SPIRITed Transport

It has been some time since I gave you an update on BIDMC SPIRIT, our employee-driven process improvement effort. In addition to a variety of small projects, we have focused on several large hospital-wide attempts to improve the work environment. One of them is the issue of transporting patients to testing. As I noted back in June,

There have been several SPIRIT call-outs by transporters and other staff related to miscommunication about the mode of patient transport. A request is made for one means of transport (for example, wheelchair), yet another means of transport is what is brought (for example, a stretcher).

At the time, we found the following underlying symptoms:

There is a communication disconnect between Service Response, the testing location, and the unit to which the patient is assigned.
There are no clear cut guidelines as to who decides the mode of patient transport, or when, or how.
Nursing’s way of determining how to send a patient differs from how the testing location might want to receive the patient. Each use different criteria. An unfortunate side-effect is that the transporters are caught in the middle of communications between senders and receivers.
When Service Response gets a call for a patient transport request, the level of detail varies depending on who took the call.
(Interestingly, Radiology has its own system, in which they call the unit to confirm “we’re coming to pick up Patient X in a wheelchair,” but still they end up with the same problem. When they arrive, it turns out that the nurse requested a different mode of transport.)

And here's what we said we'd do:

We are in the midst of collecting a baseline for Radiology and Central Transport on the West Campus. This includes the number of transports per day, and the number of “wrong” modes for each day. This also includes overall transport time. The anticipated time to implementation of a solution is about 4 weeks.

Well, it turns out that this took a lot longer than 4 weeks, but it is because we expanded the scope of the project so it became a design from scratch of the process used by all parties involved in transporting a patient between an inpatient unit and a testing area (e.g., radiology). Go-live for the new approach is this Tuesday. What follows is an outlined summary sent to me by one of our Senior Vice Presidents. She was keen to note that the effort involved participation, suggestions, and energy from people at all stages of this process, exemplifying the whole idea of BIDMC SPIRIT, lots of well intentioned people working together for the good of patients and each other.

We'll see how it goes on Tuesday! As the summary below anticipates, no doubt there will be some glitches, for -- as anyone in any hospital can tell you -- this is a complicated environment. But I hope that you get the point that even solving the glitches together is part of the idea.

---
Where did we start?

Multiple SPIRIT callouts re: mode of patient transport (e..g., transporter arrived on unit with stretcher, nurse thought patient should go in wheelchair.)
Resulted in:
Transporter hunting and fetching;
Delays (impacts our patients, our nursing unit staff, our testing areas, our transporters and transport times, etc);
Sometimes patient went to testing unit on mode that couldn’t be used in that test; test had to be rescheduled;
Confusion among transporter, nursing unit, SRC and testing area staff.

After discussion among representatives of all staff involved, the group determined that entire process of transport (not just choice of mode of transport) from inpatient unit to testing area was:
Not defined/standardized;
Created re-work and delays;
Included less than optimally safe practices;
Created frustration/tension among departments (RNs, UCOs, SRC, transport, testing areas);
Would provide opportunity for many BIDMC staff to apply Lean/SPIRIT principles.

Decision to broaden scope of project to entire process: Starting with request for transport and ending with patient return to unit following test.

What process did we use to design new process?
Front line staff from each area described to each other current practice and problems and found that:
Process differed by unit and testing area;
Some groups are doing extra work that they thought helped other group, but didn’t;
Identified lots of rework and potential for confusion;
Terminology is not defined consistently, leading to confusion;
It was very valuable to learn how all parts fit (or don’t fit) together.

We drew process flow for entire current process, listing all problems/potential for errors, then described “ideal” state and draw a new process flow (making sure we used “Lean” principles” described below) to reach that.

3. Entire group developed specific steps for each activity in pathway, understanding each others’ roles.
Tweaked process flow as specifics required.
Challenged any step that was inconsistent with “design principles” to get closer to “ideal”.

4. Developed approach and materials for staff education, roll out and continued improvement of new process.

“Lean” principles used to shape “Ideal” new process
“Activity” Principle: Specify all steps in process.

“Connection” Principle: Ensure communication and hand-offs can be carried out appropriately.

“Pathway” Principle: Include no (or minimum) “forks” or “loops”, i.e., each member of the team should have one clear path to follow.

“Improvement” Principle: Use scientific method (data driven, evidence based), involve front line staff, keep improving -- “call out” when unable to perform step as specified.

