You don't "do Lean"

If there were a form of medical malpractice lawsuit that I would like to encourage, it would be against those consulting firms that promise hospitals that they will teach them how to "do Lean."  I recently encountered a hospital in which a well known international consulting firm did it this way:  Assemble 25 top level managers for a week-long off-site seminar, teaching them all the Lean terminology and getting them ready to do Lean projects.  Then keep one or two of your consultants in residence for a few months to provide aid and comfort to the managers as they attempt to run rapid improvement events in areas of the hospital chosen by somebody as "high priority" areas needing cost savings.  Then leave behind your "trained" cadre of managers to carry on -- which they cannot or will not do.  Charge the hospital several hundred thousand dollars for this "service."  But not before you have given Lean a bad name and, worse, have caused it to be associated with layoffs (or redundancies, as they say in the UK.)

I'd like to explain all the things wrong with this, but I would just get upset.  Let me provide the simple explanation.  You don't "do Lean."  Lean is not a program.  It is a long-term philosophy of corporate leadership and organization that is based, above all, on respect shown to front-line staff.  There are two essential aspects, training front-line workers to be empowered and encouraged to call out problems on the "factory floor," and training managers to understand that their job is to serve those front-line workers by knowing what is going on on the front lines and responding in real time (when problems are fresh) to the call-outs.  Yes, there are all kinds of methods and tools and terminology, and as Virginia Mason Medical Center's Sarah Patterson notes, "Lean provides a common language for process improvement." She also reminded us, though, that it is a focus on process, not on the outcomes.  The idea is to "build key features into processes that are waste free, continuous flow."  To do this we need to "grow leaders-- to respect, develop, and challenge your people."

I hope that those of you who have been following my commentary about our Lean workshops at Ipswich Hospital NHS Trust will have seen an emphasis on these points.  You will have also seen that we employed on a pedagogical approach that relied heavily on going to gemba.  You cannot teach respect for front-line staff by sticking people in an off-site conference facility for a week.  You cannot teach people to notice the problems in work flows if they are not looking at the work flows.  You cannot teach the principles of incremental improvement and experimentation if you direct managers and staff to spend all their "Lean time" on time-consuming projects in "priority areas."

Jim Craig (seen here shadowing a person during the workshop) told me this story after we were done.  He was walking through a ward and heard a trainee grumbling about something.  He went up to her and said, in a friendly way, "I happen to overhear that you were upset about something.  Would you mind telling me what it was?"  The answer was that, many times per day, the resident would need to print out a form from the computer.  But the ward was a large ward, and the one printer was at the extreme end of the floor.  So, when she was seeing patients at one end of the floor, the resident would have to spend 5 minutes each time walking across the floor and back as she collected the form.  Jim said, "Would it help to have a printer at each end of the floor?"  "Oh, yes," was the reply.  Then and there, he called the IT department to arrange a printer to be delivered.  Result: A very grateful trainee, who will now have more time to be with patients rather than fetching papers.

The Lean aficionados out there are already fidgeting, for they have noticed other potential solutions to this problem.  And they are asking questions like, "What is the form itself, and does its production add value."  Those would be good things to explore.  The lesson, though, is that Jim was at gemba, heard the (unintentional) call-out, responded respectfully, and analyzed and solved the problem while it was fresh.  I give him an A+ for demonstrating what he learned at the workshop.  Well, let's make it an A- so he knows there is always the potential to improve!

Heather helps us all

Please check out this thoughtful blog post by Heather Thiessen, a patient I met a few months back in Saskatoon.  She tells her own story well and has some good thoughts for both providers and patients.  Excerpts:

Living with two chronic — and sometimes critical – neurological conditions made me realize that I had to start standing up and being an active partner with my health care team. No one else would be there to tell my side of the story or speak up for what I really wanted to do when my condition worsened or when it was time to explore new ways to get me back to my normal status.

The next chapter in my journey as a patient began when I was invited to be part of a patient panel for the Patient, Client and Family Centered Care Workshop in October 2010. This was a very emotional event for me, because I had to share some of my worst care experiences with many of the people who had cared for me. But I felt that doing this was an important part of my being able to be an advisor. Many of those who heard my stories came up to me afterwards and told me they too remembered the events and were so sorry for the pain I felt. This was a learning event not only for me but for them as well. After this, I was asked to be a patient advisor in both the Neurology and Rehab departments and the ICUs in Saskatoon.

Is it scary being involved in these advisory boards? Absolutely! But when I see all the wonderful things that can come out of this work, I am happy that I’m involved and I’m happy when new families and patients join. I deeply care for those who have saved my life so many times. But health care, like most things, is not all rosy. If I can help make things better for staff, then I know things will be better for me and other patients.

