Caller-Outer of the Month Award #7

Continuing our series, our Board of Directors awarded this month's caller-out award to Marylou Conant, RN, who works in our PACU (i.e., post-op area.) Regular readers will 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.

Marylou's call-out was related to the availability and location of Calstat hand cleansing pumps. She noticed that hand hygiene in the PACU was being impaired. Why? The issue is that patients in the PACU are in bays that are close together, and you approach the patient from the foot-end of the bed. The Calstat dispensers are mounted at the head of the bed, on the wall, a location that does not support ease of good hand hygiene. But each bed does have a mobile bedside table that you pass on your way to the patient. Marylou and her colleagues figured out that you could "set a location" for a Calstat dispenser on every mobile bedside stand. They came up with a simple but elegant solution that provides both a visual cue as well as a slip-proof location on the mobile table using simple magnetic strips.

Marylou received a congratulatory letter, plus second row dugout tickets to a Red Sox game of her choice.

Lean: Tortoise not Hare

Here's an update for those of you interested in our process improvement efforts at BIDMC and our preliminary thinking about the next stages. Back in March 2008, we rolled out our BIDMC SPIRIT program, our first formal experiment with staff-based call-outs based loosely on the Totoya Production System, aka "Lean." It has accomplished some good stuff, and we have learned from it. (Search "BIDMC SPIRIT"and "Caller-Outer" on this blog to see a collection of those items.)

From the very beginning, we said that BIDMC SPIRIT would itself evolve, and now we are at the latter stages of thinking through how to do it. This process included some in-depth training of several of our senior clinical and administrative leaders, a cadre of the next organizational level of directors, and several of our medical trainees. Beyond training us, those sessions served as test beds for the specific curricula developed by our staff, in cooperation with and building on materials from the Greater Boston Manufacturing Partnership. Meanwhile, too, Steve Spear invited several of our folks to audit his process improvement class at MIT, where they have had more advanced exposure to Steve's work but also healthy interactions with people from other industries.

As the graphic above displays, we view ourselves at the very beginning of a long journey to full implementation of Lean principles in our hospital. Others, exemplified by Gary Kaplan and his colleagues at Virginia Mason Medical Center in Seattle, and John Tuissaint at Thedacare, started earlier and are further along.

As I was discussing with Jim Womack the other day, it is an interesting paradox that while an important part of the Lean philosophy is the concept of standardizing work (to avoid waste and unnecessary variation), when it comes to implementation of Lean, each organization is essentially sui generis. That is, the plan for diffusing the concepts of Lean in an institution like ours has to be cognizant of the people and the culture of the place, an environment that has evolved over decades.

The idea here is to be slow and steady -- "Tortoise not Hare" -- in both planning for implementation and executing the plan. I present, for your viewing, a simplified chart of the roll-out proposal we are currently thinking about and will be sharing with our leadership groups and staff. You can click on that chart and expand it. You might not get all the points, but you can see the major themes: Lots of training; application by the trainees of what they have learned; focus on broad system work across the hospital, but also specific project work in high priority areas; and a small, nimble governance structure to keep track of things and make mid-course corrections.

I hope, by presenting these materials here, to encourage others of you who have been through this kind of transformation to submit comments to share your experiences, and to encourage those who are thinking about doing this to reach out to others who are in mid-stream. As the US considers its options with regard to health care reform, the real action will remain in each hospital and physician group. Public policy instruments are blunt and imprecise. Unless we take charge of the manner in which we do our work, the broad general policies being considered in Washington, DC will make very little difference in the quality of care and the efficiency with which it is delivered.

Canadian Lean is bakin'

My virtual and occasionally in-person friend, Farhan Merali, (Harvard Medical School MD 2011 and Harvard Business School MBA 2011), sent along this link to an excellent introductory article from Healthcare Quarterly about application of Lean principles in the Canadian health care environment. It was prepared by Dr. Dante Morra and associates from the University of Toronto and Toronto General Hospital. As you will see, Lean principles and philosophy are independent of geographic setting.

