A benign infection

We are honored to host Dan Jones, Chairman of the Lean Enterprise Academy in the UK, to be our Judith and Robert Melzer Visiting Professor in Health Care Quality and Patient Safety. He will spend a full day at BIDMC addressing Board members, conducting grand rounds, going to gemba and out-briefing with residents and others. You see him here with the Melzer's.

Dan and his US counterpart, Jim Womack at the Lean Enterprise Institute, are the instigators of a group called the Lean Global Network. This comprises sixteen organizations around the world that are promoting Lean thinking and leadership and helping organizations with their Lean transformations.

Dan had a great description for how Lean becomes a force in those organizations that carefully plan and design its implementation: "A benign infection for which there is no antidote."

Intelligent design?

My friends and I just didn't get it. We entered 1 Federal Street in Boston and found this very odd elevator system. You have to punch in the number of the floor to which you want to go on the outside of the elevator. Once you are inside, it takes you there. There is no inside panel of floor buttons. So, what if you made a mistake or want to change your mind after the doors have closed?

New blog feature coming soon

I am presenting a new feature on this blog on Monday, November 2. I hope you enjoy it, but I am also seeking your involvement now.

Some friends of mine are involved in a new company called BiddingforGood. What EBay brings to the world of auctions in general, B4G brings to the world of charity auctions. It is a consolidator, facilitator, and operator of on-line auctions for charitable causes and organizations.

With the help of B4G and some of the BIDMC staff, I will be holding an on-line auction each month to benefit one of the BIDMC's affiliated community health centers or another health care-related cause. You will have a chance to bid on neat items, knowing that the proceeds go to a worthwhile purpose.

The first auction will benefit BIDMC's owned Bowdoin Street Health Center, a wonderful place providing primary care, specialty care, and many support functions to a section of Dorchester in Boston.

Bowdoin Street Health Center was founded in the Bowdoin/Geneva neighborhood of Dorchester in 1972 by community residents to provide affordable, accessible primary care and public health services. The Bowdoin/Geneva community is a widely diverse population. 43% of the patients served at the health center are African American or Caribbean Islanders and 38% are Cape Verdean, while Latino, Vietnamese, Haitian and Caucasian populations make up the remaining base. The health center has experienced continued growth over the past 36 years, leading to several relocations to larger facilities. The current building opened in 1997, and we now care for more than 10,000 patients through 45,000 visits across a wide spectrum of care. Bowdoin Street also has a long history of working in partnership with residents, businesses and organizations on identified issues of importance to the community. A staff of 70+ employees makes Bowdoin Street the largest employer in the Bowdoin/Geneva area.

Specifically, I am trying to raise money to purchase an ultrasound machine for the health center. This would enable pregnant women to have ultrasounds in the community, rather than having to travel several miles to BIDMC for these screenings. I hope you will like the items I am offering and will bid vigorously for them for this cause.

But, wait, there's more. I mentioned that B4G is a consolidator and facilitator. You have the opportunity to offer items of your own to include in this auction. Just go here and click on the button entitled "Sign in to Donate," provide the requested information, and we'll tell you if your item will be included. (You'll need to consult your tax advisor to assess the tax deductibility of a donation.) Or use the blue Donate an Item button on the right side of this blog.

Sample items that typically do well that I’d love to include in the auction include:

Tickets to sporting events (from season ticket holders)
Tickets to entertainment events
Gift certificates
Weekend get-aways
Bottle of fine wine
Unique experiences
Lunch with a celebrity or a political figure (are you one?!)

This blog has a worldwide audience, so don't think your items have to be based in Boston. On the other hand, I do have lots of Boston-area viewers, so local items are also welcome.

The first auction will run from Monday, November 2 through November 9. I'm planning to run one during the first week of every month.

I hope that you enjoy this new feature and will choose to participate, as a bidder, donor, or both. Please pass along the word to others, too, OK?

CIMIT advances

The two young men above are Nevan Hanumara and Conor Walsh, Ph.D. candidates in Mechanical Engineering at MIT. You see them here at the current Innovation Congress of CIMIT, being held in Boston. CIMIT is a multi-institutional cooperative venture with the mission of improving patient care by facilitating collaboration among scientists, engineers and clinicians to catalyze the discovery, development and implementation of innovative technologies, emphasizing minimally invasive approaches.

Nevan and Conor work with Professor Alexander Slocum at MIT and Doctors Rajiv Gupta and Jo-Anne Shephard at MGH's Department of Radiology. They came up with a device to help interventional radiologists perform soft tissue probe insertions with greater speed and accuracy and reduced complications and physician strain. They explain more here.

This kind of project research is funded by the CIMIT member organizations, along with federal government and industry sponsors. To the right, you see some of our executive committee members getting a feel for this device.

Helping women get on corporate boards

I recently heard about an organization called WBL, or Women Business leaders of the U.S. Health Care Industry Foundation. It was founded in 2001 to provide its members with help to improve their businesses and grow professionally. The part I find especially interesting is the help that WBL offers to senior level executives (VP and above) to get positions on non-health care corporate boards.

The organization has published two books, Answering the Call and Advancing Women in Business. The first is a resource for considering the risks and responsibilities of governance. As WBL notes, "This book is a great place to start considering whether board service is right for you or to brush up on your governance-related knowledge." The second book is to help you understand how to get on a nominating committee's radar screen.

In addition, WBL holds annual Summits about serving on corporate boards and considering your first board seat.

This is a great resource for women health care professionals who want to expand their personal and professional horizons. Many corporate boards are seeking to diversify their membership, and the experience offered by health care people can often be applicable to other industries.

Not all fun and games, but they help

Following up on one of the recommendations in the item below, you may recall that I have written before about the use of games and other light-hearted events to promote better hand hygiene. That, plus a lot of hard work, has resulted in general improvement in the hospital.

A key part of the program, consistent with our transparent approach to process improvement, is that we share data about every floor with every floor, so there is an overall awareness of how we are doing. Our measurements are based on a combination of direct observation and keeping track of quantities of CalStat used on each floor relative to the number of patients on that floor. We are now at the point, as noted below, of increasing our goal.

Here's the form of the message that goes out from Linda M. Baldini, RN, CIC, CPHQ, Infection Control\Hospital Epidemiology, to each floor, all of the Chiefs of Service, Division Chiefs, and many other people at the end of each observation period:

The latest hand hygiene reports for all units are now available. Reports are available on the online Infection Control manual. The link may be found on the new portal.

The most recent report is for Period #25 (7/4/09 – 8/28/09) and is generated using data on usage (counting empty soap and CalStat containers) and census (patient days) for each unit. These data closely mirrors that obtained by direct observation of hand hygiene performance of health care workers during the same period. Note that L&D is considered an ICU in this report due to similar nurse:patient ratios.

The reports available include: ICU hand hygiene reports (all units on one graph) Non-ICU hand hygiene reports (all units on one graph) Average ICU and non-ICU hand hygiene performance over time Individual graphs for each unit over time

Congratulations to L&D, CVICU, MICU 7, 7 Feldberg, 6 Feldberg, 5 Feldberg, 5 Stoneman, Farr 10 for reaching goal this period of ≥80%!

