Session D11 at #IHI09

Yell Eureka if u c this!

That is a message to the attendees at the session I am now conducting at the IHI National Forum, entitled Using Social Media to Pursue Quality and Safety. I have asked them to keep their Twitter search open for the meeting hashtag, #IHI09, as an illustration of how quickly information can flow through the social media.

This post is timed to go up at 9:40am, just after the session starts. My blog posts automatically are fed to Twitter, and the hashtag will ensure that this post is collected by Twitter in the National Forum collection of tweets. The first person in my session to notice the tweet and yell "Eureka" will win a prize.

In the session, I will present our journey at BIDMC in the use of social media in encouraging our programs in patient safety and quality. This all started with some posts on this blog about central line infections, ventilator associated pneumonia, and hand hygiene. We discovered two things from those posts. First, the world would not come to an end if we disclosed clinical outcomes from our hospital. Second, the public presentation of these data acts as a stimulus to quality and safety improvement in the hospital. It serves to hold ourselves accountable to the standard of care we strive for.

Following publication on this blog, we moved to doing the same in a more expanded way on our corporate website. Here, you can see some of the same quality metrics, but you also see the full survey conducted by the Joint Commission when they came to accredit our hospital. Why? Well, the Joint Commission has important things to say about how well we run our place and where we should make improvements. How better for everyone in the hospital to see those things than to post them on the company website?

Each hospital has to decide for itself what degree of transparency is appropriate and comfortable, but as noted by John Toussaint here at the National Forum, it is an essential component of a culture of continuous process improvement. Social media can help spread the world.

Added later: The picture above is of the winner of the prize at this session, Dan Henderson, Health Justice Fellow, at UConn School of Medicine. Congratulations!

Poster Session at IHI

#IHI09 Sometimes you have to travel far to meet someone from home. Here are Faye Holder-Niles and Linda Haynes from Boston Children's Hospital offering a presentation at the IHI National Forum poster session, where dozens of teams offered stories about quality and safety improvements in their institutions.

Faye and Linda presented a summary of a primary care team approach to advising families and treating children with asthma. Using a combination of interventions (e.g., counseling about drug dosages, HEPA filters for vacuum cleaners, rodent control measures), they dramatically reduced the number of asthmatic incidents for the children in several of Boston's neighborhoods. A subsidiary benefit was a huge reduction in the number of emergency room visits. (Check out those charts behind their heads on the poster.)

Nice work by our neighbors across the street from BIDMC!

The Sekou Effect

#IHI09 This afternoon's keynote speaker at the IHI National Forum, at first blush, would appear to be as far removed from Don Berwick as you could imagine. While that was true about his mode of delivery, the message was remarkably consonant with Don's.

The performer was Sekou Andrews, who bills himself as a motivational poet/strategic presenter. You see him here with Forum Co-chair Polly Arango.

You really had to be there to get the full flavor of Sekou's presentations, but I attach this short video clip of his opening moments to give you a sense of his energy and creativity. This audience was ENGAGED!

Real time progress report on process improvement

#IHI90 "How am I doing?" used to say NY's Mayor Ed Koch, relying on the wisdom of the crowd in various settings to give him feedback. Well, here at the IHI National Forum, we have a real-time status report of how the attendees feel they are doing on a variety of process improvements. Using the IHI's Process Improvement Map as a guide, attendees were asked to place pins saying whether a particular topic was either "the most challenging" (Red) or "where you've had the most success" (Silver).

Mark Graban happened to come by and noted that this is a nice analog representation of the current status of things -- which now, ironically, I present here in digital format.

I photographed a few of the subject areas within the three process categories (leadership, support, patient care). You can see for yourself how this group of health care professionals feels things are going. There is definitely some "clumping" of red and silver stick pins. Maybe the "wisdom of this crowd" will be used by IHI to help set priorities and guide program enhancements over the coming months.

Berwick at the National Forum

#IHI09 Don Berwick's opening address is always a highlight of the IHI National Forum, and with good reason. He not only presents the latest and best about quality and safety improvements but also places those advances in the context of the broader health care environment.

Much of today's talk was about how to overcome the "tragedy of the commons", the natural inclination of people to ignore the externalities associated with their actions. The original formulation of this was set forth by Garret Hardin, using the example of overusing a common grazing area.

Don noted,

Like the villagers, rational health care stakeholders are eroding the common good simply by doing what makes sense to each of them – separately. In the short term, we each win. But, in the long term, we all lose. We lose the Triple Aim: better care for individuals, better health for populations, and lower per capita cost, all at once.

