Day 7

Update from my stormed-in brother-in-law in Worcester:

Home again and fridge is clean. See there are some benefits to no elec for a week. Friends and neighbors Jeff & Judy have moved in as their house is one of the 7000 in Worc still w/o elec. No cable so we listened to Celtics win 16th straight; then sang songs and went to bed, our own bed, early. Tried to get rebroadcast of Paul's interview on NPR yesterday but need an Internet connection which has not yet arrived. 12 inches of snow due tomorrow and 6 trees hanging over new wires. Seemed like a time for prayer or, better yet, a climber w a chain saw. Have good one.

Sent from my iPhone

A Spear right on target

Steven Spear writes in response to an op-ed article in the New York Times. Simple and clear and clearly correct. Excerpts:

Jonathan Gruber (Medicine for the Job Market Dec. 4 08) may be right that healthcare reform will be economically good, but his assertion that we need to spend more to get more is based on the assumption that the care we currently receive is limited by the investments we make. This premise is wrong. The problem is not too few resources available to meet overwhelming needs. Rather, it is that those resources are managed in such an antiquated fashion that 1/3 to 1/2 are regularly squandered at great human and financial cost.

We do not need to spend more. Rather, we need to reward those who are getting better and provide incentive to others to do the same so what we invest is better spent. First, the federal government is uniquely able insist that performance be measured: both of treatments for various conditions and also on how well those treatments are carried out. This will be a huge benefit to payers and patients who, right now, are severely compromised in determining where they should look for care and if they are being treated as well as possible. Second, the federal government should make choices of where to access care based on those measurements, setting a powerful example for states and the private sector to do the same. The resultant shift in resources from those who use them badly to those who use them well will mean far better care for many more people–meaning poor access and poor care won’t be drains on society, and care will be provided at less cost—meaning that wealth will be available for other important uses.

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."

Holiday Lights

Casey Macauley on our staff writes:

"If you were in search of blog ideas I was just on the shuttle with the woman who is organizing 'Holiday Lights.' What better way to warm everyone’s hearts and put people in the holiday spirit?"

Holiday Lights is a gift giving program for patients and family members of our Bowdoin Street Community Health Center. The gifts are collected in Stoneman 122 -- and they are all donated by staff members.

Says Casey, "Last year I walked in the room and there were gifts floor to ceiling. It almost made me cry to see everyone really giving from their hearts to help everyone celebrate the holidays."

I asked our able photographer, Bruce Wahl, to nab an image for me, and you can see it above. But Bruce notes, "Tomorrow at 3pm is when THE picture will be. They are going to take everything (8+ carts full) down to the loading dock and put it on a truck."

I'll post an update after Bruce sends me that picture.

Utterli amazing

No, not the content of this interview from WBUR today, but the fact that I can present it to you in this way. Thanks to Ken George for his help in making this possible.

Day 6

A note from my ice-storm-victimized brother-in-law in Worcester:

Still feel like a refugee. Albeit a warm and almost dry one. Natl grid truck slept on our street last night. She reports primary wires to poles live and on ground. 4 neighbors w juice just lost their power. Replacement poles have to be hand carried more than 1000 ft thru woods up a very steep hill. Currently snowing and more freezing rain: 6-12 inches of white stuff due Friday. On the good side I now know the names of my neighbors 3 years after they moved in. Happy holidays.

Sent from my iPhone

Phew, that's over! Now what?

One of the most disturbing aspects of having major surgery is the feeling of lack of control and knowledge about what to expect. Our cardiac surgery team, led by Dr. Kamal Khabbaz, has put together a simple graphic display to help patients and families through this time. It has all kinds of information, plus the equivalent of a patient checklist of things to do, expect, and hope for after surgery. I present it above. (You have to imagine it as a folded document, with the little red guy on the front, the "Patient Cardiac Surgery Clinical Pathway" in the inside, and the "Frequently Asked Questions" on the back.)

Arm resistance

Electrical impedance myography (EIM) is a new method for assessing nerve and muscle problems that Seward Rutkove has been developing for the past 8 years at BIDMC. In this technique, a weak electrical current is passed through the skin and the muscle evaluated completely painlessly. Working with a team of engineers at MIT headed by Joel Dawson, PhD, Seward has created a first-ever handheld EIM device for rapid, clinical use (see photo). It is still very much in a “beta-version”state, but he is testing healthy subjects and people with various nerve injuries to help further refine it.

Here are the data that Seward and his research assistant, Michelle Fogerson, obtained on me a couple of weeks ago. I had an inflammatory nerve problem about 2 years ago that occurred after I had a flu shot that ended up causing problems mostly with my radial nerve (they call it brachial neuritis). Seward and Michelle studied a couple of muscles on both my arms, including one that was affected (my left finger extensor muscles). You can see how different the electrical impedance pattern is in my affected muscle as compared to the opposite side, but how similar the two other muscles were that weren’t affected (the wrist flexor muscles).

Seward is continuing to work on this exciting technique that he hopes will one day make it less necessary to perform needle electromyography, or EMG. (Those who have gone through that procedure will know what I mean when I say that it is one test that is worth avoiding.) If you have questions, you should email him at srutkove (at) bidmc (dot) harvard (dot) edu. (By the way, he is an MD in our Neurology Department.)

Neonatal inventor

Here is a wonderful story about MGH's Dr. Kris Olson. Read it and feel good.

And more here, too.

Pump Video, Part 2

Several months ago, I told you about how we were trying to solve the thorny problem of having the right pumps in the right place throughout the hospital. As I have talked with people in other hospitals, I find that this is a pretty pervasive problem around the country.

After a lot of work and research, the pumps committee has developed several solutions for ensuring nurses have a readily available supply of medication delivery pumps. A new flow has been pinpointed and storage space is being identified to house pumps on every floor and unit.

Coincidentally, new pumps are also being purchased for the organization. The goal is to have the new process and equipment in place by early 2009.

We have been documenting this process on video. Here's the latest update.

More seriously now

I have poked a little light-hearted fun at the SEIU's current corporate campaign against BIDMC, but there are those who feel strongly about this campaign and are deeply offended by it. In addition to our staff, it also includes patients of the hospital. One, Mike Scanlon, has written this blog posting on the topic. Mike had previously written me a personal note, and when I asked his permission to post excerpts here, leaving out his name he said, "Please feel free to use what ever part you would like. As for as leaving out my name or identifying information do not concern yourself. One of my complaints about this so called campaign is its anonymity, which I think is a coward's refuge. It would also please me very much for the hundreds of staff members who have literally kept me alive over the last 8 years to know that I am not afraid to testify to their skill and compassion."

