Monday, June 30, 2008

BIDMC Spirit Update

An email I sent to the BIDMC community:


Back in chilly days of winter, I wrote you about the beginning of BIDMC SPIRIT, and it is time to present a status report. Since starting the program, we have held training sessions for about 600 managers and others. Many of the rest of you, too, have patiently participated in those training sessions when the groups arrived on your floors! Many of you have called out problems, and we have discovered solutions to some of those problems. You can check the portal for a scrolling summary of a sample of those, or you can look at the SPIRIT Problem Solving Log for more detailed descriptions.

As I stated at the outset, we did not expect a revolutionary change from SPIRIT, but we did hope to introduce a new way to solve those daily problems that get in your way when you are trying to do your job. So far, so good. Some of you really are engaged in this and like the program. Some of you view it as background noise or a minor part of your life. Some of you consider it a bother. Wherever you are on that spectrum, please keep an open mind and keep trying to use this approach, as we have seen that it can produces real improvements.

We have not solved all the problems that have been called out, but we knew that would be the case. After all, you can't undo decades of practice and systems in just a few months. There have been about 700 call-outs logged thus far. Of these, about 400 had enough information provided by the caller-outer to enable a follow-up. Of those, about 180 have been formally resolved and closed. This is about what we would have expected for this stage of the program.

Through SPIRIT, we have also discovered some very big, very pervasive problems in the Medical Center that need a special effort to solve. I am going to present a summary of these below. Let's see how we do on these. Stay tuned.

Meanwhile, though, some of you have submitted questions to me about the program. Here they are, with answers:

What made you decide to ask us to take this on? Why now? Why this approach?

I got tired of seeing our people get frustrated with the amount of fetching and work-arounds they have to do. We studied various models that highly effective companies have used to solve this problem, modified them, and came up with SPIRIT. Even now, as we get comments from you, we continue to make modifications to the program to make it work better.

My problem is so big! Is it worth calling it out even if I think that no one can fix it?

No problem is too big or small! Give it a try.

People use SPIRIT Log as a complaint board. It could be disruptive and builds distrust. How can we stop them?

This is bound to happen sometimes. When we see it being used that way, we post a message on the Log to help people learn the right way. If a Log entry is particularly offensive, we delete it.

People are afraid of retribution so they either post problems anonymously or don't use the Log at all. What can we do to make people feel safe to use the Log?

Time and results will be the key. Also, the way in which managers treat people who post problems will either send a positive signal about participation or be really discouraging. We hope that managers will help create positive reinforcement by the way in which they respond.

I think this process is wonderful! Will the research community have a call-out pathway with the contacts list available?

You already do! Try it.

I have many frustrations about how my work is set up, but since my work is purely administrative, none of them relate directly to patient care. Is it still OK to call them out? Will they be addressed with as much priority?

Yes, SPIRIT is not just about patient care. Please call out administrative problems as well.

I have told my manager about these things so many times before and nothing ever gets done. What will make this problem log call out any different?

While not all problems will be solved, managers have been asked to give priority to those items called out through SPIRIT.

Managers already have too much on their plate. They don't have the time to train their staff about SPIRIT. What tools can we offer to support the manager

Ironically, managers have a lot on their plate because they see the same problems over and over again, and they don't get solved. Over time, SPIRIT will be seen by managers as a more effective way to use their time. In response to suggestions, we are preparing a set of tools that can be used by managers and others to help introduce and implement the SPIRIT process more broadly.

We know Sr. Management reads the Log and perhaps judges our performance based on the log entries. However, we have to juggle SPIRIT issues with other daily priorities. What is Sr. Management's expectation?

No one is judging anyone's performance based on SPIRIT call-outs or the Log. SPIRIT issues are not meant to be separate issues from your daily priorities. They are supposed to be things that get in the way of your priorities. Don't view SPIRIT as an add-on. View it as a way to help solve the problems that matter to you.

How will we know when we get "there" and what will "there" look like?

When every BIDMC staff member to be able to answer these questions with a resounding "Yes!" every day:

Am I treated with dignity and respect by everyone I encounter, regardless of role or rank in the organization?

Am I given the knowledge, tools and support that I need in order to make a contribution to my organization and that adds meaning to my life?

