Tuesday, June 17, 2008

Where are the pumps? Part 1.

I have provided several examples of how BIDMC SPIRIT has been employed to solve some small and annoying work-arounds and other process problems in the hospital. But, it has also permitted us to discover some pervasive issues that can really affect the lives of our staff and the quality of care given our patients. We are about to do a full-court press on several of these, and I am going to give you the play-by-play as these proceed, i.e., in real time -- telling you what we learn, how we learn it, and how we work as a team to fix the system.

Remember, the concept of SPIRIT, which is borrowed from the process improvement programs of the best firms in other industries, is to empower and encourage all members of the staff to call out problems they see in the work environment; "swarm" around that problem and solve it to root cause; and then spread the story of the discovery throughout the organization. This is not easy to do. First, you have to develop a blame-free culture, so that the person calling out the problem is shown gratitude and appreciation for having done so. You also have to train people to see problems as problems, as opposed to the normal flow of work. Then, you need to get good at analyzing problems to their root. This often involves engaging people from other divisions or departments because the cause of most problems is usually multi-jurisdictional. Then, you need to discover and implement the solution and make sure it is sustainable.

The problem I'd like to present today has to do with medication delivery pumps. If there is one pervasive problem in the hospital, as pointed out to us by the nurses, it is making sure that a functioning pump is available and accessible at the time it is needed at a patient's bedside, whether in the surgical post-op area (PACU), a medical/surgical floor, or the emergency department. But, as anybody in any hospital will tell you, there is often a frustrating amount of fetching going on when a pump is needed. Please note that the problem is not an actual physical shortage of pumps: It is making sure that they are functioning and where the should be when they are needed.

Without further ado, I present here the first set of notes coming out of our group that is "swarming" to solve this problem. This is just the beginning. Stay tuned over the coming days as we work through this together. (By the way, the picture above is a diagram of the morning pump collection/supply cycle on our West Campus, showing the different supply paths taken by our devoted distribution staff as they try to meet patient needs -- indeed, as they try hard to reduce the burden on the nurses and other caregivers! I think you can see evidence of the some of the problems noted below.)


The Pump Opportunity – SPIRIT call-out #691

We can’t thank Julie Kelly in the West PACU enough. Because she chose to call out that they had run short of pumps needed by patients, causing stress and strain for all involved, a huge opportunity to strengthen the system and make life better for an awful lot of committed BIDMC staff has come into view. As Mary Gryzbinski, the PACU shift leader who helped Julie enter the call-out, said in first providing details about the situation, “we knew the people in Distribution were doing everything they could to find the pumps for us … we knew we all just needed some help.”

Prompted by the call-out, an effort has begun to deeply understand how the process works today, the first step of a rigorous collaborative and transparent effort to create a system capable of providing pumps exactly when needed, every time.

Key Learnings So Far:

1) There is nothing more powerful than “going and seeing” how the process actually works, through the eyes of the people who do the work. Staff and leaders we talked to noted how “the pump problem” has been known and debated in meetings for over a decade at BIDMC. Yet in just a few hours of directly observing how the process works by walking the paths of pumps and observing nurses as they encounter a need for pumps and other key nodes of the system, the core reasons the present design fails everyone involved became clear.

2) Everyone involved in the system – from the nurses who need pumps to the amazingly hard working distribution team that gathers and supplies them to the clinical engineers who maintain them – are working with great effort and dedication to meet the need. Like his peers, Mr. Cecil Whyte – the Materials Handler who does the pump resupply run and several other duties on the West Campus during the day shift – is acutely aware of how much is riding on his ability to find and supply enough pumps over the course of a day. Mr. Whyte’s physical effort matches his dedication. He walks so much every day in his search for pumps that he buys a new pair of shoes every three months!

3) This is not just a PACU need. For the most part, pumps circulate with patients across the hospital and so – not surprisingly – this opportunity involves a huge cross section of units, departments and BIDMC staff. This is not a problem that can be solved by one unit or one department; it’s going to take everyone.

4) The pump supply system on the West has some core strengths – especially the people! But it does not embed all of the core principles that a complex system like this requires in order to meet needs perfectly. With the people who do the work, we will be exploring some of those key ideas in order to design and achieve a stronger system. Those ideas include:

• The way pumps are supplied and replenished should be simple and direct. Our pump system has some of these features, but in a critical aspect or two embeds “loops” – forcing people in the process have to retrace steps in scattershot fashion – and a “fork” or two – where two parallel processes are used to meet very similar needs in a way that confuses customers.

• The system should be based on clear and unambiguous “yes / no” signals between pump customers and suppliers, but the signals in our system are more variable and vague, leading to stress, rework and missed needs.

• The activities each person performs should be highly specified, including their content, timing, and expected outcome. Unfortunately, aspects of our pump supply system make it virtually impossible for our suppliers to stay on track!

• We will also be exploring how problems can be solved quickly in the system, so that it can stay stable and constantly improve. We don’t want to have 10 more years of frustration! The people involved care too much, and deserve to succeed.

Time was also spent today to begin to appreciate the current state on the East Campus as well. Many thanks to Aurelio Gende, Supervisor, and Pedro Perez, Materials Handler, both in Materials Management; Michele Boucher, Clinical Nurse Specialist, PACU; and their colleagues for introducing us to the current processes.


