Engage With Grace

@engagewithgrace #blogrally12 Once again, a group of us (including Matthew Holt, Alexandra Drane and our friends) are launching the Engage With Grace blog rally to coincide with Thanksgiving weekend. As in previous years, we’re suggesting that people who want to join the rally simply post the attached “ready made” blog content starting tonight, November 21, and leave it up through the entire weekend (consider it a much-deserved break from blogging for a couple days).

One of our favorite things we ever heard Steve Jobs say is… ‘If you live each day as if it was your last, someday you'll most certainly be right.’

We love it for three reasons:

1)      It reminds all of us that living with intention is one of the most important things we can do.

2)      It reminds all of us that one day will be our last. 

3)      It’s a great example of how Steve Jobs just made most things (even things about death – even things he was quoting) sound better.

Most of us do pretty well with the living with intention part – but the dying thing? Not so much. 

And maybe that doesn’t bother us so much as individuals because heck, we’re not going to die anyway!! That’s one of those things that happens to other people….

Then one day it does – happen to someone else.  But it’s someone that we love.  And everything about our perspective on end of life changes.  

If you haven’t personally had the experience of seeing or helping a loved one navigate the incredible complexities of terminal illness, then just ask someone who has.  Chances are nearly 3 out of 4 of those stories will be bad ones – involving actions and decisions that were at odds with that person’s values.  And the worst part about it? Most of this mess is unintentional – no one is deliberately trying to make anyone else suffer – it’s just that few of us are taking the time to figure out our own preferences for what we’d like when our time is near, making sure those preferences are known, and appointing someone to advocate on our behalf. 

Goodness, you might be wondering, just what are we getting at and why are we keeping you from stretching out on the couch preparing your belly for onslaught? 

Thanksgiving is a time for gathering, for communing, and for thinking hard together with friends and family about the things that matter.  Here’s the crazy thing - in the wake of one of the most intense political seasons in recent history, one of the safest topics to debate around the table this year might just be that one last taboo: end of life planning. And you know what? It’s also one of the most important. 

Here’s one debate nobody wants to have – deciding on behalf of a loved one how to handle tough decisions at the end of their life. And there is no greater gift you can give your loved ones than saving them from that agony.  So let’s take that off the table right now, this weekend.  Know what you want at the end of your life; know the preferences of your loved ones.    Print out this one slide with just these five questions on it. 

Have the conversation with your family.  Now.  Not a year from now, not when you or a loved one are diagnosed with something, not at the bedside of a mother or a father or a sibling or a life-long partner…but NOW.  Have it this Thanksgiving when you are gathered together as a family, with your loved ones.  Why? Because now is when it matters. This is the conversation to have when you don’t need to have it.  And, believe it or not, when it’s a hypothetical conversation – you might even find it fascinating.   We find sharing almost everything else about ourselves fascinating – why not this, too?   And then, one day, when the real stuff happens?  You’ll be ready. 

Doing end of life better is important for all of us.  And the good news is that for all the squeamishness we think people have around this issue, the tide is changing, and more and more people are realizing that as a country dedicated to living with great intention – we need to apply that same sense of purpose and honor to how we die. 

One day, Rosa Parks refused to move her seat on a bus in Montgomery County, Alabama.  Others had before. Why was this day different?  Because her story tapped into a million other stories that together sparked a revolution that changed the course of history.

Each of us has a story – it has a beginning, a middle, and an end.  We work so hard to design a beautiful life – spend the time to design a beautiful end, too.  Know the answers to just these five questions for yourself, and for your loved ones.  Commit to advocating for each other.  Then pass it on.  Let’s start a revolution. 

Engage with Grace.   

Musings from Ostia Antica

Before I take a blogging pause for the (US) Thanksgiving holiday week, I want to pause and reflect on some items.  I was able to spend a bit of time in Rome this past week. As always "the Eternal City" is remarkable, but I was especially caught up by a visit to Ostia Antica.  This was the port of Rome in the 2nd and 3rd centuries AD, a city of over 75,000 people with active commerce and culture.  As the river shifted course, its use as a port facility ended, and its abandonment was helped along by a malaria epidemic.

Today, there are fairly well preserved ruins.  Notable features include mosaics spread throughout the city.  The ones along the Piazzale delle Corporazione--a town square surrounded by market stalls--are most revealing in that they symbolized the trades or services being offered in each shop (see above).

Near the theater we see decorative statues displaying some of the emotions one might experience in the productions of Greek and Roman dramas and comedies.

 
In another part of town, the funerary area, we find depictions of scenes from the underworld, giving hints of the activities of the gods and sea creatures.

Elsewhere, there are a number of statues, including this elegant woman or goddess.

What comes across to me in this setting is how similar the ancient Romans are to us today.  Whether engaged in commerce or the arts, or wondering about the meaning of life and death, these folks had the same kinds of interests and questions that we do.  It turns out that the passage of about 2000 years does not make much of a difference in underlying concerns.

Yet ancient Ostia fell away.  No society is guaranteed permanence.  Thinking of my home town of Boston as an example, are we still in the ascendant, or have we begun our decline?  We are too close to the situation to know, just as the Ostians of 200 AD could scarcely have known that their city would be shutting down 200 years later.

