Monday, June 30, 2008
An email I sent to the BIDMC community:
Back in chilly days of winter, I wrote you about the beginning of BIDMC SPIRIT, and it is time to present a status report. Since starting the program, we have held training sessions for about 600 managers and others. Many of the rest of you, too, have patiently participated in those training sessions when the groups arrived on your floors! Many of you have called out problems, and we have discovered solutions to some of those problems. You can check the portal for a scrolling summary of a sample of those, or you can look at the SPIRIT Problem Solving Log for more detailed descriptions.
As I stated at the outset, we did not expect a revolutionary change from SPIRIT, but we did hope to introduce a new way to solve those daily problems that get in your way when you are trying to do your job. So far, so good. Some of you really are engaged in this and like the program. Some of you view it as background noise or a minor part of your life. Some of you consider it a bother. Wherever you are on that spectrum, please keep an open mind and keep trying to use this approach, as we have seen that it can produces real improvements.
We have not solved all the problems that have been called out, but we knew that would be the case. After all, you can't undo decades of practice and systems in just a few months. There have been about 700 call-outs logged thus far. Of these, about 400 had enough information provided by the caller-outer to enable a follow-up. Of those, about 180 have been formally resolved and closed. This is about what we would have expected for this stage of the program.
Through SPIRIT, we have also discovered some very big, very pervasive problems in the Medical Center that need a special effort to solve. I am going to present a summary of these below. Let's see how we do on these. Stay tuned.
Meanwhile, though, some of you have submitted questions to me about the program. Here they are, with answers:
What made you decide to ask us to take this on? Why now? Why this approach?
I got tired of seeing our people get frustrated with the amount of fetching and work-arounds they have to do. We studied various models that highly effective companies have used to solve this problem, modified them, and came up with SPIRIT. Even now, as we get comments from you, we continue to make modifications to the program to make it work better.
My problem is so big! Is it worth calling it out even if I think that no one can fix it?
No problem is too big or small! Give it a try.
People use SPIRIT Log as a complaint board. It could be disruptive and builds distrust. How can we stop them?
This is bound to happen sometimes. When we see it being used that way, we post a message on the Log to help people learn the right way. If a Log entry is particularly offensive, we delete it.
People are afraid of retribution so they either post problems anonymously or don't use the Log at all. What can we do to make people feel safe to use the Log?
Time and results will be the key. Also, the way in which managers treat people who post problems will either send a positive signal about participation or be really discouraging. We hope that managers will help create positive reinforcement by the way in which they respond.
I think this process is wonderful! Will the research community have a call-out pathway with the contacts list available?
You already do! Try it.
I have many frustrations about how my work is set up, but since my work is purely administrative, none of them relate directly to patient care. Is it still OK to call them out? Will they be addressed with as much priority?
Yes, SPIRIT is not just about patient care. Please call out administrative problems as well.
I have told my manager about these things so many times before and nothing ever gets done. What will make this problem log call out any different?
While not all problems will be solved, managers have been asked to give priority to those items called out through SPIRIT.
Managers already have too much on their plate. They don't have the time to train their staff about SPIRIT. What tools can we offer to support the managers?
Ironically, managers have a lot on their plate because they see the same problems over and over again, and they don't get solved. Over time, SPIRIT will be seen by managers as a more effective way to use their time. In response to suggestions, we are preparing a set of tools that can be used by managers and others to help introduce and implement the SPIRIT process more broadly.
We know Sr. Management reads the Log and perhaps judges our performance based on the log entries. However, we have to juggle SPIRIT issues with other daily priorities. What is Sr. Management's expectation?
No one is judging anyone's performance based on SPIRIT call-outs or the Log. SPIRIT issues are not meant to be separate issues from your daily priorities. They are supposed to be things that get in the way of your priorities. Don't view SPIRIT as an add-on. View it as a way to help solve the problems that matter to you.
How will we know when we get "there" and what will "there" look like?
When every BIDMC staff member to be able to answer these questions with a resounding "Yes!" every day:
Am I treated with dignity and respect by everyone I encounter, regardless of role or rank in the organization?
Am I given the knowledge, tools and support that I need in order to make a contribution to my organization and that adds meaning to my life?
Did somebody notice I did it, i.e., am I recognized for my contribution?
We know we are not there yet!
Now here are the big problems that were pointed out in SPIRIT call-outs, and what we are doing about them. For all four of these, updates will be provided regularly on the "Project Updates" page on the SPIRIT home page (under "Lists" on the left hand menu). The updates will include links to video footage documenting the current state, the process, the solution and its implementation. There will also be links to my blog postings, with things we have learned from the process.
GI Specimen Reconciliation
On May 13th, 2008 a Transporter made a call-out regarding the length of time it takes for her to reconcile specimens in the GI Lab. The immediate problem has existed for quite some time but has recently been amplified since the GI labs from East and West combined and moved to Stoneman 3. This process currently takes about 1 minute per specimen. The number of specimens “per pick up” varies throughout the day with 90-100 patients per day as an average.
Currently, the labels in the specimen log book are put in order by procedure time; however, the arrival of the specimens for reconciliation does not happen in that order. Transporters do rounds, and the specimens arrive in batches.
In addition, physicians might have different times of the day that they are involved, possibly creating another instance of batching.
As a result, when the transporter arrives at GI, he/she has to flip through pages and pages of the specimen log book to look for a label with an account number or name that can be reconciled with the specimen label.
This pathway redesign presents an opportunity for decreasing the time spent by the transporter and may decrease the turn-around time of the specimens.
Observations of the nursing node of this pathway have been conducted and an observation of the Pathology node was conducted this Wednesday (June 25). The anticipated time to implementation of a solution should be about 4 weeks.
Patient Mode of Transport
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).
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.)\
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.
Medication pumps are not always available for patient care when needed. (Focus first on the West Campus)
There is no clearly defined pathway.
There is no single, known place where pumps can always be found.
Calls for a pump interrupt the resupply process, thus causing more disruptions .
There is no clearly defined signaling between the customer (nurse) and the supplier. When does one call? When one is out of pumps? When one is down to just a couple?
Because of the sense of scarcity, the supply is based more on a perception of need than on the actual need.
