Luckily, I am happy with where she is, but what a fiasco.

-- MDs need to learn how to give options to families. Her Oncologist has recommended no further treatment with hospice. That was a big pill for me to swallow. Our family does not give up. Once I was able to process that I felt pressured by him to sign off on a DNR and agree to “his” recommendation. After I really thought about it, I realized that in fact that there was no decision to make because she was not even eligible for treatment given her low counts. I had to really push back with him. I’m not sure most families would feel comfortable doing that.

-- Case Managers need to meet with families more. When selecting a rehab., I was given a photocopy of a book with rehabs in our area. The case manager had never been to one of them and recommended I go to visit. I have three children, another family member needing support, a husband, a mother with a brain tumor and full time job. When was I going to do that? This was going to be the place my mom would probably die. I wanted it to be excellent. It would have been helpful if she or another case manager could provide me with some information on the facilities, i.e. the DPH report, testimonials from other patients, etc.

-- Families need to understand the financial implications of recommended treatments and care. Her doctor recommended long term care with hospice. What he neglected to say is that although hospice is covered, long term care room and board is not. This means that if she is not eligible for nursing care or rehab. we have to pay room and board of over $300/day. Luckily, my mom has savings for this, but I was not made aware of this until I sat down with the Head Nurse at the long term care facility.

Thank you for listening.

SPIRIT can shred red tape

A recent report on the SPIRIT log shows that process improvement can show up in unexpected ways. Nice to see residents using it, too! We prefer that they spend time with patients rather than dealing with red tape. With an organization of our size and history, we can expect bureaucratic glitches to show up a lot.

Location of Problem: Employee Health & Emergency Department

Problem: I was recently splashed in the operating room and directed by employee health to have my labs drawn in the ED since it was 4:30pm. In the ED, my vitals were taken and my blood was drawn by an RN. The triage nurse of the ED confirmed that obviously there would be no bill sent, yet about 2 weeks later I received a bill from both the ED Department and the ED Physician for almost $600. After speaking with employee health, I was told this happens "all the time" and I can expect to receive another bill or two but they would work on getting the charges reversed - but it would not be immediate.

Suggested Solution: Better coordination between employee health and ED billing. First, the billing for an occupational exposure should not occur, but if it does, the reversal of charges should be immediate. I shouldn't have to waste my time and continue to follow up through a cycle of bills. I should be able to contact the billing department and have a zero balance as soon as the report of the error occurring.

Person Describing Problem: Vijay Saluja (Anesthesiology Resident)

Root Cause: Vijay, thank you for calling this out. I can address the BIDMC ED charging issue. You are correct that the charges should not have been billed to you for an occupational exposure. There are provisions for covering those cases. Thanks to your call out we have identified a system bug that caused the BIDMC charges to be billed to you and to others in error, and the inconvenience caused is regretted. Martina Comiskey, Revenue Cycle Systems and Training.

Solution (after investigation): Billing system configuration issue causing BIDMC charges to bill to patients instead of Workers Comp Coverage. Needs to be resolved to prevent future incidences. Retroactive report of all impacted patients needed. All accounts need to be corrected and the charges appropriately redirected.

Action Plan (who, what, by when)
WHO: Revenue Cycle Systems team

1) BIDMC billing system bug fix - completed 5/8/08
2) Retroactive reporting will be completed 5/9/08
3) All patient accounts will be corrected by 5/12/08
4) Monitor monthly to ensure that process is working as intended.

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

Surgical workaround

A note from one of our surgeons:

Paul,

I'm writing this out of frustration. The door C334 to the male locker room in the Shapiro OR has been dysfunctional for weeks. You need an access card to open it. The mechanism is faulty and each morning for some time now surgeons, techs etc have had to battle to get in the room and change for the OR.

Efforts have been made to 'repair' the mechanism but nothing has worked.

Please forward this to the appropriate person and have them leave the door unlocked till such time as it can work effectively. People have had to force the door open at times which is causing more damage ( to the door and shoulders).

I just don't know who is in charge of this kind of thing but am sure you can forward it to the appropriate authority.

Response from our head of maintenance a few hours later:

Dan Kendall from our offices was approached on this issue directly and has already both assessed the problem and rectified it. In essence, a staff member had taken it upon himself to tape (surgical tape) the latching mechanism so as to avoid having to use his swipe card for access to the locker room. Some of the adhesive residue remained within the moving parts of the mechanism even after the tape was removed.

Dan was able to locate the individual who admitted to taping the mechanism and agreed not to bypass this (or any other) security measures again. Dan was also successful in removing all remaining sticky residue, and the latching mechanism is once again fully functional.

Note to self: Teach surgeons how to use BIDMC SPIRIT to reduce blood pressure.