Here are some excerpts from his blog:

The billboards I have seen cast aspersions on the hospital that I know to be false and inappropriate from my personal experience. After some exploration I discover that this is an attempt to unionize the hospital, but the advertising does not say anything obvious about that issue. Questions such as who it is that wants to unionize, what group they represent, what ills might result from the lack of unions, or what dialogue is taking place between the unions and the hospital administration are not raised by the advertising.

I can see no constructive agenda which approaches the issue of unionization, and as an observer on the street I don't even know who is making these accusations or why. Add to these facts that it is only the "Jewish" hospital that is being targeted and the only conclusion I can draw is that even if this group is trying to accomplish something valid it is playing subtly on age old prejudices about Jews and money rather than presenting their position in a cogent and fair manner. This is very destructive and insults the good intentions of labor as a movement in general- a movement deeply indebted to Jews, by the way.

Why does all this matter to me? Because I, Irish Christian that I am, have been a patient at Beth Israel for years.... I came down with AIDS in 2001, and at the time had Tufts Premium health insurance. By 2003 my partner, Aramis Valverde (AKA Mad Genius)- a cuban catholic- had been unable to work for many months, had not been able to keep up his health insurance, and we found ourselves in a terrifying position. We went to the Beth Israel emergency room hat in hand, and were welcomed, immediately cared for, admitted to the hospital (for the first of three times) and the staff at Beth Israel not only cared for him in a stellar fashion, but they also treated me- who at the time had no legal standing- with a degree of compassion and respect that was truly moving. There was no talk of money and payment, except in this respect, that the hospital's social workers went into high gear to negotiate with Masshealth and Medicare to find what funds they could on Aramis's behalf, but the care they gave him was never contingent upon these efforts- and their message to me was not to worry, whatever the circumstances my partner would have the highest quality care, even if it was at the hospital's expense, and I assure you he did.

In the year following Aramis's death I found myself in the same position.... The care I received as a "Free Care" patient was identical to what I had received as a Tufts Premium member, and once again, not only the care, but the respect and compassion that the staff of the hospital extended, and continues to extend to me is truly amazing, not least the social workers who deal with the byzantine of the health care system.

I have personalized this because unlike the folks running the "Eye on the BI campaign" I want you to know exactly what my agenda is. I am a sixty year old Christian who has nursed a partner through through death from AIDS and been saved from the same fate the Beth Israel Deaconess Medical Center over the last few years. I am angered by the "Eye on the B.I." campaign not just because they attack an institution to which I owe my life, but because they are doing it in an underhanded, destructive, and malicious way.

Don't forget to clean out the lint trap

My brother-in-law lives in Worcester, MA, and has been digging out of the ice storm that hit much of New England. He has spent the weekend clearing ice and snow, repairing damage to his house, removing tree limbs from his roof and around the yard (see above) and cutting them up with a chain saw, and arranging for his power lines to be reinstalled. It is exhausting work in very, very cold weather.

His house has no heat or electricity. Luckily, his parents have a nearby apartment, which is vacant while they are "snow birds" in Florida. He has been using it, enjoying the warmth and hot showers. And, of course, doing his laundry.

My wife called Florida to report about her brother's activities and to generate some sympathy for him. Their mother had one response, "Tell him: Don't forget to clean out the lint trap."

Fighting fire with fire

This is too funny! Thanks to @KenGeorge on Twitter for the lead.

Thanks for keeping the fares down

The SEIU continues to help the regional economy by purchasing advertisements for its EYE on BI campaign. Here's a picture I took with my cell phone yesterday of one next to the trolley line at Coolidge Corner.

For those tuning in late, what SEIU is up to, as I have explained in earlier posts, is to conduct a corporate campaign to try degrade the hospital's reputation in the community, in the hope of getting concessions in the union certification process. Meanwhile, it puts pressure on Mr. Obama to file changes in the National Labor Relations Act to eliminate the private voting rights of secret ballot elections.

Well, if in buying these local ads at "T" stations, SEIU is helping to reduce the deficit of our transit system, I guess we should all be grateful!

Changing lives, one at a time

The Chayet Scholarship Trust at BIDMC was set up by Donald Chayet in October 1983 in memory of his parents, for the purpose of providing assistance to any "employee who wishes to advance their skills in any way that will improve care at the Medical Center or advance medical knowledge." This is the Chayet Scholarship’s 25th year in existence. It has grown in size, and it has enabled hundreds of people to help attend school to enhance their personal and professional lives.

One the two dozen or so recipients today was Marie G. Bruno (shown here with Eleanor Chayet), who came to the US 20 years ago from Haiti. Here is an excerpt of some of her remarks:

I have been working as a Research Associate at the Genomic Core Center since October 2000. I've been able to grow and obtain a key role in helping by providing gene expression analysis to scientists and doctors for research, diagnoses, and treatments. My work has contributed to several scientific publications in major journals. I'm a single mother who is juggling work and school in order to maintain stable living conditions for my family. I am very honored to be the recipient of the 2008 Chayet Scholarship. Thank you very much to the Donald Chayet family for their generous support. I am exceptionally grateful. The scholarship will allow me to continue to pursue my career plan, which is obtaining a Bachelor of Science nursing degree. In June of 2009, I will be receiving a Biological Science degree at Roxbury Community College. Upon completion of my Associate at RCC, I will proceed for my BSN degree at U. Mass - Lowell. Because of the Chayet family's support, I will be able to start my undergraduate career as a junior.

I believe that U. Mass - Lowell will provide me with the best possible training to become a nurse. Upon my completion there, I will be working as a nurse that provides supportive care which will touch people's lives in unique ways, as the Chayet's family has touched my life at a time when I needed support. Wherever I go as a nurse, I will be very proud and honored to tell others about the Chayet family's wonderful support that had allowed me to reach my highest potential.

Achievement of this goal is very significant and is a critical step for me because it will enable me to be a more supportive parent to my daughter. Also, I will be the first person in my family ever to finish college.

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Thanks to Bruce Wahl for the photo.