Name any stakeholder – hospital, physician, nurse, insurer, pharmaceutical manufacturer, supplier, even patients’ group – every single one of them says, “Oh, we need change! We need change!” But, when it comes to specifics, every single one of them demands to be kept whole or made better off. “Don’t stop my sheep; stop his.” So everybody draws on the Commons, the herds grow, and the Commons fails. If you don’t increase your herd, you’re a chump. And, who wants to be a chump?

Drawing on the work of Elinor Ostrom, Don stated the necessary conditions to offset those inclinations in a community of interest and pushed the attendees to action:

Here is my challenge. I challenge us to end the Tragedy of the Commons in health care. I challenge us to prove Garrett Hardin wrong.

It isn’t easy. Positive collective action, even in small communities, and especially in health care, is fragile. It could all just fall apart. But, it can work. I know it can work because, sometimes, some places, it does work.

But, I’m very mindful of who you all are. You are doctors and nurses tending patients, operating managers trying to keep 6 West going or clear the waiting lines. You’re QI directors coaxing the operating room into using a checklist, or executives getting ready to tell the Board some bad news. And, I think, you’re wondering, “What can I do from my limited perch to govern the Commons better? I’m already over my head.”

I am really not sure. But, I have a strong feeling that it can – it has to – start with you. Command and control solutions seem weaker every day, and Elinor Ostrom’s brilliant explorations suggest that, in many contexts, higher authorities simply can’t do the job. Maybe someone smart enough and courageous enough in Washington can write a few rules that change the odds.... But, the odds of real reform, “re-form,” remain zero – the Commons is doomed – unless the action is closer to home – closer to you. So, drawing on Elinor Ostrom’s work, here’s are some ideas to start chewing on:

1. Understand your health care Commons. Understand its limits and boundaries. Understand who can and does draw upon the common pool of resource, and who it serves.
2. Adopt an aim. Here’s one: Over the next three years, reduce the total resource consumption of your health care system, no matter where you start, by 10%. Do this without a single instance of harm, rationing of effective care, or exclusion of needed services for the population you serve. Do it by focusing not on the habits of health care as it is now, but by focusing on what really, really matters....
3. Develop, fast, because there isn’t much time left, your own institutional structures – the ones you will need for local rule-making to better manage your Common Pool Resource. Do not wait for external rules to be made, or to change; do it yourself. One such structure might be, for example, a Community-wide board – the collection together of all the health care Boards with shared stewardship of the whole.
4. Develop, fast, because there isn’t much time left, monitors, so that you can track the use of the common resource, and find out who is sticking to the rules you write, and who is breaking them.
5. And, when people do break the rules – opportunists, free riders – create undesirable consequences for them, if you can, and ways to isolate them, if you cannot. Collective action is very fragile. You will need militia.
6. Identify and address conflicts early, often, and with confidence. Conflicts will be frequent and legitimate, and they will demand wisdom. The social capital – the commitment to protect the Commons – has got to trump these conflicts.
7. Expect and offer civility. This is the foundational transactional rule for effective, collaborative management of what we hold in trust.... Respect is a precondition.

He closed with this thought:

My friends, we can spend our days ahead fighting for our piece of the pie. We have plenty of role models for that. But, that’s for summer camp and the schoolyard; not for here. Not for this real and fragile world. Not for the Commons. Not when there is only one pie, and it is all we have and all we will ever have, and it is in our hands to preserve, not just for us but for our children and our grandchildren. We can wait for the rules to be written by others and for the laws on tablets chiseled by others to rescue us, but those rules will be less wise than the ones we can write, and those tablets will be, not our salvation, but weights upon our spirit. It is a very tough choice. Get everything we can? Or respect everything we have been given?

Spear talks about the right info

#IHI09 I ran into Steve Spear at the IHI National Forum. He was autographing copies of his book, Chasing the Rabbit. As always, he has something thoughtful to offer.

Here is a recent article he wrote about what kind of information is useful in process improvement. Here's the key line:

Some organizations undercut their ability to discover their way to greatness by confusing the information needed to see problems with the information needed to solve them. So, they overburden staff with establishing the former and then underarm them in tackling the latter.

I am sure this is the case in our hospital and others. We all have incident reporting systems that collect a ton of data but that might not be particularly useful in providing knowledge to the organization. Then, we might not have enough data to really drill down and solve a particular problem that we see.

Food for thought for your hospital?

