Residents learn Lean, too

Part of BIDMC SPIRIT is to infuse many of the LEAN process improvement principles throughout the hospital. A key constituency in this effort are the residents who, after all, spend as much time on the patient care floors as anybody. So, we have begun a training program for this group, and the first sessions were held this week.

Shown here is Alice Lee, our LEAN guru, er, sensei, conducting a class. Also, you see a couple of the students on the floors, quietly observing things and learning how to look for waste and opportunities for efficiency improvements.

The waste patrol at work, all 6000+ of them!

I love that people throughout the hospital are now involved in ferreting out waste. And I like it even better that they are calling out problems they see. And I like it even better when our managers treat these comments politely and respectfully, even when they sometimes have to explain why suggestions might not always be the best possible idea. Here's an email chain from today between one of our nurses, me, one of the vice presidents, and then another who had been copied. (I have changed the nurse's name for privacy purposes.)

Saturday, 9:14am
Hi Paul,
I was frustrated this morning when I came into the West Campus front entrance to find a new dispenser of complimentary umbrella bags for visitors. Why would we be purchasing something so unnecessary as this when we are being forced to give up [other things]? I really felt this was inappropriate.
-Mary

Saturday, 9:23am
News to me, Mary, although I could imagine that we do it to keep wet umbrellas from dripping all over our floors, which would then have to be cleaned up. I'll inquire around. Diana?
Paul

Saturday, 10:37am
Mary,
Thanks for your note-I know it is frustrating in these times to see something that looks like waste!

As you probably know, we've been doing a lot of work on employee safety through the Spirit initiatives. There have been literally hundreds of employee slips and falls in the last several months. Besides the pain of these incidents for the employee, slips and falls result in a major cost to the medical center in claims and lost productivity.

When the slips and falls committee, chaired by Jayne Sheehan and Michael Kennedy, investigated the root cause of these events, they discovered a significant number occur in lobbies when employees (and patients) slip on water that has dripped off of umbrellas. The umbrella bags are an inexpensive solution to help keep our employees and patients safe. (And eliminating just one claim from a bad fall will more than cover the cost of the bags!)

Please feel free to contact me if you would like more information. Thank you again for your note!
Diana

Saturday, 10:47am
Thanks, Diana and Mary,
Yes, Michael and I spent a lot of time investigating real time slips during inclement weather. It was clear the dripping umbrellas caused a wake of slips for not only our employees but our patients, particularly on the slick terrazzo floors and vct floors. We immediately looked into solutions to allow folks to keep their umbrellas, but leave a safe path behind them. Michael found a great solution, used in many other environments, and thought bringing it to the health care environment would serve the same purpose.

Important to note, is that the expense of all umbrella trees and the bags came to 1/10th of the cost of one employee injury where an employee may be then out for one or two days of leave. I felt it is well worth the minimal dollars to keep our staff who hurry a lot from campus to campus and our patients and their families safe.

Thank you, as always, for your thoughts and concerns during this fiscally challenging environment.
Jayne Sheehan

Saturday, 12:20pm
OK, thank you all for your responses. That certainly sounds reasonable and well thought out.
Mary

Caller-Outer of the Month Award #3

Today was the monthly meeting of our Board of Directors, along with another chance to present our Caller-Outer of the Month Award. It was given to Deborah Kravitz, seen here, who works in our Central Processing Division (CPD).

The purpose of the award is not to recognize someone who has solved a problem, but rather to recognize someone on the staff who has noticed a problem and called it out. The idea is that call-outs lead to root cause analyses that enable us to fix problems systematically rather than engaging in work-arounds. Our Board of Directors created the award as part of our BIDMC SPIRIT program to encourage people to call out problems to make our hospital a better place to work. (Beyond the recognition, the award is accompanied by two really good tickets to a Red Sox game.)

You may recall reading about the LEAN rapid improvement event we ran in the CPD recently. Well, Deborah got the whole thing started many months ago when she invited me for a tour of CPD, and I was able to see the terrible working conditions facing her and her colleagues as they try to carry out their job of sterilizing all of the surgical instruments used in the hospital's ORs. After some delay, Deborah nudged me again a few months later and pointed out that nothing had improved. So, we got to work on the problem and with the help of the CPD staff, are now on the path to a much healthier, safer, and efficient work environment.

By the way, Deborah is also a talented artist. Check out a sample of her work here.

Good and bad news about infection control

I have been writing for some time about our efforts to eliminate central line infections in our hospital, and we have been totally transparent about our progress in that regard. While I know you can always look these things up, I want to make it easier for you and give you some advance news -- especially in light of the most recent results.

During the first four months of this fiscal year, a period covering about 7000 patient days, we had only one CLI in our intensive care units. This represents a tremendous effort by dozens and dozens of staff people.

In early 2006, our hospital's rate of infections was about 2 per thousand ICU patient days. At that old rate, there would have been 14 infections during this same four-month period. Given a 12 to 25 percent mortality rate associated with such infections, 2 or 3 people would have died unnecessarily.

Do we need a better reason to engage in these programs?

Two years ago, I raised a question: "If I can post these rates for BIDMC, why can't people from other hospitals? ... I am seeking no competitive advantage here. This is an attempt to get past a culture of blame and litigation and persuade people that transparency works: Real-time public disclosure of key indicators like this ... can be mutually instructive and can help provide an incentive to all of us to do better."