Two proud dads

A grateful note I received from a new father, and then please read the reply from the chief of service, with whom I shared it:

I just wanted to take a moment to email you in praise of the experience my wife and I had on Monday when she gave birth to our first child. The nurse we had in Labor & Delivery at BIDMC was literally a godsend and responsible for how well things went. Our nurse, Patricia Higgins is a woman that we will never forget. It was unbelievable to see the commitment she made to us to help us through the process, how skilled she was, and to benefit from the amazing energy and positivity she kept up throughout what was a very long process. Of course, I expect nurses in Boston hospitals to be top notch, but Tricia stands apart as literally the best nurse I have ever seen regardless of the hospital or specialty. I understand she's been with the hospital for 28 years now, and seems to really love her work and where she works - and it shows.

My wife was committed to a natural child birth without the need for pain medication given a history of adverse reactions she's had to pain meds. Being in labor for 60 hours (about 1/3 of it in the hospital) without sleep or food made following this plan very difficult to say the least. Tricia was there every step of the way to the end resulting in our beautiful baby boy and a birth that followed my wife's hopes for limited intervention. There is no doubt in our minds that my wife would not only have had pain medication without Tricia's expertise, support and guidance, but she would likely have had a Caesarian birth due to her exhaustion.

I am struggling with the right words to say in praise of Tricia as I feel that whatever I write doesn't come anywhere near how we feel about her and the job she did for us. I hope you don't mind my sharing this with you.

---

Thank you so much for taking the time to send this note. Trish is one of those gems who make us very proud to be associated with her. I've worked with her for many years, and I'm continually impressed by the skill, professionalism, and humor with which she approaches her work.

Trish has impressive medical roots as her father, who passed away earlier this year, was the White House physician for JFK and LBJ. He was very proud of her and would have greatly appreciated your letter.

RWJF asks you to vote!

A note from David C. Colby, Vice-President, Research and Evaluation, at the Robert Wood Johnson Foundation:

Dear Paul,

One of my great pleasures as vice president of Research and Evaluation at RWJF has been to select a list of 10 influential research articles for our RWJF Year in Research. This year, we wanted to try something different. We are opening the selections to the world, although I’m still going to select my list.

The Foundation has nominated 25 articles from work that we funded that we believe had major policy impact, affected our work and thinking, or stood out in some other way. We are asking people to choose up to 10 of the articles. Voting ends December 23, and we will publish the final list in early January, along with my own list. As a health care thought leader, I would like to encourage you to vote and to spread the word among other leaders.

We opened the voting last Thursday, and are already approaching 1,000 voters across 46 states. We are hoping you’ll mention this initiative in your blog, and maybe even encourage people to vote.

By the way, you can now follow RWJF on Twitter!

Sincerely,

David

A day in the life of an intern

Well, not actually a day, but just a couple of hours. My old friend Jordana Goren was kind enough to let me shadow her today to see what life is like for an intern on our medicine service. You need to understand that this presents a major case of cognitive dissonance for me because my major interaction over the years with Jordana was as her soccer coach when she was a teenager.

Like many hospitals, we have a great training program here, and it was good to see it close-up and watch the interaction of this intern with her second year resident, her co-intern, her attending, the nurses, the housekeepers, an interpreter, and others. I could have stayed all day, except that it was just too much work . . . and I needed to get back to the easy pace of the executive office.

Anyway, here are some pictures showing Jordana figuring out which address to use in the vacuum tube system to send a blood sample to the lab; with the help of nurse Jennifer Donovan trying to find an artery take a sample for repeat blood gas test after the first sample had clotted; moving a patient up to the ICU; and preparing for rounds with her attending Stephanie Mueller; Daniel Meyer, her second year resident; and co-intern Deborah Leong.

Also, for the sake of total embarrassment, a picture with some soccer teammates from 10 years ago.

IHI Session for CEOs and Trustees

Many thanks to Tony Chen for inviting me to write a guest column over at Hospital Impact about a session Paul Wiles, left, CEO of Novant Health in Winston-Salem, NC; and Greg Kutcher, right, CEO of Immanuel St. Joseph's Hospital in Mankato, MN; and I held at the IHI National Forum in Nashville. Jim Reinertsen ably handled the master of ceremonies job. The point of the entire session was to emphasize that final accountability for the quality and safety of patient care in a hospital lies with the CEO, with important backing from the Board of Trustees.

Sprinting to Safety?

It was also a pleasure to see and hear from Atul Gawande at the IHI National Forum. It was a bit ironic to do so Nashville in that Atul practices roughly 500 yards from my office, at our sister institution, Brigham and Women’s Hospital. (Sometimes you have to travel far to see someone close to you.) He is deservedly widely read on quality and safety issues and is very well spoken on these topics.

Atul has been working with many people and hospitals to design and implement the WHO Surgical Safety Checklist. The checklist has a number of simple steps that should take place during the sign-in, time out, and sign-out phases of a surgical procedure. While there will soon be published formal documentation on the efficacy of this checklist in reducing harm during surgery, it was clear from Atul’s presentation that its use really makes a difference.

Noting that it usually takes about 17 years for an advance in medical treatment to reach the general public in a pervasive way, Atul and Don Berwick proposed a new approach to the diffusion of the Checklist. Terming it a “remarkable social experiment,” they challenged the audience and those not in attendance to engage in The Sprint. The idea is to try to get thousands of hospitals to actually adopt the Checklist in one or more ORs within the next 90 days.

I think this is a great idea. We recently adopted this kind of checklist procedure in our ORs -- as a direct result of a wrong-side surgery in our hospital and as a consequence of our broad-based transparency about that error. The procedure takes only 90 seconds to carry out.

As someone said today, there are two types of hospitals, the kind that have had a wrong-side surgery and the kind that will have one. A Joint Commission staff member told us recently that there are six wrong-side surgeries per day in the United States. This would be a good thing to change. Atul and his colleagues have provided the tool. Let’s grab the baton and sprint with it.

Nashville reunion

It was great to see many friends and allies in patient quality and safety at the IHI National Forum. Here are three: Gary Kaplan from Virgina Mason in Seattle; Brent James from Intermountain Health in Utah; and Jim Reinertsen from IHI.

Here's who's following and how

It has been just over a week since I joined Twitter, and I noticed that there are already over 250 people following me. I didn't understand how that happened so quickly, so I posted the following query:

Who are all these people following me? Curious. Pls send a note how you found me.

