Salisbury Treats

Not so interested in game? How about these pastries from The Polly Tea Rooms in Salisbury? Just the thing after a tour of the cathedral.

Are you game?

Another in our weekend travel series. This is M. G. Fidler, proprietor of the Bladebone Butchery in Chapel Row, England. The shop is styled as "High Class Family Butchers & Game Dealers." He's seen here describing the fine points of pheasants, or is it grouses? I always get them confused. Call 0118-971-3508 to order....

Peg's story

The next speaker at the seminar (below) was Peg Metzger. Peg has been involved professionally in health care issues for many years but found herself a patient harmed in a Boston hospital. Her story reinforced Tom's lesson about the anatomy of apology.

She went for an outpatient ERCP 18 months ago. Her small intestine was perforated. Septicemia and necrotizing pancreatitis developed, and she ended up fighting for her life in the ICU. As she entered the ICU, she woke up and heard people talking and realized that she might die and that the doctors didn't know if they could save her.

Peg spent 63 days in the hospital over 7 admissions over the next ten months. There were many unexpected complications and developments, and "I suffered pain that was unimaginable." "Each setback was emotionally devastating, but I always tried to be upbeat."

"The most upsetting aspect was my doctor's response. The doctor did explain that things had not gone well," but did not tell the details. Later, when the doctor explained more, I told her that "It was not your fault" to try to make her feel better. "Unfortunately that was the last time I saw her. In all my hospitalizations, I never heard from her again. I didn't know if she was even following my case."

"I was undone by her disappearance. This leaves me tormented to this day. My life matters, and I think she should have behaved as if she thought so, too. I thought she was my doctor, and she bailed on me. It was unfathomable to me. Her seeming indifference added layers of torture to my existence."

In addition, the GI department in which her case occurred never followed up in any way.

Peg offered four take-away messages for health care providers:

1) Overcome your fears and say something. Don't try to hide. The trust the patient has in you will turn to rage if you display seeming indifference.

2) Don't wait. Act sooner rather than later. What it takes to make the patient feel supported at the beginning is small compared to what is needed later when it has been neglected early on.

3) Study the work that has been done on this and learn the techniques that have been developed, so you'll be ready. But your words don't have to be perfect.

4) Patients who experience these events have been damaged and deserve remedies or reparations.

Tom teaches about apology

This seems to be the week for meetings about error, disclosure, and apology. I am currently at a very worthwhile seminar today entitled "Medical Errors: The Power of Apology, Action and Forgiveness" at Hebrew Senior Life (co-sponsored with BIDMC.) The lead-off speaker is Dr. Tom Delbanco who reminded us that people who have been injured in the health care system often suffer from guilt, fear, and isolation. He noted that guilt, fear, and isolation are equally shared by the doctors and nurses who have been involved in medical errors. His point was that we need to bring down the walls that separate the two groups, and he offered strategies for doing that.

Tom noted that the anatomy of an apology is extraordinarily important. One person is in the mood to apologize and one is in the mood to be very upset. He created a scenario (based on someone crashing into someone else's car) and asked the audience to work in pairs, and take the two roles and spend a few minutes apologizing and receiving the apology. He then changed the scenario, and asked one person to be an injured post-surgical patient and the other the apologizing MD. Quickly, the buzz in the room changed as the one case, with lots of noise and laughing, transmogrified into the other, quieter and more serious.

"This is hard work. It's not easy. Most of you are not trained to do this," noted Tom. The same is true, he noted, for doctors. He talked about medical students he teaches, many of whom have seen an error in the course of their training, who say, "I don't have a clue how to deal with this."

What are the necessary steps in a proper and effective apology? Here's the summary. First, go over details openly and clearly with the patient about what happened. Second, display and feel real empathy, and say "I am really sorry." Third, tell the patient that a root cause analysis will be done, and that I'm going to find out what was the cause of the accident. Fourth, and most important, say what I am going to do about this so it won't happen in the future to another person. Research indicates that this last part is what patients really want.

He ended by charging the group with taking what they had learned today and trying to apply it in their practice of medicine. The talk was very well received by a diverse audience of care providers and lay people.