Is it unthinkable to hypothesize that a great city could become irrelevant in the course of a couple of centuries?  How could the home to great universities, hospitals, museums, and businesses wane in influence and prosperity?  Beyond environmental hazards, the key threat is a deterioration in sense of community.  If complacency, arrogance, and ad hominem attacks take the place of intellectual modesty, respectful curiosity about the other person's point of view, and manners, the kind of selfless behavior that is necessary for a community's well-being takes flight.

Whether you live in Boston or elsewhere, please take time this Thanksgiving to give thanks for the opportunity to live in a safe and vibrant place, but please recommit, also, to the virtues and behaviors that will provide the basis for its growth and sustenance as a caring community.

Babbitt lives on in the HR world

Sinclair Lewis, in Babbitt, (1922) made fun of the fact that real estate brokers changed their name to realtors to make themselves sound less like salespeople and more like professionals.  George Babbitt notes:

“Makes me tired the way these doctors and profs and preachers put on lugs about being ‘professional men.’ A good realtor has to have more knowledge and finesse than any of ’em.”

"We ought to insist that folks call us ‘realtors’ and not ‘real-estate men.’ Sounds more like a reg’lar profession."

His convention speech on the subject is a hit:

After the meeting, delegates from all over the state said, “Hower you, Brother Babbitt?” Sixteen complete strangers called him “George,” and three men took him into corners to confide, “Mighty glad you had the courage to stand up and give the Profession a real boost.

I think I just noticed the same thing happening 90 years later.  Someone asked to be connected to me on LinkedIn.  Her job, at a great local university, was "Talent Acquisition Manager."  Whoa!  Isn't that what we used to call "recruiter?"

Well, Recruiter.com tried to set me straight, noting:

The job title of Talent Acquisition Manager and even the use of the term Talent Acquisition, is quite new.

It goes further and says:

Corporate recruiting may be one of the few examples where a name change means something.  Recruiting has gone through a process of upheaval and transformation over the past ten years which might explain the need for a changing nomenclature. Talent acquisition now comprises a very broad field, since recruitment channels have multiplied and the scope of the recruiters’ job has broadened. Talent Acquisition Managers now head up employment marketing initiatives, branding campaigns, internal referral programs, and develop employee engagement metrics and retention programs. It’s a broad set of responsibilities that cover more internal policy and external communications than individual corporate recruiter jobs did in the past.

Sorry, I don't buy it.  Good recruiters and their directors in good human resource departments* often did much of this stuff in the past. Even if the job has expanded, the key function and purpose remains recruitment.  We don't need three words to say what one represents.  Especially when the new term uses the pompous "talent" to refer to "qualified people" and when the verb moves into the greedy realm of "acquisition" as opposed to the respectful concept of "persuasion."

I think this is a simple case of nomenclature inflation, to make it sound like there are substantially different professional attributes required.  Sinclair Lewis would be amused, I think.

---
* (aka personnel departments, but we'll let that pass for now!)

Health Foundation research tenders

I am forwarding this along to those who might be interested:

The (UK) Health Foundation is seeking experienced providers for two pieces of research: a spotlight report on healthcare-associated infections and a review of the best evidence on mobilising community assets in health and care services. The invitations to tender for both pieces of work have recently been published, and are available on our website. 
 

The spotlight report on healthcare-associated infections will bring together evidence from a range of sources on the best means of preventing and controlling infections, taking account of difficulties in measurement and recent success stories. We expect bids in a range of £100k-£120k. 

 

The best evidence review on mobilising community assets in health and care services will bring together evidence on the effectiveness of asset-based approaches to community development in health and care, drawing on models and lessons from the literature and case studies. We expect bids in a range of £55k-£70k. 

Applications for both projects close in the first week of December 2012. Full guidance on both projects and information on how to submit a tender can be found on the Health Foundation website.

CRM in intensive care settings

The use of Crew Resource Management is well known in areas like airline cockpits.  CRM, when properly implemented, maintains certain aspects of the hierarchy that is required in a command situation, but it also empowers all members of the crew to behave in a way that satisfies safety and quality concerns--even if the pilot is failing to do his or her job correctly.  An article by Haerkens, Jenkins, and van der Hoeven in the Annals of Intensive Care provides support for the proposition that CRM might make a difference in clinical settings.  No subscription is required (yay!), so please read it here.

I like some of the observations:

The majority of current interventions focus on implementing safety tools such as event-reporting systems, quality and safety dashboards, evidence-based guidelines and checklists. Even though the results of a comprehensive unit-based safety program (CUSP) are promising, introducing more stringent rules potentially increases the gap between procedure and practice. Therefore, the question remains if these tools can be truly effective in the traditional hospital climate, where highly trained professionals tend to focus more on individual performance than team effectiveness. Moreover, the typical culture in which junior members of the ICU staff should not question the decisions made by senior members adds to the challenge.

ICUs with a “team-oriented culture” have shorter lengths of stay, lower nursing turnover, higher quality of care and can better meet family members’ needs.

Human Factors account for the majority of adverse events in aviation as well as in clinical medicine. The current safety paradigm is still based on ways to limit human variability in otherwise safe systems, promoting stringent procedural guidelines. CRM focuses on improving interprofessional cooperation and team performance and thus patient safety. Even though evidence of CRM on medical errors and patient outcome is still scarce, the parallels between the critical processes in aviation and Intensive Care suggest that a well-adapted medical CRM training has potential for the ICU environment too. 