The answers are a fascinating display of the spider web of filaments that is represented by social media. Here's a sample:

Not sure! When I passed on something from your blog to @healthblawg (David Harlow), I think I ran your name through an index.

Hi! I'm a Social Work Intern @ BIDMC in the CVPR. Barbara Sarnoff talks abt your blog so I checked it out!

Hi Paul, Ralf Lippold mentioned on www.xing.com that you are also on twitter.

I've followed your blog for over a year now, share it with my top management as best example of CEO blogging.

I'm an administrative fellow & your blog has been quite helpful to me. Here's mine: http://blog.michaelmillerjr.

I'm a regular reader of your blog (keep it up - great stuff). When you said you were on twitter . . . of course I'd follow!

Twitter from yr blog. Blog I forget, but close to first post.

I picked up your twitter from your blog.

I'm a healthcare reporter writing an article about twitter. I'm curious how twitter complements your blog. Is it useful?

I work in healthcare IT, your blog is in the healthcare bundle in the new google reader update http://bit.ly/oEbw.

Via dmscott. I'm an interactive creative director we do creative for health care marketing. http://www.prestonkelly.com/#HOME-99

I work at Microsoft and my customers are mostly healthcare providers; I follow leaders in this space to know whats on their minds.

I found you reading about HealthCare IT Standards; been reading your CIOs geekdoctor blog several months! Love the transparency!

Hi Paul, found you here. Looking forward to your perspective on things. (I work in a lg hospital in NJ)

I found you because I follow @kevinmd, @doctoranonymous, etc; I'm chronically ill & have chat for chronically ill.

I found you via @dmscott. I found your blog a year or so ago by accident.

Nashville cats

Just returning from a visit to Nashville to attend the IHI annual National Forum. Several folks from our hospital attended this very informative event. Among them was our CIO, John Halamka, who offers a summary of Don Berwick's keynote address on his blog. John himself was asked to tape an interview on the topic of integration of information systems to enhance safety and quality in clinical settings. Here's a picture of him during the interview.

Holding the match

Back on November 23 and also earlier, I wrote about the political dilemma facing the new administration in Washington concerning how hard the new President should push for the so-called Employee Free Choice Act given the controversy that bill will engender.

The issue is exemplified again in a Steve Early op-ed this past weekend, entitled "Unions to Obama: Don't Abandon Us." Those strongly in favor of EFCA are trying to put pressure on the President even before his term of office begins. Chances are they are coordinating their efforts in articles like Mr. Early's and in other ways. Meanwhile, opponents are likewise trying to flex their political influence on this topic and have their point of view heard.

As many have noted, this is a tough call for a President-elect who made EFCA part of his platform and received hundreds of millions of dollars in union support during the election, plus the efforts of thousands of union members on the streets and at the polls. It is a tough call because secret ballot elections are a pillar of the American system, and it is hard to explain to the general public why you would want to eliminate them in the case of certifying unions. The election of Mr. Obama himself provides the most superb example of the power and wisdom of secret ballots. The last thing Mr. Obama needs is a divisive issue while he attempts to gain a consensus on other, more critical pieces of legislation.

This is one of the most interesting political dramas we will watch for the new administration. The next flash point will be when Mr. Obama designates his Secretary of Labor. At the press conference, there will be the question: "Mr. President-elect, will EFCA be your priority and that of your newly designated Secretary in your first 100 days?" His answer could light a tinderbox.

And you think I push the limits?

An interview by Dr. Val with Dr. Michael Shabot, Memorial Hermann Hospital System’s Chief Medical Officer. Bottom line: "If a hospital won’t reveal their quality and safety statistics, then I think patients should ask their doctor to admit them somewhere else."

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.

Short enough to fit in a Twitter update

Some thoughts after reading this article about the value of social media in the health care field. The first is from Lisa Pollack, Denterlein Worldwide, Boston. The second is mine.

Regarding use of social media for marketing: "Trust is the goal, so that you will be a brand that people will yammer about in their social networks."

Regarding use of social media to deal with an organization's problems or perhaps a short-term crisis, as below: "Asynchronous communication in service of meeting a temporal need."

"Not to the point of chaos"

A story about about institutional use of social media.

I am on the board of an organization that, like many others, is facing financial stresses. The president decided to create some task forces to deal with various sectors of the company and look for savings and other solutions. I suggested that he might use wikis, blogs, and other types of social media to permit a rapid and comprehensive exchange of ideas and information between and among the task force members and other constituencies in the organization. I also suggested that this might help with acceptance and implementation of the plans once they are ready.

The response, "Well, broad participation is fine, but not to the point of chaos."

My rejoinder, "You need to trust the wisdom of the crowd."

MedRec in the ED

Another poster presentation for the IHI National Forum in Nashville, this one about automated medication reconciliation in the emergency department. Jason Laviolette from our Health Care Quality group will be on hand to explain things.

Going to TN? Stay awake for this!

Two of our folks, Sue Dorion and Mary Grzybinski (surrounding Dr. Eswar Sundar, the handsome guy in the middle) are presenting this week at the IHI National Forum in Nashville on an important topic, a perioperative protocol for dealing with patients with obstructive sleep apnea ("OSA"). The poster for their session is shown above. My clinical friends tell me the following:

OSA affects anywhere between 6 to 13% of the population. During hospitalizations it is associated with increased rates of complications like respiratory failure, arrhythmias and death. In 2008, the Joint Commission considered screening and managing OSA as one of their patient safety goals but did not pursue it at that time. The American Society of Anesthesiologists (ASA) recently published guidelines for its management. We at BIDMC are ahead of the curve on this as one of a handful of hospitals in the country that have developed a comprehensive screening and management program for this important public health problem. BIDMC is probably one of the safest hospitals for a OSA patient or a high risk patient to come and have surgery as a result of this comprehensive pathway.

The perioperative OSA protocol is the culmination of many hours of work and many contributions from Anesthesia, Sliverman Institute for Healthcare Quality, Sleep Medicine, Nursing, Surgery, OB/GYN, Respiratory, Case Management, Information Systems, and many many more disciplines. This is truly multidisciplinary!

Here are some details: Patients get screened in the Pre Anesthetic Testing Clinic (PAT) and at the holding area. Our Information Systems folks developed an electronic screening tool as part of our PIMS. We have screened more than 10,000 patients since May 28, 2008, when we went live. OSA status stays on the OMR and POE and gets prominently displayed. Screen positive patients get a yellow sticker, known OSA patients get a blue one on their chart. Anesthesia is alerted and intraoperative management is suitably altered.