Several observations have been conducted in the PACU, on the nursing side, of the resupply efforts. We are developing measures for the time involved in hunting and fetching and the delay of transfer from the PACU to the floor. Eventually, we will have a way to figure out the average amount of time to get a pump when needed. A team has already been put together to work on this project. The anticipated time to implementation of a solution is about 10-12 weeks.
Patient belongings and valuables are getting lost. This is happening to patients across the medical center. Staff spend a lot of time hunting down patient belongings, and the medical center spends tens of thousands of dollars in reimbursement payments to patients.
Patients move from their originating location to one or several others, but their belongings don’t follow. Or, if they do, there is a delay (of several hours or several days).
There is no systematic process for collecting and handing off patient belongings.
There is inconsistent or nonexistent documentation.
There is no absolute responsibility, i.e. no one is charged with being responsible for patient belongings.
We are beginning with a focus on the ED. There is currently a thorough effort in place to collect measurements of the current state, including:
How long it takes to search for items
How many items are searched for
The response time to a call
The time it takes to return an item to a patient.
Once the baseline data are gathered and the current state established, the plan is to pilot a more centralized approach to storing/retrieving patient valuables and belongings which involves the introduction of a primary owner of the overall process.
Thanks for your ongoing support, participation, and patience.
Paul F. Levy
President and CEO
Beth Israel Deaconess Medical Center
Sunday, June 29, 2008
Here's some information provided by Nancy Mazonson, M.S., OTR/L, the program coordinator:
The Parkinson’s Dance Program came from the inspiration and generosity of Ed Rudman (in picture above), who has Parkinson’s Disease himself. (Ed is a former Chair of the board of our hospital.) This program has combined yoga dance movements from Kripalu Center for Yoga and Health in Western Massachusetts with the innovative and exciting work being done by the Mark Morris Dance Group in Brooklyn, NY with people with Parkinson’s.
Ed’s determination to bring this program to Boston resulted in a partnership with JF&CS. Nancy and dance instructor Naomi Goodman, MPH, went to Brooklyn to train with the Mark Morris dancers. This May they began the first six-week dance program. One week the group was privileged to have John Heginbotham, a Mark Morris dancer, lead the session. Last week, WCVB-TV filmed the program for their Health Beat segment. Check out the video.
For more information, contact Nancy at 781-693-5069 or firstname.lastname@example.org.
Thursday, June 26, 2008
CareGroup, which is the holding company comprising BIDMC (and BID~Needham), Mt. Auburn Hospital, and New England Baptist Hospital recently successfully sold about $500 million in bonds. See below. These bonds were issued under the auspices of the MA Health and Educational Facilities Authority (MA HEFA), which is the designated public agency for coordinating the issuance of tax-exempt bonds by schools, hospitals, and other non-profit entities in the state.
The proceeds of the bonds will be used for a number of purposes, including financing a new wing of Mt. Auburn Hospital, a variety of capital improvements at NE Baptist, new patient rooms and an expanded emergency department at BID~Needham. In addition, proceeds were used to refund variable interest auction-rate securities that, because of turmoil in the capital markets, had seen dramatically increased interest rates. Like many other institutions, CareGroup was seeking to replace those bonds with more secure fixed-rate securities.
SEIU appeared at MA HEFA and tried to interfere with the issuance of these bonds. Oh, not by directly saying they should not be issued, but by presenting misleading and inaccurate arguments about our hospital's finances and accounting procedures and auditing processes procedures in the hope of derailing the approval. Fortunately, the highly professional staff and board at MA HEFA found no merit in SEIU's arguments.
Then SEIU tried to stop the Governor's office from signing off on these bonds. The Governor has to sign an affirmation called a TEFRA (Tax Equity and Fiscal Responsibility Act of 1982) certificate, that the bonds are consistent with the public standards of tax-exempt financing. Fortunately, the professional staff in the Executive Branch conducted their own due diligence, and the certificate was signed. (As I recall, in all these years, a Governor has only once turned down a request for financing once it has been approved by MA HEFA.)
I have mentioned below that SEIU tries to arrogate to itself the powers and authority of designated public agencies. It uses the argument that it is a concerned player in the health care arena, specifically noting its interest in "healthcare costs and accessibility," and therefore has a right or obligation to intervene in these matters.
Let's be clear. SEIU's rights and obligations are not the issue, and we should not be distracted on that point. However, its actions belie its words. If SEIU has a real concern about the cost and accessibility of health care, how does that square with its attempts to derail bona fide financial transactions that seek to expand access to health care facilities and stabilize or reduce their costs? And, notably, when its arguments were not persuasive in a public forum in front of a state agency, it attempted to use behind-the-scenes influence in the Governor's office.
This is not the first time SEIU has intervened in such matters. It has done so elsewhere in the country when it is engaged in corporate campaigns.
SEIU may seek to change the topic, saying this is about changing the process by which unions are certified. That is an issue that will continue to be debated. But the manner of seeking such change matters, and it matters a lot. When the union itself tries to undermine the mission of hospitals, particularly those non-profit hospitals governed by community leaders, it does so at the risk of harming those very purposes it purports to espouse.
There have been many reports about the huge amounts of dollars being spent by the SEIU to influence races for elected offices throughout the US, from local to national elections. (Here's but one example.) When are reporters going to start asking the question of those candidates receiving support: "Do you agree with the tactics used by the SEIU in conducting corporate campaigns against hospitals?" And, "What promises have been made in return for those donations?"
As a friend of mine recently wrote to his local elected representatives:
"As your constituent, I received the flier from SEIU thanking your help for the union's organizing PCAs (personal care assistants) in Massachusetts. I know it's nice as an elected official to get a no-cost endorsement mailed to your constituents.
"But, is the mailing really at no cost to you, in terms of your ongoing political judgments? I read today in the NY Times that SEIU is setting up a $10 million fund to punish elected officials who fail to maintain pro-union positions. Are you now in the position of having to say yes to SEIU every time they come in the door?"
Wednesday, June 25, 2008
We call these our "pipeline" programs. They are designed to give lower wage workers a helping hand in learning new skills so they can get jobs in more advanced positions in the Medical Center -- higher paid jobs in fields that are bound to be in high demand for years to come and which, themselves, serve as steppingstones to future promotional opportunities. This week, we honored and celebrated people who have become certified as Patient Care Technicians, Surgical Technologists, and Research Administrators.