Did somebody notice I did it, i.e., am I recognized for my contribution?

We know we are not there yet!

Now here are the big problems that were pointed out in SPIRIT call-outs, and what we are doing about them. For all four of these, updates will be provided regularly on the "Project Updates" page on the SPIRIT home page (under "Lists" on the left hand menu). The updates will include links to video footage documenting the current state, the process, the solution and its implementation. There will also be links to my blog postings, with things we have learned from the process.

GI Specimen Reconciliation


On May 13th, 2008 a Transporter made a call-out regarding the length of time it takes for her to reconcile specimens in the GI Lab. The immediate problem has existed for quite some time but has recently been amplified since the GI labs from East and West combined and moved to Stoneman 3. This process currently takes about 1 minute per specimen. The number of specimens “per pick up” varies throughout the day with 90-100 patients per day as an average.

Contributing causes:

Currently, the labels in the specimen log book are put in order by procedure time; however, the arrival of the specimens for reconciliation does not happen in that order. Transporters do rounds, and the specimens arrive in batches.
In addition, physicians might have different times of the day that they are involved, possibly creating another instance of batching.
As a result, when the transporter arrives at GI, he/she has to flip through pages and pages of the specimen log book to look for a label with an account number or name that can be reconciled with the specimen label.
This pathway redesign presents an opportunity for decreasing the time spent by the transporter and may decrease the turn-around time of the specimens.

Current status:

Observations of the nursing node of this pathway have been conducted and an observation of the Pathology node was conducted this Wednesday (June 25). The anticipated time to implementation of a solution should be about 4 weeks.

Patient Mode of Transport


There have been several SPIRIT call-outs by transporters and other staff related to miscommunication about the mode of patient transport. A request is made for one means of transport (for example, wheelchair), yet another means of transport is what is brought (for example, a stretcher).

Contributing causes

There is a communication disconnect between Service Response, the testing location, and the unit to which the patient is assigned.
There are no clear cut guidelines as to who decides the mode of patient transport, or when, or how.
Nursing’s way of determining how to send a patient differs from how the testing location might want to receive the patient. Each use different criteria. An unfortunate side-effect is that the transporters are caught in the middle of communications between senders and receivers.
When Service Response gets a call for a patient transport request, the level of detail varies depending on who took the call.
(Interestingly, Radiology has its own system, in which they call the unit to confirm “we’re coming to pick up Patient X in a wheelchair,” but still they end up with the same problem. When they arrive, it turns out that the nurse requested a different mode of transport.)\

Current status:

We are in the midst of collecting a baseline for Radiology and Central Transport on the West Campus. This includes the number of transports per day, and the number of “wrong” modes for each day. This also includes overall transport time. The anticipated time to implementation of a solution is about 4 weeks.

Medication pumps


Medication pumps are not always available for patient care when needed. (Focus first on the West Campus)

Contributing causes:

There is no clearly defined pathway.
There is no single, known place where pumps can always be found.
Calls for a pump interrupt the resupply process, thus causing more disruptions .
There is no clearly defined signaling between the customer (nurse) and the supplier. When does one call? When one is out of pumps? When one is down to just a couple?
Because of the sense of scarcity, the supply is based more on a perception of need than on the actual need.

Current state:

Several observations have been conducted in the PACU, on the nursing side, of the resupply efforts. We are developing measures for the time involved in hunting and fetching and the delay of transfer from the PACU to the floor. Eventually, we will have a way to figure out the average amount of time to get a pump when needed. A team has already been put together to work on this project. The anticipated time to implementation of a solution is about 10-12 weeks.

Patient Belongings


Patient belongings and valuables are getting lost. This is happening to patients across the medical center. Staff spend a lot of time hunting down patient belongings, and the medical center spends tens of thousands of dollars in reimbursement payments to patients.

Contributing causes:

Patients move from their originating location to one or several others, but their belongings don’t follow. Or, if they do, there is a delay (of several hours or several days).
There is no systematic process for collecting and handing off patient belongings.
There is inconsistent or nonexistent documentation.
There is no absolute responsibility, i.e. no one is charged with being responsible for patient belongings.