In the PACU, all known OSA patients get either Continuous Positive Airway Pressure (CPAP) treatment or Bilevel Positive Airway Pressure (BIPAP) treatment. Patients who had screened positive undergo a indigenously developed "Sleep Trial" and those who fail the "Sleep Trial" get CPAP or BIPAP ttreatment. Newly developed POE screens greatly simplify the process of ordering CPAP or BIPAP treatment in the PACU.

Once they reach the floor, all known OSA patients and those patients who had screened "High Risk" will get continuous pulse oximetry and other enhanced monitoring/nursing. "High Risk" Patients who pass the PACU "Sleep Trial" will get standard monitoring, thus optimally utilizing our resources. All newly discovered "High Risk Patients" get a fact sheet informing them about OSA. Their PCP also gets a letter and requests them to make an appointment with the sleep clinic for further evaluation.

Transportive singing

A lovely story by Eduardo A. de Oliveira at EthnicNewz about one of our favorite people.

Connect to WBUR

I am reminded on Twitter (@WBUR) that WBUR is holding its December pledge drive. This is a great public radio station that warrants our support. Its news coverage and features are top rate. Please go here to pledge.

EthnicNewz

I've been meaning to write about this for months. Check out the New England Ethnic Newswire, out of the U. Mass - Boston Center on Media and Society . It is a great place to catch up on things often not covered in the mainstream media, particularly as they relate to the melting pot of ethnic groups in the metropolitan area.

My 94 year old mother was in your hospital

A letter sent by a friend to the CEO of a hospital outside of Boston. While this was not here at BIDMC or at a place where you might work, let's all look at each of her complaints and answer honestly: "Could this have happened at my place? What will I do to make sure it doesn't?"

I feel you need to know about some significant problems I experienced at your hospital. My ninety-four year old mother was a patient there from Nov 28th through Dec 4th, having fallen and broken her leg. Beginning with the nine hours she spent largely unattended by anyone but me in the emergency room and ending with her discharge a week later, the one constant was a lack of any useful communication, particularly given her age and degree of memory loss.

She was logged in to the emergency room an 2:00 in the afternoon on the 28th and finally given a room at 11:00 that evening. During that time she was in a great deal of pain, left without food or drink (in case she was going to be scheduled for surgery, even though it was clear hours earlier that no orthopedic surgeon was going to be available … she had the surgery late Monday afternoon), and although she is incontinent, not given any help or comfort until I intervened.

During her stay, I never heard from her own physician, and when I called him the day she was discharged, he told me that he had never been informed by the hospital that she had been admitted. He told me that he had recently received a letter saying that because he uses a hospitalist there, he no longer had hospital privileges. This may well be a useful policy for streamlining patient care (although my experience does not bear that out), but it needs to be shared with the patient’s family. I assumed, incorrectly, that her doctor had been called and his advice solicited.

I neither met, nor heard from the hospitalist, so I can only guess that he or she exists. The only calls I received from physicians were “witnessed” pro forma calls asking for consent for surgery and anesthesia. If the hospitalist policy precludes keeping family physicians informed, then some form of organized communication with the responsible family member needs to be instituted, particularly when the patient is elderly and mentally impaired. Her own family doctor could have given useful information on her medical history and mental state. The staff seemed generally unaware of her memory loss, her impaired hearing, and that the pain medications were causing her to hallucinate.

It was, all in all, a depressing, disorganized, and generally disillusioning experience. I will be happy to provide any further details about her hospital experience that might help you find ways to remedy these breakdowns in communication.

I look forward to hearing from you.

First snow

First snowfall of the year in Boston today. Reminds me of a time many years ago. Our daughter, then aged 22 months, who had spent many happy hours baking with her mom, woke up one morning when it had snowed during the night. She looked out the window at the snow-covered neighborhood and exclaimed, "Flour!"

Banking with Aetna

This was announced back in April and was covered by the WSJ Health Blog, but I am just now getting around to it, as its effective date is January 1. The deal is that Bank of America hired Aetna to manage all of its employee benefits for 200,000 staff members nationwide. Of course, it covered the administration of the health care insurance function, but it also includes a concierge service for health coaching, on-line risk assessments, and integrated data management to monitor trends and deliver better preventative and chronic care.

But check this out, "Besides the white-glove service, Aetna has pledged to meet targets for paying claims accurately and controlling medical costs. Otherwise, the insurer will have to pay penalties to Bank of America."

I don't know if any other businesses have since signed up with Aetna. And I don't know if other insurers offer similar services or have secured deals with other large employers; but if I were running a smaller insurance company in a region characterized by nationally based employers, I would be nervous.

And an open question for Aetna and Bank of America, do you monitor the actual quality and safety of care delivered by providers in each city to help steer employees to the ones with better documented results?

Top Docs in Boston

A musician friend says that concert reviews don't mean anything, but it's still nice to get a good one.

Each year Boston Magazine has a story listing the city's top doctors. I hesitate to comment on the methodology they use -- especially in light of my advocacy of more objective metrics -- but I know they are absolutely correct when they list one of our doctors! I only regret they didn't survey me so I could have recommended the other 700+ who work in our hospital.

Here are the people at BIDMC who were designated this week:

Allergy and Inflammation: Javed Sheikh

CardioVascular Institute: Mark Josephson; Warren J. Manning; Roger Laham

Cancer: Michael Atkins; Glenn J. Bubley; Steven Come; Lowell Schnipper; Marc B. Garnick; Bruce Dezube; Jerome Groopman

Dermatology: Jeffrey Dover

Endocrinology/Diabetes: Martin Abrahamson; Richard Beaser; Alan Jacobson (primary affiliation is Joslin); Barbara Kahn

Gastroenterology: Adam Cheifetz

Gerontology: Lewis Lipsitz

Neurology: Louis Caplan; Daniel Tarsy

Neuroradiology: David Hackney

Ophthalmology: Peter A. D. Rubin

Orthopedics: Mark Gebhardt

Pathology: James Connolly; Stuart Schnitt

Pulmonology: Armin Ernst

Radiation Oncology: Irving Kaplan; Abram Recht

Rheumatology: George Tsokos

Sports Medicine: Lyle Micheli (primary affiliation is Children’s)

Colon and Rectal Surgery: Deborah A. Nagle

Cardiac Surgery: Frank Sellke

Plastic Surgery: Sumner Slavin

Thoracic Surgery: Malcolm DeCamp;

Urological Surgery: Abraham Morgentaler; Martin Sanda.