A thorn between two roses

I usually don't post pictures of myself here, but this one is very special to me. It was taken last night at a fundraiser for MITSS, Medically Induced Trauma Support Services. That's Linda Kenney on the left. She founded MITSS out of her own terrible medical experiences. Margaret Murphy, who flew over from Cork, Ireland, to give a talk at the dinner, created a patient advocacy organization after watching her son die as a result of a series of medical errors.

These two women are extraordinary. They had every right to be bitter and angry from their absolutely awful experiences. Yet, they reached down deep into their hearts and souls and transformed those events into programs that will help patients and providers for years to come. In so doing, they set an example for us all. I was honored to be asked to join them last night.

(Thanks to Bob Bennett of Bob Bennett Photography in Middleboro, MA for the use of the picture.)

Next step for labor in Washington

With a new administration and Congress in place, we can expect a strong push for a new law that would eliminate secret ballot elections during certification drives by unions. This is the hallmark of efforts by the SEIU, which has received commitments from the President-elect and the Congressional Democrats that they will push this bill.

There is only one problem: Americans believe in secret ballot elections. Indeed, the one held on November 4 once again validates the importance of this great institution.

The SEIU and Democrats will try to brand Republicans as "anti-union" when they oppose this legislation. If the Republicans maintain a filibuster-proof minority in the Senate, the bill will not proceed. But even if the Democrats end up with 60 votes in the Senate, "Blue dog" Democrats will not want their name attached to this bill in a roll-call vote on cloture.

William B. Gould IV, chairman of the NLRB under President Clinton, recognizes this political reality in a Slate article published earlier this year, noting "Secret ballots to resolve union representation are the way to go." He follows this up with his thoughts about a compromise on the certification process that he thinks would be broadly politically acceptable. I don't know enough to know whether his detailed suggestions are reasonable, but his general analysis is certainly cogent.

One of the many tests facing the new President is whether he prefers to fight a combative battle on this issue -- among all the others he is facing -- or whether he will try an approach that brings people together.

And a similar question is whether Andy Stern, head of the SEIU, will acknowledge that Americans and their Congressional representatives will be very uncomfortable with his proposal to eliminate elections and will say quietly to his friend the President-elect, "If you back off from your commitment to card-check as part of a bi-partisan deal, labor will still support you and the Congresspeople who vote with you."

Getting specimens to the lab

Not to overwhelm you, but this stuff is really exciting for our staff, and I hope you can understand why. I present another result from BIDMC SPIRIT, this one having to do with the collection of specimens. Can you think of anything more vital to how a hospital runs every day? Note that it was called out by a transporter, and see how this caused a varied group of people to work together. What better way to demonstrate our respect for each and every person working here?

This one took a while to fix because it was a pretty convoluted, complicated, and broken process. For those reading this series of posts, please note, though, the repetition of key steps in the improvement process. Part of what is going on here is that staff members at multiple levels in the hospital are learning a consistent way to address process improvement. Thus, the organization as whole grows while individual problem areas are solved.

Where did we start?

On 5/13/08, callout made by transporter regarding amount of time spent and uncertainty re: value added reconciling GI specimens.

After discussion among staff from all departments involved (including front line staff, managers and Sr. VPs), the group determined that the entire process of tracking and transporting specimens from the procedure room to the lab (not just transporter specimen sign-out) offered multiple opportunities for process improvement:

Problems identified included:

§ Location of the specimen tray was far from the procedure rooms;

§ It was deemed unnecessarily time consuming for every individual specimen to be “signed out” by a transporter and not clear that it added safety;

§ There wasn’t an opportunity built into the system for the GI physician to interact with the GI nursing staff so that information could be compared on the specimen requisition and the specimen jar label;

§ Paperwork to accompany specimen was not always completed in a timely and uniform manner;

§ Confusion about transport pick-up times;

§ No reconciliation taking place when specimens arrived in Pathology and no immediate feedback to GI of missing specimens;

§ Time and “peaks and valleys” of volume of specimens delivered to pathology caused operational challenges for pathology;

§ Not all steps were defined and standardized;

§ Process resulted in delays;

§ Opportunities for staff time in all 3 areas to be more productive and satisfied;

§ # and process for hand-offs created opportunities to lose specimens;

§ Frustration/tension among departments (GI, transport, Pathology);

§ Project was good one to provide opportunity for many BIDMC staff to apply Lean/SPIRIT principles.