Patient Care Technicians work with nurses and others to provide direct patient care. They play a vital role in the delivery setting, on the floors of the medical/surgical units. We created a nine week in-house program to train people into this role. During the first six weeks, the employees attended class two nights a week and participated in five skill practice sessions. After successfully completing the classroom training, they entered a three week, full-time hands-on training period on a patient care unit run by a nursing educator. The trainees received their salary during this time.
A Surgical Technologist assists in surgical operations, with duties that include helping prepare the room before surgery and passing instruments and other sterile supplies during surgery. Our training program is a five semester program offered as a partnership between BIDMC and Mass Bay Community College. Students took classes and participated in clinical practica on-site at BIDMC and attended lab sessions at MBCC. They received a stipend for financial support and maintained full benefits during the final two program semesters, when they were obligated to spend 24 hours a week in clinical training and needed to cut back on their regular work hours.
A Research Administrator is a professional who is responsible for administrative operations of research grants and contracts. Our Research and HR departments worked together to create an in-house program to teach the basic concepts and skills of research administration and taught classes one night a week for eight weeks.
At yesterday's ceremony, the participants, their families, and their previous and new managers were on hand to offer congratulations. There were lots of smiles, and I believe we were able to help people in their "pursuit of happiness."
For the sake of privacy, I will not provide full names, but you will get a sense of the diversity of the participants from their first names, and you will also get a feel for how much they are stepping up, in that I list the jobs they are leaving to take on their new roles:
New Patient Care Technicians/previous job
Frewoine/food service assistant (i.e., kitchen)
Zenebu/environmental services assistant (i.e., cleaning staff)
Elizabeth/food service assistant
Doris/room service assistant (i.e., food delivery)
Jennifer/patient observer (i.e., sitter)
Louis/environmental services assistant
Surgical Technologists/previous job
Angelo/unit assistant, post-op area (i.e., transport, cleaning, etc.)
Thomas/technician in surgical instrument cleaning room
Research Administrators/previous job
Heather/program coordinator in hematology/oncology
Julianne/research assistant in transplant medicine
Gloria/AA in gerontology
Sabrina/AA in surgery
Rachelle/clinical research coordinator in hematology/oncology
Yesterday's ceremony was just one of several during the year covering these job categories and other personal advancement programs. We use hospital earnings for these purposes -- but we are also grateful for the essential support provided by private donors (including gifts from other staff in memory of Quensella Cooper, one of our beloved employees), the state government, and the Boston Foundation for their support of these and similar programs in our hospital.
Tuesday, June 24, 2008
But here's one on which you can join in, a discussion on the Health Care for All blog between me and Charlie Baker about the issue of public disclosure of the rates paid to hospitals and physicians. Try it. You'll like it.
Monday, June 23, 2008
Sunday, June 22, 2008
This is a quite good orchestra comprising doctors and others from the Boston medical community. (For example, the principal clarinetist is Mark Gebhardt, our Chief of Orthopaedics.) If you are able to attend, I think you will enjoy it. Please pass this information along to others. (If you go, please introduce yourself and tell them that you read my blog!)
Here is the itinerary:
Monday, June 23, 2008, 7:00pm, St. Bartholomew's Hospital, Great Hall.
Featuring music by Bach, Albinoni, Bizet/Borne and Copland with soloists Dr. Leonard Zon, Daniela Krause and Harvard Medical students Sherman Jia and Sandy Mong.
Tickets: £15, contact Krystal Harrison, Tel: 0207-601-7463.
Thursday, June 26, 2008, 7:00pm, Bishopsgate Institute.
A Conversation on Music and Healing.
Featuring music by Bach, Vaughan Williams, Barber and Copland with soloists Janna Baty, soprano, David Juritz, violin and Harvard Medical students Sherman Jia and Sandy Mong.
Tickets: £7 available at door. For advance ticket reservations, email email@example.com.
Friday, June 27, 2008, 7:45pm, The Anvil, Basingstoke.
Featuring music by Bach, Vaughan Williams, Barber and Copland with soloists Janna Baty, soprano, David Juritz, violin and Harvard Medical students Sherman Jia and Sandy Mong .
Tickets: £18.50, call 01256 844244.
Friday, June 20, 2008
Thursday, June 19, 2008
A twofer: Watch this program on Sunday to see BIDMC SPIRIT in action. But first, read the comments from the same training session (below) to get a preview!
(From our media relations office) BIDMC’s SPIRIT program will be featured on “Sunday with Liz Walker” this Sunday, June 22nd at 11 a.m. on WBZ-TV, Channel 4. Walker observed a SPIRIT training session in BIDMC’s Neonatal Intensive Care Unit this week. The SPIRIT trainees shadowed Cathy Young, RN, and Nina Koyama, RRT, to identify work-arounds, time-wasters and barriers to patient care with the goal of implementing solutions as close to real time as possible. The trainees, who included, Susan Young, NICU, Denise Arena and Steve Maynard, Pharmacy, Elaine Mahon and Emi Rizik, Food Services, Heidi Jay, Healthcare Quality and Manny Alves, Pathology, then gathered with trainer Diana Richardson, Director of Support Business Services, to call-out a problem surrounding the turnaround time to clean equipment. BIDMC President and CEO Paul Levy was also interviewed separately about the purpose and goals of SPIRIT.
(And, now, some of the participant feedback comments from that same June 18 SPIRIT Orientation.)
I have been involved before this training, as a supervisor getting a SPIRIT call, vaguely knowing what it was about but then getting the call and really feeling on the hot seat. Not anything that was said, just the fact of suddenly doing a big problem solving while in a crisis. It happened twice in a week. So I was thinking this SPIRIT thing is a problem. I wasn’t looking forward to today. I feel like I was turned around a little by today. I can see the benefits. It helps you look at things differently. I was pleased to see that. But as the person getting the call, knowing you may be in a crisis, it can put a kink in your day!