Relentless determination

I recently saw a note from a person I respect very much that set forth an important and interesting point of view:

Measuring quality in health care is an imperfect process. We can collect and measure such factors as compliance rates, trends, outcomes, complications and adherence to protocols, all of which are important in helping us improve care and safety of patients. And our tools and our understanding of what constitutes meaningful quality and safety measures are constantly improving. But at the same time, there are very important aspects of quality that cannot currently be quantified. For example, we have no yardsticks for technical expertise, critical thinking, fund of knowledge, keen judgment, passion, compassion, talent, profound curiosity or relentless determination to do best by each patient.

This is beautifully written and it is hard to disagree with. It reminds us that all is not measurable and that we must cherish and respect the humanity of doctors, nurses, and others who have devoted their lives to eliminating human suffering caused by disease. It captures, too, the discontent felt by many in the medical profession, particularly those who were trained years ago and who practiced for many years in a very different environment.

I believe that the discontent arises from the fact that those served by the health care establishment, those paying for it, and those supervising it are now demanding more accountability from the professions engaged in it. Those groups, too, have figured out that, for decades, those in the medical professions have ignored many important aspects of the science of care delivery. The subject gets short shrift in medical schools, in residency training programs, in academic journals, and in the administration of hospitals.

We have learned from studying other industries that have engaged in and achieved process improvement that such improvement requires an approach to the organization of work that is very different from that seen in most hospitals. But it also requires measurement and transparency. While even the best calculations and data don't tell all, they do tell a lot, and they are the only way we have for an organization to hold itself accountable.

But those in the medical profession sometimes fall into the trap of believing that because measurement is an inherently reductionist and mechanistic act, it can never be sufficiently accurate to reflect the overall realities of patient care. The paradox is that without it, we can inadvertently fall into the trap of self-congratulatory statements about our good intentions. Only with it can we demonstrate that we actually have a "relentless determination to do best by each patient."

I have spent innumerable pages on this blog discussing these points and giving examples from BIDMC in the hope of sharing our experiences for the benefit of all. As you have seen, I gratefully borrow from concepts that Berwick, Batalden, Spear, Conway, James and many others have been espousing for many years. We at BIDMC have devoted ourselves to implementation of these concepts, and yet we consider ourselves infants along the path of learning to walk. But we believe that this is an essential part of the mission of an academic medical center during an era in which the public is demanding greater accountability from the medical profession.

Short story: Good news

While you can go to our website to follow our overall progress on eliminating central line infections in our ICUs, here's something more: Although we have frequently had months where there were no hospital-acquired central line-associated bloodstream infections in our ICUs, October was the first month ever in which we had no such infections in the ICUs or in any other unit.

I want to extend thanks and appreciation to those who do the work and deserve the credit: Lots of nurses everywhere, MDs, PEVAs, our IV team, radiology, and others who place and care for the lines.

To help those who cannot hear

I have written below about our wonderful interpeters, who offer assistance to patients who do not speak in English. As part of this program, we also offer American Sign Language (ASL) interpeters for the deaf and hard of hearing.

Now, comes a new wrinkle, arriving in the next few weeks. Here's the explanation provided to me by one of the folks in our interpreter group:

BIDMC will soon have its own public videophone in the Shapiro Lobby (our main ambulatory care building) for use by deaf and hard of hearing patients and their families. Videophones, which can now be found in the homes and offices of most deaf people, consist of a regular television and a video conferencing unit with a high-speed internet connection. With this set-up, deaf people can make and receive "phone calls" and speak in their first language, ASL, by connecting with other people who have the same device. This allows deaf people to converse in ASL. Since English is a second language for most deaf people, this a tremendous improvement.

Deaf people can also use the Video Relay Service by using the same videophone, like the one we'll have in our lobby, to connect with a call center staffed by professional ASL interpreters. This means that deaf people can call any hearing person who has a standard phone; the interpreter sees the deaf person and interprets his or her message from ASL into spoken English. (See image above). The interpreter, who is connected on a standard phone line with the hearing person, can interpret the reply from spoken English back to ASL. Conversations are more natural this way and there are even interpreters available to interpret from ASL to spoken Spanish.

To the best of our knowledge, BIDMC's public videophone will be one of the first of its kind available in a public hospital lobby in the Northeast. The Shapiro Lobby public videophone will give equal access to the deaf community to make phone calls while they are in the medical center.

This time, it's about us!

A message I just sent out to people in our hospital. Thanks to Paul O'Neill, former CEO of Alcoa, for his advice and inspiration on this front. If this can be done in a mining and manufacturing environment, we surely should be able to do it in a hospital.

Dear BIDMC,

We have now been engaged in BIDMC SPIRIT for over six months, and we have accomplished a lot. But, we have also learned a lot about how to make it work better. I’ll talk about that below, but first this.

When I first introduced SPIRIT to you, I emphasized how we wanted to reduce hunting and fetching and improve the work environment in that way.

Now, we need a new focus.

It’s time to crank things up, but in a new direction.

Last year, there were 891 on-the-job injuries of BIDMC staff members – more than two a day! Almost one hundred of our colleagues were injured to the extent that they were unable to work for five or more work days.

You probably know that we have set ourselves a goal of eliminating preventable harm to our patients. It is time to do the same for us!

I have told our vice presidents that I personally want to receive a report of every employee injury in the hospital within 48 hours of its occurrence. I want a description of the injury, what caused it, and what we are going to do to help avoid that kind of injury in the future. Over time, we will uncover patterns and trends and make this a safer place to work.

We will soon have a running total of staff injuries on our portal. We will have a graphic showing how long it has been since the last injury. Right now, that is measured in hours. We’d like to change the interval to days, weeks, and eventually months. Whether slips and falls, exposures to blood and body fluids, injuries from patient handling, our goal is to drive the number of cases down to zero.

I need your help, though. There is something you can do right now to help jumpstart our safety efforts: Do a SPIRIT call-out.

1. Identify safety hazards or near misses you have experienced or look around your work place to identify potential harm.
2. Call out the problem to your manager/shift leader.
3. Work together to identify the root cause of the problem immediately and solve it as soon as possible.
4. If you and your manager can’t solve it locally, your manager can use the Help Chain to reach beyond your unit/department.