Blogging feels like the next step in my evolution as a professional patient. I see it as a way to help bring the voice and perspective of patients and families to an even wider audience, to become part of a larger dialogue about making health care better. 

Trusting myself and listening to my inner voice has helped make me a better partner in my own care and get the best possible care possible. I hope that my stories and experiences resonate with others – not only patients and families – but also people managing and delivering health care.

Cross-cultural good luck

On Uxbridge Road in London, using good luck symbols from different cultures.  Hey, it can't hurt!

An eye clinic helps us see Lean more clearly

One of the lovely aspects of Lean that we discussed during this week's training workshops at Ipswich Hospital was the concept of kaizen, process improvement accomplished by incremental change.  I often add another characteristic to the approach:  Can we achieve an improvement with no incremental cost?  Strictly speaking, that cost constraint is not part of Lean.  After all, sometimes you have to make an investment in personnel or equipment, and it often has an excellent return to consumers, the firm, or both.  But I have found that asking people to think about how to change things at no cost opens up floodgates of creativity.

Here's an example from our discussions.  Ipswich Hospital operates an eye clinic and has an open access policy, i.e., you do not need an appointment.  The open hours are from 9am to 1pm, and then from 2pm to 5pm.  The idea of open access is terrific: More and more organizations have employed it.

What happens here, though, is not quite terrific.  A patient goes to a GP and is told that s/he needs an eye exam or other treatment.  S/he shows up the next day at 9am, only to discover that the people referred by any number of the several dozen GPs have also decided to go first thing in the morning.  The staff cannot handle this huge batch of people, and many are left waiting for two or more hours to be seen.  These are often elderly people with vision problems, and so you can imagine the discomfort and, ultimately, the frustration and anger that result.  Also, as word has gotten out about this problem, people have started to show up even earlier, at 8:30, in the hope of getting to the head of the queue. It feels like a case of "no good deed going unpunished," but it is actually a classic case of batch processing when what is desired is a flow.

When this scenario was presented to our class, I asked them to invent an improvement with which we could experiment that might alleviate the problem.  How do we transform the batch to a flow, to match the consumers' needs with the resources available in the clinic?  People immediately started by adding steps to the process:  Perhaps GPs would have pre-printed chits, with different times of day, that would be handed to patients.  (But how would we coordinate the chits across all of the GPs, with changing numbers of patients every day?)  Perhaps the staff in the GPs' offices could call ahead and see how busy the clinic was.  (But then we would add to their work and would also be interrupting the people working in the clinic.)  Perhaps we could install a computer system that would post on a website the number of people waiting at the clinic and the expected delay in appointments.  (But then we have to pay for that system and have someone at the clinic enter the information throughout the day.)

I then asked the group to consider a process that would involve no new steps and add no costs.  The answer emerged:  Make it clear with a simple one-time message to GPs and a poster on the clinic entrance that the clinic would prefer (but not require) that people whose surnames began with "A" to "F" would be welcome at 9am; "G" to "M" at 10am; and so on.  "Ah!," said the person who had mentioned this problem, "So simple.  Let's try it."

Ipswich leaders offer next steps on Lean

As we ended our Lean training workshops at Ipswich Hospital NHS Trust, I asked the participants to send me an email indicating what concrete steps or actions they would take in the next week to practice or implement some of the principles we had discussed.  Understand that I was not asking for a full implementation of the Lean philosophy in the hospital:  That requires a huge commitment at all levels of the organization and is something not lightly entered into.  Rather, I suggested that the basic principles of Lean can be practiced by managers and leaders at any time.  Quoting Don Berwick's line that "soon is not a time," I suggested that if you don't actually begin to practice those principles, they are easily left aside during day-to-day activities.  Here are some responses, with names omitted:

-- I think we do not do enough of this, that is the reflecting on the work we do and how we do it. There have been a few gems over these events, but one for me to highlight was the response that I did not get time to write after the second day of the course, when I was going to tell you how much I hated my office. It’s actually a nice room, light, airy, and well located, but I’m in it too much, and that’s why I don’t like it. The trip we had to stores was an important reminder for me to get out and about more – and I have now scheduled time in my weekly diary to do just this. In my own unit we have initiated a new ideas scheme, and I think this is a good practice, but your element of calling out issues, build on that even more, and I am now thinking about how we can recognise and encourage such behaviour. It’s funny that last night I realised that one of our excellent middle grades in the Oral department has called out just recently, pointing out an important issue with our outcome forms that we are now resolving. I intend to write about this in my next newsletter.

