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.

What if?

Just thinking, along the lines of a New Year's resolution. What if all of the hospitals in the Boston metropolitan area -- academic medical centers and community hospitals -- decided as a group to eliminate certain kinds of hospital-acquired infections and other kinds of preventable harm? And what if they all committed to share their best practices with one another and to engage in joint training and case reviews in these arena? And what if they all agreed to publicly post their progress on a single website for the world to see?

Let's start simply. My candidates:

1 -- Eliminating central line infections (Metric: The number of CLIs, as defined by the CDC. Goal = 0)
2 -- Adopting the IHI bundle to help avoid ventilator associated pneumonia (Metric: Percent compliance with the bundle. Goal = 100%)
3 -- Adopting the WHO protocol developed by Brigham and Women's Hospital's Atul Gawande for surgical procedures (Metric: Percent of surgical cases in which the pre-op, time-out, post-op checklist has been followed. Goal = 100%)

The medical community in Boston likes to boast about the medical care here, but we don't do a very good job holding ourselves accountable. This would be a terrific way to prove that we are serious about reducing harm to patients and that we can cooperate across hospital lines for the greater good.

Caller-outer award of the month

A key part of BIDMC SPIRIT is the idea that everybody in the organization is encouraged to call out problems they see in the workplace, problems of safety, efficiency, or anything else.

A few weeks ago, when holding their retreat, our Board decided to create new monthly award. Instead of honoring someone who had solved a problem, they would honor someone who had called out a problem. The idea was to provide further encouragement through the organization to those who notice and mention problems.

The first award has now been presented, to Gloria Martinez (in picture), who called out the problem with the delivery of specimens from the GI department to the pathology laboratory. This led to a complete revision of that delivery process, which later spread to other areas as well, as noted below.

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

Spreading the story of discovery

Several weeks ago, I told you the story of how we had improved the process for getting GI specimens to the laboratory for analysis. But part of BIDMC SPIRIT is to transfer the lessons learned in one setting to another.

I received a report last month that the process that was developed to improve specimen pick-up and transport in the GI department was successfully implemented in all other interventional procedural areas in the medical center. Our folks note, "This process was designed to provide a timely and safe transport of specimens bound for the departments of Pathology and Cytology. (These types of specimens are especially sensitive in nature due to the fact that they are often un-recollectable.)"

"This new process, developed by a multi-disciplinary team of staff from all levels, ensures that specimens are signed out in a timely manner while also providing full reconciliation at the point of intake. It improves the process for employees preparing the specimens for transport, those providing transport and those receiving the specimens in pathology, while minimizing the chance that any specimens will be misplaced or misassigned."

The 5S's + 1

Here's more about the CPD Lean rapid improvement event discussed below. It is in the form of report to the entire OR community from the director of that area, Elena Canacari:

Last week we completed a 5S Rapid Improvement Event in the West CPD decontamination room and in the OR core tech room. We spent much of our time on sorting out unneeded items (S1) and continued through each of the other 5 “S’s.” We even decided to add a sixth “S” for SAFETY because our team identified many opportunities to improve the safety of the staff who do the work. We accomplished a lot this week, and this improvement process will continue.

Let’s take a closer look at the 6 S’s:

1. Red tags and "sorting things out"

Clutter clogs up physical and mental flow of material and information. We went around the CPD and OR areas and looked for things that were broken, dirty, homeless, over stocked or no longer needed. We used 5S red tags to identify all of these items and we placed them in a “red tag holding area” so we could decide what was really needed and what was not. Once this was done, we realized how much space all of the unused items were taking up and how much space we could now use for the items we actually need!

2. Why is it necessary to set locations?

Set locations is another name for smart placement. Organization is the first step in rearranging work flow and we want to avoid reaching, bending and searching to use the items we need. Like items are now co-located and commonly used items are at eye-level, so no one needs to bend over or use a stool to reach items. In addition, there is no need to search for items now that we gave them all clearly defined homes as well. We want to create good flow with no barriers.