An email reminder will be sent to you after each intervention period, approximately every 9-10 weeks. Please share these data and information with your unit-based staff at all levels and physicians. Feedback of data has been shown to help improve performance.

You can see the data, too, on our corporate website. As I have often mentioned, we believe that public presentation of our performance data stimulates internal improvement by helping to hold ourselves accountable to the standard of performance for which we stand.

But back to the game idea, here's the latest campaign, announced last week:

To: BIDMC Community

From: Ken Sands, MD, MPH, Senior Vice President of Silverman Institute for Health Care Quality and Safety

Sharon B. Wright, MD, MPH, Director, Infection Control/ Hospital Epidemiology

Subject: Raising the Bar on Hand Hygiene

Starting with the new observation period that begins Oct. 24, BIDMC will increase its hand hygiene compliance goal from 80 to 90 percent across the medical center. To help roll-out this new initiative we will introduce a fun new incentive program to help inpatient unit staff improve their hand hygiene compliance.

BIDMC Bowl-O-Rama (Knock Down The Germs) will use a bowling-themed scoring grid to communicate unit performance in each measurement period. Those units meeting the new goal will receive rewards such as bowling shaped cookies and coffee to winning units at the halfway mark (April, 2010), and a big party with raffles during Infection Prevention Week in October 2010.

Our grand prize will be a Wii game system, including the sports/bowling program, as well as other bowling-themed prizes, gift certificates to area bowling alleys, custom made bowling shirts (for select Hand Hygiene advocate champions), and movies such as and “The Big Lebowski.” Unit-based bowling trophies will also make the rounds to highlight and reward compliance.

To learn more about this new initiative, please join us at the Infection Prevention Week informational fairs in the east and west campus cafeterias on Oct. 21 and 22, from noon to 1:30 p.m. The fairs include free prizes and Wii bowling.

Amateur hour

Sometimes the "amateurs" come up with important observations. Samantha Sherman and Patricia Henderson (above) are two of our Sloane Fellows who took on an interesting assignment suggested by MIT's Steven Spear. Thinking through the issue of hospital acquired infections, Steve suggested that a couple people could go to gemba and watch how germs might invade the perimeter around a patient in the hospital. Perhaps this kind of observation could lead to process improvements or other changes that could reduce the rate of infection.

So that's what Sam and Pat did. They are not trained clinicians and have frankly not spent all that much time in clinical settings. But they have good eyes. For many hours, they sat in patient rooms and watched as people entered and left, keeping track of potential sources of infection.

Here's a short excerpt of what they noticed, just the part focusing on hand hygiene. Please remember this was not meant to be a statistically valid sample. Some of the observations have been helpful to our infection control people as they design changes to improve compliance with this important aspect of the hospital. In other cases, the recommendations might be deferred because different approaches have been found to be more effective. See the post directly above this one for an update on the entire issue.

Sloane Project
Observation Findings

Overview:

Over the course of 4 weeks, we spent approximately 25 hours observing interactions in inpatient rooms to evaluate what passes the perimeter of the infection zone. We were able to compare notes from our observations and categorize our findings into five categories.

They are:

1. Physical space
2. Equipment
3. Hand hygiene
4. Use of gloves
5. Outside visitors

Hand hygiene

Observation:
Major inconsistencies with staff using Cal Stat upon entering and exiting patient’s room.
This observation includes: nurses, co workers, food services, physical therapy, family members, couriers and Phlebotomist.

Recommendation:
Further training in targeted work groups and visitors (see list above).
All visitors must sign in at front desk before entering patient’s room at that time.
Educate or give visitor a hand hygiene pamphlet that explains the importance of this
requirement.
Involve the patient; include an antibacterial wipe/napkin on food trays along with an educational reminder to use before eating.

Observation:
Empty Cal Stat – people were still going through the motions even if nothing was coming out.

Recommendation:
1. Monitor Cal Stat usage
2. Install empty warning alerts
3. Flag – visual identifier
4. Blinking red light
5. Beeping sound

Gloves
Observation:
No standard protocol for when to wear gloves and when not to (medication delivery, checking wounds, etc.)

Recommendation:
Establish best practices; undergo refresher training for all staff.
Use educational humor, display slogans in certain areas of the institution, i.e.
“Spread the word not the Germs”.

Observation:
During our visits we observed that there is no designated work space for staff within the patient room. Caregivers are often observed using the soiled linen cart as a place to check and/or update the patient chart or they use the space to regroup before coming into the room, or moving on to the next patient room. Also, often times, equipment or charts would move back and forth from the clean bed to the patient bed increasing risk for infection. Floors, chairs, patient bed, and patient tray were used as work spaces to hold phlebotomist cart, charts, medications, and even urinals.

Recommendation:
One recommendation is to create a designated space in the room that gets sanitized – perhaps one of those tables that fold down from the wall? If there is no space within the room, it could exist immediately outside the room. In some situations such as the phlebotomist, a rolling work station might be appropriate.

Observation:
The cleanliness of the rooms also presented some risk. We observed dirty gloves on floor next to trash can; empty drain hanging out of trash can; and dirty paper towels on floor. Additionally, we observed a coworker who cleaned the patient’s belongings while wearing the same gloves used when she cleaned the patient.

Recommendation:
Perhaps an easy fix for trash could be to buy taller trash cans. The trash cans are quite short and are often placed in a far corner of the room. If the cans were taller, there might be less likelihood of missing the can. Additionally training is recommended for all staff that is responsible for cleaning and sanitizing the room to educate on the various ways that infection can be transferred.

Observation:
Some equipment is used on multiple patients – this includes tourniquet, stethoscope, and blood pressure cuff. Not all equipment was wiped properly before being used on the patient.

Recommendation:
Some of the items could be assigned to each individual upon arrival – such as a tourniquet or blood pressure cuff. Communication and education around the importance of cleaning stethoscopes may help with consistent cleaning prior to use on patients.

A note to other 89%: You are in the minority

A couple of weeks ago, I wrote about a Boston hospital that had shut down employee access to various social media sites and offered my view that it was not a productive thing to do. Here's a similar view from Socialnomics. The site notes that only 11% of companies do not put some kind of limitation on use of Facebook by their workforces.

I like this set of comparisons.

Banning social media in the work place is:

• Analogous to banning the Internet
• Analogous to banning the phone because you might make a personal phone call
• Analogous to banning paper and pens because you might pass a note that is not related to class or work
• Could potentially signal to current workers and future recruits that your company just doesn’t “get it”

Journal of Participatory Medicine has its debut

E-patient Dave informs me of a new venture, the Journal of Participatory Medicine, a peer-reviewed open access journal. It is the product of the Society for Participatory Medicine. Here's the lead-in to issue #1, along with other material from the Society:

Our mission is to transform the culture of medicine to be more participatory. This special introductory issue is a collection of essays that will serve as the 'launch pad' from which the journal will grow. We invite you to participate as we create a robust journal to empower and connect patients, caregivers, and health professionals.