What process did we use to design new process?

1. Front line staff and managers from each area described current practice and problems.

2. Included GI physician in design process.

3. Drew process flow for entire current process, listing all problems/potential for errors.

4. Group described “ideal” state (using “Lean” principles described below). New process flow drawn.

5. Entire group developed specific steps for each activity in process, understanding each others’ roles.

6. Tweaked process flow as specifics required.

7. Challenged any step that was inconsistent with “design principles” to get closer to “ideal”.

8. Rolled out new process; called out outstanding issues – continued to tweak process; managers shadowed staff; process improved continuously when problems arose.

9. Deemed successful and ready to be “spread” to other procedural areas.


“Lean” principles used to shape “Ideal” new process

“Activity” Principle: Specify all steps in process;

“Connection” Principle: Ensure communication and hand-offs can be carried out appropriately;

“Pathway” Principle: Include no (or minimum) “forks” or “loops”, i.e., each member of the team should have one clear path to follow;

“Improvement” Principle: Use scientific method (data driven, evidence based, willingness to experiment), involve front line staff, keep improving -- “call out” when unable to perform step as specified.

Major Elements of New GI Specimen Tracking/Transport Process

-- Specimen tracking book moved to more convenient central location in GI, reducing delays and distance staff need to walk.

-- Binary connections between staff members: Procedure RN and MD interact directly (when possible) with resource nurse at time of dropping off specimen and req so discrepancies can be discovered and remedied at time of hand-off.

-- Consolidation of responsibility: One resource nurse designated to “tag” all specimens. As a result, process occurs in more timely fashion and specimens are delivered more uniformly to pathology.

-- Modification of Sign-Out Sheet: Transporter no longer has to sign out each individual specimen by patient name.

-- Each patient’s specimen placed in single clear bag (easy for nurse to count/identify).

-- Each patient bag placed in large disposable clear bag with single letter designation eliminating need for Transport to return to GI in between and bags to be tracked to Pathology.

-- Completion of reconciliation process in Pathology.

-- Rounds occur more frequently/consistently which GI can count on and delivers more consistent number of specimens to be delivered to Pathology (did not require adding resources as transporter time freed up by not having to complete individual test reconciliation as noted below).

-- Log created so Transport could indicate what time they arrived/which lettered bag they dropped up. This also includes a column for Pathology to indicate # number of specimens that were actually in the bag.

Bottom Line

-- A reduction of 57% in the amount of time between when a specimen was ready for transport and when transport arrived to pick the specimen up.

-- A reduction of 61% in the time it took to transport specimens to Pathology.

-- Freeing up of hours of transport time/day without sacrificing the safety associated with this task.

-- Much improved workflow for the pathology techs.

-- Improved communication between nursing and physician staff, further reducing instances of mismatched information between the specimen label and requisition.

What does this mean to BIDMC?

Reduction in time-wasted activities by staff
+
Clarity in role responsibilities re: specimen tracking
+
Consistent and standard process from point specimen is taken to point specimen is received in pathology
=
Improved Patient Care/Safety Controls + Improved Employee Satisfaction and Collaboration + Better Use of Resources

Next Steps

Spread this standardized process (with refinements as needed given the specific operations and physical layout of each department) to all departments in the medical center that collect and send tissue specimens bound for the department of Pathology.

The actual numbers

This graph shows the progress described below.

Fixing bad blood tests

Here's another example of process improvement that typifies BIDMC SPIRIT, with remarkable success resulting from application of Lean principles, applied with advice from our small, but able, Business Transformation group. I supply an edited version of the narrative given to me:

What do you get when you cross well intentioned Emergency Department (ED) Nurses (RNs) with fastidious laboratory technologists? You get a problem, an opportunity, and a bevy of talented professionals poised to collaborate on a mutual solution.

Why would ED RNs do anything that might delay treatment? Why would a lab technologist take an extra 56 minutes to provide a potassium test result? Why…because each role cares deeply about the patient; but in divergent ways. This divergence spoke to us. We had two groups not understanding the impact they had on each other, and combined, their impact on patient care.