Remember: Call-outs that point to a bigger, medical center-wide problem will go up the Help Chain to the leaders of BIDMC.

SPIRIT Update
We have seen some incredible successes with SPIRIT, but we have also learned from you comments and suggestions that there were some problems with our initial approach. Through it all, we have confirmed that the basic principle of SPIRIT is strong – the people closest to the work are the best problem-solvers.

Your feedback told us:
• There is uncertainty about what to use SPIRIT for – hunting and fetching? Patient care problems only? Big problems? Little problems?
• It was unclear when to do a call-out instead of a regular operational response to a problem, like calling Service Response.
• Using the SPIRIT log was frustrating and it was unclear whom on the help chain to contact. Entries were often made – sometimes anonymously – without a constructive way to act on them.
• There is confusion about how SPIRIT, Lean and other quality improvement efforts are related. The short answer is that they are all different ways of solving problems and improving quality – SPIRIT through staff call-outs; Lean through a trained team of specialists that works side-by-side with staff; and Healthcare Quality and other staff through a wide range of activities, from incident reporting to Joint Commission preparation.
• You need more resources to understand and use the SPIRIT principles – and more practice.

When we started SPIRIT, we expected that our first try would probably need some improvement. We fully intended to improve SPIRIT itself over time, just as we are trying to improve our work environment.

So here's what will change:
• As noted above, the second year of SPIRIT is beginning with a focus on a specific topic – safety in the work place.
• We will more actively use our formal patient and staff incident reporting systems to identify problems.
• More training and coaching through actual problem solving efforts – for all staff, managers and physicians – in person and through easier access to materials and tools.

Here’s what will remain:
• Those of you who are engaged and using SPIRIT principles are encouraged to keep it up and let us know about your work.
• We will continue to share with you stories about how SPIRIT, Lean and quality improvement projects are working.

Sincerely,

Paul

Lessons from (Open) School

The Institute for Healthcare Improvement has a wonderful adjunct to their in-service training courses, a section on their website called "IHI Open School." Here, people participate in discussion threads about interesting cases in hospital management. One of the threads is, "The wrong-site surgery at Beth Israel Deaconess Medical Center," based on how we handled our "never" event back in July.

I have enjoyed reading the back-and-forth on this website. Recently, there was comment that was so honest and revealing that I made note of it, and I want to share it with you here:

While this was an unfortunate incident that resulted in a life changing outcome for the patient, it did provide an opportunity for Beth Israel to improve on their time out process. As a nurse, I can relate to the guilt that the surgeon felt when he realized his mistake.

During my early career as a nurse I administered the "right" medications to the "wrong" patient. I retrieved the medications from the pyxis and cross referenced them against the patient's medication administration record. I then left the MAR in the nurses station and went into the patient's room. I called the patient by the name of the patient's medication that I had retrieved from the pyxis. He replied to me and did not dispute the fact that I called him by the wrong name. After I administered the meds and walked out of the room I immediately knew that I'd made a mistake. While it was difficult to call the doctor and admit to my mistake I felt better about the situation because I was not punished and given a verbal lashing. Instead the doctor reassured me that everyone makes mistakes. He told me the signs and symptoms to monitor for and then gave me call orders in the event of complications.

Admitting that you've made a mistake requires alot of courage. Denying and defending your mistakes, however, is a dangerous approach. Especially as it relates to a patient's life. As a result of my error and my admission of the error our hospital designed a better process for identifying and verifying patient identity prior to medication administration. If these mistakes had not been made, reported, and then investigated, we would have continued operating by a flawed system that we "thought" was efficient.

Great progress to the west

OK, so not really that far west, but in Northampton, MA, at Cooley Dickinson Hospital. The press release follows. Congratulations to the entire group for a job well done!

NORTHAMPTON, Mass – It’s been one year and 28 days since a Cooley Dickinson Hospital ICU patient has become sick with ventilator-associated pneumonia, a serious infection that can occur in people who rely on ventilator machines to breathe.

“As of Nov. 29, that’s 393 days since the last ventilator-associated pneumonia infection,” Daniel J. Barrieau, director of respiratory care services says of an infection that in October topped a list of the most costly and common hospital-acquired infections.

According to the Centers for Disease Control’s National Healthcare Safety Network Report, Cooley Dickinson’s accomplishment of preventing Ventilator-Associated Pneumonia or VAP ranks the hospital’s performance in the top 10 percent of the nation’s medical/surgical intensive care units (ICUs).

VAP can occur in patients who, because of severity of illness or condition, require mechanical ventilation. When the ventilator tube that pumps life-saving air into vulnerable lungs becomes contaminated, the tube can act as a pathway for bacteria or secretions to enter the respiratory tract, paving the way for VAP. According to the Institute for Healthcare Improvement’s (IHI) website, VAP typically “afflicts up to 15 percent of those in ICUs so weakened by illness or trauma that they need mechanical help to breathe.”

Physicians and staff at Cooley Dickinson are working to eliminate VAP and have adopted a zero-VAP philosophy. Says Barrieau, “We are being aggressive about eliminating VAP, and our track record demonstrates our commitment to delivering the highest possible care to our patients.”

This aggressive approach is paying off. Barrieau says VAP infections in Cooley Dickinson’s intensive care unit have gone from 5 in 2007 to zero as of Nov. 29.

“Besides searching for clinical solutions to the VAP problem, we asked ourselves, ‘what could we change about our culture and our systems to improve our outcomes?’” says Barrieau.

This culture change began in 2005 when team of respiratory therapists, physicians, nurses, quality improvement staff and infection prevention specialists adopted a set of instructions from the Institute for Healthcare Improvement known as the IHI ventilator bundle. The IHI bundle offers a series of interventions determined to be the best evidence-based practices related to reducing the risk of VAP to patients.

Then, Barrieau explains, staff began to “push beyond the bundle of strategies to look for other ways to reduce the risk to patients and eliminate VAP altogether.”

They scrutinized the VAP cases to identify patterns and trends. For example, their analysis indicated that patients on ventilators for more than 19 days, those with difficult intubations and those who required transportation within the hospital were the most vulnerable.

Using an approach called clinical Microsystems, where front-line teams are empowered to make improvement decisions based on scientific data and best practices the team evaluated how each clinician relates their daily work and actions to VAP.