This is free, online journal dedicated to documenting how healthcare encourages, supports and expects active involvement by all parties, and leads to improved outcomes. An interdisciplinary publication founded, written, edited, and reviewed by health professionals, patient advocates, and researchers, the journal will explore how participation affects outcomes, resources, and relationships in healthcare; which interventions increase participation; and the types of evidence that provide the most reliable answers.

Caller-Outer of the Month Award #8

Continuing our series, David Mangan, shown here, received this month's Caller-Outer of the Month Award from our Board of Directors.

Sometimes a call-out is just a sign of initiative and caring. It might not result in a new process, but it might help confirm that something that has been put into place is working well. Such was the case here.

Dave is a pharmacist who helps nurses and other staff learn to use our sophisticated medication-delivery pumps. During a pump's testing phase, he will sometimes distribute a few pumps to people in training and then collect them before the full roll-out occurs.

He did this recently and found one pump was missing, having disappeared. Previously, finding one pump on the dozens of floors in the hospital would have taken forever, during which time it might have been misused or create other problems. Here, Dave immediately called Pam Dicapua in our clinical engineering department. That group had recently installed an RFID system and labeled hundreds of medication pumps. This particular lost pump was located within 37 minutes of Dave's query to Pam. It had traveled downstairs from one floor on our West Campus, across the street three blocks away, and then upstairs to a floor on our East Campus.

In short, good heads up thinking and initiative by Dave, and excellent follow-through by Pam at clinical engineering, using the latest systems put in place by her and her colleagues.

Dave says he has renamed RFID to mean "Really Finds Infusion Devices"!

That's two in one day

And here's another excellent appointment, of Sarah Iselin as head of the Blue Cross Blue Shield of Massachusetts Foundation.

Welcome back, Betsy!

Brigham and Women's Hospital in Boston has a new President, Elizabeth Nabel, currently at the NIH. Read Rob Weisman's story from the Boston Globe here. A superb choice. It will be great to have her back in Boston.

Minorities in Boston

I just returned from a session for minority students at Harvard Medical School where I joined my Harvard hospital CEO colleagues in addressing the students on the topic of "Why Boston? Building your Career in Academic Medicine in Boston." You might be interested to know that, decades ago, Boston was considered one of the friendliest places in America for African Americans to live and advance professionally. Unfortunately, that reputation was tarnished greatly in the 1970s and 1980s (thanks in part to this image) when the controversy over school busing to integrate the public schools divided the city in so many ways. More recently, civic, academic, and corporate leaders in the region have reached out in an attempt to revive that older, more tolerant and friendly view of the city.

A lovely moment in tonight's program was the presentation of an "Excellence in Mentoring Award" to Dr. Johnye Ballenger (seen here). Johnye is a instructor in pediatrics at Children's Hospital, and she has spent the last 20 years tutoring and mentoring HMS students. In accepting the award, she said to the students, "It has been my passion to be part of your lives," and received a standing ovation.

Next year?

The season is over for the Red Sox, but they are scouting for talent for the future. BIDMC Chief of Neonatology DeWayne Pursley took batting practice at Fenway Park today in the hope of securing a better job.

DeWayne reports: "At the end of that session the head coach, assessing my season’s performance, told me that I could probably have a good career in medicine." Then, "I’ll be in a little late tomorrow. I’ve got a physical therapy appointment lined up."

Question for Glenn Steele and colleagues

Much has been rightfully made of the success of the Geisinger Health System in delivering high quality care at a lower cost. Here's an article from Philly.com that discusses the issue.

A pertinent quote:

"Medical care is more fragmented in most hospitals, with many doctors self-employed or working for independent groups, and insurance provided by separate companies. That pits those groups against one another economically. In a fully integrated system, like Geisinger's, everyone benefits more easily from holding costs down and improving care, experts said."

Question: How much is due to the common bottom line between the MDs and the hospital, and how much is owning the insurance company? Also, how much of this is transferable to other settings that do not have the dominant market position enjoyed by Geisinger?

Glenn and colleagues, can you please reply?

Making stairs fun

Watch this. I love the theory set forth: Can we get more people to use the stairs by making it fun to do?

OK, it's part of an ad campaign for Volkswagen, but who cares?

A doctor confides

This post on WBUR's Commonhealth blog is very moving. Please take a look.

Honoring CPD

We held a luncheon last week to honor the members of our central processing division (CPD) staff. These are the folks who sterilize, sort, and pack surgical instruments for use in the operating rooms. You have read about some of them before, either for their individual contributions or for their Lean process improvement event.

I am not allowed to play favorites, but I will tell you that this group includes many of my most favorite people in the hospital. They are wise, engaged, thoughtful folks with a great sense of team spirit and a marvelous sense of humor that develops from the technically demanding responsibility that surrounds their jobs.

Here is a slide show that was produced to honor them at the luncheon. I dare you to watch it and not share my affection and appreciation for these very fine people.

Immigrants creating jobs

An excellent op-ed in today's Wall Street Journal by MIT President Susan Hockfield.

(Disclosure: I serve on the MIT Corporation.)

Sorrel King @ HCFA

Deb Wachenheim at Health Care for All reminds us that Sorrel King, a nationally-known patient safety advocate, will be speaking at HCFA at 1:00pm today. Sorrel has important things to say, and I urge you to hear her.

Who should tell your MD what to do?

In this Wall Street Journal op-ed, Norbert Gleicher suggests that expert panels won't improve health care because the the quality of the research on which they would base their physician practice guidelines is not reliable. Instead, he suggests that our system can self-correct when experts lead us astray. He asserts that we have a "well working free market of ideas in health care, where effective therapies can rise to the surface and win out."

I'm somewhat sympathetic to Dr. Gleicher's point about a government-imposed clinical review process, but he overstates the case about a current free market of ideas. Individual insurance companies and Medicare currently make payment decisions with regard to therapeutic judgments every day. How are they informed, and what are their sets of vested interests? Much of that remains hidden from public view.

Meanwhile, too, doctors and hospital practice what Brent James calls "regional medical mythology," patterns of care divorced from scientific evidence, based as much on the local supply of specialists and what they learned from their predecessors as any other factors.

Perhaps what Dr. Gleicher is trying to avoid is the replacement of this array of unscientific medicine with the establishment of a centralized panel of unscientific medicine. In essence, he is suggesting that it is worse for the federal government to get it wrong for the whole country at once than for the individual participants (payors, MDs, and hospitals) to get it wrong each in their own way.

Seriously, though, one can apply some analytical rigor in support of Dr. Gleicher's thesis. Just as a diversified investment portfolio does better over the long haul in terms of risk mitigation, so too might the country do better over time with a diverse set of views as to appropriate diagnostic tests and therapies.

Digitizing Directors

Shown here are my fellow panelists from a session today at the 2009 Corporate Governance Conference of the National Association of Corporate Directors in Washington, DC. Our session was entitled, "Transparency & Technology: Directorship in a Digital Age."

Shown left to right are Moderator Jessica Lipnack, CEO of NetAge; Thomas Gensemer, Managing Partner of Blue State Digital, LLC; and G. Scott Greenberg, Director of Sahale Snacks, Inc., InSpa Corporation, and Calidora Skin Clinics, Inc., and Senior Partner at K&L Gates, LLP.