Readmissions on WIHI

November 15, 2012: Reality Knocks with Reducing (Hospital) Readmissions
(2:00 – 3:00 PM Eastern Time)

Featuring:
Patricia Rutherford, RN, MS, Vice President, Institute for Healthcare Improvement; Co-investigator, STate Action on Avoidable Rehospitalizations (STAAR)
Elizabeth H. Bradley, PhD, Professor of Public Health (Health Policy and Management), Yale School of Public Health; Faculty Director, Yale Global Health Initiative

Of all the improvement issues facing health care, reducing avoidable hospital readmissions may well be the one that finally breaks down traditional silos — and allows promising changes to realize their full impact. Why? In order to prevent patients from bouncing back into the hospital, front-line staff must create robust care coordination strategies across multiple health care settings, as well as the home and the community — taking a fundamentally broader view of the patient journey and the reforms needed. However, doing the right thing ​— keeping patients out of the hospital — often hurts a hospital’s bottom line.

So far, anyway. In the US, the Centers for Medicare & Medicaid Services (CMS) has now imposed fines on some 2,200 hospitals for higher-than-average readmission rates, as part of new federal policy. This latest move won’t make the financial piece any easier, but it does put hospitals on notice that there’s “nowhere to run, nowhere to hide.” If you want to reduce readmissions, you have no choice but to fundamentally redesign what you’re doing now. We'll explore this on the next WIHI on November 15: Reality Knocks with Reducing (Hospital) Readmissions.

What are the most promising ideas and strategies to look to and build upon? WIHI is pleased to convene two important leaders and thinkers on reducing readmissions and care coordination that, between them, have a comprehensive view of what’s working, what’s challenging, and where we go from here. Elizabeth Bradley is the lead author of a recent article in the Journal of the American College of Cardiology (the title page is shown above) that examines the all-too-persistent gap between best intentions and uneven execution of known best practices. Dr. Bradley is eager to discuss the study findings and what can be done to help health care organizations follow through on their own robust policies. In her role as Co-Principal Investigator of IHI’s STAAR initiative, Pat Rutherford has been deeply involved with hospital leaders and officials in three states that have taken to heart the challenge of reducing readmissions, with results to show for it. Pat Rutherford also carefully tracks the work of multiple initiatives in the US, including Project BOOST, Project RED, and Hospital to Home (also known as H2H).

WIHI host Madge Kaplan scheduled Dr. Bradley and Pat Rutherford because their insights are crucial and couldn’t be more timely this fall. The two improvement leaders are keenly aware of the ways in which policy and reimbursement changes surrounding readmissions are giving hospitals that want to do the right thing a jolt. They’d like to share what they’re learning, and to learn from you, on the November 15th program. Please join us!

To enroll in the broadcast, please click here.

MBAs say: This place can't exist

As the years go by, I like the Midwest portion of the US more and more.  There is a palpable sense of community in that region. Here's an example from Jeff Thomspon, CEO of Gundersen Lutheran Health System in La Crosse, WI. 

Jeff was recently interviewed by some management and compensation experts who asked what the structure of the leadership and executive incentive bonus program was.  He summarized the interview in a note sent to his staff:

I pointed out that there was no structure, we had no program.  They corrected me and pointed out that of course our salaries and benefits would follow the market, but they wanted to hear about the incentive program because at their graduate business school it was understood as sure as water flows downhill that to run a high performing organization you needed 15, 30 or 40% of compensation to be delivered in incentive bonus program.

I pointed out that all of our staff deserve to be paid fair wages, good benefits, a long term pension program that is secure, an environment with a consistent set of values, and trust that they will be treated well.  But the amazing success of the organization is not related to large financial payouts for anyone.  Still exasperated, one consultant said, “So what is the incentive?”  I said the incentive is we have a large number of people who genuinely believe in the mission of the organization.  They believe by focusing on the greater good, we can accomplish a greater good.  We all want to be paid fairly and have good benefits, but many of our staff turn down opportunities for just more money because they also value delivering excellence in patient care, education and research and improving the health of our community.

Another person then asked, “So is there nothing at risk?”  I said everything is at risk; the well-being of our patients and their families, the well-being of the community – they are at risk every time we touch a patient or family.  As for the staff, most look at it as an opportunity – the opportunity is to work with others with a high set of values focused on something bigger than any of us individually.  I pointed out that we do have part of our pension plan at risk, but everyone is in that, there are no exceptions.  We will all either get a little less, historical normal or a little more.

The consultants left shaking their heads wondering how this place gets along on a system that their college professors don’t seem to believe exists.

Thanks for all your efforts…all through the days and all through the nights…to serve something bigger than any one of us individually.

Pronovost advises all boards and CEOs

Johns Hopkins' Peter Pronovost offers sage advice to the board of the troubled Parkland Memorial Hospital in Dallas as it searches for a new CEO.  Actually, though, his elegant advice could apply equally well to "untroubled" hospitals because most of them still are not fully carrying out their public trust--a task that requires a deeper view of how to deliver quality and safety to patients and families, to respectfully engage all staff in front-line driven process improvement, and to be transparent with the community about their successes and failures. Excerpts:

History may provide some guidance. Historian Rufus Fears [right] notes that great leaders — leaders who changed the world — have four attributes: a bedrock of values, a clear moral compass, a compelling vision and the ability to inspire others to make the vision happen. Parkland needs one of these great leaders.

