Becker's shows how Lean fights the Nut Island Effect

I wrote an article in the Harvard Business Review a while back called "The Nut Island Effect: When Good Teams Go Wrong."  It was about a group of folks at a sewage treatment plant in Quincy, MA: A team of skilled and dedicated employees became isolated from distracted top managers, resulting in a catastrophic loss of the ability of the team to perform an important mission. The irony was that most people viewing the team would say that it had all the attributes of an ideal working group -- dedication, collaboration, a strong sense of integrity and values, and indefatigable energy with regard to doing the job. It is probably no coincidence that many of the staff members had served in the military, where those virtues were highly valued.

Over the years, many people have noticed the same phenomenon in other industries.  Bob Herman, with Becker's Hospital Review, has picked up on that fact, with an article focusing on the presence of this syndrome in hospitals.  He cites my experience after entering this field:

[H]e found that the "us versus them" behavior was rampant in healthcare. "We have a team of people that's motivated by the best possible values — physicians, nurses, operating room staff, people in the pathology lab — and they get isolated the same way the guys at Nut Island did," he says. "You can go into any hospital in the world, and I bet if you described this syndrome to five or 10 people, they'd look at each other and say, 'That happens all the time.'"

 

Bob relates how the use of Lean process improvement in the hospital setting can help reduce the likelihood of this pattern occurring.

Once frontline staff members are trained to report setbacks and managers act on those calls, hospital leadership can map out the processes in question, diagnose the problems and reduce the waste that is bogging down production.... [T]here is a bevy of benefits from this type of systematic hospital improvement based on Lean principles: Employees are not as tired; employees are less likely to make a medication error because they are not as rushed; staff morale improves as more people get to know each other; there is less staff turnover; there is an improvement in overall quality of care; and money is saved as the waste in all processes gets weeded out.

Thanks to Bob for such a clear exposition of these points.

Leaning together in North Carolina

Here's a heartening story from Alexandra Wilson Picci at HealthLeaders Media, entitled "NC Rural Hospitals Lean Together to Zap Waste."  An excerpt:

With the help of the North Carolina Hospital Association, a consulting firm, and a grant from the Duke Endowment, Caldwell Memorial Hospital teamed with four other hospitals to learn how to apply lean management principles. The hospitals shared ideas and resources, including funding and consulting services, and attended each other's learning events.

This is a great way to mitigate the expenses of a Lean program and share the enthusiasm.  As you have seen in examples on this blog, a portion of the Lean approach consists of rapid improvement events.  These focus on specific value streams within the organization, mapping out the entire work flow, identifying areas of waste, and experimenting with a new process. Here's a wonderful quote about how this kind of employee engagement works:

"It's remarkable to watch employees sit down and map out issues and discover possible solutions in a team environment and then have the wherewithal and the authority to implement these changes and see if they work," said Edgar Haywood III, president and CEO at Dosher Memorial Hospital, which is part of the new Eastern North Carolina Rural Hospital Lean Collaborative.  

Caldwell Memorial CEO Laura Easton added a key point:

"This is not something that you can delegate to one of your executives," she said. "I think Lean is only really appropriate if the CEO is committed to changing the way they operate the organization, and learning too, and being part of running their organization in a new and different way."

She is right, of course. As I have noted, like physical systems in which entropy takes over, consistently applied energy is necessary to maintain the process improvement system that we call Lean.  Without commitment from the top, the process will wither.  Congratulations to this group of CEOs for walking the walk.

Peter Pronovost is a liar. He must be. Isn't he?

Peter Pronovost and his subversive friends are at it again.  Imagine, first they assert that implementation of a standard protocol and checklist could reduce the rate of central line associated bloodstream infections.

"It wouldn't work here.  Our patients are sicker."

Then, to make matters worse, they go and contend that reducing the rate of central line infections saves money.  Here's the abstract from the American Journal of Medical Quality:

This study calculates the costs and benefits of a patient safety program in intensive care units in 6 hospitals that were part of the Michigan Keystone ICU Patient Safety Program. On average, 29.9 catheter-related bloodstream infections and 18.0 cases of ventilator-associated pneumonia were averted per hospital on an annual basis. The average cost of the intervention is $3375 per infection averted, measured in 2007 dollars. The cost of the intervention is substantially less than estimates of the additional health care costs associated with these infections, which range from $12,208 to $56,167 per infection episode. These results do not take into account the additional effect of the Michigan Keystone program in terms of reducing cases of sepsis or its effects in terms of preventing mortality, improving teamwork, and reducing nurse turnover. 