Jessica started us off with an electronic survey of the audience:

Does your Board uses websites for purposes of meeting management and board communication:
No: 54% Yes: 46%

Do you personally keep a blog?
No: 97% Yes: 3%

Do you read blogs as part of your Board work?
No: 68% Yes: 32%

Do you participate in Facebook, Twitter, or other social media sites?
No: 35% Yes: 65%

How would you place yourself in the "digital continuum" relative to your colleagues?
Novice: 17% Competent: 64% Out-in-front: 19%

Much of Scott's presentation dealt with the pervasive presence of digital media and with the tools available to boards for meeting preparation and management and board communication.

Thomas talked about the essential elements of a social media strategy: Timeliness; transparency; authenticity; and personalization of messages. As one of the brains behind the Obama internet campaign, he had a particularly vivid experience upon which to draw.

My topic was the value of transparency in building trust with customers and other constituencies. I drew on our experience at BIDMC and also the approach used by Salesforce.com.

Jessica ensured that our presentations would be short and focused, leading to an extensive and engaging question and answer period.

Cab, buddy?

Regular readers know that I have an obsessive interest in infrastructure, city services, and the like. Well, here's a taxi cab meter that I saw today while visiting Washington, DC. Look at the attributes. In addition to a very clear display of the fare, and credit card reader, it has a GPS map of the route you are traveling. You won't always see this if you are in DC. These are only available in Alexandria (VA) based cabs.

Don and Tom's marvelous adventure

In preparation for a day-long mini-course at the 21st Annual National Forum on Quality Improvement in Health Care in Orlando, Florida (December 6-9, 2009), Don Berwick and Tom Nolan at the Institute for HealthCare Improvement are asking for your input on how to design a low-cost, high-quality health care system for the future. To learn more, submit your ideas and stories, and engage in a conversation about health system transformation, click here.

Here's the initial compelling question on the site:

"In an average American community with 500,000 people, what three changes in the health care system (organizations, resources, personnel, etc.) would contribute most to simultaneously reducing the per capita costs of care and improving care outcomes and health status?"

First Snow in Boston

View just taken of the back yard and the park behind our house. I know it has snowed earlier than this in Boston, but it has been a long time since I remember one this soon. There was a Columbus Day about 7 years ago, as I recall. And then one snow squall earlier in October in 1970. I remember both of those because I went out bike riding on a sunny morning on both of those days, totally unprepared for the change.

In any event, the first snow always makes me recall this story.

Not bad. Did you really expect more?

Several weeks ago, I suggested that the debate on national health care issues had moved from policy to politics. We are now at the point where real horse-trading has begun to get the requisite number of votes in the Senate.

Here's one aspect of this, where certain Congressman are trying to protect medical device companies located in their states. And here's another summary, showing the interplay among several groups of constituents:

Doctors are expected to win a $240 billion boost in reimbursement rates that would shield them from a 21 percent pay cut next year for treating Medicare patients. Women who now pay higher insurance premiums for caesarean sections would be protected under antidiscrimination provisions. And although Congress is strongly considering a tax on high-cost “Cadillac’’ insurance plans, the charge is likely to be imposed on a smaller number of health plans, appeasing angry labor activists.

None of this should be a surprise. It is the legislative process in action, based on a republican form of government that was written into our Constitution by John Adams and his colleagues to assure that minority interests are considered.

In similar fashion, we should really ignore non-stories like this one in today's Washington Post. It contains complaints that the final negotiations are being held by a small group of people as opposed to the "big table" approach promised by the president during his campaign. This has been standard practice for decades, and it is necessary to actually get the final work done. It does not, by the way, guarantee full approval by either house of Congress, but without a small working group at some point in the legislative process, you never get close to a conclusion.

All that has really changed recently is that the sausage-making aspects of legislation are now more visible for the world to see.

What it will mean for the final bill, though, is that health care reform will not satisfy the President's three-part test of offering more access, lower costs, and consumer choice, but those in all segments of the industry have known since the start that this was not possible. In my view, the most important things that will be accomplished are eliminating nasty practices of insurance companies; establishing a national requirement for people to have health insurance; and subsidizing at least some of those who need it. The first will give security to those who have insurance but who fear losing it. The second will cause those healthy people who choose not to buy insurance to do so, helping to assure that they do not end up being a burden on all of us when they show up at the Emergency Room. The third will help some portion of the population get insurance and more access to preventative and diagnostic care.

We will find out months and years from now what our Congressional buddies horse-traded away to get this package. Some of it will not look pretty. Some of it will actually harm the underlying causes of more access, lower costs, and consumer choice. There will have been missed opportunities to rationalize the health care system, too. But all of that, I submit, is the nature of the legislative process, where the reality that "one person's costs are another person's income" gets transmogrified into a bill that gets enough votes to pass.

Hey, that's our money!

An article by Todd Wallack and Andrea Estes in today's Boston Globe demonstrates the risks inherent in direct governmental participation in private corporations.

Here, the Commonwealth of Massachusetts decided to put money into a solar energy company:

The incentive package from the state included nearly $21 million in direct grants to the company, $22.6 million in tax incentives, $13 million in grants to build roads, upgrade electrical transmission lines, and upgrade other infrastructure to support the 450,000-square-foot Devens plant, a $1-per-year lease for 23 acres at Devens worth $2.3 million, and $17.5 million in loans.

There are two types of risk associated with this kind of investment. The first is that the firm might fail, taking with it millions of dollars in state assets. That is particularly likely in the energy field, where changes in world oil prices and advances in technology or unexpected competition can quickly make mincemeat of a firm's business plan.

In this case: A big problem is the price of solar panels, which keeps dropping, in part because of sinking demand and competition from China. The U.S. Synthetic Fuels Corporation, staked with billions of dollars in federal support, was another casualty of these kinds of market forces.

The second risk is that political bodies have trouble with the concept of sunk costs. Private firms consider past investments as fiscally "gone" for purposes of evaluating future investments. But the government often behaves as if investments have a carry-forward risk of embarrassment, so it is more likely to throw good money after bad.

This part of the story demonstrates the latter point:

...After its efforts to borrow elsewhere failed, the company recently asked MassDevelopment for a new $5 million loan. ...MassDevelopment staff members warned last month that the company does not currently generate enough cash to pay it back, and gave it the highest score possible for risk, 6 out of 6. The $5 million request is also double the $2.5 million limit allowed under MassDevelopment’s own guidelines. Nevertheless, MassDevelopment’s board unanimously approved the loan at a board meeting Sept. 17.

Some Governors and Presidents like to believe that they are more able than the private markets to evaluate and support technologies and companies consistent with their policy agendas. The problem is that they use our money in support of their hunches, changing the private sector's risk-reward calculus that is essential for a proper evaluation of the investment's value.

Silver Lining

The American League playoff series is taking place between the Angels and the Yankees, with the Red Sox eliminated in the previous round. The last several days in Boston have been cold and wet. A BIDMC staff member, a true and loyal fan, said to me, "I'm sure glad the Red Sox don't have to play in this terrible weather."