-- You might have already worked out the NHS problems such as long waiting period for clinic appointment, long waiting list for routine surgical operations, failure to meet targets,  ineffective utilization of theatre and some of the staffing issues in the department. I observed the measures the management teams are taking and miserably failing to sort out the problem or fixing it temporarily and finding them in the same situation again. I do not have any management training, but I try to put myself in a mangers position and think. Often, I think if they try a certain approach it could work. As a clinician, being in similar situation at other hospitals and seen different management strategies which work, I wish I could shout out my ideas and open a dialogue, eventually solve the crisis. But often people in management or power don't listen. I feel embarrassed and often apprehensive as how others take your opinion. Also, I do not want to offend my colleagues and consultants with ideas which will direct implication on them.  I sincerely hope this Lean workshop will help Ipswich Hospital to work out the areas which needs careful management intervention.

-- I will use every opportunity to visit the shop floor and in doing so change my approach to one of observation and learning. I will start referring to little changes that I have made each week when I meet with my senior team, and I will begin to ask them the same so that we can all learn from our changes and how these have been achieved.

-- In the next few weeks I want to implement a number of small projects implementing the Lean principles. These include looking at the way my colleague and I process colorectal referrals, which currently come to us in batches and take ages to work through, with the resultant work being delivered to the secretary all in one go. I am sure we can turn this into a continuous work flow.

This morning, I saw in the store room, theatre gowns, which I was told had stopped being ordered. They prevent my forearms being covered in blood after long abdominal and pelvic surgery. I will speak to the relevant people to ensure they are delivered to theatres on a regular basis. 

-- I have long thought that Lean is a system that we must embrace. I have read often of the benefits of its application in healthcare. However from your tutelage I now understand that it is a methodology first and foremost to improve the quality of care we give our patients. Any financial benefits are as a result of this ‘the virtuous relationship between quality and finance’ as you put it.  I think this fact is lost often in translation (the pun is intended!) and certainly has been an impediment to its dissemination in healthcare in the Ipswich.

It is my hope that as a result of your visit we now have a nidus of colleagues who have seen the huge potential of working in this way. I will try to bring us together, initially informally, once a fortnight to share our experiences and our successes. I am going to suggest that we each try to cascade Lean to one other individual every month and so on and so forth (a bit like Amway!). In time incrementally we will develop a philosophy across our shop floor of continuous improvements.  From our group we will identify someone to receive more comprehensive training to become our Lean coordinator or sensei.

-- I believe that the changes we make have to be sustainable. Small changes will make a difference. As an organisation facing many challenges, we must ensure we do not waste energy by repeating processes that do not work.

My mission will be to engender a 'can do ' attitude.I will challenge any negativity from staff, and  I will challenge myself to ensure I have the systems in place to allow all my staff the opportunity to contribute ideas and comments. I will work with my team leaders to action these.

I will challenge myself to visit areas in the Hospital I am unfamiliar with, in relation to the patient pathways and processes that affect patients who are cared for in my areas. This will help me understand the real experience the patient has and allow me to examine ways to improve the systems.

I will also invest some time to reorganise my office to improve my access to information etc!

-- Pledge to spend 1 hour a week with a colleague observing work with an aim to make improvements to their working life. And do this with respect for a co-worker who knows more about their job than I (as a manager) will ever know. Then ask that person to do the same for 1 of their colleagues to rapidly spread lean principles across the organisation.

-- After an energised afternoon looking at the 5S, I and my other 'Lean' colleagues returned to our offices. At least four of these colleagues took this opportunity to check their inbox. As responses hit my inbox during the time I sat also responding to emails. I asked myself 'Is email the best way to communicate this message?'

There must be alternative ways of conveying a message. I plan to involve staff by asking them to discuss the benefits and drawbacks of looking at other channels of communication

Could we consider a no email day? Why do we send an email when a face to face meeting or a phone call maybe more effective & even quicker than waiting for an email response.

Perhaps a coffee or lunch break with a group could be utilised to share information and we can encourage staff to think of alternative ways of communicating information.

I will review the types of information that I regularly send and receive. Many of them are to request information required on weekly or monthly. Instead of chasing on a weekly or monthly basis perhaps develop a timetable of the information required. 

My initial thoughts are that perhaps phone calls and face to face meetings could be more time consuming however as an organisation we need to make a real effort to reduce email overload and I believe this has the potential to ensure better teamwork, a quicker problem solving approach and a happier workforce.

-- Next week I plan to improve our ultrasound scanning service to inpatients.