I liked the day because it’s structured how you have to approach problems. It gave a process to do so, and then expanded on the process to show you how to get to root. The patient safety reports we have we are expected to get to root as well but I don’t think we ever got a tool to do it. This gave me the tools, and also the insight to see that I might not have been getting there in my patient safety reports.
I was trained more in systems. It was great to see how this goes hand in hand with systems work. They are not mutually exclusive.
The facilitators were great in emphasizing safety with us and all the folks out there. They were very professional about it and I just wanted to say thanks.
People do get defensive. That will change over time. The best part about this is it takes the finger pointing out of it.
I enjoy the log. It’s like my Boston Globe in the morning! I want to see the latest activity. I also use it to find out about problems others have had that can help me. For example, one of my staff came to me and said, "our old copier is broken again and we just have to throw it out the window and get a new one." It was constant. But I looked on the log and saw that a tech had helped fix another copier by showing how a certain piece jams. When I read that, I got in touch and asked if we could freeze the drawer we print on since we only use one size paper and that would take that piece that jams totally out of the picture. He said yes, we did it and guess what? The copier works perfectly. No more problems.
I work in research off site. To see the clinical side, the compassion, the excellence is very exciting. I feel more connected to the mission after my experience. I got a lot out of the day beyond SPIRIT itself. It was something much deeper for me.
I like the role playing. It really prepared us. My first experience with SPIRIT was coming into my area and seeing 20 SPIRIT folks training and thinking “Oh my G-d what is this?” It was interesting seeing pharmacy have to do lots with paper when I would have thought it would have been more automatic.
I thought we had a solution in place, but I learned we have lots of systems but they don’t talk to each other or no one gets the information in so that we must rely on the person and word of mouth to get the allergy and put it in the record … and a similar issue with a medication timing issue.
In our group we were all afraid to ask a doctor to explain something to us but then A. was bold and helped us ask one and it worked out very, very well.
Wednesday, June 18, 2008
I just wanted to take a few moments to provide you with some first hand feedback on your organization - my personal experience.
On Saturday afternoon (June 14) I tripped and fell in the steps leading into the Copley Square entrance to the Westin Hotel and dislocated the fourth finger on my right hand. At first when I got up, I brushed myself off and was ready to go on my way until I looked at my hand and saw my fourth finger on my right hand pointed off at a 90 degree angle. (It was the strangest thing to look at ... and it was my hand!!!! ) I quickly realized I had a problem ... and jumped into a cab and sat for a minute to figure out which hospital I should head to. I must admit my mind is no longer geared up to think about emergency rooms since my kids have all grown. It took a call to a friend in the medical profession (my daughter the NP was out of town) to suggest I head off to the BID ... he called again to tell me to head off to West Campus.
The cabbie was great ... especially when I told him I only had $11 in my wallet.
From the first instance I walked into your emergency room there was an immediate positive response to my situation. The young woman checking people in saw my hand and said "that must be painful" and lead me into a check-in room. A nurse came in and quickly checked my vital signs, soon followed by an administrative person who entered my current information into your data base. They then asked me to wait in the waiting room ... at that point I was ready to plead for some pain relief ... but took the opportunity to practice my patience. A couple of minutes later ... seriously only a couple of minutes, I was taken into a patient room. And soon a nurse came in to check my finger out, then a doctor came in, and she explained that I had probably dislocated my finger and they could pop it back in place.
The doctor first ordered an x-ray to be sure nothing was broken. But before I was taken off to x-ray, they shot my finger up with lidocaine (I think) and gave me a couple of Percocet. As you might guess, I was very ready for that shot. Feeling no pain, I was off to x-ray where they verified that I had no broken bones. The doctor quickly popped my finger back into place. After one more x-ray, I was sent home.
I was in and out of emergency in less than 2 hours. Everyone was very pleasant and extremely professional. All very impressive ... including the facilities. I'd go back in a heart beat, (though I'm not making any plans.) And or sure I'd recommend your emergency department as a first choice to everyone and everyone in need. I'd rate the experience a 10 out of 10. Thank you.
Tuesday, June 17, 2008
I have provided several examples of how BIDMC SPIRIT has been employed to solve some small and annoying work-arounds and other process problems in the hospital. But, it has also permitted us to discover some pervasive issues that can really affect the lives of our staff and the quality of care given our patients. We are about to do a full-court press on several of these, and I am going to give you the play-by-play as these proceed, i.e., in real time -- telling you what we learn, how we learn it, and how we work as a team to fix the system.
Remember, the concept of SPIRIT, which is borrowed from the process improvement programs of the best firms in other industries, is to empower and encourage all members of the staff to call out problems they see in the work environment; "swarm" around that problem and solve it to root cause; and then spread the story of the discovery throughout the organization. This is not easy to do. First, you have to develop a blame-free culture, so that the person calling out the problem is shown gratitude and appreciation for having done so. You also have to train people to see problems as problems, as opposed to the normal flow of work. Then, you need to get good at analyzing problems to their root. This often involves engaging people from other divisions or departments because the cause of most problems is usually multi-jurisdictional. Then, you need to discover and implement the solution and make sure it is sustainable.
The problem I'd like to present today has to do with medication delivery pumps. If there is one pervasive problem in the hospital, as pointed out to us by the nurses, it is making sure that a functioning pump is available and accessible at the time it is needed at a patient's bedside, whether in the surgical post-op area (PACU), a medical/surgical floor, or the emergency department. But, as anybody in any hospital will tell you, there is often a frustrating amount of fetching going on when a pump is needed. Please note that the problem is not an actual physical shortage of pumps: It is making sure that they are functioning and where the should be when they are needed.
Without further ado, I present here the first set of notes coming out of our group that is "swarming" to solve this problem. This is just the beginning. Stay tuned over the coming days as we work through this together. (By the way, the picture above is a diagram of the morning pump collection/supply cycle on our West Campus, showing the different supply paths taken by our devoted distribution staff as they try to meet patient needs -- indeed, as they try hard to reduce the burden on the nurses and other caregivers! I think you can see evidence of the some of the problems noted below.)