As this scenario shows, many patients cross multiple departments and value streams as they receive care. The departments knew that quality was a problem but wanted to benchmark how they stood in relation to the rest of the hospital. One measure of quality in the ED is the hemolysis rate (the rate of defect specimens that skew a patient’s laboratory test results). Data was collected by the ED nurses and laboratory technologists and was then presented in a rapid improvement event to uncover the root cause of the quality problem.

The hemolysis rate for lab specimens collected in the ED was found to be 22.4%, approximately five times their counterparts on the inpatient units (3.9%). This rate had several deleterious effects: patient’s hemolyzed specimens often had to be recollected and retested, therefore these patients had to wait on average 56 minutes longer for lab results, and frustration levels in both the ED and the laboratory were high.

As we knew, hemolysis is a byproduct of improper specimen collection and has an unintended effect on lab results. The effects on results can be can be minor, moderate, or actually cause inaccurate and incorrect results. One test in particular, potassium, is significantly impacted by hemolysis. It is a very significant test for heart patients where small changes can be noteworthy. We saw an opportunity to examine practice, past studies, and identify opportunities for improvement. A decreased hemolysis rate would result in improved ED throughput, reduced length of stay for the patient, fewer recollections (savings in both time and materials), and better patient satisfaction.

To address the high rate of hemolysis in the ED, two in-depth studies were completed. The first was to obtain the hemolysis rates for collections via an IV insertion versus a peripheral blood draw (venipuncture). The second study focused on hemolysis for specimens drawn through the IV using one of three methods: Vacutainer, extension tubing, or syringe. The data indicated that specimens collected during IV insertion showed a much higher rate of hemolysis, especially when using a vacutainer (the ED’s current preferred method).

We also assembled other hospital experts. The phlebotomy manager and a venous access nurse came to our event to observe, comment, and critique our ED nurses and ED techs as they simulated current practices (on a dummy arm). Each of us learned a lot and took note of areas in the process where we noticed a lack of standardization. We were most struck by the variability of practice, not only staff in the ED but of staff around the medical center. Thus, we had a great opportunity to standardize and create best practice for the medical center. A mistake-proof, proper technique is the key to preventing hemolysis.

Our goals were simple: develop a standardized method of drawing labs in the ED by engaging the ED and lab staff who do the work and strive for the common goal of reducing the hemolysis rate by over 18%. This would generate a cost and time savings as a result of fewer patient re-sticks, fewer repeat tests, improved quality due to better sample integrity, and potentially contribute to higher patient and staff satisfaction.

Our intent was not to place blame but rather to really understand the root of the problem. We gathered data from other areas of the hospital which also collected specimens during an IV insertion. Each area reported no problems with hemolysis, but our investigation uncovered they did, in fact, have a problem. None of the tests they ordered were impacted by hemolysis; so these groups were unintentionally blind to the problem. But this showed us that the individual technique of the person collecting the specimens although variable, is less of the root cause.

As we talked about hemolysis, we broadened our outlook and realized how complicated this is to operations. Due to the unpredictable patient flow, changing clinical needs of each patient, and variability of each RN, ED Tech and MD practice-styles, this was a very complex process to define. But we were committed to finding a solution. Each area owned this problem and for various reasons wanted to find a solution. The lab would have fewer critical values to repeat, call, and document. The ED would have fewer patients to re-stick, faster results, and happier patients.

During our time working on this issue we learned and communicated the following to the respective Lab, and ED staff:

• Long tourniquet time (>1 minute) increases Hemolysis
• IV product manufacturer does not support blood draws from IV equipment.
• Medical center IV and Phlebotomy Experts do not teach or recommend IV Draws
• Most ED staff worried about sticking the patient twice (once to set-up an IV and again to draw blood through venipuncture) - creating a negative experience for the patient. However, almost 30% of the time they did stick people twice due to Hemolysis which created a 56 minute delay.