"No, it can't work that way unless we get rid of fee-for-service payments and go to capitation.  We all know that nobody will act to reduce infections because they will get paid less."

And then he has the nerve to tell us that reporting of central line infections is highly variable across the United States.  Here's the abstract from that study, again from the AJMQ:

The authors searched state health department Web sites for publicly available CLABSI data. Fourteen states, all with mandatory CLABSI monitoring laws, had publicly available data. The authors identified significant variation in the presentation of infection rates, methods of risk adjustment, locations and care settings reported, time span of data collection, and time lag to reporting. The wide variation in availability and content of information illustrates the need for standardized CLABSI monitoring and reporting mechanisms.

"We'll publish our numbers in a real-time, standard way when we are good and ready, but our numbers are better than their numbers."

MHA does CLABSI right

Here's a great step forward by the Massachusetts Hospital Association, a public presentation  of current data on the rate of central line associated bloodstream infections among its participating members. Here's the current chart:

Let's talk about what's good about this. First, the data are quite current, just a few months old.  Next, the monthly figures, which are subject to minor variations, are smoothed out with a three-month moving average, so you can see the trend.  Third, there are no punches pulled.  When the rate goes up, they say it.

Since each hospital knows it own rate, it can easily compare its progress to others in the state.  N0t for the sake of trying to attract more patients or for other kinds of marketing, but to act as a form of creative tension within the organization to do better. Now, that's the right kind of competition.

Follow-up from Den Bosch

Those of us involved in improving the processes of health care understand that this is always a work in progress. You never know, though, what will prompt an improvement in an organization. Sometimes, an action in a passing moment sparks a change.

In a previous post, I expressed great admiration for the quality, safety, and transparency initiatives underway at the newly constructed Jeroen Bosch hospital in the Netherlands. The hospital, in many ways, is setting a standard for others in the country and beyond, and they have cause for great pride and satisfaction.

One reason for that progress is that the staff has an almost compulsive drive for order. But, this is a new hospital, and things are still in shake-down mode. With over 1 million square feet of space, there are bound to be things that go unnoticed for some time.

As I received a tour of the place, we passed through a corridor to the operating rooms, and I saw this scene in a corridor -- a visual cacophony of clogs left behind by the OR staff. I could see that my host, Jan Olsman, the Chief of Surgery, was aghast. Jan has been meticulous about maintaining a shipshape environment around the ORs.

He and others noted that I took a picture of the scene. I just thought it created an interesting visual pattern, but I did promise not to publish the incriminating evidence for the world to see. I sent it along to Jan, and he, in good humor replied:

Thanks a lot for the nice footwear "tableau!" I actually start liking it as a piece of art. But not in this place.
Today, I received this photograph in my email. It came unadorned, with no explanatory message, but I knew immediately what had happened. I wrote:

I assume the picture came from you. Congratulations!

Sure enough, in a follow-up note, Jan said:

Correct! The threat of that picture with all the white shoes put on your weblog was enough for one of my staff members to remove them that same day!

And he also said he would be comfortable if I told the story, with illustrations. Perhaps this is another example of the power of transparency: Even the threat of disclosure prompts self-improvement!

I think, though, that is mainly an example of good humor and intellectual modesty by Jan and his colleagues at Jeroen Bosch. Thanks to them for letting me tell the story and, again, for setting such a fine example for so many in the hospital world.

Seeing things clearly in the Netherlands

In the post below, I summarize a conference held today at Jeroen Bosch Hospital in 's-Hertogenbosch (den Bosch), in the Netherlands, entitled "Quality and Transparency in Care and Training." In addition to the conference, today was a significant day in that a new website was launched by the hospital to present quality and safety data to the public and to the hospital's staff.

As explained by Dr. Marjo Jager, patient quality specialist, Jeroen Bosch has a strong commitment to transparency as a key element of process improvement in the hospital. The leadership of the hospital views transparency as the most powerful way to reduce preventable injuries, but also as essential to successful and ethical responses to patients and to safeguard employees.