Here's the beef

My friend Vamsi arrived in America many years ago from Chennai (formerly Madras), India, to attend college at the University of Iowa in Ames. Pretty soon, his favorite eating place was Perkins Restaurant, and his favorite dish was chicken fried steak. There was only one problem. Unknown to this Hindu, chicken fried steak was actually not chicken. It was beef, a forbidden food. He never could tell from the taste because he always smothered the dish with lots of gravy. Finally, after 4 1/2 years of college, he made the discovery. He now wonders how and when he will be punished for these multiple violations!

Meanwhile, just this week, a friend reports that, in honor of Diwali, the company where she works is serving Tamarind Masala Meatloaf. Really. Picture included. Hopefully, the White House was a bit more culturally correct.

ICU = I (really) care for you and your family

Several months ago, I wrote about work being done in our ICUs to make them more patient- and family-friendly and responsive.

Each year, the Society of Critical Care Medicine (SCCM) selects one (and only one) hospital or ICU for its Family-Centered Care Award, the purpose of which is to "recognize innovation that improves the care provided to critically ill and injured patients and their families." If you’re not familiar with SCCM, it is the largest multiprofessional organization focused on critical care, with more than 14,000 members in 80 countries. This is an international competition.

I am very proud to announce that BIDMC has received the award, which will be presented in January.

As Dr. Michael Howell, Director of Critical Care Quality, explained to our staff:

Why did Critical Care at BIDMC win this award? Because of your work. Literally hundreds of people have made small, incremental changes to help improve the experience of critical care for our patients and families. Anyone who has had a family member an ICU knows that it’s an extraordinarily trying time. From simulated family meetings for the medical residents, to family pagers in the SICU, to transition-out-of-the-ICU work in CVI, to pro-active rounding of chaplains, there have been a tremendous number of improvements over the past year and a half. Family satisfaction data (which we have meticulously collected) supports this as well. Today, families are more than twice as likely to report that they are completely satisfied with their decision-making role than they were when we started in April 2009, and we’ve seen improvements in other areas as well.

I also want to give special thanks to IHI's Maureen Bisognano, who had a special role in stimulating our activities in this arena. Maureen had a friend in our ICU for some time. Afterwards, she said that the medical care had been extraordinary, but that other aspects of our care were substandard and outdated. She was absolutely correct. Beyond that criticism, she has been a loyal guide in our work.

Here is the more detailed explanation from our award application:

DECIDING WHAT TO IMPROVE: MOVING THE LOCUS OF CONTROL TO PATIENTS AND FAMILIES

Strategically, we believed that how we chose what to improve was tremendously important. To be truly patient/family-centered, patients and families should set our improvement priorities. We therefore developed two initiatives to address this critical issue:

ICU Patient and Family Advisory Council

We believed that ongoing, longitudinal guidance from our patients and families was critical. We therefore assembled the ICU Patient and Family Advisory Council, a group of former ICU patients and family members (of both survivors and non-survivors). Each Council member serves for one to two years. The group meets bi-monthly.

As the first advisory council for our hospital, we consciously sought a model that could be emulated by others. After we identified potential Council members, we had a thoughtful selection process, including in-person interviews by a social worker and by a member of the Critical Care Quality staff. This selection process resulted in a group of patients and families who provides exceptional advice and guidance.

To elicit the best possible guidance, each Council meeting is facilitated using careful focus group methods. Each session focuses on a different aspect of the ICU experience. Examples of topics include (among others): emotional support in the ICU, family meeting curriculum design, waiting room revitalization, overall prioritization of improvement opportunities, and others.

FS-ICU: Family Satisfaction in the Intensive Care Unit

Traditional hospital-wide patient-satisfaction tools (e.g. Medicare’s HCAHPS; Press Ganey) have significant limitations in understanding the ICU experience. However, the FS-ICU is emerging as one of the potential gold standards in assessing families’ ICU experience.1 This rigorously developed survey instrument captures key domains of the ICU experience and has undergone multicenter validation. In addition, the survey has three open-ended questions designed to solicit opportunities for improvement. The FS-ICU is administered to families of ICU survivors within three days of transfer out of the ICU; it is mailed to families of non-survivors several weeks after the patient’s death.

We began administering the FS-ICU in April 2008 (i.e. just over one year after the multicenter FS-ICU’s publication) and have surveyed nearly 400 families to date. Quantitative analysis allows us to detect targets for improvement and to follow improvements over time. Qualitative assessment of the open-ended questions ensures that our Advisory Council’s advice resonates with a broader sample of patients. In addition, because we administer surveys in-person and in near-real-time, our team can perform real-time problem solving and address issues as they arise.

GETTING BETTER: A PORTFOLIO OF FAMILY-CENTERED CRITICAL CARE

Based on themes and specifics gathered from our ICU Patient and Family Advisory Council and the FS-ICU, we began the journey toward comprehensive, meaningful patient- and family-centered critical care. Below is a selection of activities, limited by space:

Communication
Simulated Family Meetings: Residents provide a great deal of direct patient care, but the optimal way to train them how to conduct family meetings is not known. We have implemented a program in which all medical house officers (>150 physicians) now rotate through our Simulation Center, receiving didactic and high-fidelity simulation sessions on conducting family meetings. The ICU Advisory Council provided major input into the curriculum for this educational program.

Transitioning out of the ICU: The move from an ICU to a regular floor can be very stressful. Now, when patients transition from the Cardiovascular ICU (CVICU) to the floor, RNs from both areas perform a hand-off with the patient in the room with a focus on pain management requirements. Patients have a direct say in their care and in how their pain is managed.

Including Families on Multidisciplinary Rounds: For several years, families have routinely been invited to stay in the patient’s room during the exam and discussion in many of our ICUs. However, we believe this involvement should be expanded. In October of this year, we will begin a pilot to actively invite and include families on multidisciplinary work rounds. In order to help in moving the field forward, we are planning a meticulous effectiveness evaluation of this strategy, using time/motion analyses and the FS-ICU as outcome measures.

Standardized Communication at ICU Admission: Our Advisory Council provided guidance on what kinds of information was most helpful in the first day of a patient’s stay. This new introductory brochure covers information on staff roles in the ICU as well as the day-to-day logistics of visiting (such as parking). It also provides pointers to additional information and information about how family members should take care of themselves during this trying time.

Spiritual Care: Chaplaincy staff now actively solicit patient/family needs by pro-actively rounding in the ICUs. Spiritual care satisfaction scores have more than doubled (p =0.005). Our chaplaincy was recently covered in a major metropolitan newspaper.

Improving the Critical Care Experience
Waiting Room Revitalization: Our Advisory Council and FS-ICU results identified the waiting room as an important factor in satisfaction and a major opportunity for improvement. In spite of the economic challenges of the past year, our hospital dedicated capital to renovating a waiting room serving three of our ICUs. The renovation was designed with active input from our Patient/Family Advisory Council. Thus, the waiting room (now “Family Room”) included functions that are meaningful to our family. Opened in July 2009, we have seen marked improvement in the FS-ICU scores for the waiting room (p = 0.04).

Family Sleep Room: Providing the ability to stay close to loved ones is important. In tandem with our waiting room revitalization, we created two rooms to provide overnight accommodations for our families.