Current status:

We are beginning with a focus on the ED. There is currently a thorough effort in place to collect measurements of the current state, including:

How long it takes to search for items
How many items are searched for
The response time to a call
The time it takes to return an item to a patient.
Once the baseline data are gathered and the current state established, the plan is to pilot a more centralized approach to storing/retrieving patient valuables and belongings which involves the introduction of a primary owner of the overall process.

Thanks for your ongoing support, participation, and patience.



Paul F. Levy
President and CEO
Beth Israel Deaconess Medical Center


Anonymous said...

I am once again strongly struck by the similarity of issues across hospitals, reinforcing my conclusion that we need some way of nationally distributing solutions that work, instead of each hospital reinventing the wheel. Maybe invent "The Journal of Hospital Quality Improvement". (:
I can identify with the GI specimen reconciliation issue, one that we had ourselves, but with a lower volume than you experience. Our lab used to also experience a run of urinalyses daily around 3 pm (at our own shift change), when the nurses went off shift and only then delivered the urines to the lab!

Also similar is the perception that a new QI initiative is an "add-on" and that it is being used to judge performance. It is exceedingly difficult to make people comfortable with change. And one instance of it being used to judge will have far greater impact than 100 instances of it NOT being used to judge. Keep up the good work!


Anonymous said...

A helpful comment from a staff member on one of the topics mentioned:

Hi Paul,

I just wanted to pass along some thoughts on the patient belongings issue that you addressed in this e-mail. Before coming to work at BIDMC, I worked as a paramedic and found that while interacting with patients in the community, particularly those preparing to go to the hospital, patients were not particularly well informed about what the did/didn't need to bring with them to the hospital. In particular, I noticed the following general observations about my EMS patients:

1. Patients are not aware of the resources of the hospital pharmacy, and some feel the need to bring large quantities of medications (including unsecured controlled substances) to the hospital with them because they feel that they won't otherwise receive their routine medications during their hospital stay. Obviously, this issue also involves the patient's responsibility to inform their healthcare providers about medications/supplements that they are currently taking or carry a list of their medications and dosages.

2. Patients tend not to be aware that certain types of tight or restrictive clothing can impede assessment and the performance of medical procedures. Likewise, patients are sometimes unaware that jewelry may need to be removed for surgery or other procedures. This is perhaps an issue that could be addressed in pre-admission instructions for patients being admitted for routine procedures, and patients could be instructed to send restrictive clothing and valuables with a trusted friend or loved one.

Anonymous said...

And another:

I know you probably get many emails over the course of your day, but I was hoping I may be able to make a suggestion that did not seem appropriate for the SPIRIT initiative. I love that we have an opportunity to call out problems that we see at the BIDMC, but I was wondering if there is already a mechanism, or if we could perhaps put one in place that would serve as a forum for positive feedback about our supervisors, or particular individuals who we believe go above and beyond.

I have often seen people just doing their jobs that I wish I could call someone or email someone or even post something on a message board saying that I appreciate something they are doing. More importantly, I feel I am very fortunate to have an amazing supervisor, and I think there should be a central forum where I could go to deliver positive feedback. There are also various facilities employees who I feel deserve to have positive feedback posted or sent about them that they may otherwise not hear.

If such a mechanism is in place I would love to know about it. If there isn't, I think it would be wonderful for institutional morale for it to exist.

Anonymous said...

And another:

I appreciate your focus and leadership with this initiative. I think that this program is worthwhile and I believe that the results are also real.

Nebiye said...

Paul – I just wanted to inform you that I posted your last Spirit Update for our staff to read it. Because I think it is important for our staff to understand that the problems they call out to us are not sitting on our desk. If I may put my two cents in I think the BIDMC SPIRIT progress is where it is expected to be. This is changing a culture of a large institution, and as you said it doesn’t happen overnight. Your assessment of were the managers are on the spectrum is accurate. On the other hand the employees are watching if this is going to materialize. As we continue to make progress, the outcome will be apparent. Ultimately the desired result will be archived when we have the buy in of all managers, and when the employees are convinced that their voice will be heard, and can bring about change in the way they do their daily work, and are able to answer the three questions with a resounding “Yes” every day. Your consistent massage of”this is here to stay” will eventually tip the scale.