We embarked on a pilot project after the event. Our intent was to stop collecting blood specimens at the time of IV insertion. To accomplish that goal, the ED techs (who only can draw via venipuncture) would draw all of the blood. Prior to the implementation, our phlebotomy team retrained the ED techs according to the Pathology venipuncture standards. Once this process was in full swing, the plan was to review all specimens from the ED and check the tubes for hemolysis and feedback the data to all of the parties on a daily basis. Each day the lab reviews over 100 specimens collected from the ED needing potassium results. We post the daily hemolysis rates and investigate each hemolyzed specimen with the RN caring for the patient. The average hemolysis rate over the past few weeks is now averaging 6.5%. As of this past Monday, this trial becomes the official way we draw blood in the ED.

We realized these incredible results by walking in each other’s shoes, touring each other’s areas, and understanding impacts by using data. We talked to each other and brainstormed together and cooperatively moved forward. Lab staff now attend the ED huddles so continued learning and sharing can take place; even after we solve the hemolysis problem.

In the end, it was our collective actions, willingness to put departmental issues aside, strong desire to improve the patient experience, and ultimate respect for each other’s talents and expertise that propelled our project forward.

Name, Role, Title
Gina McCormack, Pathology Admin, Operations Director
Kirsten Boyd, ED Director, Director of ED
Larry Mottley, ED MD, Quality MD
Jane Dufresne, ED CA, Clinical Advisor ED
Steve Wood, ED RN, RN Staff ED
Tammy Galloway, Chemistry, MGN Chem
Manny Alves, Lab West, Lab Supervisor
Blanche Murphy, Venous Access Nurse, RN Staff ED
Susie Fontes, ED RN, RN Staff ED
Pam Hulme, Phlebotomy, Customer Service manager
Kellie Glynn, ED RN, RN Staff ED
Christine Yennaco, ED Tech, Staff Tech ED
Brian Orsatti, ED Tech Supervisor, Tech Supervisor
Alice Lee, Lean, Office of the President
Kimberly Eng, Lean, Office of the President
Brandan Holbrook, Lean, Office of the President
Bonnie Baker, Lean, Office of the President

Whew!

See post below. A good result, by a very substantial margin.

Please vote "No" on Question 1

I want to take a moment to talk to readers who are registered voters in Massachusetts. I have a simple message: Please vote on November 4 and please enter a “No” vote on Question 1. This is a binding referendum question designed to eliminate the state’s income tax.

The income tax accounts for $12.6 billion, or about 40 percent, of the yearly state budget. Proponents of the question assert that there is sufficient waste in the state budget to offset these cuts. But this is simply not true. Let’s say, for instance, that all of the 68,000 state employees were fired, $5 billion would be saved.

What else is there? Medicaid? Medicaid already pays the lowest rates to hospitals and doctors, when compared to private insurers and Medicare.

Interest payments on state bonds? I haven’t met anyone who thinks that it would be wise to undermine the Commonwealth’s credit rating in this fashion.

Supplies and equipment for state prisons, state colleges, state parks? No one has presented evidence that these expenditures are out of line.

State aid to cities and towns for schools, fire protection, and police service? Please, those municipalities are already facing their own budget struggles.

And so on. It is very easy to assert that there is sufficient waste in the state government to absorb a 40% budget cut, but there is simply no support for this conclusion.

Of course, we could eliminate the income tax and replace the revenues with higher sales taxes or property taxes. But those revenue sources are more regressive than the income tax, putting disproportionate burdens on lower income families.

In summary, please vote “No” on Question 1 at the polls on November 4. Thank you.

Is unilateral public disclosure really necessary?

Regular readers will know that BIDMC is remarkably open in publication of clinical outcomes, taking transparency to a place seldom seen in American hospitals. Our governing boards are comfortable with this and are strongly supportive even though it occasionally leads to publicity of the sort that can sometimes get them nervous.

That happened a few weeks ago when one of our Trustees asked the question explicitly, saying "I understand the power of transparency within the organization, but is it wise to be so open about clinical outcomes with the public? Can we be sure that the incremental value, in terms of staff performance within the hospital, merits the exposure of our warts and flaws to the broad public?"

This is, of course, a legitimate question, in that we live in a very competitive health care environment here in Boston, and we certainly do not want to engage in behavior that would undermine the reputation of the hospital and perhaps hurt its financial performance. My answer had three parts: First, an acknowledgement that what we are doing is an experiment; second, that there has been no evidence at all that it has adversely affected our clinical volume or our standing in the marketplace; and third, that studies of organizational change suggest that public disclosure has extra motivational value in encouraging people to engage in continuous process improvement.

