Thursday, February 07, 2008

Trainees report back and train trainers

As promised, I want to keep you up to date on our experiences as we implement BIDMC SPIRIT, our process improvement program of the sort described by Steve Spear. We are now at the stage of orienting people and training the trainers, the people on our staff who will train over 600 staff members in the techniques of calling out problems and pulling together help teams to solve them. We are assisted by some folks from a firm called Value Capture, which was founded by Paul O'Neill based on his experience at Alcoa.

After the first session, as part of an effort to improve the orientation and training sessions themselves, the group leader asked:

“Tell me one thing that was great or positive about today/SPIRIT so far … and one thing that was negative or is worrying you.”

Here are the replies:

Great: The observations, the real time problem solving and action plan development. The wonderful openness of Donna (director) and her team. Some of the role plays. Today was an incredibly useful exercise. The train the trainer approach is the right one. Scary to think about doing the training, but workable. As valuable as the Value Capture people are it’s important that we show we really own this in as many ways as we can. What was bad or am I worried about? It’s a long day! The chairs were bad. The room. We are training several hundred people, but only a small portion by March 1st. I am worried we will not have enough people ready with the language and the tools. But somehow I think it will work out. We need to manage expectations and the anxiety. We need to tell people we will not be great at this at first … but it will be a start.

Ditto to everything above. Great was the observation and work on the areas we went to – that was the highlight. We called out that the PACU role play should be further simplified (told as a simple story, holding discussion until end). I also agree about changing the room.

I came in with skepticism … a lot of skepticism … and I am leaving feeling a lot better, less skeptical. Going through this was transformative. My worry is that there are still 1,000 things to learn … will we be ready? Should we cut our teeth by piloting this in a few units first?

Great: The observation and the hands on problem solving. The willingness of the staff to participate! They were really ready. They knew about SPIRIT from Paul’s messages. My worry is the same. Do we really have the readiness to train? Will management be ready. Should we ramp up from a pilot?

Great: I was pleased to see the staff’s wariness melt and the problem solving process become fun! I worry that we have to get it deep enough down to the front line staff level. Use the code team example – have an outsider who wears the lanyard who can come and help – objective eyes in an observer – together with maintaining the transparency. Those are the keys to make it safe.

I see that this could be so incredible. But I worry there on the same count. Will we be able to be fully engaged and work staff through the barriers … to really get this rolling. I am somewhat overwhelmed by the number of problems. I don’t want to let staff down. We want it to work for them.

I see the positive culture change here. I loved the value of outside eyes for problem solving. We need to add the additional helpful hints, watch outs, useful phrases to help managers approach this w/employees in real time.

This is transformative. In the middle of doing the work on the floor today it hit me. Earlier in the day, I was hung up on the connection between the log and problem solving, and then it hit me – Is this a tool or is it about a new process and way of thinking about problems. It’s the latter.

Great: It’s simple steps … we laid it out easily and we followed it. Not easy to do but still good. It’s easy to understand (the method). What worries me? We have different skill levels in the organization. I worry about will it be used at a level that it will be used well? I’m worried about time. I worried that we’ll be able to take time away from other things, especially when it’s patient care. I need more tools as a trainer. I’d like more exposure to the help chain; we didn’t have to use it in our problem.

The observation opportunity was fantastic. We struck gold with our group and problem and the staff we worked with. What’s positive is we are pushing decision-making closer to the people who do the work. I worry about training. I need more problem solving exercises to feel comfortable as a potential trainer. Also, I think this is OK/great in departments with a participatory culture, but in departments with different norms if not implemented and supported well it could be quite harmful to the people. We need to think about the involvement of coaches/outside eyes.

I went from being skeptical on the (problem solving) log to feeling it could be very useful … and applied to all kinds of problems. The last module on the log was very useful.

In terms of worries: We have not been good enough messaging that this process is for hunting and fetching problems. We’ve got to be clear about what this is for. And also for the other systems that we are preserving.

Keep in mind, it’s hard when a few things are still blurry. But consider how this is being designed as a process to improve as improvements are suggested. It’s already been improved and will continue to do so.

Have Paul continue to message directly to the staff on this. They hear him. He is such a popular figure. He is clear. They also listen because he doesn’t fill up our e-mail with too many things.

I’d like another review session, to help prepare as a trainer (in addition to the planned development sequence – just a couple hours to go over the design, etc).


Anonymous said...

During our training session yesterday, I had the privilege of going to the Cath Lab with my clipboard to "observe" Eric, the nurse educator. My colleague and I gowned up, went into the procedure room with the patient's permission, and stood watching, taking in it all in. I realized that I quickly became distracted by the big picture of what was actually going on in there--a seemingly fluid and capable team at work. I tried to look for potential obstacles/problems to facilitate solving with my lay person's eyes. Didn't really see any. Well, just one--a blockage in the back part of the patient's heart. I decided to leave that one to the team. What a learning experience!

Anonymous said...

This is a terrific process. Yesterday during training we observed several activities in HCA. We observed Francine, a clinical nurse doing the prescription renewal processing, and she called out something that bothered her. She stated it would save a lot of time and help our patients if we had a stamping machine located in HCA for mailing prescriptions to patients. Her comment was "if we send the renewed prescriptions to the mail room it takes up to 2 weeks for our patients to get them" Francine then gave examples based on patient feedback. The team probed further to get to the root cause asking Francine for more details and included two HCA managers, Brigitte and Chris. Brigitte activated her "help-chain" and called the manager of the mail room, David. His response was immediate, he came directly to HCA, met with the team and explained the process. He also furthered the process of getting to the root cause by engaging the mailing vendor and faciliated a meeting between the vendor and HCA Managers next week! It was learned the mail actually doesn't take as long if certain steps are followed. The system and process for a quick turn around on mail was not however transparent to the HCA team until David explained it. It was also learned each letter we sent using a stamp versus sending through the mailroom cost an extra 20 cents to the practice...about $10 a day if not more. To ensure others learn of this Chris then requested this story and solution be placed on the agenda at an Ambulatory Operations managers and directors meeting.

All engaged in this process LOVED it. It was energizing, satisfying to learn how quickly a process can be addressed and corrected and rewarding to see a solution can be found rapidly.

I have heard call out and real time problem solving stories for many years as this system has been used successfully in the Navy nuclear program. My husband had a career in the nuclear program and regularly shared their stories, always with excitement. It was satisfying to him that changes could be made so quickly, respectfully, and effectively in such a huge organization. All Navy personnel in this program know they will be heard and if the process of finding the root cause indicates the need for change they know the changes will be made.

I am confident the BIDMC SPIRIT program will be a huge success and I am excited and proud to be a part of it.

Anonymous said...

Dear HCA,
In case you didn't already know this, your prescriptions can be instantly transmitted electronically to your patient's "transmit" button in OMR instead of the "print" button (an even better "solution" to your problem than creating multiple meetings with managers from other departments, vendors, etc.) Save yourselves not only the stamps but also the ink, paper, and envelopes, not to mention the time it takes to print, fold, stuff and address the envelope (and take the calls from the patients wondering where their lost prescriptions are.)

Anonymous said...

Thanks for the feedback about prescriptions. HCA does nearly all their prescriptions electronically now. It is a wonderful feature. Unfortunately there are still some situations that require old fashion mail...not all pharmacies are using the electronic systems, some scripts for legal reasons can't yet be sent electronically, mail order scripts will very soon be able to be sent via e-prescription but we aren't there quite yet and some folks need a hard copy if they are traveling...where we can we fax, or phone in the prescription but sometimes we just have to send by mail....