Eliminating Visiting Hours: Our Critical Care Executive Committee voted unanimously to support open access for families, eliminating formal visiting hours. This helps accommodate family members who work late and allows loved ones to visit at their convenience, rather than at ours.

Untethering Families from the ICU
Family Pagers: Our Advisory Council pointed out the feeling that they had to stay in or near the ICU at all times, in case anything happened. We now provide pagers (think Olive Garden) to families that allow them to go to the coffee shop, cafeteria, and nearby shops with the confidence that we can page them if they are needed. These have received rave reviews from families, nurses, and doctors alike.

Computers for ICU Families: Many families use email and social networking to update extended families and friends. Access to the web and email also allows some family members to keep up with some work/employment duties while being close to loved ones. In addition to ubiquitous wireless internet, we now provide public computers in our revitalized family room. These computers open a customized ICU website which includes links to online medical resources such as SCCM’s Official Patient and Family website.

CarePages: Our hospital contracted with Carepages to provide an infrastructure to support patient- and family-created blogs about their health challenge. These private and personalized web pages allow families to share the latest news with friends and family and receive messages of support, without the time and effort required to call large numbers of people.

EVALUATING EFFECTIVENESS

This comprehensive, family-guided program focused on improving the family-centeredness of critical care in our nine adult ICUs. We believe there are two measures of evaluating its effectiveness:

Organizational commitment: In this challenging environment, hospitals cannot commit resources to ineffective programs. Besides being featured on our CEO’s blog, our medical center has supported this key effort in several ways. First, a half-time critical care nurse helps lead this work. Without this, our program would not have been successful. In addition, the Division of Critical Care Quality focuses the resources of the Director of Critical Care Quality (an MD) and a Masters-trained Critical Care Project Manager. Finally, we were fortunate to receive the capital support required for our waiting room revitalization.

Improvement in Outcomes: The FS-ICU provides an opportunity to rigorously measure family-centered outcomes of our work. In addition to statistically significant improvements in spiritual care and waiting room scores, we have seen consistent improvements in families’ rating of overall satisfaction with decision-making, which we believe represents a true outcome measure of our improvement work. In the baseline period (n=45 surveys), 40% of families reported complete satisfaction with their decision-making role. In the past six months, 66% of families report complete satisfaction with decision-making (n=95); in the past three months, 82% of families report this highest level of satisfaction (n=34). Mean decision-making satisfaction scores have correspondingly increased from 3.7 to 4.85 (p=0.005 for Spearman correlation between month and mean decision-making score).

1. Wall RJ, Engelberg RA, Downey L, Heyland DK, Curtis JR. Refinement, scoring, and validation of the Family Satisfaction in the Intensive Care Unit (FS-ICU) survey. Crit Care Med. Jan 2007;35(1):271-279.

The 5S projects are spreading

Remember the 5S component of Lean process improvement? Well, it applies in all kinds of settings, not just clinical areas. Here are some examples from our Human Resources staff. Laurie reported: "A small group of us in Staffing took this Columbus Day to discover not a new land, but to reclaim our offices through 5S!"

Going virtual @ BlogWorld

I just finished participating in a panel discussion at BlogWorld & New Media Expo at the Las Vegas Convention Center. Except I was in Boston. We had hoped to have a video link, but that didn't work out, so I joined by telephone.

Here's a picture of our panel, provided by Dr. Val Jones, entitled, "The value of blogs to hospitals, news organizations, and industry." Shown are moderator Gary Schwitzer (Health News Review), Marc Monseau (Johnson & Johnson's JNJ BTW Blog), Bob Stern (MedPage Today), and me. I offer the closeup of me in case it is unclear in the top picture.

Update on October 20: Here's a video clip from Dr. Anonymous. October 22: An another on You Tube.

A rock star!

It isn't often that one of our young investigators hits the top ten, but check out this feature from Popular Science about BIDMC pathologist John Rinn.

Not all that long ago

Passing through London earlier this week, I visited a friend who had met Paul Robeson during one of the latter's trips to England several decades ago. Robeson told my friend of a reception at the White House, where he had been invited by First Lady Eleanor Roosevelt. As noted here, "At the height of his popularity, Robeson was a national symbol and a cultural leader in the war against fascism abroad and racism at home."

A certain US Senator approached Robeson and addressed him as "Professor." Robeson, confused, said, "Senator, I am not a professor. Why do you call me that?"

The reply, "Well, normally, I would call you nigger, but I can't use that term in this White House, so I'll just call you Professor."


---
Note: Picture courtesy of Wikipedia.

For Thyroid Cancer Survivors

I wasn't aware of the Thyroid Cancer Survivors' Association, Inc. before receiving a note recently. I am happy to pass along information about a conference this weekend:

Thyroid cancer survivors and families from around the United States, as well as Canada, Brazil, and United Kingdom, will gather in Danvers, Massachusetts, on October 16-18, 2009, to learn from expert physician specialists about the latest research in thyroid cancer, during the 12th International Thyroid Cancer Survivors' Conference.

Speakers at the more than 100 sessions at the Sheraton Ferncroft Hotel at 50 Ferncroft Road, Danvers, Massachusetts, include more than 30 medical professionals, mental health professionals, an attorney, other specialists in well-being, and thyroid cancer survivors and caregivers. There are speakers about each type of thyroid cancer (papillary, follicular, medullary, anaplastic, and variants), for people of all ages at all phases of testing, treatment, and follow-up.

This educational and supportive event is FREE to anyone who requests a scholarship to cover the $50 registration fee (or $30 for one day). Walk-in attendees are welcome.

For the complete program schedule and further conference details, click here, call 1-877-588-7904, or e-mail to thyca [at] thyca [dot] org.

South Cove welcomes Dr. Yeh

South Cove Community Health Center is one of the health centers affiliated with BIDMC. It has locations in the Chinatown section of Boston and also in Quincy.

Last night, the folks at South Cove kindly sponsored a welcoming celebration for our new chief of Obstetrics and Gynecology, John Yeh. Here's a picture of some of those attending. From left to right, they are: Dr. Hee Man Chie, OB SCCHC; John; Helen Chin Schlichte, BIDMC Board of Directors; Dr. Steven Tang, SCCHC Founder and Board Member; April Tang, SCCHC Founder and Board Member and BIDMC Overseer; and Cindy Chen, SCCHC Board Member.

Judith Kurland, Mayor Menino's Chief of Staff, offered greetings on behalf of the Mayor. John presented his plans for the OB/GYN department and for continued close collaboration between BIDMC and South Cove. And, of course, the food was delicious!

MITSS Annual Dinner

Medically Induced Trauma Support Services (MITSS) is a non-profit organization whose mission is “To Support Healing and Restore Hope” to those patients, family members, and clinicians who have been affected by a medical error or an adverse medical event.

MITSS holds one major fund-raising event each year, and it will be held on November 12 at the Boston Marriott Copley Place. Proceeds from the event will be used to fund support groups for patients, families, and clinicians; individual counseling; phone support and referral assistance. MITSS also work with health care organizations to assist them in setting up an internal process for supporting their clinicians.