The Pump Opportunity – SPIRIT call-out #691
We can’t thank Julie Kelly in the West PACU enough. Because she chose to call out that they had run short of pumps needed by patients, causing stress and strain for all involved, a huge opportunity to strengthen the system and make life better for an awful lot of committed BIDMC staff has come into view. As Mary Gryzbinski, the PACU shift leader who helped Julie enter the call-out, said in first providing details about the situation, “we knew the people in Distribution were doing everything they could to find the pumps for us … we knew we all just needed some help.”
Prompted by the call-out, an effort has begun to deeply understand how the process works today, the first step of a rigorous collaborative and transparent effort to create a system capable of providing pumps exactly when needed, every time.
Key Learnings So Far:
1) There is nothing more powerful than “going and seeing” how the process actually works, through the eyes of the people who do the work. Staff and leaders we talked to noted how “the pump problem” has been known and debated in meetings for over a decade at BIDMC. Yet in just a few hours of directly observing how the process works by walking the paths of pumps and observing nurses as they encounter a need for pumps and other key nodes of the system, the core reasons the present design fails everyone involved became clear.
2) Everyone involved in the system – from the nurses who need pumps to the amazingly hard working distribution team that gathers and supplies them to the clinical engineers who maintain them – are working with great effort and dedication to meet the need. Like his peers, Mr. Cecil Whyte – the Materials Handler who does the pump resupply run and several other duties on the West Campus during the day shift – is acutely aware of how much is riding on his ability to find and supply enough pumps over the course of a day. Mr. Whyte’s physical effort matches his dedication. He walks so much every day in his search for pumps that he buys a new pair of shoes every three months!
3) This is not just a PACU need. For the most part, pumps circulate with patients across the hospital and so – not surprisingly – this opportunity involves a huge cross section of units, departments and BIDMC staff. This is not a problem that can be solved by one unit or one department; it’s going to take everyone.
4) The pump supply system on the West has some core strengths – especially the people! But it does not embed all of the core principles that a complex system like this requires in order to meet needs perfectly. With the people who do the work, we will be exploring some of those key ideas in order to design and achieve a stronger system. Those ideas include:
• The way pumps are supplied and replenished should be simple and direct. Our pump system has some of these features, but in a critical aspect or two embeds “loops” – forcing people in the process have to retrace steps in scattershot fashion – and a “fork” or two – where two parallel processes are used to meet very similar needs in a way that confuses customers.
• The system should be based on clear and unambiguous “yes / no” signals between pump customers and suppliers, but the signals in our system are more variable and vague, leading to stress, rework and missed needs.
• The activities each person performs should be highly specified, including their content, timing, and expected outcome. Unfortunately, aspects of our pump supply system make it virtually impossible for our suppliers to stay on track!
• We will also be exploring how problems can be solved quickly in the system, so that it can stay stable and constantly improve. We don’t want to have 10 more years of frustration! The people involved care too much, and deserve to succeed.
Time was also spent today to begin to appreciate the current state on the East Campus as well. Many thanks to Aurelio Gende, Supervisor, and Pedro Perez, Materials Handler, both in Materials Management; Michele Boucher, Clinical Nurse Specialist, PACU; and their colleagues for introducing us to the current processes.
Monday, June 16, 2008
We are happy to support the activities of the Greater Boston Sickle Cell Disease Association in its upcoming Walk-a-Thon on June 28 (9am to 1pm) and urge others to do so, too.
Sunday, June 15, 2008
Apologies for being slow in moderating comments during the last three days, but I was in the company of 1800 others participating in the 180-mile Trek Across Maine, a bicycling fundraiser for the America Lung Association of Maine. This particular bike ride starts in Sunday River (Bethel) and proceeds to Farmington on the first day, Waterville on the second, and ends at the coastal city of Belfast on the third. Supported by over 600 volunteers, the ride was extremely successful, raising over $1 million for the programs and initiatives of ALAME.
Did I happen to mention that there are a lot of hills when you go across Maine? Fortunately they go down as well as up. You can get a sense of the slope of these hills from the photo showing the maximum speed on a friend's odometer -- that's 37.5 mph -- and she was riding a hybrid, not a road bike!
Other pictures show scenes from the first rest stop in Farmington: laundry in the tent city housing some of the riders; a two-fisted ice cream cone eater at dinner after a 65-mile day; part of the bike corral; welcoming sign at the local pub, a favorite of the riders; and, last but not least, a picture of my cousin Tom, who persuaded me to join him for the ride. Thanks, Tom!
Friday, June 13, 2008
“The train dumped. We are hoping to reset the brakes and get underway.”
Pause. Noise from front end of train.
“The train dumped again. That is the noise you heard.”
It did sound familiar. Hence, I am guessing, the etymology of the term.
I figured that on a hot summer afternoon, it would be safer and faster to take the Acela from Boston to New York City. After all, you never know when a thunderstorm will develop and hold up air traffic. And then you are stuck for hours, sometimes on the tarmac, sometimes in the air. The train will take 3.5 hours and be a lot more comfortable. And cheaper!
So, we left on the stroke of 5:20pm and all went well. All supplies had been secured in South Station -- sandwich, fruit smoothie, NY Times -- added to Dreams from My Father that I had brought along (really should read it now that Obama has clinched the nomination) -- and so I’m set for a pleasant ride.
Dreams turned out to be a bit soporific, or maybe I was just a bit sleepy from staying up to see the very last second of the Sunday night 2-point Celtics victory over the Lakers, so I woke up to a lovely coastal view, including the Block Island ferry terminal somewhere along the Rhode Island/Connecticut shoreline. Finished the Monday-easiest Times crossword puzzle.
Gene Wilder took the Silver Streak saying, “I want to be bored.” There is something to that. Daydreaming as the train flew through Connecticut. Remembering the tour I had years ago of the Millstone power plants. Whizzing through Bridgeport and remembering visits to my grandmother’s store, the La Rose Specialty Shop. Women’s girdles, bras, and other intimates sold by my grandmother and other Eastern European immigrants, including one named Myrtle. Passing Darien, Cos Cob, and Port Chester. And then the train stopped. An overheated compressor.
10:52pm. Train starts up. Announcer says “We appreciate your guys patience.” Someone else on the P.A. says, “And we appreciate you!” Who was that?
Arrival in Penn Station four minutes later. About two hours late. You mean we were only four minutes from our destination! We could have walked the last segment . . . .