3. S3 is scrub, shine, and sweep

Before we could move ahead with our improvements, we cleaned the workplace to prepare it for new organization. This included mopping the floors, scraping off old labels, washing the walls, and shining counters and shelves. A clean workplace is a happy workplace!

4. Create standards

When you walk past CPD or go through the OR core tech room, you will notice parking places for trash and linen bins, color-coded signs to direct flow of instruments and kits, and taped areas to separate dirty areas from clean ones. Different colored shelves now help to set different levels of priority for turnover of dirty instrument trays and time tickets will be used as a new technique for visual communication. These are all methods for creating standards so that anyone who is involved in the process can have the right materials, in the right place, and at the right time.

5. We need to sustain the gains!

Everyone is an owner of the process and we should all be proud of our work. Building relationships between departments was an important part of the Lean journey, and in addition to teamwork between CPD and the OR, we now have friends in facilities, environmental services, housekeeping, and infection control. Practice makes permanence, and it is all of our jobs to communicate with other staff to share knowledge, highlight successes, and catch people doing the right thing.

6. Improving Safety in the Workplace

During our “waste walk” through both areas, many of the team members identified wastes that could impact the safety of the people doing the work. In keeping with the Lean principle of respecting people, the team decided that it was important to address safety issues. Some safety issues that the team addressed were marking off space in front of the fire extinguisher and hose, removing fabric materials from the decontamination rooms, marking off space in front of clean sinks, adding hand sanitizer and germicidal wipes, among many others. As important as it is to make process improvements, it is as important to ensure the safety of the process and the safety of those involved.

Feel free to stop by and provide feedback. Remember, this is a work in process. We are not waiting for perfection, but are going to make small incremental improvements that lead to big gains.

Should you have any questions, feel free to ask anyone on the event team, or speak to the management team. Thanks to the entire 5S event team: Ray Clarke, Heideman Zayas, Anderson Gray, Deborah Kravitz, Cheryl Wiggins, Kelly Cormier, Marti Cunningham, Jack Field, John Dzialo, and to the Lean team: Alice Lee, Bonnie Baker, Jenine Davignon, Kim Eng, Brandan Holbrook, and Samantha Ruokis.

Thank you to the Lean 5S Event Team. We look forward to your input and involvement. Elena

Don't stop. Don't stop. Don't stop.

Whenever we run a Lean rapid improvement event as part of BIDMC SPIRIT, we ask the participants to fill out a questionnaire. One question we ask is, "Was this a worthwhile experience, why?"

We had an event last week in one of our central processing divisions, the place where surgical instruments and supplies for the ORs are cleaned, sterilized, and maintained. The group comprised CPD folks and also nurses and surgery techs from the ORs. There are often tensions between these two groups, as misunderstandings arise in the stressful OR environment between the people in the two areas who are pursuing parallel parts of the same surgical processes. But, look at the answers to the question above after three days of very hard work together:

Yes, I feel like I was exposed to so many other departments and learned so much about the amount of time it takes to accomplish what you would think of as simple goals and tasks.

Yes, this event uncovered and exposed the process issues between OR/CPD. I feel that this is a good beginning, but will have to continue with other Lean projects to prove process and standardization.

Yes, I think it shows people how changes can be made and they can be effective and well received. Don't stop. Don't stop. Don't stop.

This was a worthwhile experience. I was able to learn more about the facilitation of good communication. I was able to learn more about effectively engaging others. Issues that affect both productivity and employee satisfaction were clearly revealed.

Yes, because the safer we are the better the Department is.

Yes, finally the staff sees that this whole process was not just lip service. Everyone in CPD and the OR has gotten involved.

This was more than a worthwhile experience. It shows how much can be accomplished when people put their ideas together and work as a team.

Yes, it involved multiple team members from different departments working on a common goal. Everyone's input was valued.

I was able to learn more about my co-workers' ideas, talents, and values. I found that particularly rewarding. The process provides many tool for creating change.