The keynote speaker for the event is Susan E. Sheridan, Co-founder and President of CAPS, Consumers Advancing Patient Safety, which focuses on creating a partnership between consumers and providers of care.

MITSS is an organization worthy of support. For more information, click here.

Back to the insurance tax issue

Watch the House-Senate reconciliation process closely after the Senate acts and the health care bills move to conference committee. As I mentioned weeks ago, the scope of the so-called "Cadillac" tax on insurance premiums will be a key issue.

Why? Because many insurance plans adopted as part of collective bargaining agreements would be covered by the Senate-proposed tax. There will be no such provision in the House bill.

As reported by the Commonwealth Fund, members of the House are already gearing up on this issue.

It would be a odd policy choice, indeed, if the Democratic majority gives a special exemption to union health plans while taxing non-union benefits.

A more democratic approach and one that takes advantage of the existing progressivity of the US tax system would be to eliminate or scale back the current tax exemption for all employer sponsored insurance plans. Higher income taxpayers (whether union members or not) with higher marginal tax rates would pay proportionately more under that kind of proposal.

But I predict that you will not see a real public debate on this issue. It will be decided in the closed door sessions of the conference committee and placed before both houses as an understated component of the final bill. It will be a bargaining chip that the House uses in returning for giving up the public option insurance plan. The Obama administration, which feels it owes its existence to major financial and organizational support from the SEIU and other unions but has been unable to deliver on explicit pro-labor bills, will be quietly lobbying in this manner.

Shutting down social media? Not here.

The following email message was broadcast last week in a Boston hospital. Of course, you can guess my view of this: Any form of communication (even conversations in the elevator!) can violate important privacy rules, but limiting people's access to social media in the workplace will mainly inhibit the growth of community and discourage useful information sharing. It also creates a generational gap, in that Facebook, in particular, is often the medium of choice for people of a certain age. I often get many useful suggestions from staff in their 20's and 30's who tend not to use email. Finally, consider the cost of building and using tools that attempt to "track utilization and monitor content." Not worth the effort, I say.

Good morning,

Effective immediately, the Hospital is blocking access to social networking sites including Facebook, MySpace, and Twitter from all Hospital computers.

The decision is based on recent evidence that some employees have been using these sites to comment on Hospital business, which is a violation of the Hospital’s Electronic Communications policy and a potential HIPAA violation.

The Executive Team will be working in the coming months to ensure that we have written policies in place that articulate the appropriate use of social networking sites while on duty at the Hospital. Once these written policies are in place, we have educated all employees about expectations and disciplinary action associated with violating the policies, and we have the appropriate IS tools in place to track utilization and monitor content, we will consider once again providing access to these sites. We expect this will take a period of about 6 months.

In the interim, please note that the Electronic Communication policy states that “incidental personal use of electronic communications systems may be allowed so long as such use does not consume more than a trivial amount of resources, interfere with staff productivity, preempt any business activity or violate Hospital policy”.

Employees are free to use Hospital computers during their break periods to check personal email, or access the Internet, but you should be aware that the policy also states, “employees should not have any expectation of privacy with respect to any information on Hospital electronic communication systems or the contents thereof, including email, internet usage, voicemail, fax or other similar vehicles. [The hospital] reserves the right to monitor, review and inspect all uses and the contents thereof.

Should you have any questions or concerns, please feel free to contact me.

On the day of judgment . . .

We've just returned from a jaunt to Italy's Amalfi Coast, a celebration with friends of one of those special birthdays of my wife. Here's a typical coastal scene along with a plaque near the main piazza in the town of Amalfi. Take a moment to figure out the translation, and you'll get a sense of the place and why it has been a tourist destination for several centuries.

And below, why you never gain weight even though you eat very well.

"Ground level"

To briefly continue the travelogue from above, consider the hillside construction of the towns along the Amalfi Coast. One of the natives gave us a short lesson in real estate advertising: "Anything within 150 steps up or down is considered ground level."

Here's a photo essay of the steps we walked each day.

Happy Columbus Day!

Short break for a long weekend. See you soon.

Kaizen Corner -- standardized work

A late September edition of Mark Zeidel's weekly tutorial on Lean process improvement. See this pig exercise for a great example of this week's principle.

We have been describing the strategies for improving patient care, called, in Toyota parlance, “countermeasures.” Last week we described visual systems as tools towards standardizing processes and improving reliability. This week and next, we discuss standardized work. If we do not have a stable, standardized way of doing our work, we cannot develop ways to improve it.

Standardized work is a form of “playbook” for workers, defining the methods to be used, and the outcomes that we expect each person to reach, each day. Standardized work spells out the number of workers needed and what each needs to do, and in what order, to make sure that defined customer expectations are met.

The workers must understand the need for standardization. They must be trained and practiced in the expected methods to do the work and they must have the ability to improve and adjust the processes as they gain experience with them. Unfortunately, in much of what we do, any two people trained to do the same task likely perform it in completely idiosyncratic manners. Interestingly, we have policies and procedures manuals that fill shelves of storage, but these do not specify how the work is done.

Standardized work is the best way we know today to do the job to ensure that desired outcomes are met. In part because we have standardized the work, we are able to experiment with changes in the process, and then to modify the process of work to make it more effective. Without standardization it is impossible to improve.

There are many benefits to standardized work:

1. Improved process stability: Stability means repeatability and the ability to meet quality, cost, lead time, safety and environmental targets every time.

2. Clear start and stop points for each process: These plus an understanding of the customer’s rate of demand allow us to see if things are on track, ahead or behind, and to divide work among people in a sensible manner.

3. Organizational Learning: Standardized work permits us to preserve know-how and helps avoid problems that occur if work methods are not documented and key employees leave.

4. Audit and problem solving: Standardized work makes it easier to define the current condition and identify problems.

5. Employee involvement and error-proofing: If we have a stable process, then those doing it can improve it and can build in visual systems and other devices to avoid errors.

6. Kaizen: Standardized work provides the baseline against which to measure improvement.

7. Training: Standardized work makes it possible to train new people effectively.

Next week we will discuss the elements of standardized work, and approaches towards standardizing where possible the clinical care of patients.

Kaizen Corner -- Visual Systems

Mark Zeidel's Kaizen course continues:

We resume this week with a discussion of Visual Systems. In the effective work place, things are self-explaining, self-ordering, self-regulating and self-improving. We described previously the approaches toward organizing the workplace (5S, which stands for: Sort, Set in Order, Shine, Standardize and Sustain). Our goal is to assure that material and information have been organized to support worker productivity by providing everything needed to get the work done in a predictable place.

Visual Systems help us achieve 5S in the workplace. They are designed to make vital information known, at a glance, to those who need to know it. They tell us what we need to know and what we need to share. There are four types of visual devices that comprise visual systems:

1. Visual Indicator: This provides key information in the workplace, like a street sign or a room number on a patient’s room. The information is useful, but we must seek it out.

2. Visual Signal: This grabs our attention. A traffic light is a visual signal. When it changes from green to yellow we are supposed to notice and slow down (Of course, many Massachusetts drivers regard this transition as a stimulus to accelerate). Many of our clinics use a visual signal such as color coded door labels, to indicate when a patient is in a room and ready to be seen, or when a room needs to be prepared for the next patient.