At present, at the start of the day, all the pending inpatient ultrasound scan request forms are reviewed by the radiologist scheduled to perform the scans. This means there is a flurry of activity (batching of work) in the early morning with the radiologist sorting through a large pile of paper forms, the imaging assistant ringing the wards with instructions and writing out collection slips for the porters, the ward clerks receiving those instructions and passing on the information to the relevant nursing staff who in turn speak to their patients about what is about to happen. It is all a mini whirlwind as this needs to occur before the radiologist starts scanning the first patients on the list (who are outpatients arranged in advance - to prevent downtime whilst waiting for the first inpatient to arrive). 

The rush means it is stressful for all in the chain. For the imaging assistant it means time on the phone and liaising with the porters when she should be helping with the first (out)patients. On the ward other tasks are interrupted to prepare their patients to come down for their scan. Because of the short notice often the doctors on the ward rounds do not know that the scans have been scheduled and ring up to enquire if and when the scans will be performed thereby disturbing the radiologist who has to stop scanning the patient of the moment. Additionally, there is frequently inadequate time to get the necessary preparation right, e.g. the patient for a pelvic scan has an under filled bladder and the scan is inadequate or worse still needs to be repeated. Most importantly, the patient and their relatives, who have usually been told by their attending ward doctors that they need a scan, are anxiously waiting not knowing what is happening for longer. 

How can we make this better? 

One possible way would be to review all outstanding request forms at the end of each afternoon and schedule the scans for the next day. That way everyone knows well in advance and can be planned to fit in around other activities. Waste could be reduced. 

Can I persuade my colleagues to change? Will they come up with a better solution? Watch this space.

-- Have largely been doing this process for the last 7 years thus the result of a large well functioning AMU which is Nationally acclaimed for its results.  My steps now will be to insist other departments work with us in the same way to allow a smooth patient journey...first e mail has been met with horror so far!!

-- I am currently tidying my office!

Last week we had a crisis meeting about an inability to find slots for patients to have lung function tests. I now realise how we can make the situation better but using existing capacity in a smarter way. In the next week I intent to meet with our lung function unit manager to find a way of better matching his work load to the chest clinics. His team appear to run the same timetable every day even though the chest clinics are not evenly distributed.  Also, if I go on holiday, I don’t warn him that this is the case and so he can’t plan a different task for his technicians.  Given enough warning they could book more patients for routine tests on these days that don’t have to be coordinated with my clinic.

-- I have today agreed to mentor a colleague who works at a supervisory level in the Trust, meeting her once a fortnight to discuss the issues she faces, and help her to work through them.  I plan to share practical Lean principles during these sessions with her.

Whatever I am doing I will always watch, listen to and spend time with my teams to truly identify the root of problems/obstacles; working with the team to resolve them together – this is the crux of every manager’s job!

Ipswich pigs teach the value of standardization

Standardization, or reduction of variation, is a big part of the Lean philosophy, and that was our topic today during our training workshops at Ipswich Hospital NHS Trust.  To illustrate the value of standardization in helping to bring about consistent quality of output with less effort, we employed the pig exercise.  Regular readers are familiar with it.  You can see the first of the sequence of three blog posts describing it here.  In part one, participants are asked to draw a pig on a grid, following oral instructions.  In part two, written instructions are provided.  In part three, the written instructions are accompanied by a picture of the desired work product.

Fortunately for his patients, resident Satheesh Iype is a better surgeon than artist.  With good humor, he accepted the friendly ribbing of the entire group at his depiction of a rabbit -- or goat -- or pig.

By round three, all participants were able to produce an accurate and speedy rendition of the desired pig design.

On a more serious note, Sateesh offered the following thoughts after the workshops and particularly after spending time at gemba, shadowing and observing workers in the hospital:

I think my greatest achievement [from this week] is a change in attitude.  I am taking a positive attitude.  Over the last two days, I have been observing other employees of the Trust, i.e Darren, the X-ray porter, and Tom, the HSDU stock manager.  I respect them even more and understand the important role they are playing in the process.  I see things with a different perspective and will try to take every effort to cut down time wasting.

Supplying Ipswich Hospital

As we continued our Lean training workshops at Ipswich Hospital, we spent some time with Thomas, the young man who is in charge of the major receiving and distribution center for supplies entering the hospital.  Specifically, the HSDU ("hospital sterile and disinfection unit") storeroom contains medical devices and supplies and sterile equipment and packs for wards, departments and theatres (i.e., ORs).

All of the managers taking the workshop were tremendously impressed with Thomas -- his devotion to the health care mission of the hospital, his sense of initiative, and his strong sense of responsibility to the patients whose care depends on maintaining an adequate supply of mission-critical equipment.  And yet they also quickly came to understand that Thomas, in essence, is working with one hand tied behind his back, i.e., in an environment that is designed to be inefficient and wasteful.  In that regard, I told the group, he typifies many other inventory supply people in hospitals worldwide.