Thursday, June 12, 2008
At a recent event, I mentioned this personal dress code and later received the following note:
You opened the event by talking about your desire to have a no neck ties when the thermometer is over 80 rule at BIDMC. I mentioned this to a number of my co workers who all expressed support and in some cases great excitement about this proposal. About 15 years ago Mitch Rabkin sent out a letter declaring casual Friday's with rules (this is from memory so I hope I have the facts correct). You may not see it in your contract, but you are not only Chief Executive but also Chief Fashion Icon, therefore it falls on your shoulders to push this tie thing into the rule book.
Since there is no "rule book" on this matter, I am posting it here for all to see! Go for it, guys....
A medical journal (PLoS Medicine) published a study that examined the accuracy of 500 medical/health stories by mainstream journalists. It says mainstream journalism health coverage may be harmful to the audience. At best we exaggerate, at worst our articles completely mislead the public. The article contains embarrassing anecdotes of medical coverage. It says that the mistakes are not intentional. We're just poorly informed about what we are covering.
And here is an editorial in the same journal summarizing the implications of the study. Excerpts:
When it comes to the quality of health reporting, why is the bar set so low? One problem is that today's health reporters may have been covering crime last week and politics the week before. They have rarely been trained to understand the complexities of health research.
There is also a broader context in which medical stories get exaggerated—the 24-hour news cycle means that media organizations are battling for audience share, which in turn means that “the press has moved towards sensationalism, entertainment, and opinion”.
Researchers benefit from the publicity because it may increase citations to their study and help their chances of promotion or tenure, while a highly visible story of a dramatic medical breakthrough can boost a journalist's career.
When a health story gets hyped, it is all too easy for medical journal editors to deny any responsibility. The reality, of course, is that journal editors themselves are the third party in the “complicit collaboration”—the journal's press release is the usual mechanism for linking the researcher to the journalist. Medical journals issue press releases about their upcoming studies partly because media publicity drives readers to the journal and builds brand recognition. A bland press release may be less likely to get your journal and the study noticed.
Schwitzer's alarming report card of the trouble with medical news stories is thus a wake-up call for all of us involved in disseminating health research—researchers, academic institutions, journal editors, reporters, and media organizations—to work collaboratively to improve the standards of health reporting.
Wednesday, June 11, 2008
Here's the heart of the argument:
The physician-patient compact basically states that a doctor will care for a patient in exchange for compensation and that the patient will heed the doctor’s advice. Patients who disagree with their physicians, or just dislike them, are free to go elsewhere.
By the same token, this mutual contract gives a doctor the right to dismiss a patient. The most obvious reasons are failing to pay or missing multiple appointments. Refusing to adhere to treatments can lead to dismissal. So can being abusive to the medical staff.
Of course, we need to exercise this option sensibly. Doctors cannot fire a patient in dire straits like severe pain, bleeding or a life-threatening situation. And of course, we cannot refuse to see patients because of their race, age, sexual orientation and so on.
But could I fire a patient because I didn’t like his mother? Colleagues who had studied the ethics and legal issues told me that the answer wasn’t clear-cut. Obviously, I couldn’t just abandon them. Yet like a lot of legal jargon, the word “abandonment” is open to interpretation. I decided it meant that as long as I wasn’t leaving anyone out to dry with a serious, immediate medical problem, that I gave a patient reasonable notice and provided options about where to continue getting care, I was within my rights.
We patients living with diabetes don't have a cure yet. But life has gotten A LOT better since the Internet has given us a place to gather and a collective voice.
It's also changing our relationship with the medical establishment and pharma companies, so they finally view us as consumers, demanding the right products and treatments to help us live better.
Please have a look at this video: http://www.youtube.com/watch?v=ZKHLmKGPUuM
Tuesday, June 10, 2008
The topic is medication adherence -- what people do with those prescriptions that are written by doctors. I have written about this before, but George makes the case more tangible.
Of all patients who get a prescription, 24% either do not pick it up or don't begin using it.
Among those who begin taking their medication:
- For those with diabetes, the average adherence is 78.9%;
- For those with high blood pressure, the average adherence is 83.7%; and
- For those with high cholesterol, the average adherence is 84.7%.
Looking at it another way:
- For those with diabetes, 4 out of 10 patient comply less than 80% of the time;
- For those with high blood pressure, 3 out of 10 patient comply less than 80% of the time; and
- For those with high cholesterol, 3 out of 10 patient comply less than 80% of the time.
What happens when there is poor adherence? At a subsequent visit, the doctor sees persistent symptoms and assumes that the dosage is not working. The doctor then reissues the same drug at a higher dose and/or adds a second drug!
George estimates that poor adherence to drug regimens in these categories of chronic disease adds $22 to $34 billion in increased costs because the patients' conditions deteriorate to the extent that hospitalization is needed. He did not quantify the cost of drugs that are purchased by the insurance companies and never used by the patient, but that should be added in, too.
In all the debates about cost control and improving quality care, I have heard very little on this topic, particularly from payers. I have heard some suggest that insurers do not have a strong interest in the matter because they perceive that patients will churn out of their membership ranks. If we were cynical, we could say that they don't mind if people don't use as many drugs. They avoid the short-term costs, and the long-term costs are likely to be paid by the next company or by Medicare. Is it fair and accurate to suggest that?
CareGroup, which is the holding company comprising BIDMC (and BID~Needham), Mt. Auburn Hospital, and New England Baptist Hospital recently sold several hundred million in bonds to finance various purposes for its member hospitals. I may have more comments about that bond issue in a future post, but for now I wanted to provide some pictures from the closing for those of you who have never seen one.
Like a mortgage closing for a house purchase, a bond closing basically consists of signing papers in which the borrower makes promises and attestations and disclosures. Only this involves many more documents and many more lawyers! The pictures above show the "accordion file" of those documents; Jeff Liebman, CEO of BID~Needham signing some, accompanied by an assisting attorney and a witnessing Notary Public; the old-style, venerable corporate seal of New England Baptist Hospital (founded 1893) next to the new-style corporate seal of BIDMC (founded 1996); and finally, the actual bonds themselves.
Monday, June 09, 2008
Sunday, June 08, 2008
Throw out the life-line! Throw out the life-line!
