Dan Jones at Medical Grand Rounds

Dan Jones continued his visit as our Judith and Robert Melzer Visiting Professor in Health Care Quality and Patient Safety with an appearance at Medical Grand Rounds. You see Dan here with his friend and colleague Jim Womack.

The topic was "Realizing the potential of Lean thinking in healthcare." I'll try to hit the highlights.

Joking that, after visiting our hospital, "I'm encouraged because your problems are the same I see everywhere else," Dan set forth the challenge as one of delivering more and better service to patients for less money. He noted that progress in the quality movement can be viewed an complimentary to implementation of Lean approaches. Whereas the quality movement strives to define best practice interventions and to eliminate variation and errors, Lean focuses on the context of the flow of work to eliminate delays for patients, wasted effort for staff, and unnecessary costs. The two movements share a common sceintific-evidence based methodology.

Lean, says Dan, begins with engaging the staff in improving work, liberating the potential to take action. But, he warns, point improvements are hard to sustain without an end-to-end perspective and management systems to support them. There is a need to manage an interdependent process throughout an organization. This requires a different level of engagement, in that making the system more "fragile" and subject to interruption is an inherent characteristic of the lean approach.

Dan illustrated the hospital environment as a set of processes (see above). Usually, nobody can see the whole set of interactions, "but we need to be able to do that," or each segment will just react to events rather than working on the greater good. In the example he gave us, he showed an analysis of patient flow from the emergency room through to discharge. "If demand is generally predictable, why are there so many delays" he asked, "both at the front end in the ER and at the back end, waiting for discharges?"

Based on his work at many hospitals, he noted that there are pioneers who have make progress in each segment of the care process. "Yet, the big opportunity is leveraging the gains of that work by linking the entire system together. The challenge, now that we see the hospital as a collection of processes, and we know how to improve most of them, is to connect all the pieces together."

After a detailed review of one particular case, Dan laid out the conditions for successful implementation of this kind of integrated approach:

There has to be a will to act.
Someone has to be the value stream manager, the person who takes end-to-end responsibility.
That person works to establish the foundations of progress: stability and visibility.
That person has to gain agreement from the team on the right actions, based upon the facts on the ground.
That person has to have the backing from senior officials to resolve conflicts that arise between departments and the overall value stream objectives.
That person, has to be able to deliver results, and yet has to do so with no authority over resources (just like the engineers at Toyota.)

Our doctors and students were engaged and very interested in all of this. Many had been primed by previous activities and instruction from Mark Zeidel, our Chief of Medicine. But, I think the fact that this is a whole new way of thinking about care delivery was evident to the audience. It is an approach that will take lots more practice and thoughtful planning and priority setting for hospital-wide implementation.

Figures lie

The old adage about "figures lie" takes on a new meaning when you are the target of an SEIU corporate campaign. In a recent mailing sent to the homes of our staff members (accompanied also by voice mails left on home phone lines), SEIU cites the rise in the cost of insurance benefits to our employees and notes that a number of our staff relied on "taxpayer funded health insurance."

Well, it turns out that many employers in the state, including unionized organizations, have employees who rely on taxpayer funded health insurance. Indeed, that was part of the design of Chapter 58, the universal health care coverage law passed a few years ago (the one being used as a model for national health reform). Here is the chart published by the Commonwealth of Massachusetts on this topic. Let's see a sample of which governmental organizations and nonprofits are included: The Commonwealth of Massachusetts itself, City of Boston, U Mass, Salvation Army, City of Springfield, Brigham and Women's Hospital, Bay State Medical Center, Boston University, Boston Globe, Catholic Charities, Action for Boston Community Development, U Mass Memorial Health Care, City of Cambridge, Boston College. As you can see, there is a mix of both unionized and non-unionized organizations included.

The SEIU mailing also decries the fact that our workers last year had cuts in earned time, retirement benefits, and raises. Absolutely true. As has been documented in national and local news coverage, BIDMC was a national example in avoiding hundred of layoffs by asking workers to make a sacrifice for the greater good. And all the while protecting the lowest wage workers by ensuring that they would continue to get raises. This is what happens when workers care for one another. In contrast, how many stories have you heard about where unions have refused to consider this kind of shared approach, resulting in layoffs of their most junior members.

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.