Major Elements of New Transport Process
Scheduling:
Testing area determines mode of transport (exceptions only permitted based on patient clinical condition and only after resource nurse discussed with testing unit to ensure that test could still be carried out).
Only one call made to Unit to schedule patient test, with standard set of info using standard nomenclature. (Currently, many testing areas call several times to give “heads up” of when test probably will be. Nursing staff noted this does not help them.)
Time communicated is the scheduled pick-up time (not test time). That’s what matters to the nursing unit and transporter.
All testing locations to schedule tests/transport via phone (some were using fax, causing staff to look for info in different places)

Patient Preparation:
Clear assignment to and definition of role of UCO in chart preparation and notification of RN re: transport.
Increased communication and established time frame (5 minutes) for nursing assistance with patient departure or arrival.
Involvement of the Resource RN to assist transporter if delay of 10 min. occurs
15 minute maximum time for transporter to wait before going to next job.

Handoffs:
Face-to-face handoff must ALWAYS occur between patient’s nurse/designee and transporter upon patient’s departure AND return to unit. (Important safety improvement and will ensure that patients are receiving appropriate information).
Nursing unit staff ALWAYS to assist transporter in transferring patient to/from stretcher or wheelchair (important safety issue).

Continuous improvement:
Members of design group shadowing transporters first 2 weeks;
Managers assigned to serve as extra “help chain” for first 2 weeks so as much “real time” review of calls outs can be done;
Encouraging call outs for whenever process doesn’t work as designed (and underscoring it’s nobody’s fault);
Meeting 2 weeks post go-live to review all call outs and tweak process (and/or education) as needed.

Bottom Line
Reduction in time-wasted hunting & fetching
+
Alleviation of frustration and confusion (for both staff and patients)
+
Clarity in role responsibilities re: transport
+
Consistent and standard communication throughout patient transport process

= Improved Patient Care + Improved Employee Satisfaction and Collaboration + Better Use of Resources (through minimizing delays)

Sunshine in Worcester

Douglas Brown writes an important op-ed in today's Boston Globe about the experience of his hospital with public reporting of clinical outcomes. His conclusions are below. Please note again: Transparency is not about competition. Is about each institution making itself better and safer, and sharing what is learned across the health care system.

What have I learned?

First, public reporting works. It created a strong incentive to improving our quality. Second, responding to the crisis transparently, while more risky, was the right thing to do. At times, even lawyers must lean into the discomfort of transparency. It was the best course for our patients, our staff, and our community. Finally, humility saves lives. There is nothing more humbling than having to suspend a program. But it taught us to never accept the status quo, to know we can always get better, and to highly value a culture of learning and continuous improvement.

Transparency, a reprise

The Institute for Healthcare Improvement offers an occasional 2.5 day course for hospital senior leadership teams, which they call their Executive Quality Academy. They admit hospital teams to develop action plans to lead quality improvements in their organizations. (The group above is from Winchester Hospital, a very fine community hospital in Eastern Massachusetts. There were also folks from Stanly Regional Medical Center in North Carolina, the Indian Health Service's Red Lake Hospital in Minnesota and North Dakota, and several hospitals in Florida.) Dr Vinod Sahney, one of the faculty members, asked me to come by this last week and talk about the role of transparency in this kind of effort.

As I did, it occurred to me that recent arrivals to this blog might not be familiar with how I have used it to experiment with reporting of clinical results, with the hope of helping to hold our organization accountable for meeting quality improvement metrics. As I said in an article in Business Week about one year ago:

There are often misconceptions as people talk about "transparency" in the health-care field. They say the main societal value is to provide information so patients can make decisions about which hospital to visit for a given diagnosis or treatment. As for hospitals, people believe the main strategic value of transparency is to create a competitive advantage vis-à-vis other hospitals in the same city or region. Both these impressions are misguided.

Transparency's major societal and strategic imperative is to provide creative tension within hospitals so that they hold themselves accountable. This accountability is what will drive doctors, nurses, and administrators to seek constant improvements in the quality and safety of patient care.

Rather than repeating my IHI talk here (boring!), I am just going to list below some key posts to which I referred during my session. (Who needs PowerPoint if you have a website!) If you are interested, you can follow them through and get an idea of the journey we have taken during the past two years. As always, I welcome comments on these, but I am also seeking comments from those hospitals that have also tried this approach, so we can learn from your experiences, too.

These things happen -- a description of the point of view, all to often found in hospitals, that a certain level of harm that occurs to patients is "just the way things are."

We saved one person's life -- one of series of posts on our effort to eliminate (yes, eliminate) central line infections.

Teamwork wins against VAP -- one of a similar series on our efforts to eliminate ventilator associated pneumonia.