Thomas and his colleagues in many places live in a world in which they are put in the middle, receiving no visual cues as to incoming supplies from vendors and also no visual cues as to the demands of customers, the wards and ORs upstairs.  Some of his suppliers are reliable, but at least one is not, sending packages slowly and in deficient quantities.  On the demand side, if there is a surge in, say, OR utilization, he learns of it by a quicker depletion of his stocks.  He also has no idea how much inventory is being stored on the wards or, as here, in trolleys in the hallways outside the wards.

So Thomas does what you or I would do.  He plans conservatively, using rules of thumb that result in over-stocking of supplies.  After all, the last thing he would want to do is run short when a patient's life is at stake.  For example, knowing that one supplier is slow and unreliable, he over-orders from that supplier.  If he still runs short, he can pay extra for an emergency delivery.  In both instances, he is essentially rewarding the unreliable supplier.  Because Thomas is not in charge of the procurement process itself and has no influence with that department, it does not matter if he calls out this problem to a superior. 

The knowledge Thomas needs to do his job is essentially inside his head.  If he were to get sick and injured, there is no one else in the hospital with his abilities.  When he leaves for a two-week holiday, he pre-orders extra supplies for those two weeks.  "When I am on leave, I have to cover stock whilst I'm off."

The managers in our Lean workshop left with a greater appreciation for people like Thomas, but also with an understanding that their role as hospital leaders must evolve.  In a health care system facing ongoing cost pressures, the kind of inefficiency represented by the environment within which Thomas is working is unacceptable.  He should be given the tools he needs and the support he deserves to efficiently stock and deliver the millions of dollars of inventory needed for safe and effective patient care.  I believe that, whether or not Lean becomes a hospital-wide philosophy,  our team felt strongly a new sense of responsibility to take steps to adopt its principles in their own work environments.

Learning Lean in Ipswich

Today was the first of a series of workshops on the Lean process improvement philosophy at Ipswich Hospital, and I was pleased to meet two dozen people from various jobs around the hospital.  We started with an introduction based on the Toast Kaizen video produced by and featuring GBMP president Bruce Hamilton.  Then it was off to gemba, the "factory shop" floor, where the class members shadowed a member of the staff. The idea was to practice observation skills and try to identify the various types of waste found in all organizations.  (You see one example above, with a student watching the work done by the unit coordinator of one of the wards, and another below, observing a staff member keeping up with the status of his patients.)

The class members gained a new appreciation for the degree of difficulty faced by their colleagues in doing their everyday jobs.  They noticed impediments, inefficiencies, and work-arounds.  We listed these and posted them to compare the experiences from different areas of the hospital.  Later, I gave everyone a homework assignment, which was to answer the following question: 

Waste exists in Ipswich Hospital because the people who work here are uncaring and lazy. True or False? Provide evidence in support of your answer.

I suspected (and hoped!) that the answer would be "false," and it always was.  People understood that the well-intentioned and hard working people in the hospital face the common problems of complex organizations.  I promised to include the "best" answer here, but they were all excellent, so I have chosen a few a random.

Gary Picken wrote: 

False. I believe the large majority of staff at Ipswich Hospital are caring people who want to make a difference to patient's lives. Waste exists there because we are working in systems and with processes that are inefficient. These have often come about more by accident and the legacy of history, than by design and gathered evidence. The waste continues because we either do not see it or we feel impotent to effect change. Certainly, as clinicians in this organisation, we have not received the investment of the training for such leadership in the past. 

An example of waste:  An elderly man with lower limb arterial insufficiency referred to me for a femoral arteriogram, a procedure involving puncture of a large artery in the groin and an overnight stay in hospital.

Imagine, he has the worry of waiting for the 'test', the myriad of social arrangements to enable him to be there on the allotted day, his hospital bed and slot on the list are ring fenced so unavailable to anyone else.

He arrives in the angio suite after being admitted to the ward (time of ward clerk, nurse, junior doctor, porter) only to have his procedure cancelled because nobody has told him to stop taking his clopidegrel (strong blood thinning medication).

None of the staff wanted that outcome for him, just the opposite. The system had failed him. An ancient system that relied totally on the experienced medical secretary and faltered when she was absent, ill or made redundant.

That's where LEAN, I hope, can improve our hospital.

Jenna Ackerly noted:

The statement that waste exists at Ipswich Hospital because the people who work here are uncaring and lazy is false.  My experience in EAU today and from working in the hospital generally, proves this by constantly demonstrating dedicated, hard working and caring staff, going about their work in good humour.  Waste in fact exists because people are so busy going about their day jobs, in the same way they have always done (or been shown to do), that they fail to spot duplication, waste and inefficiency – or if they do, they feel that they do not have the responsibility to change it. 