The key values of the next CEO should be humility, courage and love — and these values must guide the leader’s behavior. Parkland will not be able to improve unless it acknowledges its shortcomings; this will take humility. Yet Parkland is a great organization with a rich past and bright future. The leader must honor the past and look forward. The leader must be able to live with the paradox of being humble yet confident.

To avoid a revolt and get staff passionate about the vision, the leader will need to transparently communicate where Parkland is going and why, how Parkland makes decisions and what those decisions are. Yet the next CEO will need to deftly dance between democracy and autocracy, between conversations and results. To make all the needed fixes, to bring Parkland back to where it needs to be, much needs to be done, and only with a passionate and engaged staff can real change happen.

Yet perhaps the greatest value will be love. Avedis Donabedian, one of the fathers of quality improvement, was interviewed on his death bed by a student. The student asked, “Now that you have been a patient and devoted your life to improving care, what is the secret of improving quality?” Donabedian told him, “The secret of quality is love. If you love your God, if you love yourself, if you love your patients, you can work backwards to change the system.”

This is what Parkland needs. The hospital’s doctors, nurses and administrators care deeply about patients; they do not want to harm them. They work with broken, underresourced systems. The next CEO must recognize this and seek to understand rather than judge, to learn and improve rather than blame and shame.

We shouldn't need a waiting room.

Our Lean workshops at Jeroen Bosch Ziekenhuis ended today with a session about the differences between batch and flow processing.  It turns out that many hospital settings are based on batches of patients or tests or procedures.  This is often less efficient than a flow-based process.  It is also a lot less customer-centric.

Frederieke Berendsen (above) started talking about this with regard to out-patient clinics, noting that the waiting rooms are often full of people who arrive in batches (or near-batches) and then often wait to be seen.  She noted that in an efficient system, "We shouldn't need a waiting room."

I immediately awarded her with the astute-observation-of-the-week prize, as she had codified one of the Lean principles in a simple declarative sentence.  I then related the story of Dr. Sami Bahri, the Lean dentist in Jacksonville, Florida, whose "clinic prides itself on minimizing the amount of time patients spend waiting -- whether for an appointment, sitting in the front area, sitting in the procedure chair, or whatever."

Brava to Frederieke--and also to the other people in our workshops--for their attentive participation and excellent observations during our sessions!

Coffee breaks demonstrate Lean essentials

The essence of Lean is to have a focus on the needs of the customer and, when problems become evident in the workplace, to think about the obstacles and apply the scientific method to invent incremental improvements.  Such change originates with the front-line staff, but it is the job of leaders to encourage an environment in which this is encouraged.

An example arose recently at Jeroen Bosch hospital in the Netherlands.  It was the brainchild of Jeanne Smith, whose job includes serving coffee to patients on the wards.  You see her here. 

Jeanne was hearing complaints from patients about the temperature of the coffee.  It was highly variable, ranging from properly hot to less so to just warm.  She conducted a root cause analysis as she walked through the wards and noticed that coffee stored in the larger thermos containers stayed hot longer than the coffee served from the smaller containers.  (The greater thermal mass of the larger container held the temperature better.)  So, the solution was simply to use the larger containers.

Immediately, the complaints disappeared, as the coffee was served at a uniform temperature throughout the wards.

Now, admittedly, this is not an item of high clinical importance, but it is an indication of patient satisfaction.  After all, if you are going to offer coffee, why not make sure it is the correct temperature?

Jeanne's improvement won first prize in the poster portion of the hospital's Quality and Safety Day last week. Her poster title was "Dit is andere koffie!"  ("This is different coffee!")  CEO Willy Spaan said, "This is just the kind of sense of initiative and constant improvement that we are trying to encourage."

Wesley and Ziko's fine Lean adventure

One goal of conducting Lean workshops at Jeroen Bosch Ziekenhuis was to create an archive of pedagogical material that could be used by the training staff in future sessions.  We decided to supplement the various games and exercises with a collection of pertinent video clips.  So we had two nice young film production students from Koning Willem 1 College join us.  You see them here, Wesley Martens and Ziko Assink. 

They followed several participants during the gemba walks and shadowing.

What they did not expect was the moment we had an odd number of students to participate in a game requiring an even number.  One of our film-makers found himself immersed in the 5-S game, learning to be Lean (while his partner looked on with amusement!)

Taking one for quality and safety

I want to try to provoke some sympathy from my gentle and caring readers by demonstrating that serving on the Quality and Safety Day jury yesterday at Jeroen Bosch hospital was hazardous duty.  As the jury convened to compare our individual rankings and reach a consensus, Kees Smulders, director of quality and safety, showed up with this plateful of Bossche bolls (one for each judge.)  The Bosch ball is a profiterole type of pastry the size of a softball, filled up fresh whipped cream, and covered with dark chocolate.

I could try to make an argument that this delicacy has great nutritional value.  After all, it contains at least three of the food groups--grain, dairy, and, er, chocolate.  But I fear you might see through that characterization.  The truth is that this is an outrageous dessert or snack, loaded with calories and fat.

So, I approached the challenge gingerly, knowing that I would have the will power to take just a bite or two.  I got off to a good start.

But there is a problem.  There is something about the mixture of the three flavors and textures that is absolutely irresistible.  The time-space continuum is disrupted, you lose consciousness, and in the blink of an eye, the thing practically disappears!