Now frankly, I had no empirical evidence of the last point but was relying on presentations I had heard from MIT's Steven Spear and IHI's Jim Conway on this topic. I trust both of them as experts in this field of process improvement, and both have been extremely helpful to our hospital as we proceed with this adventure.

Then, this weekend, I read a somewhat old article that supports this proposition. It is from Health Affairs and is entitled "Hospital Performance Reports: Impact on Quality, Market Share, and Reputation," by Judith H. Hibbard, Jean Stockard and Martin Tusler. You can read it here. The article concludes, based on several hospitals' actual outcomes, that "making performance data public results in improvements in the clinical areas reported upon."

Intuitively, this feels correct for lots of reasons, but it was interesting to see research supporting the conclusion. I wonder if people reading this know of other studies that reinforce or undermine that result. Please comment.

As a final point, I also want to note that in today's electronic environment, it is virtually impossible to keep data "private" if it is sufficiently distributed to the hospital's staff. So, if you don't want the public to know, don't even tell your own people!

Good ale, too

Speaking of UK signage (post below), note this creative front and back approach to the display sign for this pub.

Scenes from the English countryside

Two sets of road signs I saw recently in the UK. They are so much more expressive than the ones we see here, but when you start putting two or three on top of one another, it can lead to some confusion. Do I go over the bridge before the road narrows? Does the road curve before I turn left?

Then, again, since I was driving on the left, I barely noticed the signs anyway!

The electrical pole warning sign, however, left no doubts.

The downside of competition

A funny moment the other day.

The CEOs of the larger Harvard hospitals founds ourselves in several meetings over the course of consecutive days, working together on areas of common concern -- clinical research, supporting greater diversity on our staff and faculty, and stimulating enhancements between engineering and medical care. These were great sessions, with a clear commonality of interest and purpose, characterized by healthy give-and-take in friendly and helpful discussions, and good progress. After the last of these sessions, one of my colleagues turned to the rest and said, "Okay, enough collaboration for today. Let's go back to competing."

He was joking, of course, and we had a good laugh; but, as I have noted before, this is in fact the nature of the relationship. It has its advantages and disadvantages.

I think the major disadvantage is that the competition in the clinical arena is so intense that we end up duplicating services that could be consolidated or otherwise rationalized. (In saying this, by the way, I also mean to reference the duplication that also occurs when we include the non-Harvard hospitals in Boston.) I have talked about this before, focusing on the area of solid organ transplants. If there are fewer than say, 400, adult liver, kidney, and pancreas transplants in all of Eastern Massachusetts per year, does it make sense to spread them out among six or seven hospitals located within 15 miles of one another?

Each hospital has to make major investments in staff and equipment to carry out a proper transplant program, and the current organization makes economies of scale impossible. It also means that each program is unlikely to be highly profitable -- or perhaps profitable at all -- because it lacks sufficient volume to spread the fixed costs across a large enough patient base.

And yet we persist in this fashion, responsive to the demands and wishes of our physicians and because we have a mindset that we cannot be a "real" hospital unless we offer this service to the public.

As I have said in recent forums and elsewhere, we need to be protected from ourselves in this regard, either by the insurance companies or the state government. Thus far, though, they have been too timid to act. The public ends up paying the price for this inefficiency.

The story of Mike, the gentleman

I received the following story from a friend. It is hard to post it without appearing to take a position in the current Presidential election, but I am really not doing so with that purpose in mind. I have been very careful on this blog not to discuss my personal political preferences, as I think those are not relevant to the topics I discuss on this website. You should not assume anything about my vote (which I took this morning) from this story. Regardless of your preference in this election, or how you think it is going to turn out, I hope you will agree that is a wonderful story about elections in America, one that gives a warm feeling about the possibility of comity and good will during even hard-fought campaigns:

Upon arriving at the Hamilton County Board of Elections in Cincinnati to vote early today I happened upon some friends of my mothers - three small, elderly Jewish women. They were quite upset as they were being refused admittance to the polling location due to their Obama T-Shirts, hats and buttons. Apparently you cannot wear Obama/McCain gear into polling locations here in Ohio.