Often new processes are introduced without explicit instruction that the old process can be dropped – thus creating confusion and duplication.  In my experience the only problem with our dedicated and caring workforce is that they work hard but not always smart, thus refuting that they are lazy or uncaring.

Jonathan Douse opined: 

Waste does exist at Ipswich Hospital but I don’t think it is because people are uncaring or lazy:

1)      I chose to work at Ipswich Hospital because it is a friendly place to work and because people generally say yes when I ask for their help.  If they say no it is because they have a good reason.

2)      When I walk down the corridor I see people directing the lost visitors and patients.

3)      My clinic receptionist is frustrated by her inability to get inefficient processes changed. 

4)      Many  of my colleagues work far more than their scheduled hours.

And Sam Bower offered this thought:

Waste exists because we do not dedicate the time to think about how to eliminate waste and improve process. For example the ward clerk redirecting all the mail today. She knew it was a problem as it "annoyed" her but when does she have an opportunity to tell someone it's a problem? She did today when I dedicated an hour of my time to observe her work. We need to do this more often. An hour a week with a colleague to identify waste and to embed the philosophy of lean thinking into our organisational culture. Not linked to finance, not linked to targets, but linked to improving the working lives of staff and improving morale.

Lessons from a taxi driver

I took the train from Ipswich to London this weekend for a break between my first and second week of lectures and workshops at Ipswich Hospital.  En route to the train station, I received a running (and unsolicited) commentary from my taxi driver.  As we drove by the hospital, she gave me her idea for process improvement there (knowing nothing about my background or purpose for being in Ipswich.)  It was something like this:

My mother was in the hospital a while back and I noticed, when picking her up to leave, that patients often sat in their rooms for 4 or 5 hours waiting to be discharged.  They were all set to go but just needed some test result or medication.

What a waste!  Those rooms could be used for someone else.  All it would take would be to have the hospital electrician -- who is on the grounds anyway -- to string a wire for an emergency buzzer, and buy a few easy-chairs for a couple of hundred pounds.  Then they could wait there comfortably and free up beds for others.

Well, I took it upon myself to write to the Chief Executive.  I didn't get a reply but I noticed in the newspaper a week or two later that the hospital had decided to create a new discharge lounge, ad so I felt like someone had actually listened to me.

But then I learned that instead of just stringing a wire and buying a couple of easy-chairs, they had spent a ton of money on building a whole new section and hiring nurses and nursing assistants to staff them.  I guess when you have other people's money to spend, you are likely to spend more!

I am guessing that it was regulatory requirements rather than a desire to spend other people's money that led to the hospital's design and staffing decision on this matter.  After all, until a patient is formally discharged, s/he is still a total responsibility of the hospital.  I would have explained this, but my voluble taxi driver was already on to the next topic.

But the story reminded me again about the interest that family members and patients have in being helpful to their local hospital.  They might not always have enough knowledge of all aspects to correctly frame the solution, but they have good instincts and perspectives on how the care environment might be improved.  (See this example from my former hospital's ICUs.)

It behooves all hospitals to create a process by which well-intentioned and thoughtful constituents can be heard and integrated into the clinical care process and setting.

Negotiating in Ipswich

Quality and safety improvement is as much about communication and relationships as it is about protocols and techniques of process improvement.  That was my message today at Ipswich Hospital as I conducted an afternoon seminar on strategic negotiation.  About 40 people attended, from all types of positions in the hospital, to learn principles of negotiation.  These included the concepts of BATNA (best alternative to a negotiated agreement); interest-based versus positional negotiation; trading on differences; and how to recognize the structural, contextual, and personal aspects of a negotiation environment.

One of my favorite exercises to illustrate the last point above is a game called "Win as Much as You Can."  This was developed by my friend Michael Wheeler and is technically described as a four-person, simplified, iterated prisoner's dilemma exercise. A group of four participants display index cards marked with "X" or "Y" to try to win the (virtual) prize money available in the game.  The payout depends on how many people put down an "X" and how many put down a "Y" over ten rounds of play.  The structure of the game encourages people to play "X," even though doing so causes them all to lose relative to the case in which everybody plays "Y."  This causes some good-humored strife within each group of four players, with some players (above) chortling as they win by reneging on the deals struck with the others, and others (below) expressing shock that their colleagues could ever do such a thing to them.

Recognizing stars at Ipswich

As I spend more time at Ipswich Hospital in the UK, I have had a chance to get to know people and admire their approaches to improving patient quality and safety.  Given the financial issues facing the NHS, there is also a growing recognition that such improvements often have a virtuous relationship with cost efficiency.