Welcome reception at IHI

#IHI09 Shannon Mills, Community Manager for IHI, was on hand at the IHI National Forum to help people learn about the IHI Open School. Rebecca Vellejo and a colleague from the University of Kansas were explaining about the National Database of Nursing Quality Indicators. Lucille Skuteris joined a colleague to give information about Joint Commission Resources Consulting. Monda Shaver and Susan Lautner were marketing the Healthcare Facililties Accreditation Program, a competitor of the Joint Commission. And a new nanofiber product produced by a company called Vestagen Technical Textiles was on display, complete with a demo showing how it repels fluids.

Dr. Ship's Speech

If you -- as a health care provider or patient, or someone who knows one -- watch no other video about health care, watch this one of Dr. Amy Ship's acceptance speech when she was awarded this year's Compassionate Caregiver Award by the Kenneth B. Schwartz Center. It is an extraordinary summation of the meaning of compassionate care.

Auction for the Borum closes tonight

Our online auction to support the Sidney Borum Jr. Health Center closes tonight at 8pm. There are many wonderful items. Please bid generously here.

The Eliot School artistically helps The Borum

The Eliot School offers classes in crafts and fine arts to people of all ages – both at their schoolhouse in the heart of Boston and through the school partnership program, which sends teachers to classrooms throughout the city.

Founded in 1676 as a grammar school for colonial, African, and Native children, the school turned its focus to the manual arts in 1889. Since then, the school has taught craftsmanship and the pleasures of creativity. They are known for their excellent faculty, welcoming atmosphere, small class size, and the charm of their historic site in Jamaica Plain.

You can bid at our online auction to support the Sidney Borum, Jr. Health Center and join instructor Cecilia Galluccio for a new class, Burning Art & Design onto Wood. Here's the description:

With judicious use of wood-burning tools, drawings can elegantly decorate any wooden surface. In this workshop, learn from a compulsive doodler who creates stunning designs on bowls, spoons, tiles and furniture. Each student will complete a decorative tile just in time for Mothers Day. All materials will be supplied. (2 Sundays, 10 am–12:30 pm, Apr. 25–May 2)

What a great present to give to a member of your family or a friend!

Boston Baroque plays for The Borum

The Boston Baroque performance of Messiah is a Boston classic. The orchestra has generously donated a pair of tickets to the December 11 or 12 concert to support our online auction to benefit the Sidney Borum Jr. Health Center. Also included is a copy of Boston Baroque’s Grammy-nominated recording featuring highlights from Messiah.

The orchestra has also offered tickets to its wonderful New Year's Eve Gala Concert at Sanders Theatre.

Bid for both here.

An international quiz

#IHI09 I attended the international reception tonight at the IHI National Forum, which is representation from 42 countries. My tablemates (seen here) included people from Norway, Sweden, United Kingdom, India, and Canada.

The first order of business was a quiz, to be answered as a team. This was a good ice-breaker and also somewhat informative. Here are some questions. See how you do:

1. The smallest General Practice in the UK is in one of the 70 Orkney Islands off the coast of Scotland. How many patients are registered with this practice?
A. 300 B. 220 C. 120 D.40

2. What is the maximum number of patients an Italian General Practitioner can enroll?
A. 1000 B. 1300 C. 1500 D. 2000

3. What proportion of the financial compensation of an average English General Practitioner is "pay for performance" for achieving quality goals?
A. 0% B. 5% C. 10% D. 30%

4. In low income economies, which of the following interventions has the largest ability to reduce infant mortality?
A. Oral rehydration solutions B. Strong primary care C. Antibiotic availability
D. Clean running water E. Breast feeding

5. In a recent international survey of GPs, which country had the highest percentage of doctors using electronic medical records in their practice?
A. New Zealand B. Netherlands C. Germany D. USA

6. The Swedish government has announced a national fund to support the achievement of equality goals in healthcare, including gender and race equality in the health services. What is the fund worth?
A. $25 million B. $80 million C. $100 million D. $120 million

7. A woman in the West Midlands region of the English NHS recently became the oldest person in the world to have a hip replacement. How old is she?
A. 99 B. 101 C. 103 D. 108

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Answers: D, C, D, E, B, B, C

Steps to change a culture

#IHI09 John Toussaint, CEO of the Thedacare Center for Healthcare Value, presented a session called Leading a Continuous Improvement Transformation at the IHI National Forum.

What does it really take to change a culture? He outlines several steps, requiring a focus on purpose, process and people, based on the Toyota Production System, or Lean, philosophy. Examples of success are Group Health of Puget Sound, University of Michigan, Thedacare Collaborative, and Gunderson Lutheran. All have made significant reductions in the cost of delivering care while improving quality. Bolton, in the UK, likewise showed dramatic improvements in clinical quality indicators.