Marjo noted that preconditions for successful implementation of transparency are a culture of learning rather than blaming and judging; ownership by those who deliver care; significant participation by physicians in designing new care regimes and setting an example; and strong support from the board.

Above you see an action shot of the moment of truth, as staffers Miriam Casarotto and Bart Deijkers prepare to push the "activate" button on the new website.

Beyond the website, the hospital is also posting clinical data on patient care floors for all to see. They are experimenting with locations and topics, and this is all bound to change with experience, but the commitment to openness is evident, even when the numbers indicate a need for improvement.

Here, for example, is the current scoresheet with regard to pain management on one of the floors. The hospital clearly indicates a result less favorable than they would like, accompanied visually with a cartoon face that is not smiling.


In contrast, note this one with regard to avoiding decubitis ulcers (bedsores), which indicates performance at the hoped-for standard of care.

Congratulations to the administrative and clinical leadership of the hospital, and for the support provided by its board, for these significant steps in improving the quality and safety of patient care.

Borrowing safety ideas in the Netherlands

I just attended and presented at a conference at Jeroen Bosch Hospital in 's-Hertogenbosch (den Bosch), in the Netherlands, entitled "Quality and Transparency in Care and Training." It was held on the occasion of the opening of an entirely new hospital, following a merger with two other hospitals in the city (Bosch Medicentrum and the Carolus Hospitals). Hospital administrators and clinicians from throughout the country attended.

Our MC for the day was Jozein Bensing, professor of health psychology at the University of Utrecht. Relative to today's topic, she is most known for a paper she published a few years ago documenting that 1700 people per year unnecessarily die in Dutch health care facilities. This report gave substantial impetus to improvements in patient safety in the country's hospitals.

Jozein chairs the quality and safety committee of Jeroen Bosch's supervisory board (the equivalent of the board of trustees of a US hospital.) She said that the hospital has a goal of being the safest hospital in the Netherlands and plans to do so by "practicing what you preach" and learning as much as possible from others, in the health care field and beyond.

So it was appropriate that the chair of the symposium committee, Marck Haerkens (CEO of Wings of Care), and his colleagues decided to bring in the lessons of quality and safety from other fields. They see parallels with airline safety, and so we heard from Pieter van Vollenhoven Chair of the national Safety Board; Jos Nijhuis, CEO of Amsterdam's Schiphol Airport, and Tames Oud, head of training for Transavia Airlines.

Tames suggested that, while aviation and medicine are two different worlds, there some striking similarities, such as highly motivated professionals and critical processes. In both worlds safety and quality depend on effective cooperation between different disciplines. Like Captain Sullenberger back in the US, Tames asserted that the medical community could benefit from Crew Resource Management (CRM). Its objective is to reduce incidents (and worse) due to lack of situational awareness and team cooperation. He noted that CRM training makes people aware of the relevance of the human factor in team performance, and aids in creating a blame-free environment for people to work in.

In addition, Scott Higginbotham, mission manager at NASA's Kennedy Space Center, presented on "Safety and Mission Assurance." (He is seen here on the right with Willy Spaan, the hospital's CEO.) Scott's primary responsibility is to lead the multi-disciplinary team of engineers and technicians that assemble and test the experiments and satellites that fly aboard the Space Shuttle and the International Space Station. A summary: Manned spaceflight is an incredibly complex and inherently risky human endeavor. As the result of the lessons learned through years of triumph and tragedy, NASA has embraced a comprehensive and integrated approach to the challenge of ensuring safety and mission success. His presentation provided an overview of some of the techniques employed in this effort.

Regular readers of this blog will know my topic: I presented the experience of my former hospital with regard to its goal to eliminate preventable harm for its patients. I explored the hospital’s success in improving quality and safety for patients, endorsing public transparency of clinical outcomes, and engaging in process improvement driven by front-line staff.

As I have noted before, 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.

Many thanks to the symposium's major organizers, Marian de Bont and Dr. Kees Smulders, secretary and manager, respectively, of Jeroen Bosch's quality section (seen here) for their invitation and for planning a day of interesting and insightful talks.

In the post above, I include recent activities of Dr. Smulders and his staff with regard to new approaches to transparency in their hospital.