Anonymous said...

Why don't we just stock a "par level" of extra pumps on every unit, avoiding a separate "hunt and fetch" every time we need one? Then distribution could easily see where the pumps need to go just by "rounding" the units once or twice a day. (Yes, I know the pumps are expensive, but how much are we spending in nurses' time, etc. when one isn't readily available? and in "delayed discharge from PACU" time which often has the effect of backing up the ORs.) Pretty much EVERY patient in the hospital has an iv on a pump, so we should have at least one for every bed (more in the ICUs.)

Anonymous said...

That's certainly one possible solution. We'll see where this leads.

Anonymous said...

I seem to get the same pump with each visit over a two year period. I recognize it because the bottom ring that holds other stuff like the cath bag doesn't stay up. I take a rubber glove and twist it around the pole, pushing the ring down on it. This works very well. Cheesy, but good.

Curious about a few things -- How much do these pumps cost? Does anybody lease them and therefore replace broken ones? Is there a routine maintenance schedule?

Anonymous said...

Anon 8:49,

While I agree that is one possible solution, I would submit that it does not get to the root of the problem and fix it which is the goal of the SPIRIT program as I understand it from this blog (I'm not a BIDMC employee). It is possible that the team finds the supply of pumps is too low, but I would venture that the problems turn out to be more along the lines of getting an accurate number of pumps needed by PACU at various times throughout the day, how the pumps are returned to the distribution area once the patients no longer need them, the process for preventive maintenance and how long that takes, having a few extra to replace those that are being serviced, lack of a reliable tracking system so you can determine where a pump is, and hoarding by departments because this has been a problem for such an extended time period (as it is pretty much everywhere else, my own hospital included). I think it's great that the SPIRIT team is tackling this problem and will follow it with great interest in hopes of shamelessly "stealing" good ideas. Congratulations, BTW, Paul on your hospital being a 2008 Premier Award for Quality winner!

Anonymous said...

I loved a lot of things about this post, but ESPECIALLY "key learning" point #1. There is absolutely no substitute for "going and seeing", as so aptly put.
It's utterly amazing to me that management people (this is not confined to health care) don't do this more often. It also pays immeasurable benefits in staff morale. I look forward to part II!


e-Patient Dave said...

And I thought I had something to be annoyed about when I simply couldn't find a wheelchair at checkout time!

Re "simply go and see" - I guess that explains why so many good managers I've known have practiced MBWA, which (I just discovered this moment) is now enshrined in the Toyota method as Genchi Genbutsu, aka Getcha BootsOn. And the Japanese literally means "go and see for yourself." Huh!

Along similar lines, I hope everyone involved in the next generation of healthcare IT will spend a few months actually having a critical disease. Genchi Genbutsu stage IV cancer! :)

Anonymous said...

Dear Paul, - SPIRIT is usually applicable on the Clinical Side. What are we doing to improve the Research Side (administration/bench work)?

BIDMC has been always very active in the clinical side. I would like to see BIDMC more offen involved in research side. I thinks moving to CLS should be a new start point where evaluating the necesities of research are considereted seriusly and it is not just moving from one building to another.

Research administration is soo inefficient that sometimes I need to guide them in how to run their business. They do not care about our science and we are just a number.

Anonymous said...

Dear Anon 2:09,
Actually, it is applicable to research, as well as clincial activities. Trying calling out a problem . . .

And, your characterization about their not caring is not at all true. If you have a suggestion, make it, please.

Anonymous said...

Paul, just wanted you and the BIDMC team kow how far you have reached...I gave a talk on leadership this morning in Africa, and the leaders in the room asked for an example of what a CEO could really do (I have included specific leaderhsip behaviors, such as rounds, etc.) and so I opened your blog and walked them through this entry. They were amazed, impressed and will all be tuning in to watch the progress on the pump team! Thanks!
Maureen Bisognano

EB said...

Working closely with hospital emergency departments, I can say the same issue exists with the typical "Stretcher Hunt". Things are fine in the AM but come afternoon, staff must do a search and recovery mission when they are needed most in the unit which detracts from patient care and safety.

Wondering if you have looked at this...

Anonymous said...

Paul – thank you for sharing! One of my colleagues, an MD, had this comment “this blog is written by the hospital CEO...there lays the difference between a lean transformation and using lean tools to solve some of our issues”. We applaud your leadership!

We have also tackled the wayward IV pump issue. Here is a link to a write-up on that project:


It will be interesting to see if your team comes up with a similar process.

Anonymous said...

OOPS - here is the correct link to my previous post:


Anonymous said...

iv pumps are definitely hoarded (in out-of-the-way-not-easily-observable-spots) on floors - pretty understandable given the frustration of waiting, waiting, waiting for them (sometimes for critical meds) but of course that's no reasonable solution... think par number for each floor/unit would be good start.
west campus rn

Geewhiz said...

While I don't know if you consider this a major issue of public policy, I just thought I would throw out that this particular post and its much anticipated follow up is by far the most interesting to me.

I am curious to see how successful you are with this set of employees, who sound very dedicated (in contrast to what little first hand observation I had at a NYC hospital). Also wonder if you're looking into any shortfalls that could result in some serious bumping of heads with some Dr. egos.

Anonymous said...

Thanks, Steven. Stay tuned. More to come!