What the CEO cannot do

This is what leadership looks like. It comes in the form of an email from Michael D. Howell, MD, MPH, our Director of Critical Care Quality and Associate Director of Medical Critical Care, to the ICU nurses, house staff, fellows, pharmacists, respiratory therapists, and attending physicians. Without these kind of champions throughout the hospital, the CEO's job is impossible.

All –

Fifty days. No splashes in any of the nine adult ICUs.

For those I haven’t met (welcome, new interns and fellows!), I’m the Director of Critical Care Quality and one of the ICU docs. In the past, I’ve written about our work to improve patient safety (90% reduction in central line infections, etc), speed delivery of critical medications to our patients (70% reduction in time-to-first-dose antibiotics), and more recently about work we’re doing to improve the experience for patients and families in critical care. Today, though, I’m writing about your safety.

Most of you will have noticed the box in the upper right corner of the Portal [note: our intranet home page] that lists the number of days since an employee injury. You’ve probably noticed that it’s always zero, meaning that one of our colleagues is hurt every day. I’ve been sort of agitated by that, and a few months ago we set it as one of the major improvement priorities for critical care.

As our first target for improvement, we sought the elimination of exposure to bloodborne pathogens by splashes. If you or a friend has ever gotten blood in your eye, you know it’s unpleasant, shocking, and scary. Some of our colleagues have, in fact, even been exposed to HIV and hepatitis this way. We know that nearly all exposures from splashes should be preventable by using personal protective equipment. And yet, before we started our work, someone got splashed about every week or two in our ICUs.

Many of you have participated as we began to try to figure out how to prevent these. Here are a few things we learned:

· ABGs and accessing arterial lines are especially risky procedures. In January alone we had *five* splashes from this mechanism.

· Glasses don’t offer adequate protection. Many people have gotten blood in their eyes (or mouth) while wearing their own eyeglasses.

· Splashes happen at unexpected times: disconnecting a Foley, flushing a PICC line, suctioning an ET tube, and being in the room while someone else was doing as ABG – people have been splashed in all of these ways.

Yesterday, though, we crossed an important threshold -- it has been fifty days since our last splash exposure in any of our nine adult ICUs. That’s definite, meaningful progress. Distribution tells us we’ve more than doubled our mask usage, and in some cases they have even had trouble keeping up with demand. That’s because of your work.

From my own practice, I know that it can be irritating and sometimes challenging to put on a mask and visor every time you’re doing something with a patient. But look at it this way: If we’d done things like we used to, we would have expected three to five more of our colleagues to have gotten blood splashed in their eyes during this time period. Instead, no one did.

I want to make a special request of those of you who are more senior, with lots of ICU experience: Please watch out for your junior colleagues, and if they are forgetting to wear a mask with visor, please remind them. Remember also that you set an extraordinarily powerful example with your own practice. By not wearing a mask, you may unconsciously be training your more junior colleagues to put themselves at risk.

Finally, I want to say ‘thanks’ to everyone who is helping with this, and particularly to Sabrina Cannistraro who is helping to lead the project, analyze the data, and coordinate the work. We will keep focused on splashes for the next several months, and once we’ve convincingly eliminated them we’ll begin to focus on needlesticks, lift injuries, and other challenges to our own safety.

As always, feel free to send comments, questions, and rebuttals directly to me, and please forward to anyone I’ve omitted.

Thanks,

- michael

Interns learn Lean -- They get it in two days!

With medical education focused so heavily on the cause of disease, diagnoses, and therapies, an area that is usually neglected relates to the science of care delivery and process improvement. We're trying to make some inroads here. I told you about one below, and here's another.

Three of our interns (Maryanne Kazanis, Nina Nandy, and Paul Bailey) are participating in a pilot educational experience in quality improvement. As noted by Dr. Julius Yang, who is coordinating the effort, "This is not yet standardized for all new interns, as we are trying to learn from these three whether this is worth expanding to a larger group in the future. The pilot experience is an outgrowth from our participation in the ACGME Educational Innnovation Project, where we are attempting to incorporate continuous health systems improvement skills in the standard training for all our residents."

