Monday, April 13, 2009

Looking for your help

A short introduction is called for here. Over the past two years, I have shared things with readers of this blog that usually are not made public by the CEO of an organization. I have done so because I think the issues facing hospitals are of sufficient societal import -- i.e., beyond the particular interests of our own hospital -- that they warrant public attention and discourse. Further, I believe that academic institutions like ours have a responsibility to provide educational materials to others, and what works better at that than real time case studies of what we are going through?

In so doing, I show us for what we are in real time, warts and all. This makes us vulnerable to nasty anonymous commenters in the blogosphere, as well as to people who think they benefit from embarrassing us and making us uncomfortable. And, even a few of my board members have said, from time time, "Transparency is one thing, but did you have to post
that?" The answer is that this is an experiment in real time, but that I believe BIDMC ends up being a stronger, more effective, more efficient, and more humane organization for having done so.

Here comes the next example, an email I sent out over the weekend to our staff, entitled "Looking for your help." It is self-explanatory. As always, I welcome your comments:


As you can imagine, I've been giving a lot of thought to the events of the last several weeks with regard to the MRSA infections and the lapses found by DPH and CMS in our hospital with regard to infection control. We have already made some changes in response to those findings that should be quite helpful, but I want to draw back a few steps and ask your indulgence to think through the issue with me in a more comprehensive way.

Let me start with a story. I have a friend named Tom Botts, who works with Royal Dutch Shell. Tom and his folks had put in place the world's most extensive safety program for people working on oil rigs. Much to his dismay, two workers went to the wrong part of a rig called Brent Bravo and did something totally contrary to all their safety training and were killed. It would be all too simple in a situation like that to blame the two workers for being inattentive to the safety rules, but Tom and his colleagues did something different. They engaged in what he called a "Deep Learning" exercise and discovered that the problem lay not in well-intentioned people who made mistakes, but in the leadership of the organization for failing to fully understand what it would take reduce the chance of errors.

Here's an example of one of his conclusions:

"A system full of well intended, competent people working world class systems trying their best to meet expectations can produce fatalities."
Probably the most profound learning for me. In the Brent Bravo story, there were no obvious ‘villains’, but rather a number of causal patterns that came together to produce a tragedy. The whole point of Deep Learning for each of my senior leaders and me was to be able to see ourselves in the system and what causal patterns we could have been able to break (if we had a better appreciation for the unintended consequences of our many well intended decisions). Key questions: Am I asking the right questions? Am I curious enough?

(If you would like, you can read other parts of the story and Tom's other lessons on my blog here.)

So, now let's go back to BIDMC. That there were flaws in our infection control procedures and techniques is quite evident from the DPH/CMS report. Let's not deny those. But let's also assume that the well-intentioned and highly trained people in our hospital were extremely unlikely to have made these errors intentionally. As one of our nurses said to me, "There is a difference between knowing what to do properly, and deciding not to do it despite knowing it." And then she said, "I truly believe we are the best hospital here in Boston. That is why I choose to work here. We are open with our mistakes, as that is how we are able to learn and progress. It hurts to see our name slandered, and our reputation diminished over this. Can we do better? Yes. And we are already. Our policies are being rewritten, and our procedures reviewed. This is an issue that is in EVERY hospital. Please don't let this disintegrate further into an atmosphere of fear and punishment. Please use this as a tool for internal review and reflection."

Although we have made a full and complete response to the DPH/CMS findings, we are in the business of continuous improvement here, and I want to see if we can do better still . . . with your help. In the past several weeks, we have seen the power of our joint action in adopting budget and personnel actions that reflect our deepest values of caring and compassion. Our town meetings and chat rooms and emails produced a result that solved a serious budget problem . . . and by the way, brought great national acclaim to our hospital.

I would like to try to do the same here. I don't think large-scale town meetings fit the bill for this exercise, and I also don't think the imprecision of chat rooms and emails would work in this case, either. Instead, over the next several weeks, I will convene a series of focused discussion groups with those of you who would like to join me and a small group of Chiefs and Vice Presidents. Your task will be simple and direct: Tell us what we don't know that we should know to help make it more likely that future quality and safety problems will be diminished. We'll then take what we learn from you and do our best to construct the training, procedures, and infrastructure that will move us along in this journey.

In the next few days, you will see an email setting forth a schedule for these meetings, and you will be able to sign up for one that is convenient for you. I welcome and treasure your participation.




Anonymous said...

Excellent move, of course - feedback of the true story from the front lines is always essential. However, it still takes guts, especially in the current economic climate, for an employee to stand up in such a meeting and say things that administration or physician leadership may not want to hear. Therefore, being 500 miles away and not involved, I'll ask one question for them - it appears that you have physicians-in-training and attending physicians who are not following infection control protocols. (NOTE: this is true of every hospital in the United States.) How does your institution plan to address this issue, knowing that a single standard of compliance should prevail? Will some of your focus groups be with physicians? Will medical departments be asked to present concrete ideas for increasing compliance, and establishing real consequences for noncompliance, among their members? (And by ideas, I don't mean issuing another memo saying "wash your hands.") This must go beyond requiring nurses to be the handwash police - an unsatisfactory solution for all concerned.

Second, given all the fearful comments from patients and upset comments from employees, I'd like to observe, based on my longterm experience in other states, that the State's response to this incident is a carbon copy of most any concerned State health department - an initial focused inspection, followed by a hospital-wide inspection looking for anything and everything, and a report couched in the most critical language possible, guaranteed to make you cringe. Don't be surprised if this also generates a JCAHO inspection, as often happens. It doesn't mean you're a bad institution; it's just the way accrediting bodies react to such incidents. I think they do it to scare people, and there's absolutely nothing wrong with that for the patients' sake.
Good luck with your process, and I am sure it will have good results.

nonlocal MD

Anonymous said...