They were practically on the verge of tears. After a minute or two of this a huge man (6'5", 300 lbs easy) wearing a Dale Earnhardt jacket and Bengal's baseball cap left the voting line, came up to us and introduced himself as Mike. He told us he had overheard our conversation and asked if the ladies would like to borrow his jacket to put over their t-shirts so they could go in and vote.

The ladies quickly agreed. As long as I live I will never forget the image of these eighty-plus year old Jewish ladies walking into the polling location wearing a huge Dale Earnhardt racing jacket that came over their hands and down to their knees!

Mike, patiently waited for each woman to cast their vote, accepted their many thanks and then got back in line (I saved him a place while he was helping out the ladies). When Mike got back in line I asked him if he was an Obama supporter. He said that he was not, but that he couldn't stand to see those ladies so upset. I thanked him for being a gentleman in a time of bitter partisanship and wished him well.

After I voted I walked out to the street to find my mother's friends surrounding our new friend Mike - they were laughing and having a great time. I joined them and soon learned that Mike had changed his mind in the polling booth and ended up voting for Obama. When I asked him why he changed his mind at the last minute, he explained that while he was waiting for his jacket he got into a conversation with one of the ladies who had explained how the Jewish community, and she, had worked side by side with the black community during the civil rights movements of the 60's, and that this vote was the culmination of those personal and community efforts so many years ago. That this election for her was more than just a vote...but a chance at history.

Mike looked at me and said, "Obama's going to win and I didn't want to tell my grandchildren some day that I had an opportunity to vote for the first black president, but I missed my chance at history and voted for the other guy."

Global Triggers

My regular readers know that, at BIDMC, we keep track of lots of clinical outcomes and post our progress towards our goal of eliminating preventable harm for all to see. But there is a problem. Even with the best of reporting systems and even with a strong no-blame environment that encourages people to report errors and bad outcomes, things go on every day that are undetected or unreported.

So, even though we think we are doing a pretty good job in monitoring our progress, it would be great to triangulate our current methods of reporting and collecting adverse events (aka "harm") with other analytically rigorous approaches. One that we have started to use was developed by the Institute for Healthcare Improvement and is called Global Triggers.

This is a thoughtful and interesting method that is based on reviewing a sample of clinical records each other week to look for "triggers", which are basically clues that a patient may have experienced an adverse impact during his or her treatment. The harm that has occurred to the patient is not necessarily in the category of preventable harm. Rather, it is simply an indication of something going wrong from the patient's point of view.

In a way, the method is similar to the kind of sampling that a manufacturing company uses by taking a small number of widgets out of its assembly line and measuring how many are defective. It turns out that you don't have to take very many to get a statistically valid result. And, if you do it every week in a consistent way, you can see through the week-to-week variation and watch trends over time.

We've just been doing this for a few months now, and IHI says you need at least a year's worth of data to have sufficient observations to have a useful tool. Even though the Global Triggers approach captures all kinds of harm and not just preventable harm, there should be some correlation between the direction of the two categories. We are looking forward to getting those results and monitoring them over time as a way of validating our other reporting tools and feeling more confident about measuring our progress.

Are there others of you out there who have used this IHI methodology and would like to share what you have learned or how it has helped you in your quality improvement programs? If so, please comment.

Getting ready for the holidays

Time for a major change of pace. My cousin Roger sends this note, which I post now so that people who are interested have time to bake this by the holidays:

I just came across an interesting article in the Milwaukee Journal Sentinel on a Caribbean traditional Christmas fruitcake. See it here. It has a resemblance to the Panama wedding cake in many of its ingredients and preparation.

The Panamanian wedding cake to which he refers has been described, with some elaboration, in my daughter's article in Salon here.

Role model

A letter like the following is a wonderful affirmation of what people here at BIDMC try to do. I reprint it with permission of the patient. I embed the link to the Globe article for those of you who haven't seen it.

This morning, I read the Boston Globe article about transparency, errors and surgery at BI and was compelled to write to you about the remarkable experience I had 4 weeks ago when I had a radical nephrectomy (based on a Dx of a 9 cm renal cell carcinoma) at BI performed by Andrew Wagner. I’ve been in healthcare for over 30 years and before I met Dr. Wagner my opinion of surgeons was probably stereotypical although reinforced with actual experience. That is, if I talked to a med student who said they were interested in becoming a surgeon I had one of two reactions. The first was “Good, he/she should definitely have limited contact with conscious people,” and the second was “What a waste…he/she would be great with people.”

