Luy and Ethel discover gemba

Lean training for our senior executive group continued apace this week. As always, a segment was a return to gemba, the place where work happens and value is created for the customer. Here, SVP for Health Care Quality Ken Sands visits with radiology staff members Michael Hogan and Caitlin Buchsteiner to learn about what visual signals exist in the workplace that give a sense of the status of the pace of diagnostic radiology exams. One part of the Lean theory is that it should be easy for staff members to get at-a-glance information on the status of a given work flow or process.

The classic example of a system in which the workers are disconnected from the upstream aspects of production system is found in this episode from the I Love Lucy show. How many examples of this can be found in your hospital? We find them all over. As always, this is not a case of ill-intentioned people working in a bad environment: Rather it is the all-to-common case of really good people working in an environment that has not been designed to reduce waste. The result is work-arounds, wasted effort, errors, and staff who go home more tired each day than they really need to.

Simply stated, the goal of Lean is to train people to see these examples and also to have the team learn how to address them in a comprehensive and thoughtful way. The idea is not to solve for the complete perfect solution all at once, but to be "very good at getting better."

Caller-Outer of the Month Award #5

Our Board of Directors yesterday presented this month's Caller-Outer of the Month Award to Susan Adams and Lora Morgan, whose near-miss call-out I have previously described. Susan was the ICU nurse mentioned in that story, and Lora was the clinical pharmacist. Please recall that this award is presented by the Board to reinforce the underlying concept of BIDMC SPIRIT -- that each person should be encouraged to call out problems in the workplace and be recognized and appreciated for his or her contribution to safety, quality, efficiency, and a better work environment.

Gemba calls again and again

The training sessions for the senior management in Lean philosophy and techniques continue, in an effort to integrate that approach with the ongoing BIDMC SPIRIT program. Each session involves a visit to a front-line process or clinical area. Here you see Suzanne Albright, a recruiter in our human resources department, explaining the steps in recruiting, screening, interviewing, and hiring to Mark Gebhardt, Chief of Orthopaedics.

Above, you also see the group at play, with a simulation of a meeting to discuss process improvement. Each person is labeled with a characteristic -- unknown to him or her -- that causes the other participants to treat him or her in a stereotypical fashion. The lesson is clear within just a few minutes: If you draw assumptions about your colleagues with regard to their ability to participate fully in process improvement, it is a self-fulfilling prophecy. The result is a diminution of the ability of the group and the organization to learn from one another and achieve the best results.

Returning to Gemba

You may recall that I discussed the Lean training program being taken by our senior management group. A second session was held this week, and we returned as a group to Gemba, the place where work happens, where value is created for consumers. Today's visit was to the pharmacy. SVP Jayne Sheehan, seen above in her "bunny suit", and I observed how things are done in the clean room.

We watched Rena Lithotomes (left), a trainee, and Rosmara Harvey (right), a pharmacist, as they carried out the incredibly precise and important work of preparing dosages of a wide variety of drugs used in clinical settings.

Later in the classroom setting, we compared notes to refine our observational skills and ability to see opportunities for reductions of muda, mura, and muri in our work areas. These concepts have often been used in other industries, but not so much yet in the health care industry. Probably the best example is Virginia Mason Medical Center in Seattle, where CEO Gary Kaplan has made this the hallmark of his administration for several years. We are earlier on the path to adoption of this philosophy in our hospital, merging it into our BIDMC SPIRIT program in a more systematic way over the coming months.

Going to Gemba

I have related below our efforts to spread the word about Lean techniques (aka Toyota Production System), for example to our residents, and apply them to the hospital setting. We're also conducting a similar set of training sessions for our senior management team.

For those not familiar with Lean, one of the concepts is "going to Gemba," where Gemba is the place that work is actually done, where value is created for the customer. By witnessing problems and work-arounds in real time, the team can have a better idea of how to solve problems to root cause and make incremental improvements in work flows. This is a critical part of a program of continuous process improvement, the theory behind BIDMC SPIRIT.

Here are (from top) Senior Vice Presidents Jayne Sheehan and Walter Armstrong following nurse Pam Moss, and Radiology Chief Jonny Kruskal following nurse Sarah DeCristoforo. The purpose of today's exercise was not actually to solve problems but to train our team in aspects of going to Gemba. As always, we all left with an enhanced appreciation for the dedication, outstanding work, and endurance of our nurses in the high-pressure environment of a medical-surgical floor.

Caller-Outer of the Month Award #4

Our Board of Directors met yesterday and presented their fourth Caller-Outer of the Month Award. There were two recipients, Holly Dowling and Susan Keefe, nurses in our hematology-oncology outpatient clinic.

As I have noted previously, 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.)

The story here was that Susan, a new employee, noticed that the rubber gloves she was asked to wear in the unit were thinner than gloves she had worn in her previous place of employment. She called this out to Holly, her group leader, and Holly then proceeded to investigate. It turns out that the supplier had mistakenly sent the wrong kind of gloves. Although other people had noticed that their gloves had changed, no one else had thought to call out the issue.