I awoke in the nick of time and stopped at this point.  One of my fellow judges, though, couldn't resist and cleaned his plate (below).  This just shows you how dangerous it can be to be involved in pursuing quality and safety improvements in the health care field:  A total lack of mindfulness takes hold if you let your guard down even for a moment.

Kinderwebsite wins the gold medal at JBZ

Today was the annual Quality and Safety Day at Jeroen Bosch Ziekenhuis in the Netherlands, and it was a marvelous opportunity for the staff and public to learn of initiatives taken by people in the hospital.  I was asked to be on the jury judging from among the top entries in the day's friendly competition.  Our six-member body quickly reached a consensus on the winner, the Kinderwebsite, or children's web site.

Please go and try it out here.  You come to a home page welcoming you to the hospital (see portion above), with noise of a playground in the background, and you are asked to click on or touch your age. (As you go over each button, it says the age aloud to help you.)  Click on age 9, for example.

When you get to the next screen, the background noise changes to that of a hospital, and you find the area you are interested in.  Let's say you have an operation coming up.  You click on operatie, and a series of short videos show up.  An age-appropriate child is featured, and each video accurately depicts what you will experience as you show up for pre-op, the operation, and post-op.  In video number one, you see the identification band being put on, the child walking down the corridor (still being permitted to hold her favorite stuffed animal), and her blood pressure being taken.  There is no sugar-coating of what will happen and what it will look like.  The idea is to present an accurate representation that can help a child and his/her family prepare for what otherwise would be a scary environment and uncertain set of procedures.

Activity on the site during its first few months, from April 1 to October 1, was 4,624 visitors, of whom 65% were new viewers and 35% were returning.  The average residence time for each viewer was 5 minutes and seven seconds, impressive for any website.

Our jury was asked to rank projects on the basis of patient-centeredness, the various dimensions of patient care, the value to the patient (and family), the sustainability of the project, and its creativity.  Kinderwebsite was the clear favorite, although all of the projects were very good.

Two of the brains on the team behind this website were Yvonne Pulles and Matthys Timmerman, and they were very excited when the announcement came that they had won the top prize.

Lean games in Den Bosch

We played a couple of my favorite games in the last two days at our Lean training workshops at Jeroen Bosch Ziekenhuis.  The value in using simple and amusing games is to remove the participants from their day-to-day frameworks and allow them to focus on exercises that reinforce Lean principles.

Yesterday's game was designed to illustrate the concepts of 5-S, fixing the workplace so it is conducive to easy acquisition or use of needed supplies by removing extraneous materials, organizing according to how often they are used, keeping the workplace neat, reducing variation across the institution, and ensuring that these practices are persistent.  The terms used to describe these steps are: sorting, setting in order, shining, standardizing, and sustaining.

The game is a simple number sorting game.  Teams of two are asked to look at a sheet of paper and tick off the numbers between 1 and 49, in order.  The first sheet starts with a jumble of numbers going up to 100 (top picture).  The next sheet, having been sorted, appears with no numbers after 49 (see above).  The next sheet places the numbers on a grid (see below), so it is easier to find the next one in sequence.  

The next sheet offers the numbers in sequence. The final two sheets require the players to perform a quality audit, as two numbers are missing.  First, they are all presented in a jumble.  Next, they are presented in sequence.  Our students quickly saw the value of the 5-S principles, and we later went up to areas of the hospital to see how it might be applied in settings like supply rooms.

Today's game, an all-time favorite, was Pig.  It is meant to demonstrate the value and power of standardized work.  In round one, participants are asked to draw a pig on a grid, following oral instructions.  The results, to say the least, are mixed!  Compare the drawings above and below this paragraph.

In round two, written instructions are provided, and things improve a bit.  In round three, a picture is provided along with the written instructions and there are high quality, consistent results (as seen below).

Beyond fun and games, the issue of standardization is a deadly serious concept when we turn to the problem of clinical variation.  We always want to leave doctors and nurses with the discretion to vary from protocols when necessary; but, for the most part, we want to remove creativity from the workplace with many clinical procedures.  Our class viewed this problem as we watched a video of two nurses carrying out a straight-forward, but important, procedure, cleaning a central line.  Even though a written protocol exists, it contains some ambiguity.  It might be that the ambiguity resulted in the nurses carrying out the procedure in slightly different manners; or it might be that they had committed the protocol to memory rather than reviewing the documentation each time; or it might be that they simply had habitual variations in how they conducted the procedure.  But the lesson was clear to our participants:  Achieving standardized work in the clinical setting is important but difficult.

Dutch doctors thank Helen Haskell

I was honored to participate in an extraordinary meeting tonight at Jeroen Bosch hospital.  Hendrik Brink, head of the medical staff (seen at left), wanted to hold a session for doctors from various disciplines to discuss issues surrounding medical errors.  I recommended that he use The Story of Lewis Blackman, a video produced by Transparent Learning, Inc., as a way of stimulating and focusing the discussion.  The video features Helen Haskell, the mother of this 15-year-old boy who died as a result of a series of medical errors after elective surgery.  The story is powerful, and you could have heard a pin drop as it reached its sad conclusion.

After the movie, the 50 or so staff doctors and residents broke into three discussions groups and then reconvened for a plenary session. They considered questions like the following: Was the situation in the movie recognizable?  Could it happen in our hospital?  What would you teach your residents to help avoid these kind of events?  What are the obstacles to discussing mistakes--personal obstacles, those related to the patient and the family, those coming from the colleagues in your own discipline, and those coming from colleagues in other disciplines in the hospital?