Dr. Wagner caused me to re-think those assumptions as he is as extraordinary in his people skills as he is technically. His technical skills were evidenced by my recovery. Upon leaving the hospital I didn’t take as much as a single Advil. To me, that means that he moved my organs so minimally they didn’t even know he was there!

It was his humanity, though, that left a profound impression on me and caused me to trust him absolutely. Some examples…..

His first sentence to me was “I am so sorry this happened to you;” and he meant it! After a few minutes of conversation, he asked if anyone accompanied me to the appointment. I responded that my husband and closest friend did and he asked for their names. He then left the room and went to get them. He didn’t ask a nurse or a secretary to do it…he brought them in himself. He gave me his email address and responded when I had questions. Finally, he called me the night before the surgery (a Sunday evening) to ask if I had any last minute questions or any anxiety that he could help with. I have never heard of a surgeon doing that and neither have my doc friends.

If you were responsible for bringing him to BI, congratulations…you hired a brilliant mensch!

My total experience at BI was a good one although as with any patient-hospital interaction, there could be improvement. I responded to the BI ambulatory care survey with some observations and recommendations. I hope to hear if there are any changes in process. Specifically, using your clinical decision support technology as a partial proxy for patient advocacy would be a great strategy. I’m attaching that survey response in case you’re interested…

Anyway, thought you might want to hear about an extraordinary physician…what a role model for the rest of the clinical staff!

Sincerely,

Eye on SEI

The picture above is of the mobile billboard hired by the SEIU to publicize its "Eye on BI" campaign. The union sent it to be visible at a fund-raising event held Friday night for our affiliated community hospital, BID~Needham.

Let's think about this. The attendees at this event are loyal supporters of this community hospital. They serve as voluntary members of its governing bodies, and they donate their hard-earned money to the hospital because they believe in its mission and have confidence in the management and staff. They know that SEIU opposed the issuance of bonds to finance the expansion of the hospital's emergency room and other services. They come out for a pleasant evening together to support the hospital, and they see the SEIU spending money on a mobile billboard to denigrate the reputation of the academic medical center that has also provided millions of dollars in support of their community hospital.

(In case you are wondering, a mobile billboard like this can be purchased for stints of 220 hours of travel time. The rental cost is $12,100 per 220 hours. There is also a $3,500 production fee for the panels.)

Is this effective? Well, you can be sure that attendees at this gathering were not impressed and remain very loyal to the institution. Well, how about the workers at BIDMC itself?

To answer that, in the post immediately below this one, I am sharing the responses I have received from staff members about SEIU's advertising campaign -- beyond those comments on my blog posting a few days back. The short summary: Even staff members who are sympathetic to unions are put off and insulted by the campaign.

So, is this a strategic error on the part of SEIU? After all, why would you want to alienate the very work force you are ultimately trying to recruit or from who you are trying to obtain support?

The answer, as I have explained in earlier posts, is in the nature of a corporate campaign. The object at this point is not to organize the workers: It is to organize the company by attempting to degrade its reputation in the community, in the hope of getting concessions in the certification process. In this case, too, there may be an interest in showing other hospitals in Boston what the union can do if it wants to spend money trying to hurt your reputation.

Once upon a time, unions would try to organize workers. Their organizers would actually spend time getting to know the workers, trying to build trust, and thereby enhance the likelihood of winning a certification election. SEIU, though, does not start by trying to organize the workers. It tries to organize the company using the methods we are now seeing. Beyond the mobile billboard, SEIU has spent tens of thousands of dollars in just one month on misleading advertising at bus stops, on radio, and on television about topics that have little or nothing to do with workers' concerns.

So, maybe we need a new slogan: Boston needs to keep an eye on SEI. After all, a union that spends this kind of money to undermine the reputation of a respected part of the health care system, that leads dedicated people working in that hospital to feel insulted and attacked, and that denigrates its volunteer community leadership needs to be watched very, very closely.