3. Visual Control: These cues limit or regulate our activities. For example, we do not park in areas with yellow lines or in front of fire hydrants because the visual cues make it clear that we can expect a parking ticket if we do. Similarly in hospital work areas we can make it visually clear that some areas are sterile, thatsharps go into particular containers and the like. If we organize our work space we might have specific, very clearly labeled bins for specific forms; these bins tell us where to put the forms within the work area.

4. Visual Guarantee: This is the most powerful visual device, which actually prevents us from introducing defects into patient care. An example of this sort of device is a forcing function in the
electronic record, which requires that a field be filled out before the computer will move to the next step.

In the factory setting, visual systems alert workers to stoppages in the line, help assure that parts are put in the same place every time, and, in some cases, ensure that parts are snapped into place only in the correct configuration. Try to think about your own work areas. Are there visual cues that might enhance patient care? One thought would be a visual signal on patient rooms that would alert interns and residents that a new admission has arrived, who needs to be evaluated and admitted.

Kaizen Corner -- for lack of a battery

Mark Zeidel's commentary continued in late August with actual application of Lean principles.

As we move into our efforts to enhance the flow of patients from the Emergency Department to the medical floors, I have had the privilege of visiting with multiple people in the ED and Admitting. I have done Gemba’s at ED signout, with an ED core nurse, with an ED charge nurse, with Triage, and with the Admitting Office. I have been enormously impressed with the ability and dedication of these people.

At the same time, ED people are and will be, observing our admissions and patient care processes on the floor. From what I haveseen I have no doubt that we can reduce markedly the time it takes for many of our patients to transit the ED and reach the floors.

Last week we discussed Toyota’s approach to problem solving. We expand on this topic this week by describing how Toyota employees reach the root cause of a problem, with the goal of seeing that it never recurs. The idea is to keep asking why (the 5 why’s) until they discover the root cause, which is defined as that level of understanding that will permit development of a countermeasure that will prevent the problem from occurring again.

As an example:

Symptom: Mrs. Jones’s discharge was delayed for 3 hours until the medicine orders could be written.

Why #1? The intern could not get the orders written during work rounds, wrote down the medicines on a piece of paper, and did not have time to enter them into the electronic order
set until later in the day.

Why #2? Work rounds were rushed because the team needed to gather the data on each patient by hand.

Why #3? The team needed to gather the data and could not easily enter orders because the computer on wheels was not available.

Why #4? The computer on wheels was not available because its battery has run out and must be replaced.

Why #5? No one is responsible for regularly checking and maintaining the computer on wheels to ensure that it is always working.

An analysis like this would develop a standard that each team making work rounds must have (and use) a functional computer on wheels, and would assign the maintenance of the computer on wheels to appropriate staff. Coupled with this would be the expectation that the vast majority of orders should be written on patients by the end of work rounds, so that tests and discharges can occur promptly. We have a group which is developing Lean improvements to work rounds.

Crystal Lake at dawn

Taken with my 1.3 MP Motorola cell phone on a walk a couple of days ago.

Kaizen Corner -- Inaugural edition

Our chief of medicine, Mark Zeidel, was one of our senior management group who took a course in Lean process improvement philosophy and techniques. He decided he would share what he was learning with his faculty and students, in the form of a section of each week's departmental newsletter named "Kaizen Corner".

Mark is an enthusiastic and excellent teacher, and there are already reports throughout his department of lots of use of Japanese terms! (Courses for the residents and interns will expand and reinforce these messages.) I reprint excerpts here from his June 9 inaugural edition and will give you some later editions for each of several days next week.

The hospital has engaged Greater Boston Manufacturing Partnership, Inc., to partner with Alice Lee and her staff in developing training in Toyota production and process improvement techniques for BIDMC. I am enjoying the privilege of taking one of the first courses, a series of 8 or 9 six hour sessions, (with homework) focused on the fundamentals of continuous improvement. The course is terrific, and is beginning to point to the way in which we can become a self-learning, continuously- improving organization of the kind that Steven Spear, our recent visiting lecturer, outlines in his book, Chasing the Rabbit. Members of our Department who are taking these initial courses include Ken Sands and Julius Yang.

To help spread an understanding of the principles of the Toyota system, I will outline elements in the Newsletter each week. We start with the Japanese term, kaizen: This means, “incremental improvement.” Kaizen is the continuous pursuit by all employees of ways to do their jobs better (more safely and reliably), faster (more efficiently, with less strain) and cheaper (at lower expense because there is less waste).

We will go forward with four critical concepts:

1. Customer first.
Customers may be our patients, or referring physicians or the physicians we sign out to.

We strive to provide to each customer exactly what is needed and desired—immediately. This is summarized by the directive, “Produce the customer’s exact order immediately.”

The only acceptable level of quality from the customer’s standpoint is zero defects.

2. Employees are the most important resource.
This means that we must strive to engage each and every employee in helping improve the work we do. We must help each employee to work creatively in our environment.

3. Direct observation as the path to improvement.
Even after years of observation of a process, new discoveries as to how it can be improved can occur every day. If you want to improve something, go and see for yourself how it is working now, with an eye toward how it can be improved

4. Kaizen is for everybody, every day.
We must make improvement part of everyone’s job, something that they do as part of their job, every day. This is the key to becoming a self-learning organization. We must make it possible and normal for people at the front lines to recognize when a process is not going as well as it could go, call it out and work with coworkers or management to fix it as soon as possible.

There is an enormous amount of content in this one page. Over the next series of newsletters, I will try to outline many of the critical elements of the Toyota system. I hope that these descriptions will help people become acclimated to some of these concepts, so we can move them from the minds of a few to the practice of all.

Can you help me find these people?

This is a personal item, but I am asking help from those of you in the social media world. Curt Bakal, chief of radiology at Lahey Clinic, gave me this old paper from our days in the Oceanside (NY) public schools. We had been on a student research team that studied the properties of RNase, as part of a educational program run by the Waldemar Medical Research Foundation in Woodbury, Long Island. Roy Deitchman, vice president for environmental health and safety at Amtrak, another classmate, gave it to him to pass along to me.

By the way, this the first and last bit of medical research that I ever did, but that is another story.

My request is this. I would love to track down the co-authors of the paper and see what they have done in the intervening years. If you know one of these folks or know someone who might know them, would you ask them to please post a comment with a short life history? If we can find all or some, their bios might present an interesting slice of life of the baby boomers generation.

Happy 40th! HCHP->Atrius

Congratulations to Atrius Health, the successor organization, on the occasion of the anniversary of the creation of Harvard Community Health Plan, forty years ago today. HCHP was the the nation's first academic health maintenance organization. It was the brainchild of some of the medical giants of Boston back in 1969, including Robert Ebert, Richard Nesson, Howard Hiatt, Mitch Rabkin, and Joe Dorsey. Starting with 88 patients on the first day, it grew to 30,000 by 1972, and then to hundreds of thousands in the years afterward.

The theory of HCHP was to provide health care at lower costs to patients by concentrating on keeping people healthy in addition to treating them when they became sick. Not a bad idea.