Aspirations for BIDMC and BID~Needham -- the story of how our Boards established an overall goal for these two hospitals of eliminating preventable harm over the next four years.

Source material -- Detailed background on the material behind the Boards' votes.

Next stage of transparency -- A link to our website documenting our progress, quarter by quarter, towards the goal to eliminate preventable harm.

The message you hope never to send -- How we used transparency to learn from one of the most egregious errors that can occur at a hospital, a wrong-side surgery.

Surprising use of Lean

A note from one of our rehabilitation staff, who had gone through an exercise in learning and applying Lean principles in the occupational therapy clinic:

The Lean organizational concepts have been helpful for me with patient care and in one case recently in particular!

Recently I treated a young patient with early Alzheimer's who needs to organize home etc. to help him with memory impairments. It was very helpful to show him some of the ways we have organized our department to improve our efficiency, particularly with the labeling. I feel that those same concepts will be helpful for him to organize in his home environment as it needs to be extremely organized to help him with memory impairments.

I don't know if people elsewhere have used this approach in a therapeutic way and put this story out there to see if so and to welcome comments if you have. (Mark Graban or others, do you have examples of this from your extensive experience?)

Lean is not about dieting

Following yesterday's story, here's another example of the Lean methodology in action, as presented in an email from one of our nurses to her colleagues this week. Note the involvement from others in the hospital that have had experience on their own floors. Wait, are they having fun, too!? I have heard too many reports of that. Quick, call out the seriousness brigade and put a stop to it.

From: Serrano,Marjorie I. (BIDMC - Nursing)
To: Nursing Farr 6 All
Subject: LOOK At THE CLEAN SUPPLY ROOM!!!

Lean Update on Farr 6 Clean Supply Room

As you could see, there was a lot of activity in the clean supply room today. The Lean team from the President’s office, Distribution plus 11R’s Marnie Pettit, RN and Martha Clinton, PCT, and Farr 7’s Beth Morrison, and Catherine McCollin worked with the Farr 6 team to redesign the clean supply room for better flow. We will be back tomorrow to continue this work.

We received training on key Lean principles which taught us that spending time searching and fetching items means less time spent on real work – time with our patients. Even when we can easily find an item, does it make sense for us to put items out of reach, i.e. too high or too low? Why not imitate the supermarkets that place frequently used items at eye level, like bread!

Lean calls these non-value added steps, “waste”. We spent the day removing as much waste out of the clean supply room process as possible. Last week, we counted the par stock right after it was fully stocked, then counted again the day after before it was restocked. This gave us the number used for one day and was used to determine the amount needed on your supply room carts (called the par number). We realized we had more stock than we needed in some cases and not enough in other cases based on this count so we removed all excess stock as well as added additional stock where needed.

Once we regained additional space, we organized the stock logically by function and for flow. For example, you will see we now will have zones for Housekeeping, ADL, GU/GI, Wound Care, Procedures and Respiratory. We then placed the most frequently used items at eye level to reduce bending and reaching. Most items are now in bins and the bin sizes indicate the amount of stock needed. The bins will have 3 labels: the “common name label” on the front of the bin – what most of you call the item, the “picture of the item label” on the bottom of the bin to tell you when that bin is empty what belongs there, and finally the “reorder label” also on the bottom of the bin that tells you the item number, cost & the ordering amount so when you are out of an item, you have the information needed when calling distribution.

Some examples of changes:

Items moved to the kitchen: Pitchers, liners, straws, cups
Items moved from Med Room to Clean supply room: Stat Lock for Piccs
Some skincare items were removed at the suggestion of the wound care specialist. These items will be reevaluated at the wound care task force tomorrow. (Keri Oil, Keri Lotion, Duoderm, Sheepskin, A+D Ointment, Antibiotic Ointment
Items that were added include: Duoderm Gel, Barrier Wipes, 5x5 Allevyn Foam, Non sterile suction tubing, Wound Cleanser, 9” armboards
Cable ties were moved to the resource drawer with the gun
Flashlights are now stored on equipment shelf in RN station.
Sustaining the gains

Lean taught us that this is a continuous improvement process so please give us your feedback and we will continue to improve. All of us own this process and keeping the Clean Supply room neat and tidy depends on all of us.

Thanks to Marnie, Pam, Bettyna, Marie, Singh, Beth, Catherine, Marnie, Martha, Bill, Jenine, Sam, Brandan

Margie

Bullish on the Container Store

Before

 

After

Quick, buy stock in the Container Store. As we continue with our expanded use of Lean process improvement techniques at BIDMC -- often originating from a BIDMC SPIRIT call-out -- a big part of each project seems to be reorganizing stuff. Here's an example from a recent exercise in our food service area.