That being said, I have found modesty to be evident, with full recognition of where improvements are still needed.  But appropriately, that does not preclude recognizing people who have made notable contributions to the organization.  On a main corridor, there are photographs of "Shining Lights," staff members who have done particularly noteworthy things.

And then, this morning as I arrived, there was a photo session taking place to prepare images to accompany an internal newsletter story about a significant improvement in one of the surgical specialties.  The colorectal surgery group has reduced the length of stay associated with major bowel surgery from 11 days to 4.5 days.  Among those getting credit for this improvement was Vicki Reid, a colorectal nurse specialist, who is universally acknowledged by the doctors as a key player in implementing the steps necessary to accomplish this.

Patient safety lecture in Ipswich

The next event in my visit to Ipswich, UK, was a talk on patient safety at University Campus Suffolk, offered in partnership with Ipswich Hospital.  The topic was on reduction of preventable harm in hospitals, something familiar to readers of this blog.

As I often have done in lectures and classes, I promised that selected people who asked really good questions after the talk would be featured on this blog.  Here are two of them, along with some other friendly attendees.

The other, original, Ipswich

When you are from Massachusetts, Ipswich is a town that brings to mind steamed clams.  Here in the United Kingdom, the original town of Ipswich has a number of attributes -- as a major port, as the center of a farming district (the football team is known as "The Tractor Boys"), the location of British Telecomm research and development center, and -- my destination -- Ipswich Hospital NHS Trust.  I have been invited to give some presentations and hold workshops on quality and safety, front-line driven process improvement, and transparency.

The first meeting this morning was with the Trust Board of the Hospital.  (You see here interim chief executive Nigel Beverley and board chair Ann Tate.)  We discussed the similarity of issues facing hospitals in the UK and the US, notwithstanding differences in the institutional and funding structure in place in the two countries.  Questions of how to sustain process improvement and calling out of impediments, errors, and near misses was a key topic.

I was later joined at lunch by medical director Peter Donaldson (left) and chief nursing officer Catherine Morgan (above, center) for a discussion about pre-surgical protocols and check lists and other mechanisms for reducing variation in the delivery of clinical care.  Peter related a couple of stories to me from his own clinical career, many years ago, one in which he experienced a near miss before such protocols were in place.  This one involved almost removing the wrong kidney from a patient.  Each person in the clinical chain of treatment had repeated that it was the left kidney to be removed, notwithstanding the patient's saying to her GP that she was confused because it was the right kidney that was painful.  The GP said to her, "You can trust Mr. Donaldson to do the correct thing."  When Peter arrived in the OR to remove the left kidney, there were no X-ray images posted, and he asked to see them before proceeding.  Once they were displayed, he understood the error he had almost made.  He still shows evidence of the shock of that moment as he tells the story.  Peter tells this story to other doctors in training to reinforce the need for proper adherence to the pre-surgical protocol.  Unfortunately, as we all know, there are a persistent number of wrong site surgeries throughout the world (with a pertinent example shown here), and the potential for such harm exists everywhere.

I was impressed with the staff's commitment to quality and safety initiatives and their openness in learning from their own errors and near misses.  I look forward to sharing stories and ideas with them over the coming days.

Original Edwardian entrance, with maternity suite above

Ipswich Hospital original architectural detail

The case for science-based training in patient safety and quality

Peter Pronovost and Myron Weisfeldt make the case in an article in the Annals of Internal Medicine for an expansion in science-based training in patient safety and quality.  That it should be necessary to have to make this case is indicative of a sorry lack of commitment in medical schools, residency programs, and funding agencies.

Nonetheless, it instructive to review their logic.  The authors first note that the public has benefited greatly from prior research investments in biomedical research.  Looking at diseases like AIDS, pediatric kidney cancer, adult kidney disease, orthopaedics, congestive heart failure, chronic myelogenous leukemia, and others, they point out that many people live longer and/or with better quality of life as a result of those funding commitments.

Then, they remind us of documented results from investments made in patient safety research and researchers.  They note that cite central line associated bloodstream infections cause nearly as many deaths as breast cancer each year in the US.  They show how this rate of disease can be reduced, citing the Michigan program, children's hospitals, and elsewhere where tens of thousands of cases were eliminated and where millions of dollars were saved.  But such efforts were possible only because people with an interest pieced together available time and funding from various sources and learned how to make this progress.  Those efforts have been exceptions:

The limited progress in reducing preventable harm during the last decade was, to a large extent, because the science underlying this field was dynamic, evolving, and had little funding.  However, the field too often sought quick fixes rather than a deeper understanding of whether an intervention worked and why, undertaking less robust evaluations, failing to partner with social scientists, and downplaying or being incognizant of the need for formal degree programs in patient safety research.  For example, sentinel events recur in spite of investigations; yet, human factors engineers are rarely involved in these investigations.