Here are the steps.

Purpose: This comprises a general statement of mission -- e.g., to improve the health of the citizens of the communities we serve -- but it also must be translated into a more detailed strategy, and still more detailed goals.

Strategy: Deliver measurably better value to customers. For example, we want to achieve reliable quality, measured as 3-4 defects per million opportunities.

Understandable goals: Focus on only three! For example, Quality: Decrease defects and waiting time by 50% each year; Business: Increase productivity by 10% each year; Engagement: Number of suggestions implemented (number/employee). Set the bar high but pick clearly understandable measures.

Process:

Transparency of data drives change. (By the way, in terms of reducing harm, he notes, "Zero is possible, and from a leadership perspective, we should ask for nothing less.")

Metholodogy for achieving results: It is the leader's responsibility to create the system that allows people to solve problems. Use of A3's creates a rigorous approach to problem solving. This formalizes PDSA ("plan, do, study, act"). (There are 5400 active A3s going on in Thedacare!) This approach makes it easier to persuade others and understand others, to foster dialogue, to develop thinking problem solvers, and to do all this on the front lines.

Other TPS activities include: value stream analysis; rapid improvement events; continuous daily improvement; visual tracking. Improvement results in less staff "hunting and gathering." New standard work improves both logistics and care.

People:

White coat leadership <-- versus --> improvement leadership.
All knowing, in charge, autocratic, buck stops here, impatient, blaming, controlling <-- versus --> patient, knowledgeable, facilitator, teacher, student, helper, communicator, guide.

Continuous improvement is based on respect for people. The leader's job is to develop people.

Can you say yes to these three Paul O'Neill questions every day:

--Are my staff treat with dignity and respect by everyone, regardless of role or rank in the organization?
--Are they given the knowledge, tools and support they need in order to make a contribution to our organization and that adds meaning to their life?
--Are they recognized for their contribution?

New habits are needed by managers and leaders: Help define the problem; ask questions instead of providing answers; think of problems as golden nuggets instead of opportunities to blame; teach subordinates how to solve problems; mentor subordinates to replace you; be humble.

Participatory Action Research

#IHI09 Roger Resar (speaking) and John Whittington (with some audience participants), of IHI's R&D team, recently were involved in developing and testing an innovative approach to actively engaging physicians to provide evidence-based and effective care through "clinician-friendly standardization." The two engaged the Faculty Mindwalk attendees in a hands-on exercise.

Beyond the National Forum, Roger and John hope to try out "participatory action research" with the attendees to test novel solutions to tough problems. They want to create a network of the attendees to be involved with IHI as innovators who will "create new approaches to seemingly intractable health care delivery issues."

Katharine Luther, RN, from Texas Medical Center, gave an example. A local team did on-site work on the area of fall prevention while communicating with Roger at IHI to test out concepts, engaging in an iterative collaboration approach between the "field" and the resources back in Cambridge. The idea was to ask clinicians to discern between "usual" and "special" patients, 80% and 20%, respectively. About 50% of the falls occurred in each category, which, interestingly did not correlate with the usual Morse score for fall susceptibility. This led the team to a create a bundle of three items (more easily reached call buttons, lower bed height, better placement of IV stand) that could be used to reduce falls across the broad population of patients, notwithstanding the Morse score.

The lesson of this example, Roger concluded, was about co-learning between the field and the IHI R&D group, with the immediate benefits accruing to the local partner, but eventually offering advances that might also go beyond the particular local partner to a broader audience.

Mindwalk at the National Forum

#IHI09 -- The IHI National Forum just started with a session called Faculty Mindwalk for those involved in teaching sessions over the next three days. This is a nice opportunity to reconnect with others involved in the patient quality and safety movement and also make new friends.

Seen here are: Eugene Litvak, President and CEO of the Institute for Healthcare Optimization, with Vin Sahney of Blue Cross Blue Shield of MA; Mark Splaine, the newly appointed Director of the Center for Leadership and Improvement at the Dartmouth Institute for Health Policy and Clinical Practice, with Paul Batalden, his predecessor; and June Wylie, Jackie Ley, and Jane Murkin, from the NHS Quality Improvement program in Scotland.

Out with the bad air, in with the good

As the cold weather arrives, we all know how to button up our home to reduce energy loss, but sometimes we end up not allowing enough fresh air to enter the house. How to do it without losing lots of heat is the question. An answer is provided by an item in our online auction to benefit the Sidney Borum Jr. Health Center.