I'm sure it is hard to stay committed to both the ideal and the practice of transparency right now, but it's important. Your experience looking at systems as sources of errors and not just at individuals will stand you in good stead.
BTW, I have heard anecdotally of a hospital in Mass with norovirus issues persisting over the past 3 months, with new infections still occurring among visitors and those who visit the campus for outpatient services - and not a word in the local press! So, I can see the unfairness of it.
Personally, I am glad BIDMC is committed to transparency - it gives everyone the power and responsibility to try to make things work better. None of us in healthcare ever INTEND to harm a patient.

Anonymous said...

Have you looked at infection control standards for different departments of the medical community that address sterility? How is the microbial surveilance in central processing, OR's and pharmacy?

David Keefe, M.D. said...

Transparency is a necessary but not sufficient condition for transformation
You need to improve implementation.
Larry Bossidy has written extensively about the importance of implementation.
Who, besides you, owns the MRSA problem on the newborn and obstetrics units?
Where are the leaders of those units?
Processes are important, but change requires champions.
I agree with Nonlocal MD that physicians pose particular challenges in effecting transformation.
Doctors especially underestimate the importance of handwashing. They're more readily engaged in building a "national model" for something, cloning a gene or serving on an NIH study section than simply washing their hands.
When you bring issues like hand washing to their attention, they would prefer to debate the science behind nosocomial infections than simply start washing their hands.
Your physician leaders need to work with their doctors to drive this important initiative. You can't do it without them,
short of standing at the sink and washing their hands for them.
Doctors respond to metrics. Indeed, they've lived by them since pre-med days.
Why not measure and incentivize compliance with quality iniatives, including hand washing? Our hospital improved hand washing rates taking this approach.

Bob Yokl said...

Paul you are sailing on uncharted waters here for all the right reasons keep up the good work.

When I think of any professional especially healthcare professionals I think of baseball players (Pros right?) who show up every day before the big game to take batting practice to shag ground balls to be coached and to make their games better and better for the good of the team. Why are healthcare professionals any different? Are the healthcare professionals only showing up to play the game?

Granted they get training enough to keep their certifications but we need more and we need to make it part of the whole game once healthcare understands that the only way we will get better is to constantly train train train!

Can you wake up a SPIRIT Team Member in the middle of the night and they can spew out the mission of the SPIRIT program you have going? Same with your MRSA/Infection Control program...etc.

Anonymous said...

Good luck to you and your team--it takes tremendous energy and iron will to continue to dig deeper to find out how to continuously improve. But those organizations that don't commit to that will surely face more heartache in the future. The system we are working in (no matter where we work) is constantly changing--just when we think we have it figured out and "controlled", something new crops up or develops. The only answer is an organization that is constantly curious about what we don't know, what is changing, what are the implications from the change I introduced yesterday. It's a muscle most organizations have yet to develop.

Anonymous said...

Hi Paul, I like this approach. I think bringing people together across departments can result in some great brainstorming, and hopefully bring about better solutions. I hope we continue to do more of this at BIDMC.

Anonymous said...

The idea of focused discussion groups is a good idea. It will take effort to elicit input from nurses and managers who are in contact with patients and families, and with physicians who are part of the process.

It is important to encourgae the "contact level" staff to be forthright with upper management and to be protected from subtle adverse payback from a few who may feel they must justify existing practices. I was once in a position where I was asked by the president of the division to come up with a reorganization for a troubled project to which I was recently assigned. After I presented the plan, which was implemented, the person to whom I directly reported, and who was losing control of the project, wrote a performance review on me that proposed to have me fired. It was only through the intervention of his boss that I remained with the company and the project.

After all of the tough issues have been resolved and everyone gets together for a self-congratulatory attitude adjustment session (a party), and the policies are written and people have been trained, then there must be a clear understanding that those involved must either buy into the process or can expect to "bye out" of BIDMC. Intentional or careless disregard by those who should be leaders cannot be accepted or there will not be effective implementation by the staff.

Anonymous said...

Very well stated on all points. Thank you.

Anonymous said...

thanks paul. i am going to have to agree and say that i really like this approach also. thanks
Jay Stevens
Cyber Monday, Gunvault Safes, Umbilical Cord

Deanna Bland Hiott PhD, MSN, RN said...

I love following your blog. It stands as a shining example that everyone works better in an environment of truthfulness and transparency... Everyone loves to be a contributing member of the team and to be valued as such. You wouldn't consider going into politics would you, I'd love to see some transparency and truthfulness there!

paul o'neill said...

In an organization committed to identifying everything gone wrong, in real time every day and sharing transparently across the organization every day it would have been apparent after the third or fourth incident that there was a failure pattern in preventing MRSA.

The best leading indicator of an institution's progress on the journey to be the best in the world at everything it does is the injury incident rate for the people who do the work. If the processes necessary to create an injury free work place are not in place and operating, it is a virtual certainty that MRSA cannot be eliminated or contained because there is no continuous improvement.

Chris said...

I'm a regular reader (and feed subscriber) who's appreciated your candor. This isn't the best place to put this comment, but I've often wondered what you've thought of other hospital CEOs approaches to essentially what you're doing here on the blog.

A new CEO in suburban Cleveland has decided one way to insure customer satisfaction is to give out his cell number to every patient.

The story is here at MedCityNews.comI figured your insight would be valuable (maybe make it a regular feature: highlights of other approaches that work). I had to post this in your comments section because there's no way to e-mail you on the blog - which makes me assume you don't give out your cell. ;-)