The authors note that funding that has existed for research training and research in this field has been substantially reduced:

Yet, these young researchers offer hope by enhancing health care value, reducing preventable harm, reducing health care costs, improving patient-reported outcomes, and ensuring that patients receive the best possible health care for the public's investment in them.

If as David Mayer suggests, we need to "educate the young and regulate the old," this is not the right time to cheap out on the education part of training in patient quality and safety research.

Waiting for the Supremes to sing

As we await the Supreme Court ruling on the national health legislation here in the US, it is good to reflect on what the country wants.

Goodbye, Orbitz. Hello, Expedia.

Apple Insider reports "Orbitz displaying higher-priced hotels to Macs versus PCs."  Whoa!  Talk about segmenting a market:

Executives for the online travel agency told The Wall Street Journal that their company is testing a system that displays different deals depending on the user's operating system. Orbitz did clarify, though, that it is not offering the same room at different prices and users can always sort options by price.

"Orbitz found Mac users on average spend $20 to $30 more a night on hotels than their PC counterparts," the publication noted Wai Gen Yee, Orbitz's chief scientist, as saying.

Compared to PC users, Mac users are "40% more likely to book a four- or five-star hotel" and generally prefer higher-priced rooms when they book the same hotel as their PC counterparts, according to the report.

Brookline Booksmith tonight

I will be giving a presentation about my book Goal Play! at the Brookline Booksmith tonight at 7pm.  If you live or work in the area, I hope you can come by.

Here are details: http://goalplayleadership.com/2012/05/08/goal-play-event-at-brookline-booksmith/

Please pass the word along to others who might be interested.

Brookline Booksmith is a fantastic independent bookstore, so it is worth checking out if you've never been there.  The address is 279 Harvard Street.

Jordan's song tells the message

#TPSER8 There have been many written expressions by residents and medical students about how they were affected by the time they spent at the Telluride Patient Safety Roundtable this summer.  You can read those stories over at Transparent Health.

But, in the spirit of the folk festival that occurs in the town, at least one participant has been moved to song.  Here Dr. Jordan Chanler-Berat, a PGY 1 in Emergency Medicine at NY Methodist Hospital, sings about his experience at Telluride and what he will bring back to his own hospital from the conference.  (Thanks to Hillary Kunizaki from CIR for sending this along.)  If you cannot see the video, click here.

Dear Mark@facebook.com

When you have a brand and an outreach like Facebook, you can do anything you want, but why would you want to do it a ham-handed way?  Kashmir Hill at Forbes was one of the first to pick up on the latest case, calling it "Facebook's lame attempt to force its email service on you."

Technolog on MSNBC explains what happened and what you can do about it:

You see, what happened is that the email address — or in some cases, addresses — displayed on your Facebook profile was changed from whatever it was to your Facebook email address. (Your Facebook email address consists of whatever is at the end of your Facebook URL slapped in front of @facebook.com. For example: My Facebook URL is http://facebook.com/rosa, so my Facebook email address is rosa@facebook.com.)

For most people, this is pretty darn annoying as all the mail they receive at the Facebook email address winds up in their regular Facebook inbox. Based on a quick survey of friends and colleagues, it seems that this is inconvenient to a majority, as they prefer to receive their email in ... you know, their actual email inboxes.

Now that you understand the somewhat bad news better, here are two good pieces of news: Facebook didn't alter the default address on your account, meaning that the social network's whacky system only altered what is visible on your profile. And you can change your profile back to normal pretty easily.

All you have to do is open up your profile page (hit the "About" button under your personal info), scroll down to the "Contact Info" box, and hit the "Edit" button. There you can toggle who can see which email address and whether it is displayed on your Timeline or not.
 
If you're not a fan of receiving your email in your Facebook inbox, I suggest hiding that address and simply making the one you favor visible.

Adding votes for Vidler's

With thanks to Catherine Arnst (Vice President, Health Content Director, National Health Media, at Edelman), I share what I have learned about Vidler's, "an old fashioned 5&10 cent store now run by my best friend Bev and her brother Don. If you ever find yourself in Buffalo, take a half hour to drive there. It's like going back in time."

Here's a video to give you a sense of this 82-year-old throwback to what American towns used to be like.  After you watch the video, please vote here for Vidler's as the best company in Buffalo business.  (Click here if you cannot see the video.)

The is the first of an occasional series on old-time America stuff.  Stay tuned for more, and please send me your ideas.