The "before" picture shows you what things were like for the folks who organize and retrieve kitchen and serving supplies. Notice the mish-mosh of boxes, and look to see how hard it is for the staff member to reach the high shelf. Also, consider how dangerous it is for her to do so, with the chance of boxes falling on her head. The supplies themselves are kept in the original packing boxes, requiring someone to open a box each time something is needed. Only after opening the box, too, can they see if the inventory is running low.

The "after" picture shows you the change. Notice that the top shelf is now off-limits. Meanwhile, supplies have been organized in see-through containers, each with a clear label showing what is packed therein. The bins are easily pulled to permit removal of the supplies. And, because the original delivery boxes have been emptied, inventories are clear on a continuous basis.

As we say in the hospital world, this is not brain surgery, but it does require a thoughtful view of the work situation. That view, by the way, is constructed by the people who work in this area, not by some high ranking administrator. They get guidance from our Lean project team in the basic principles, but they are the ones who own the solution.

Next stage of transparency

Several months ago, we announced some audacious goals for BIDMC that were established by our Board, including elimination of preventable harm by 2012. We also promised that we would publish our progress towards that goal. We have now set this up on our website here. You can watch to see our data each quarter in each of the several categories listed.

When we were getting ready to publish these numbers, some of our trustees asked if we could put the numbers in terms of the percentage of cases in which there was preventable harm. By that measure, the number would be very, very small, about 40 cases out of over 200,000 in a calendar quarter, about 2/100's of a percent.

We said, "No, the point is to emphasize that each of the case involved an actual human being." Describing them as a percentage would dehumanize the physical impact on a real person, someone's mother, father, sister, or brother.

Last week, I was invited to give a lecture on this topic at the Harvard School of Public Health, and a different question was posed by a doctor in the class. "How can you set a target of zero," he asked, "when we know that zero is impossible?" I replied, "Putting aside the question of whether zero is impossible, the most motivational target is zero. If you say that we are trying to reduce, say, infections by 20 percent per year, people will feel satisfied if they meet that target. The idea is to establish creative tension for the organization by adopting an audacious goal. And, by the way, in certain areas, other hospitals have shown that zero is attainable for extended periods of time for certain types of error-avoidance."

At the other end of the spectrum, we are taking criticism from some people who see an inconsistency between these efforts at transparency and our lack of discussion or disclosure about particular cases. But we need to do that for reasons of patient privacy or for other legal reasons. For example, when a malpractice case is filed, we cannot and will not discuss that case publicly. For one thing, any comment we make can be construed as a violation of the patient's privacy. For another, as any lawyer will tell you, it is simply bad policy to discuss issues of this kind of litigation in a public forum. The plaintiff's attorney faces no such constraints, of course, and might perceive some benefit in holding a press conference to discuss the case. While we understand a reporter's desire to write a balanced story, our reply usually has to be, "No comment."

But outside of a particular lawsuit story, what are we going to say and disclose about all these cases of harm that are summarized on our website? The answer is that it depends. You can see from the chart that there are currently over 100 cases of preventable harm per year spread over several categories. As we have recently, when we think a specific case warrants wide public disclosure to help our staff be alert to a major challenge or teaching opportunity, we will give it wide circulation. Other specific cases will be given more limited distribution among our staff, consistent with their value in teaching about the need and means for quality improvement in a given sector of our hospital. And, in other situations, a pattern of several cases of a certain type might be presented to particular segments of our staff as a warning of a problem area.

We understand that our inclination towards transparency will garner criticism from some who think we are not being transparent enough when they have an issue or curiosity about a particular case. That is a by-product of what we have chosen to do, and we accept that.

Another by-product is that publication of these numbers may give the impression that we harm patients more than other hospitals. After all, we publish our numbers, and they do not. And many cases we publicize to our staff will inevitably be considered newsworthy by the local media. This, in fact, is why doctors and hospitals often don't like to talk about this stuff. Fundamentally, they don't want to be judged by the general public and the media, whom they deem to be unqualified observers of the medical scene.

Anyway, I want to assure you that there is no indication whatsoever that we harm patients more than other hospitals. (In fact, we know that our figures for certain types of hospital acquired infections are well below average.) But please remember that every study or analysis ever done indicates that hospitals rank highly among the country's public health hazards. Don't think that you are more safe in a place just because they don't talk about their errors. We believe that the only way to improve in this arena is to be open and honest about your mistakes and thereby enable people to learn from them.