Hendrik was assisted in facilitating the discussions by medical education dean Hans Hoekstra (seen above) and JBZ patient security officer Marjo Jager.  They helped elicit comments and observations that were thoughtful and heartfelt.  It was a very good evening.

At the closing, I asked them what messages they would like me to relay to Helen if I happened to see her in the coming days and weeks.  Here they were:

Please tell her that we deeply appreciate what she has done in permitting this video to be made and in contributing personally to it with her extensive appearances on screen.

Please tell her that watching her make us feel that she understands the issues we face and that we therefore consider her to be a real partner with us in the medical community.

Please tell her that we will think about Lewis' story often and will do our best to make sure that this kind of tragic event does not occur in our hospital.

"No such thing as bad student, only bad teacher."

As we head into day two of our Lean workshop here at Jeroen Bosch Ziekenhuis (hospital) in the Netherlands, it is good to reflect on the nature of complex organizations and the messages given by an organization's leaders to the staff.  Why is it that people in hospitals engage in wasteful activities and behavior?

I posed the question in a slightly different form to our participants as a huiswerk (homework) assignment, asking them to write a short essay in response to this true-false question:  "Waste exists at JBZ because people are uncaring and lazy.  Provide evidence for your answer."  As expected, the unanimous answer was "false," and people offered the following commentaries. 

John replied with some evidence of the staff's good intentions:

Last Saturday we had an disaster exercise where a few hundred employees of the JBZ took part on their day off.  We saw a lot of enthusiasm and willingness to learn.

The employees on my unit are happy to share their knowledge with other units, in collaboration, teaching, exchanges.  They also did this for a television series about emergency care.

Anne-Marie agreed about these good intentions:

The willingness of the staff is great. They are willing to do something extra.

Monique observed, though, how people can be trained to become resigned to the way things are:

Employees are often not listened to when so they report on a problem. When people say something several times, where nothing is done, they get a resigned attitude and do things no longer. 

Hélène expanded on this thought:

 

If nothing is done by managers with signals of ineffectiveness from the staff, indifference arises and there will be more wasteful actions. 

Judith concurred, noting the inevitable presence of inertia in such situations:

A lot of things that we do we do because “we always do this like that”.

Or, noted Paul, the staff are forced to invent work-arounds:

The employees are very creative in circumventing problems that occur, causing many inefficiencies.

And then Monique offered the following underlying causes:

There are too many islands in within the hospital.  People can not or will not "watch each other's kitchen" so everyone re-invents the wheel and things are not aligned. 

If you are a long time in the same spot you will get, whether you intend to or not, a tubular vision. Someone from outside your processes can give you a whole new image and ensures that your own eyes widen.

Riny gave a similar diagnosis:

People who work in the JBZ are certainly not lazy and indifferent. It is working protocols and regulations that are not kept up to date that cause waste to occur. People in the JBZ work hard but must abide by certain old rules that are not based on the current situation. This results in noise and miscommunication, making much unnecessary work.

Jacqueline agreed, noting:

Preconditions do not always exist for employees to be efficient, and to experience the pleasure of  satisfaction. This frequently leads to demotivation and resignation.

Karin asserted that change is difficult because of the multitude of constituencies found in a hospital:

The people working there are involved and are willing to think about changes and improvements. Very often, secretaries in the clinic indicate that some things do not work. Often they already have an idea of ​​how it could be otherwise. To carry out these solutions, though, is complex. Often they must then be discussed with other stakeholders (other secretaries, nurses and medical specialists) because they would also have consequences for those people. Sometimes there is no agreement about the proposed solution.

But Jo then emphasized the importance of leadership in resolving those complicated interactions:

Leadership is crucial in achieving results and how we work on a unit.

And Hélène explained,

To prevent indifference, an equal dialogue with respect and trust is necessary, between a manager displaying serving leadership and the employee.

Izaak expanded on this, saying:

I think there are lots of initiatives that show the enthusiasm of staff to improve quality and safety. Sometimes the enthusiasm gets lost because of the lack of empowerment by the management. We forget to celebrate the success in improvements that are made on the initiative of staff members.  This gets back to them as lack of interest from the management in their efforts.

The answers are an important reminder that the introduction and dissemination of the Lean philosophy--or other any approach to improving quality, safety, and efficiency--requires leadership attention to the nature of how people learn and improve.  Our goal is to create a learning organization, to be "good at getting better" in the face of exogenous and endogenous challenges.  Leaders must have sufficient empathy to respond appropriately as the staff goes through the stages of learning--interest, distress, and pleasure.  If leaders are not attuned these stages, the staff will not learn the right lessons.  Then, we will be reminded me of Master Miyagi's statement in The Karate Kid: "No such thing as bad student, only bad teacher."

It is not the fault of well-intentioned and dedicated staff if they do not learn the aspects of process improvement that can transform a hospital: It is a failure of leadership.  As set forth by the great basketball coach, John Wooden, "You haven't taught them if they haven't learned." 

Lean lessons at Jeroen Bosch Ziekenhuis

I was so pleased to be invited back to Jeroen Bosch hospital in the Netherlands to conduct some three-day workshops on the Lean philosophy for a number of the senior managers.  Now, you can't learn everything about Lean in three days, but this set of seminars is designed to cover some of the basic principles--and especially to get participants out on the floors to see what life is like for the front-line staff.

