IWantGreatCare advances the Lean agenda

I don't think Neil Bacon (of IWantGreatCare* fame) meant to reinforce one of the main tenets of Lean process improvement in a recent blog post, but he did do so. I also don't think Neil meant to enhance the Lean philosophy by adding a new key dimension, but he did that, too.  Let's start with his story from University Hospitals Morecambe Bay Trust:

The senior nurse from the surgical unit recounted to her colleagues how last week an elderly patient had used his iPad, from his hospital bed, to provide feedback on his care, highlighting a problem and concern he had using the iWantGreatCare pages for the hospital.

The nurses on the wards are able to receive instant alerts if there are concerns that need addressing for their ward – and thus the nurses were instantly made aware of a problem. Interestingly, in his comment the patient said something along the lines of “this needs sorting at some point, but I don’t want to interrupt anyone now”. Whilst the comments on iWantGreatCare are anonymous there were not many elderly patients sitting in bed with iPads! Thus the nurse was able to go directly to the patient and say “Let’s solve that problem now”.

I am told that the patient (who is still in the hospital) was completely amazed, not really expecting anybody to do anything ever, let alone seconds after he had given his feedback – this was not what he had come to expect from the NHS! Not only was the problem fixed, but the patient has been telling all his visitors and family about the incredible hospital and how the staff really listen, really care and get things fixed. His confidence is high, as is the morale of the staff who see people talking about the great care they deliver.

Lean is about front-line driven process improvement.  We encourage staff to call out problems they see in their work environment, and then managers "swarm" on those call-outs--in real time--and invent experiments that might improve the situation.

Here, though, we've gone a step further.  Here, the patient has been added to the front-line team by being given a simple technological approach that permits him/her to be empowered to make the call-out.

Whether Neil knows it or not, he just advanced the science of process improvement in the health care environment by one great leap forward. Well done!

--
* Think TripAdvisor for health care to get the concept.

"Wounded" comes to America

Emily Mayhew's book Wounded, about which I wrote in early October, is now available in the United States through Amazon.  This is simply the best book I have read about World War I, the 100th anniversary of which occurs this coming year.  It tells the intimate stories of doctors, nurses, and other medical personnel assigned to the front during this terrible war.

Terry Wise shares

Terry Wise is an extraordinary person--wise, empathetic, warm, thoughtful, and vulnerable.  She shares all these attributes with us in her book Waking Up, but she shares the benefit of her work with others through The Missing Peace Foundation:

The Foundation provides financial assistance, public speaking and other resources to entities that lack funding to advance their efforts to help those confronted with mental and physical health issues. Qualifying recipients include organizations, communities, schools, and other associations who aspire to raise awareness and educate others on topics related to long-term caregiving, grief, depression, mental health, suicide prevention, and the process of recovery.

Please check out the website to see if the foundation might be able to help your organization, or whether you might feel moved to contribute money to help the work of the foundation.

How the British Empire lives on

From The Times of London, a new type of Advent calendar!

Leadership Skills on WIHI

Madge Kaplan writes:

The next WIHI broadcast — New Leadership Skills for Better Health and Health Care — will take place on Thursday, November 21, from 2 to 3 PM ET, and I hope you'll tune in.

Our guests will include:

• Gary R. Yates, MD, President, Sentara Quality Care Network; former Senior Vice President and Chief Medical Officer, Sentara Healthcare
• Lee Sacks, MD, Executive Vice President & Chief Medical Officer, Advocate Health Care; Chief Executive Officer, Advocate Physician Partners
• Derek Feeley, Executive Vice President, Institute for Healthcare Improvement
• Andrea Kabcenell, RN, MPH, Vice President, Institute for Healthcare Improvement

IHI has been doing a lot of thinking of late about leaders and leadership… in particular the skills, behaviors, and outlook necessary to steer today's health care organizations toward a very different future. A new IHI white paper (working title: High-Impact Leadership) will be out before the end of the year that captures this complex transition. Among other things, it offers a new framework for leaders who are not just responsible for making change manageable, but enthusiastically supported by all staff. You can get an early look at the new leadership framework on the Nov. 21 WIHI: New Leadership Skills for Better Health and Health Care. One of the goals of this WIHI is to describe the interdependence between the growing focus on population health, the shift from volume to value, and the corresponding leadership skills required to address these challenges. 