Then, a short while ago, I asked the question in a more direct way, posing a challenge to all the Boston area hospitals to jointly engage in a program to eliminate these kinds of infections and share their progress with the public.

The response to my public and private entreaties in this realm has been silence -- from hospital professionals, from insurance executives who care about a transformation of this industry, and, indeed, from public advocacy groups who care about access to care and the quality of care delivered. Some observers attribute the medical profession's lack of engagement to an underlying fear of transparency. And yesterday, a world expert in this field, whose wisdom and advice I treasure, told me that he has come to accept gradual progress in quality and safety improvement, citing the kind of training doctors get, which does not emphasize these areas. That such a person has become content with gradual changes in the status quo is an indication of what it must be like to beat your head against this wall of recalcitrance for several decades.

My advantage, being without medical training and having had but a short tenure in this field, is that I retain a sense of outrage. Our collective failure to approach this problem using well established methods of process improvement -- including publication of current performance results -- represents a moral and ethical lapse by the clinical and administrative leadership of the medical establishment in this city. Why? Simply put, a profession that takes an oath to do no harm is, by inaction or incomplete action, doing harm. We are causing people to die who should not die. What would we call that if we saw it happening in other sectors of society?

How was your visit?

A couple of years ago, I wrote about our use of mystery shoppers to evaluate how well we provide service in our ambulatory clinics. (You can also read more about it in this Boston Globe story by Liz Kowalczyk.)

Now, we are going the next step, not only conducting surveys of patients about their experiences in our clinics, but posting the survey results in those very same clinics. A portion of the survey is shown above. You will see three particular questions highlighted (just here, not on the actual survey). Those are the ones about which we receive the most complaints.

You also see above a mock-up of the kind of poster that will be prominently displayed in each waiting room, showing the performance results of that clinic for all to see. We believe this is part of "putting ourselves under the microscope." We have aspirations, not only to have an incredibly safe hospital, but also to rank highest in patient satisfaction in the country. We believe that you cannot achieve aspirations like this unless you hold yourself accountable by being transparent with regard to your progress.

I'd love to get comments from others out there, whether in hospitals or other businesses, as to whether you have tried this and what you have learned from it.

P.S. The mystery shoppers are still at work. We never stop learning from them.

The fear of transparency clouds all

I have been worried lately that I may have adopted radical views on quality and safety in hospitals, that I may be out of the mainstream of American life when I suggest that we should jointly determine to eliminate certain types of infections or engage in protocols to enhance patient safety. I was also worried that my insistence on the importance of transparency with regard to these issues was just too outlandish for people to absorb and accept.

Imagine my relief then, to read this editorial in USA Today. Hardly a radical journal, the editors write:

Too many Americans go into hospitals for treatment and end up getting sicker....

A greater sense of urgency is needed....

Why are infections so widespread? In part, of course, because hospitals are full of sick people and germs. But medical professionals, hospital administrators and government regulators are failing to demand adherence to actions they already know will protect patients....

Secrecy allows the problem to fester. Although 23 states require hospitals to report infections to one of four unlinked federal databases, reporting is so scattershot that there's no way to determine whether the problem has been getting better or worse.

On the comments under the post below, some of the world's experts on quality and safety offer their perspectives on this issue. What is it about the medical community that makes it so hard for these views to be accepted? A close colleague writes to me saying, "I imagine the fear of transparency clouds all."

Look at the numbers in the editorial: Tens of thousands of deaths from often preventable infections. We -- and I mean the academic medical centers in general -- rely too much on our reputations. It is beyond time to hold ourselves to a higher standard. As I have said before, if we fail to do so, it will be done for us and to us by legislative and regulatory action, and such action is bound to be less accurate and helpful than the kind of self-reporting I have advocated here.

Caller-Outer of the Month Award #2

It was time last night for the second Caller-Outer of the Month Award, given by our Board of Directors to an employee who exemplified the principles of BIDMC SPIRIT in pointing out a problem that was interfering with the staff's ability to do their jobs. This one went to Sharon O'Donoghue, clinical specialist in the medical intensive care units, seen above.

Here's the story. Last spring, based on observations from several ICU nurses, Sharon called out a frustrating problem: Inpatient nurses were unable to read many consult notes or follow up on tests because they did not have access to webOMR. WebOMR displays results and provides access to notes and other documentation. Instead, the nurses had to waste time searching in different locations for labs, imaging and plans of care.

Why? Because the original version of webOMR was optimized for outpatient workflows and was initially rolled out to outpatient providers. It had never been offered to the inpatient nurses or authorized to them as part of their information system log-in credentials. In fact these nurses first learned about the existence of the system when they happened to look over the shoulders of some doctors! Absent this access, the nurses had to use older programs that were not as complete, were not web-based, and were not as easy to use. This situation had existed for years.

Within a couple of days, Larry Markson, MD, Vice President, Clinical Information Systems, provided a simple way to give read access to webOMR to the inpatient RN staff, fitting the inpatient workflow. The result was enhanced patient care and improvement in the day-to-day lives of our 1400 nurses.

Sharon received a congratulatory letter, plus two super tickets to a Red Sox game of her choice this spring.