“Doing the minimum is not enough to achieve our zero-VAP philosophy,” states Barrieau. He says clinicians in a culture of zero VAP understand how their actions matter and that acting to reduce risk is part of the clinician’s standard practice.

In addition to preventing VAP infections in patients and providing best-practice care, there is a significant cost savings to the hospital. In 2007, based on Cooley Dickinson’s VAP prevention measures, the organization saved $200,000 by reducing or eliminating the occurrence of the infection and reducing the patient’s length of stay in the intensive care unit.

In 2006, the Institute for Healthcare Improvement named Cooley Dickinson a mentor hospital in three clinical areas including VAP. Since then, Barrieau and his colleagues have presented Cooley Dickinson’s VAP elimination strategies at professional conferences, and he has served on the Mass. Department of Public Health’s Healthcare Associated Infection Task Force.

In December 2007, Cooley Dickinson was one of three hospitals in Massachusetts to receive the Betsy Lehman Patient Safety Award for the organization’s work to eliminate hospital-associated infections including VAP.

In October 2008, Cooley Dickinson was featured in the Joint Commission Journal on Quality on Patient Safety and lauded for breaking new ground in quality improvement.

The five healthcare groups that contributed to the guide include the Healthcare Infection Control Practices Advisory Committee (HICPAC), the Society for Healthcare Epidemiology of American (SHEA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology, Inc. (APIC) and The Joint Commission.

Tipping point?

One of the nation's most thoughtful and foremost patient advocates, noticing that I had perfected the challenges of Twitter, wrote me and said,

How about a challenge that's CEO sized...

Get all other health care execs in your region to be as transparent...

I found it hard to reply in meaningful way to this offer. I already feel a bit like the beaver that has been chewing the tree in this picture. It is hard to imagine what more we could do at BIDMC to push the transparency agenda. And it is so clear that it has tangible benefits for the quality and safety of patient care. So, I feel like we have been nibbling away at this issue for quite some time, but the tipping point remains an indeterminate distance away. And, with regard to this challenge, I think that the next steps have to take place elsewhere.

Perhaps the resistance comes from those who misconstrue that this is all about competition. As I have noted, it is not.

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.

But I am starting to think that, within a short time, we might back into the competitive issues because a lack of transparency might hurt the reputation of some hospitals. Maybe that will show up as a result of a contrast with BIDMC when specific events occur. For example, if there is a wrong-side surgery in a hospital, and folks there try to downplay it instead of admitting it and learning from it, there will be an inevitable comparison made with the way we handled that kind of event.

I truly hope that things don't work that way. I hope instead that Boston becomes known as the place in which all major providers, supported and encouraged by the insurers and the state government, engage in the real-time public presentation of clinical results in those areas that are medically significant and reasonably good candidates for process improvement.

Follow me @Paulflevy

When you have an addictive personality (any doubts, check my blogging record here), you have to be careful what you start.

I figured, though, that I could trust Scott Hensley, one of the guys who runs the Wall Street Journal Health Blog. He strongly suggested that I sign up for Twitter, noting that their blog appears there.

Oh, it was all too easy to slip into this. After all, I already had a Facebook account and was used to the idea of that kind of social media interaction.

Sure enough, after just two days of updates (42), attracting followers (60), following others (35), Hensley writes: "You're on fire! Good stuff."

But it was too late that I learned. As noted in an early update to me, Bob Coffield, who writes the Health Care Law blog, "Facebook was the gateway drug that led me to the crack that is twitter."

And, then to add insult to injury, Dr. Val, author of Getting Better with Dr. Val, reminded me that I had said, on a blog radio interview with Dr. Anonymous last April, that I would never sign up for Twitter.

And, since this "dialogue" is splayed out for all to see, Ramona Bates, author of Suture for A Living, wisely commented, "Things change. Times change. Circumstances change. Best to never say never."

Dr. A himself replied, "I admit I didn't get twitter at first as well. But, things change. We're glad you're here!"

Of course, he's glad I'm there. Addicts crave company of like-"minded" people.

So, now, like any self-respecting addict, I want my friends to join me, too.

Start here and follow the all-too-easy instructions. As an extra incentive, this blog is now automatically fed to Twitter.

Warning. One friend writes plaintively on her first update: "Trying to understand Twitter."

To which Yoda offers the eternal advice: "Do, or do not. There is no try."

"The most important part of my job"

I know I have overloaded you a bit with end-of-life issues, but I want to share two articles on the subject. The first is a very nice post by Bob Wachter, entitled My Patients Are Dying... And I've Never Been Prouder.

The second is an article written by BIDMC's Dr. Richard A. Parker. It is in the Annals of Internal Medicine, Volume 136, Number 1, 1 January 2002. I include excerpts from the introduction and the conclusions here, which are elegantly stated.

Introduction
Quality end of life care benefits patients, families, and physicians. Fear of abandonment, indignity, pain, discomfort, and the unknown trouble most of us when we contemplate dying and death. In my primary care practice at an urban teaching hospital, I have cared for 95 patients who have died over the past 12 years. I believe that relationships among the patient, doctor and family built over time usually allow a “good death,” and almost always prevent unwarranted resuscitation, futile interventions, and unnecessary suffering. I now view the end of life not as failure for either patient or doctor, but as a valuable opportunity for growth, insight, and closure.

Death is the bookend experience to birth, yet we are far from our agrarian roots, where the cycle of birth and death was a normal part of daily life. Our society celebrates and worships birth but flees death as if it were avoidable. And the only person empowered to directly assist in navigating life’s end, the physician, with skill and caring, must bring meaning and solace to patients and families as death looms.

Conclusions
Daily, physicians strive to comfort, diagnose, treat, cure, and extend life with quality. Yet we must recognize when to shift to palliative care. Patients expect, hope, and trust that their doctors are versed in dealing with end of life issues, but physicians need to learn and practice these skills. How ironic that doctors rarely, if ever, talk about dying amongst ourselves even though are patients expect to be experts in such care.

Keeping a record of all my patients who have died has helped me honor their memory and reminds me of the lessons they have taught me. Collecting such a history also sheds light on issues deserving improvement, such as instituting a home visit near the end of life. Regardless of the inexorable march of technology, birth and death will continue to bound our existence. Our society awards to physicians the authority and privilege of caring for people at the end of life. I have learned that caring for patients in the last chapter of their lives is the most important part of my job.