Julius reports about the first two days: After a whirlwind morning introduction to the field of health care quality and “lean practice” (facilitated by a video that features making toast in a less wasteful way), this group spent an afternoon with clipboards and stopwatches (on day 1 of internship) to observe our current discharge process – using their “uncommitted eyes” to watch the process from the perspective of both nursing and physician workflow. They then spent the next day generating a “future state” concept of what attributes would comprise the ideal discharge process, complete with very near-usable “checklists” (one for the patient, one for the physicians) to help standardize the process.

To give you a sense of the perspicacity of our new doctors, here are just a few excerpts from their observations (some of which paralleled our senior management visit to gemba). Not bad for two days on the job!

GOALS:
To highlight the less efficient aspects of the patient discharge process from a nursing perspective.
To provide a standardized patient discharge protocol for the nursing staff.
To explain why the recommendations implemented in a more standardized discharge protocol would lead to a more efficient discharge process overall.

ASPECTS REQUIRING IMPROVEMENT:
Waiting:
Discharge orders are often entered by the MD at a time that is later than ideal for the nursing staff. This especially contributes to a less efficient overall process when nurses have multiple discharges to complete at once, and when the patients to be discharged are particularly complicated and require more time/teaching by the nursing staff.

Another issue that arises with later discharge order entry is that patients are left to wait 8 hours or more from the time they are told about discharge in the morning to when they are actually free to leave the hospital. This leads to increased questions by the patients to the nursing staff, pages to the MD, potentially displeased patients, and fewer beds available for new patients awaiting admission from the ED.

Forms:
The completion of online forms at this time is redundant with nurses cutting and pasting much of the same information into the patient’s copy of the discharge summary that the MD completed for the permanent medical record. In addition, some online forms include default information that is not relevant to all patients and require frequent deletion by the nursing staff.

Medication reconciliation:
At the time of admission, ED physicians are not consistently completing the handwritten carbon-copy version of the medication reconciliation form and filing it in the patient’s chart. As a result, nurses are required to transcribe by hand this information onto the carbon-copy form which can be quite time consuming.

Obtaining and recording vital signs, removing IVs, and completing medication reconciliation:
At the current time, nurses are often making multiple trips back and forth to the patient’s room to do these items at separately. This leads to inefficient use of time walking back and forth, and may potentially lead to errors in excluding an important part of the discharge protocol.

Front row syndrome

Here is a picture of our entering class of residents at their orientation session. What, you don't see anybody? Well, it is because these are the rows at the front of the auditorium. There seems to be some kind of Darwinian imperative -- perhaps based on their experience in undergraduate medical education -- for trainees to sit in the back rows. If you go back a few rows, you can find people, like these three new Emergency Department residents, seen with Dr. Sean Kelly, head of our graduate medical education program.

Notwithstanding their seating proclivities, this is a great group of trainees, and we are happy to have them with us for the coming years. My major points of advice to them? Wear bicycle helmets. And, help us eliminate preventable harm in the hospital by being vigilant caller-outers.

Pig -- Part 1

One of the lessons of Lean is that if you standardize work, you not only reduce variation, but you improve the quality of the product or service. This is known to be true in the delivery of medical care, but it is often not practiced in hospitals. Instead, hospitals remain cottage industries, with each craftsperson (doctor) plying his or her craft (clinical care) on the basis of experience, intellect, and creativity rather than on the basis of scientific evidence. This leads, nationwide, to extension variation in practice patterns (and cost). More locally, it leads to greater potential for harm. What we need, instead, is a greater reliance on standardized practices in those portions of medical care than can and should be standardized -- still leaving to doctors their ability, creativity, and craftsmanship for those circumstances that truly demand those attributes.

This pig game demonstrates the value of standard work flows. It's fun and illustrative of the concept. Find some friends on whom you can experiment. We'll start with this posting in round one, and then rounds two and three follow below. First, prepare standard size pieces of paper with the grid shown above -- one per participant. (If you click on the picture of the grid, you will get an enlarged version you can print out on paper.)

Now, read the following instructions to your friends: You'll probably have to repeat the instructions.

1) Draw the side profile of a pig, centered on the page.
2) Make sure the pig's head is facing left.
3) The pig should be drawn large enough so that a piece of it is in every box EXCEPT the top right.
4) You have 2 minutes to draw your pig.

Now, have everyone show their pig drawing to everyone else. OK, go to round two, below.