After being greeted by hospital CEO Willy Spaan with a pertinent quote from William Glasser's Choice Theory, we started with the marvelous video Toast, produced by the GBMP.  Here, you see participants chuckling as Bruce Hamilton displays the simple inefficiencies of the toast "production" process in his home kitchen.  By viewing waste in this kind of neutral setting, people avoid getting defensive and applying preconceptions and then are better able to apply the lessons to their own workplaces.

Then it was off to gemba, to shadow various people throughout the hospital.  The point here was to identify the obstacles that people face in doing their day-to-day work and to learn better how to see waste in the organization.  Not by interviewing the staff people, but by just watching them do their work.  For example, here you see Paul van Hall, unit manager of Perinatology, as he has a chance to watch Evelyn in the central sterilization area as she organizes surgical instruments for cleaning. 

(This kind of exercise has to be done very respectfully and carefully, lest those being shadowed fear that they are being judged.  Instead, they are told, truthfully, that the point is for senior leaders to learn about how things are done in the hospital.  Most people being shadowed soon forget they are being watched, and many later express appreciation for the interest shown in their work.)

Upon their return, we asked all the participants to tell some stories of waste they had seen and to enter the examples into the categories symbolized by the acronym UWITDMOP, standing for Unused Human Talent, Waiting, Inventory, Transportation, Defects, Motion, Overproduction and Processing. (Check Mark Wroblewski's blog for a variant, WORMPIT!)  The examples seen at Jeroen Bosch were quite similar to what I have seen in other hospitals and are common to all kinds of large, complex organizations.  Also, the experience of going to gemba opened the eyes of many of these managers, as they gained appreciation for the obstacles encountered by staff every day and for the tendency to invent work-arounds to carry out their tasks.

Social media hospital usage compared

Our friend from Nijmegen, @lucienengelen, presents an infographic prepared by one of his colleagues about the use of social media in hospitals, comparing the Netherlands, the UK, and the US.  Tom van de Belt did this by crawling through the websites of hospitals in the same way an interested patient might do so.  Here's an excerpt showing the relative use of Facebook, LinkedIn, YouTube, and Twitter:

No surprise on my part with this result.  US hospitals tend to be slower on the uptake of such tools.  Indeed, some even block the use of social media on their hospital servers!

Wachter comes to Boston

@MITSS_Support. Boston area people are in for a treat if they attend the annual dinner of MITSS (Medically Induced Trauma Support Services) on Thursday, November 29.  The keynote speaker is Bob Wachter, from USCF.

Regular readers know Bob as one of the world's experts on quality and safety in health care. (See this post about his book.)  He's also a kind and wonderful person who will certainly set just the right tone for this organization, whose goal in life is To Support Healing and Restore Hope to patients, families, and clinicians whose lives have been impacted by medical errors and adverse medical events.

Brown versus Warren: A pre-Election Day view

Back in August, I offered a pre-Labor Day view of the Scott Brown-Elizabeth Warren race for US Senate here in Massachusetts.  I suggested that Warren was in trouble on the emotional front having "failed, so far, to convey in a visceral way who she is and why we should like her."

The polls now show a close race with Warren ahead by several points. I'm hearing otherwise in my unscientific research.  My non-random sample (in Middlesex county) has been college-education, employed men and women who view themselves as being on the liberal end of the political spectrum.  I first ask them how they handicap the race and, without provocation, most then tell me how they really feel.  These are the kind of sentiments I get from men:

He's a good guy who works in a bi-partisan manner.  We need people like that in a divided Congress.

From women:

I feel like she is lecturing at me, and I am tired of it.  I don't want to have to listen to that for the next six years.

From both:

Isn't it a good idea for Massachusetts to have some Republicans in the delegation?

These reactions are in spite of an acknowledgment that they might agree more with Warren's policy prescriptions.

Interestingly, the presence of young Joe Kennedy as the apparently anointed replacement for Congressman Barney Frank may have a spill-over effect into the Senate race.  People seem to take his election as a sure thing because of the family dynasty, but they are uncomfortable with that presumption, even if they plan to vote for him.  How odd if his being on the ballot actually causes cross-overs to Brown!

Speaking of cross-overs, let's consider the impact of the elimination of polling machines--where you just run you hand down a bunch of levers and vote for one party--to the use of paper ballots--where you can't.  I voted early this week because I will be away for election day.  You have to work hard to vote a party line.  The placement of the Democrat and Republican on the ballot is different in each race (President, Senator, Representative.)  While Obama will sweep the state (after all, we really know Romney!) I expect to see a lot of cross-overs this year in the other races in Massachusetts.

Ex-external defibrillator

Is this a trend?  I noticed this excised AED in a building at MIT.  My colleague there suggested that this and others had been removed because of the difficulty in ensuring that they would be properly maintained.

Have others seen this in other buildings where they work or places they frequent?  I wonder if these kind of devices will end up like those home exercise machines, abandoned after a short time.

So what do they do for us?

A recent blog post by Sarah Kliff on Ezra Klein's Workblog sets forth the strategy and plan of the nation's insurance companies to lobby Congress after the election. The purpose:

Moving into a potential debate over deficit reduction, health insurers want to carve out a different role in Washington. Namely, they don’t want to be the bad guys anymore. To that end, they’ll soon start arming their lobbyists with data that argues that other health care sectors are actually the ones to blame.