The problem is that OSHA requires a heavier grade of gloves for people working with chemotherapy drugs because of the potency of those drugs. If the medication gets on skin, it can be absorbed. In a clinic like this, with a number of younger women nurses who might be pregnant or might be planning to get pregnant, this could be particularly dangerous. The attentiveness shown by Susan and Holly quickly resulted in a review of the situation, determination of the root cause, and fixing the problem.

DPH and CMS help out

While we are justly proud of many of our quality and safety initiatives at BIDMC, we have to acknowledge that we still fall short in a number of ways. The memo below, distributed to our staff yesterday, contains an example.

Just as we view transparency around our clinical outcomes as an important management tool, we view transparency about regulatory activities, findings, and requirements in the same way. If a regulatory agency finds that we are doing things wrong, why would you want to keep that conclusion secret from the staff? After all, the doctors, nurses, and others are the ones who ultimately must correct the problem, and we trust their ability to evaluate and act on legitimate criticisms received by us.

In a previous post about the Joint Commission, I stated: "If the Joint Commission did not exist, we would want to invent it. An objective outside review of this sort is extremely helpful to a hospital as it strives to provide better and better care to the public." Ditto for our state and federal regulators.

Here's the memo:

To: BIDMC Community

From: Ken Sands, MD
Senior Vice President,
Silverman Institute for Health Care Quality and Safety

DeWayne Pursley, MD, MPH
Neonatologist-in-Chief
Interim Chief, Obstetrics and Gynecology

Marsha Maurer
Vice President, Patient Care Services
Chief Nursing Officer

We are writing to share important information about some serious clinically related issues at BIDMC over the past few months. To begin, we will give you some background, and then we will fill you in on what happens next.

What Has Occurred
First, between last November and March, BIDMC experienced several occurrences or “clusters” of methicillin-resistant Staphylococcus aureus, or MRSA, infections that have affected some of our patients (19 newborns and 18 mothers) days to weeks after discharge from our obstetrics and newborn services. These infections have been, for the most part, superficial skin infections and breast infections. It is important to note that no babies in our Neonatal Intensive Care Unit have been affected.

We are thankful that all identified infections have been successfully treated, in most cases with antibiotic cream or pills. We are working to identify any other patients who may have been affected. It appears that these clusters of infection have not impacted other parts of the hospital.

As with other hospitals and institutions that have experienced similar groups of MRSA infection, it is often impossible to identify a singular source or explanation. We have determined the bacteria to be the most common type of “community-associated” MRSA, meaning that the origin of the bacteria is most likely outside BIDMC. Despite extensive investigation, we have been unable to determine how it has spread. However, we have taken many steps within our obstetrics and newborn services to address this situation, including testing our employees and patients and strengthening our efforts on hand hygiene and sterilization.

We promptly reported these occurrences to the Massachusetts Department of Public Health (DPH) and the Boston Public Health Commission (BPHC) and continue to work closely with them. In addition, to help us with this ongoing challenge, we are working with the national Centers for Disease Control and Prevention (CDC), and we welcome their expertise and knowledge of similar situations. Our outreach has included communications with affected patients, patients who we believe have not been affected but were here at the same time as the affected patients, pediatricians and current patients in our obstetric units.

Second, during the course of a DPH visit regarding the MRSA matter on behalf of the federal Centers for Medicare and Medicaid Services (CMS), investigators observed instances when our infection control practices failed to meet our own standards. In addition, they had concerns about our system for reporting infection clusters to leadership bodies within the hospital.

What Happens Next
We have received the official CMS report and are putting together what is called a Plan of Correction to show how we will correct any and all deficiencies that were identified. We will make both their full report and our response available to the BIDMC community when they are filed within a couple of days. But as a result of the findings, a more vigorous, hospital wide survey by CMS will be coming to BIDMC in the near future for their own review and inspection of our policies and procedures. Every physician and employee must be prepared to welcome the CMS surveyors and show them the good work that we know BIDMC staff are doing every day.

Some Observations
We take the report on our lapses and the expected CMS visit very seriously. When we make this report available to all, you may find reading the report makes you uncomfortable. It is difficult for a group of expert and dedicated staff like our colleagues in Obstetrics and Newborn services to go through this process. They have worked extremely hard over the past few months to battle these MRSA infections and to re-dedicate themselves to the most rigorous infection control processes.

Yet the truth is any one of us at any time could be subjected to the same scrutiny and observation and we each need to ask ourselves how we would fare in this situation. This is an important learning experience for every one of us as we deal with the patients and family members who put their trust in us.

There is much to be proud of at BIDMC with our efforts to control infections. We have virtually eliminated central line infections and ventilator associated pneumonia over the past few years by implementing and standardizing major new processes. Each year, the outstanding clinicians at BIDMC provide quality care with exceptional outcomes to tens of thousands of patients.

The serious nature of the initial survey does not change those facts. But it does require that we continue to commit ourselves to providing the highest quality care to every patient who counts on us for their health care needs. Ultimately we believe the changes we will put in place as a result of this experience will make us stronger and better caregivers.