Someone is drifting away;
Throw out the life-line! Throw out the life-line!
Someone is sinking today.
So, here's the question. In his introduction to the piece, one of the singers said that it was a temperance song, and this is supported in some places, like this one, on the web. But various websites, like this one, refer to it as a missionary piece, and the last verse in particular makes it seem that way.
Now, maybe this doesn't matter at all. Maybe there was a lot of overlap between the temperance movement and missionary zeal at the time.
I don't quite know why this has left me curious. Anyone out there want to jump in with a knowledgeable or speculative opinion?
Addendum. Meanwhile, e-Patient Dave was kind to send me these two renditions: Mahalia Jackson and James Cleveland.
Saturday, June 07, 2008
When I saw this in a friend's yard here in Newton, MA, I thought it was an opening to a cistern, or maybe to an aqueduct passing through. But no. The picture is the cover of a fallout shelter built in the 1950s. (The current owners keep it securely locked.) As young children of that era, we would practice hiding under our desks in school during air raid drills, being told that to do so would protect us from the atomic bombs that would rain on us from the Communist enemies of America who lived in the dark society of the USSR. It was all part of a fearful time that was manipulated by political leaders and corporations.
The cover of this bomb shelter is made out of lead to protect you from radioactivity -- since the government would promptly announce through the CONELRAD alert system that intercontinental ballistic missiles were en route so you would have enough time to get into the shelter. A nearby vent shaft brings in outside air -- no doubt through a filter that was sold as incredibly effective in sifting out any contaminants. Electricity was provided by, ahem, a line from your house -- as though the supply would stay remarkably reliable through the bombardment of the Boston metropolitan are. You would store lots of water and food in anticipation of your time in the shelter. Not exactly clear what you would do with solid waste, food waste, and human waste while you were locked up in your concrete bunker for several weeks. And what exactly would you come out to see after your hibernation?
As noted in this article:
The image of the nuclear mushroom cloud hovered above the thoughts of American citizens throughout the fifties, and in to the early sixties. Propagandists would capitalize on this, by creating an immediate need in the consumer mind for a bomb shelter. The idea was planted that a bomb shelter would protect you from the horrible effects of a nuclear attack, assuming you were able to construct such a shelter. Though the idea seems ludicrous now, since the effects of a nuclear attack are fully known, people were caught in the trap that the propagandist had set.
By 1960, The Office of Civil and Defense Mobilization, estimated that a million families had constructed their own private bomb shelters. Shelters ranged in price from $1,795-$3,895, and of course many came in kits that make assembly much easier. Advertisements were found in magazines throughout the country. Many companies were capitalizing on Americans fear. Life Magazine in 1955, included a feature ad for a H-Bomb Hideaway, and the sale price was only $3000. Bob Rutske, a Michigan Sheriff at the time, remarked that "To build a home today without a shelter, would be like leaving out a bathroom twenty years ago." The amount of shelters that were built in that era, show how well propaganda had penetrated the American mind.How gullible were we then? How gullible are we still?
Friday, June 06, 2008
If you miss that one, there will be a repeat at Russo's, 560 Pleasant Street, Watertown this coming Saturday, June 7 between 10:00 am and 1:00 pm.
Eduardo is from Argentina, but did you know that Buenos Aires has one of the largest Italian populations (outside of Italy) in the world? Because of hemispheric seasonal differences, gelato purveyors in Argentina traditionally spent the summer there and then spent the summer (again) in Italy!
Thursday, June 05, 2008
One of the things I love is the feeling of being in the United Nations as I walk around the hospital. One measure of that is how busy our interpreters are. These two charts show the distribution of foreign language encounters in the hospital so far in FY 2008.
Hello Mr. Levy,
I missed your blog from Thursday, but Dave Fobert from the Shapiro Institute and the Simulation Center recently pointed it out to me. I'm thrilled to hear that we've been able to reduce our central line infection rate, and more thrilled to hear that we've been able to maintain (and even further reduce) the infection rate over the last year! I've had the privilege of working with a number of colleagues who have helped make the reduction in central line infections possible, and have been impressed with the thoughtful dedication and effort of all of them. I would like to take a moment to point out two projects that I hope have helped contribute to the reduction in central line infections, and, more importantly, highlight the many individuals who helped make these projects possible.
The first is the Department of Medicine procedure service. While many residency programs have begun to develop similar programs, ours was the first of the kind. The AHRQ recently asked Dr. Grace Huang and I to write a perspective piece detailing a variety of issues related to the creation of this service. At the bottom of this e-mail I've included a link to the article, but wanted to share with you a comment from the article and acknowledge some of those involved in the creation of this service.
"As with any new program or intervention that affects an entire department, the success of this program depends on the collaboration and cooperation of many. The willingness to dedicate the resources and faculty support to an untested endeavor was a direct reflection of the institutional spirit and dedication to providing the best possible care for our patients and education for our students and residents."
"Acknowledgment: The authors owe special thanks to those who showed an uncommon foresight and dedication to make the Medical Procedure Service at Beth Israel Deaconess Medical Center successful, including Drs. Moellering, Weinberger, Zeidel, Strewler, Weiss, Reynolds, Feller-Kopman, Gordon, Ernst, Aronson, Clardy, and Weingart."
The second project is our use of simulation to more effectively teach central line insertion. For last year and a half we have brought interns to the simulation center on the first day of their ICU rotation to provide them a comprehensive education of central line insertion in a safe environment. In addition, we have created a validated assessment tool to help determine competency at these procedures (believe it or not, such a tool hasn't existed until now) and are investigating how much our simulation education improved the resident's skill and whether it has resulted in improved patient outcomes. In the meantime we only have the anecdotal reports from our housestaff. Below is an e-mail from Dr. Arash Mostaghimi (a HMS graduate and now one of our outstanding interns) who recently put in a central line while rotating at the Dana Farber Cancer Institute:
From: Mostaghimi,Arash (BIDMC - Medicine)
Sent: Saturday, May 24, 2008 4:34 PM
To: Smith,Christopher (HMFP - Health Care Associates)
Subject: central lines
I wanted to let you know that I put a semi-emergent IJ in yesterday on one of my patients at the DF in less than 10 minutes, which was fairly impressive to my BWH colleagues. They were especially surprised to hear that I've only put in 5 central lines before. I think the key was the training that I had with the simulator earlier in the year--even though that was a subclavian line, just becoming comfortable with the equipment and having been able to practice it a couple of times (during the session and later during the testing session) was of great benefit.