Check out the charts.  You will be pleased to know that the rate of growth in insurance premiums lovingly tracks the rate of growth in medical costs in the country.  In the 2010s, for example, medical costs rose 54.61% and premiums rose 56.09%.  What that is supposed to tell us, I don't know.

Is it meant to tell us that insurance costs as a percentage of overall health care costs have stayed roughly constant?  I guess so, as seen in this chart:

So, let's think this through.  As health care costs have soared over the decades, the insurance companies' share of the costs have stayed about the same.  That means that they have been unable to implement the kind of technological and operational efficiencies of other sectors in the financial services industries.  Such is certainly the case in Massachusetts, something I noted a couple of years ago:

Golly, we see an average annual increase in the administrative costs of Massachusetts insurers of 9.3%. How can this be the case? In other financial services industries, unit costs of transactions have gone down, not up. What is it about health care that suggests the opposite should be the case? 

But let's go further. The lobbyists plan to use a chart showing the overall growth in US health care expenditures.  Here it is:

I don't know the purpose of this.  I think it shows that those in the industry are tacitly admitting their failure to contain prices--if one accepts that is part of their function.  But is it?  Actually--as I have just noted--if their share of the health care budget has stayed constant, they have had an interest in watching the total number of dollars go up.

What's the next phase?  Well, if the Massachusetts experience is prologue, the insurance companies will next want to shift risk as much as possible from them to the providers, doctors and hospitals.  As I have noted about Blue Cross Blue Shield of MA:

Think of it.  The firm, in the face of little or no empirical proof, has persuaded an entire state to adopt a rate-making approach whose main value is to shift risk from it, the dominant insurance company.  Now, risk does not disappear.  Usually in society, we pay people to assume more risk.  Also, people from whom risk is shifted usually expect a lower return.  Here, the risk is shifted, but the insurance company gives up nothing.  Indeed, it is secure in pricing its product because it knows exactly how much money it will pay out in medical claims.  Meanwhile, the percent of premiums it collects to cover administrative costs remains remarkably constant, even as revenue grows.  The capital reserves that it has accumulated over the years to cover actuarial risk remain untouched, even though the degree of risk assigned to it has fallen.

There may be an odd result from this lobbying campaign:  Insurance companies will have destroyed every argument for them to exist.  They will have demonstrated that they have had no impact on overall health costs.  They will have demonstrated that they are a constant tax on the growing health care budget.  Meanwhile, they will no longer be insurers, having shifted risk away from them and on to other parts of the sector.

In short, they will have done everything possible to justify a single payer health system.

With undergrads at Northeastern University

It was back to Northeastern University today, this time to address Professor David Boyd's undergraduate leadership class.  You see him here with Caroline, one of the students who made a very good observation.  Pictures of two others are also included here.

Today's topic was the paradox of hospitals in America (and elsewhere).  Well-intentioned, intelligent, and well-trained doctors somehow participate in making hospitals extremely dangerous places to be.  (Listen to this story on Marketplace for more particulars on that topic.)

We spent a lot of time talking about the nature of medical errors. In particular we discussed the concept of normalization of deviance, explained nicely in this blog post by Steve Whitehead:

Each time a behavior or standard doesn’t lead to a catastrophic result, we are more tolerant of that standard.

It makes for an interesting contradiction. A history of success and positive outcomes does far more to erode our standards than a single negative outcome. The longer our success, the more normalization of deviance comes in to play.

Get away with doing something unsafe or substandard enough times and the unsafe and substandard become your standard.

Cognitive errors of this kind are rampant in organizations where work-arounds become the norm.  Each time some well intentioned, task-oriented person designs a work-around to overcome some obstacle in the workplace, it creates the potential for an unsafe or wasteful process.  Quality and safety in hospitals therefore requires a knowledge of cognitive errors and of the science of process improvement.  The leaders of such institutions need to create an environment in which mistakes and near-misses are cherished as opportunities to be "hard on the problem and soft on the person," rather than opportunities for blame and criticism.

With the Northeastern MBA's

I always enjoy giving guest lectures at Professor David Boyd's leadership classes at Northeastern University. Last night's session with his MBA students was no exception.  As is my custom, I include pictures of a few who made particularly insightful observations.  Names are included so you can hire them!

I started out by asking the students to set forth likely characteristics of the high performing anomalous company in a given business sector.  Mark, here, pretty quickly keyed in on the importance of empowering front-line staff.

But, what, I asked, did we hope those front-line staff would do?  Someone replied, "To suggest solutions to problems in the workplace."  We probed this a bit and concluded that--while suggested solutions were always welcome--the more important value brought by front-line staff is to point out problems in the workplace.  What conditions might lead to poor production quality, to a poor production process, to waste, or to an unsafe condition?  The responsibility then falls to the supervisor to be responsive to those concerns and to bring in people from throughout the company to explore the problem in real time, invent possible solutions, and experiment with those.

I had them recall the work of Steve Spear, who has diagnosed companies that do well.  Here's a summary from a previous post:

As Steve has written in his studies of Toyota and reviews of other high performance organizations, the common characteristic of these organizations is not in their ability to design perfect and complex production or service delivery systems. Rather, it is their ability to discover great systems. They do this by managing their work flow to encourage people at all levels to call out problems; to "swarm" together to solve those problems; to share this process of discovery with others in the organization so that the solutions are diffused widely; and to cultivate the skills of people throughout the organization to be involved in this kind of constant improvement.