Company owner Mark Bernfeld has donated the Tamarack DreamAire 5000 home or office air purification system as an auction item. Here's his description of how it works:

This machine will kill viruses, mold spores and bacteria before entering the home. Every 30 seconds fresh outside air is brought into the home, filtered through an electrostatic precipitation process (ESP) heated (if so desired) and then reverses direction to pull stale inside air out of the home. Using only 15 watts of electricity the air replacement/filtering and cycling operates constantly. Extremely quiet, the DreamAire 5000 uses one 4" duct for bringing air in and exhausting it out of the home. Rated for 1,200 square feet, the DreamAire 5000 will clean the air in an entire home, office or classroom. Attractive LED control panel makes operation simple. Filter cleaning indicator will illuminate when necessary.

See more and bid here.

As good as cash, for The Borum

You can spend this weekend fighting traffic and shopping for holiday gifts, or you can bid from the comfort of your home for gift cards that support the Sidney Borum Jr. Health Center.

Cards include the following: $150 for Saks; $50 for L'Occitane; $110 for City Sports; $50 for John Dewar; and $500 to spend at any of 40 locations.

Need stocking stuffers? How about free admission coupons for National Amusements cinemas.

Here is the auction site.

Helping Our Bodies, ourselves

A note from Judy Norsigian, Executive Director of Our Bodies Ourselves.

Like other valuable "social benefit" organizations, Our Bodies Ourselves is facing a very difficult financial period and needs your support more than ever. As we are approaching our 40th anniversary of the first publication of Our Bodies, Ourselves, we hope that you will visit our website, consider all that we do now, and contribute to our longstanding, non-commercial, public interest work that has benefited millions across the globe. I also hope that you will forward this message to others who might value and support what we do.

All contributions large and small greatly appreciated:

http://www.firstgiving.com/judynorsigian

Thanks so much for your consideration.

Best- Judy

Noah's Ark arrives in Needham

I am so impressed by the generosity of our patients and their family members. Here is a tapestry from South Africa, entitled "Noah's Ark", that was given to our community hospital in Needham from a grateful family. Here's the story behind it:

The artist, Alexa Kirsten, was born in South Africa to a British mother and a South African father. She grew up in the Hogsback in the eastern cape, a rugged mountainous area. Alexa's cloths have found homes all over the world. She notes:

"All the years at Hogsback and the years in the bush and now living near the sea and the mountains, all these things have influenced me. I love color and find great solace in it. A friend and I started a little screen printing business 30 years ago. We printed lengths of cloth. I found it too tedious and eventually branched out on my own and started painting tablecloths. I have lost count of all the cloths that I have made, I would estimate close on 1000 by now after all these years."

You can see more on this website. Dan Siagal from Capetown Trader tells me: "In 2005 Alexa was assaulted, stabbed repeatedly in the back and left for dead on the floor of her neighbor’s house. She had a near-death experience and feels that she touched the face of God. After having to learn to walk again she has continued with her fabric art; however, it has changed and become more vibrant and meaningful. The colors are brighter and the pictures clearer and stronger. She draws solace from her work. It has been a huge part of her recovering and therapy. She would like to share her work as an encouragement to the struggling, depressed and sad people of the world.

"Cloth Art images are hand-drawn, hand painted, original artworks of African images caught on cloth. Decorated with enchanting scenes drawn from African life, each one is individually hand painted. Inspiration is drawn from the accumulated cultural diversity of today and of a time altogether more ancient. Scenes may include a combination of animals, villages, the breathtaking African night sky, or whatever the artist chooses; no two are exactly alike, but each is a brightly-painted delight. The colors are bold and cheerful. They evoke a childlike perspective, full of wonder and smiles, celebrating life under the South African sky. Some tell a story such as Noah’s Ark."

When a great big zero is A+

On several occasions, I presented data here on this blog about the efforts of BIDMC to eliminate central line infections. You can now view those data on our hospital website.

Our community hospital, BID~Needham, operates under its own license and has a staff and Board highly committed to quality and safety improvements. It also chose to engage in a program to eliminate central line infections. The Needham effort had several components:

-- Develope guidelines for the prevention of blood stream infections;
-- Work with procurement to create a standardized supply kit;
-- Use a standardized protocol for maximum sterile barrier precautions;
-- Use Chlorhexidine-based antiseptic for skin preparation;
-- Use a standardized protocol for catheter hub and port disinfection; and
-- Educate both health care worker and patients.

Well, the results for this small hospital are pretty spectacular and are presented above. They have demonstrated that a sustained rate of zero is possible. I say that this is one case where zero warrants a grade of A+!