So thanks for the teaching! I hope it's standard for our new interns.
Arash Mostaghimi, MD MPA
Internal Medicine/Dermatology PGY-1
As with the procedure service, the success of this simulation project is due to the efforts of many, including Dave Fobert (who sent the e-mail below); Dr. Grace Huang (Shapiro Institute and co-investigator of procedure service and simulation projects); Lori Newman (co-director of the Rabkin Fellowship and co-investigator of the simulation project); Drs. Ennaceril, Cho, Miller, Cobb and Leder (all 5 are senior fellows who helped with the simulation teaching over the last year); Drs. Clardy and Weiss (who have supported these project and have allowing interns to leave their ICU rotations for this training); Drs. Zeidel, Strewler, Schwartzstein, Aronson and Reynolds (for their continued support of these projects).
Not infrequently I have colleagues from other institutions inquire about our procedure work. What impresses them most is the degree of collaboration and cooperation that exists among colleagues at BIDMC!
From: Fobert,David V. (BIDMC - Res Academic Affairs)
Sent: Friday, May 30, 2008 5:31 PM
To: Smith,Christopher (HMFP - Health Care Associates)
Subject: Central Line
Just a quick question. Is Paul Levy aware of the central line simulations done in the simulation center? I noticed his blog entry from earlier. Given that it looks like we'll be able to do the training as part of the rotation for next year, I hope it can help to bring the infection rate even lower!
Anyway, saw his post and wanted to mention it. Have a great weekend!
David V. Fobert
Administrative Manager for Operations, IT
Carl J. Shapiro Simulation and Skills Center at
Harvard Medical School and Beth Israel Deaconess Medical Center
Wednesday, June 04, 2008
Continuing in our series on the roll-out of BIDMC SPIRIT, here are comments made by participants in the most recent training session in response to these questions posed by Dr. Ken Sands, our SVP for Health Care Quality:
“What about SPIRIT and the training works? What needs to work better? What should BIDMC do differently?”
One of the things that works best about is having other disciplines see what other disciplines do. The old saying “walk a mile in another person’s shoes.” I think a lot of us are coming away with a lot of renewed respect for what other people do around here. And it’s ok that it’s managers doing it, but it would be key for front line staff to do too.
I’d like to see more MD involvement. I know some have been coming through. Is there a plan to accelerate?
Do you have a place where everyone who has been through training is listed?
How do we encourage front line staff to use this? Managers and supervisors are familiar with it. We had staff meetings and talked about it but I’m not sure it’s gotten out there enough.
I haven’t seen much of this in the area where I work. Pre-SPIRIT, I was told how to reach out for some guidance on making improvements. One time, it was very successful. Another time, with another kind of problem, I had someone in my office two days later yelling at me. I’m not sure there’s a clear enough structure for this yet where I work so I hope it can continue to be strengthened.
Is there a way for the log to drop an e-mail to a manager who’s been named in the help chain?
We have been problem solving in our area, but not following through to enter on the log. But we’ll follow through and log it now that I’m reminded of the value to others.
We have noticed that when you are on the screen of one of the problems, the number is not visible. You have to go back out of the problem and then find it again, which can be hard (require a search or scrolling if it’s not one of the newest problems). It would be very helpful if the number could be displayed on the problem screen.
I found this concept so affirming. I have been a staff member for 15 years. I can’t tell you how many thousands of times I have become vaguely aware of how frustrated I was getting, but I had absolutely no way of doing anything about it. I want to tell you how moved I am that the institution wants to do this for us. It’s basically about how our day is. How do you mobilize people to do this, like you were asking? Tell them this if for us! I am the kind of person who has to process things, so I’ll have to return to the materials, but some of the tools that are shared like the activities and pathway principles – those are news to me. I’ll use them in my own life. They don’t teach you that in nursing school!
Tuesday, June 03, 2008
Monday, June 02, 2008
Here is a short video about a potential patient safety problem with code carts that was called out by a nurse as part of BIDMC SPIRIT and how it was handled. It will give you a sense of the steps involved. Worth watching all the way to the end. And a clear contrast with the definition below!
Sunday, June 01, 2008
For the wish list: This might be a substantial change but I ask that you put it into the hopper for a someday rethink. I ask that you (BIDMC) begin to define an appointment from the patient's point of view, or at least offer us a view that serves us. For me, the "appointment" object is a trip to the hospital that may have a one-to-many relationship with several sub-objects that are of interest only to the hospital, for whom each person is a schedulable resource. Right now, I have one trip to BIDMC scheduled for Monday 6/9. To me that's one appointment, one trip, and patients would be better served if we had visibility into more appointments. To you it's appointments (resource bookings) for three separate objects (people). Bottom line, I'm appealing to the hospital to consider presenting things appropriately to the POV of the individual stakeholder. You might say that it does me very little good to offer me visibility into YOUR view of the resources, when that isn't the information that *I* need.
Our programmer has checked the code again. You are correct, as just 5 appointments can be displayed on the Home page at one time. There is a finite number of appointments that will display. If you have a long list of appointments, the (later) appointment with Dr. X will display after some of the others have passed.
This is way below your radar but I want you too to be aware of this as a thought. Here's something I just submitted to the PatientSite support team, to put onto the wish list.
I'm not sure what would be involved in changing this, but we will follow up with the team and get back to you.
I reviewed with the team, and it would be possible for us to increase the number of appointments and other events that display in MyEvents in PatientSite. I have attached a screenshot for your reference.
There are three options:
1. Raise the limit of future appointments from 5 to some higher value.
2. Show all appointments that fall within a specified date range, e.g., the next six months.
3. Show all future appointments regardless of date.
All three options are technically feasible. Approaches 2 and 3 would seem to better address the patient's request that we adopt a patient's point of view in the display.
Let me know if you would prefer one of these options over the others, and we can proceed from there.