At Advocate Health Care, Dr. Lee Sacks has been hard at work learning by doing, with the help of other physician leaders. He’ll explain in concrete terms what his team’s leadership practices look like day to day, including those needed to lead an Accountable Care Organization (ACO). Sentara’s Dr. Gary Yates will spend his time on WIHI outlining key leadership behaviors that signal to staff how change is going to come about and what’s expected of everyone. If leaders want to alter the perception that they alone have all the answers, hashed out in some corner office, they must become a regular, approachable, and authentic presence throughout the organization. Discussions in the hallways talking with staff, and learning from patients and patient stories, need to become the norm.

Fresh from his leadership perch at NHS Scotland, IHI’s Derek Feeley has been thinking hard about what’s applicable and relevant to the US context and in many other countries seeking better health and health care for their citizens. He, along with Andrea Kabcenell, will discuss how leaders can better manage and prioritize all the tasks necessary to succeed. WIHI host Madge Kaplan invites you to put on your leadership cap wherever you reside in your organization, and take part in this next discussion on Nov 21. Tell us what you’re doing to lead differently, with a different future in mind, and what impact this is already having.

I hope you'll join us!  You can enroll for the broadcast here.

I have no way of knowing whom I may have hurt

A colleague writes with a thought-provoking story:

As is often the case, learning the meaning of something can happen well after the actual events that precipitate our own maturation.  So it was for me when my mother developed a growth on her esophagus just before her stomach, in the fall of 2009.

My mother was scared and my father was trying not to appear scared.  Together, they were preparing themselves to be lead by the healthcare system in the discovery of exactly what my mother was afflicted with and how it would be treated.  Having started my life in healthcare 29 years ago, working then as an X-ray Technologist, it took no time for me to launch into an effort to assist my mother and father in navigating through this event.  The reflexive urge I felt to help is well known by all those who work in healthcare.  As healthcare professionals of all disciplines, we know, that despite the best intentions and the best training in the world, there is no predicting how a health episode will go.  Nor is there an outcome that can be reliably delivered.  

After some phone calls by me, my mother was seen, biopsied and got her results well ahead of the typical time frame for these millstones of care.  She also had the benign growth removed well ahead of what would have been normally scheduled.

When I recount my efforts to help my family, with my friends and acquaintances, who also work in healthcare, every person affirms they would do the same for their spouse, children, family members and friends.  Normally, this affirmation is heartily expressed like those who are part of an exclusive club.  It was not until earlier this year that I was struck with a profound sense of guilt as I reflected on my actions.  I most certainly delayed the care that would have otherwise been given to someone with a malignant growth.  Someone who my mother and father, knowing her growth was benign, would have gladly had go ahead of them.  I have no way of knowing whom I may have hurt or if my actions had no consequence at all.

Aim for muscle fitness

My friend, colleague, and neurologist Seward Rutkove has invented several new fascinating medical devices.  One of these--Aim--is designed for the general marketplace (as opposed to medical clinics.)  He and his partner have started an Indiegogo campaign through which you can support the introduction of this device, plus get one for yourself.  What does it do?

Press Aim against any major muscle to measure the fat percentage and muscle quality (MQ) for that muscle.

• Each measurement takes less than a second and results are immediately displayed
• By measuring four muscles (biceps, triceps, abs, and thigh), you get an accurate estimate of your total body fat percentage and MQ
• Aim sends your results to an online dashboard via Low Energy Bluetooth
• You can review your results on the online dashboard to track progress and get tailored fitness advice

Expanding our horizons as teachers

Bradley Flansbaum tells an amusing story about an international medical graduate he was mentoring and then concludes:

Watching an international graduate take his first step assimilating into a new professional role, American style, opened my eyes once again to the valuable guidance we provide as teachers.  I consider moments with them as prized as the interactions with my patients.  What is the difference really?  In both instances, you provide the knowledge and comfort the other side lacks.

The learning is a two way street however, and I get as much as I receive.  Over the years, I have absorbed distant perspectives on religion, the roles of gender and family in the home, and viewpoints on sickness and death.  As a result, I believe my connection with trainees from other countries has made me a better person.

A lovely, concise, and perceptive observation.

Coaching as a leadership theme

Dr. Brian Wong has written a book called Heroes Need Not Apply.  A number of friends have recommended it to me.  I've not read it yet, but I did watch Dr. Wong's video in which he answers the question: "In your book, why does coaching become such an important leadership theme?"  I found his answers thoughtful and compelling and recommend the short video to you.  I'll look forward to reading the book some day.

Sweet to be mentioned. Thanks!

How lovely to have this blog listed as one of the "100 Important Sites for Healthcare Leaders and Executives" on the MHAPrograms.org website. They note: "Blogs, news sites and magazines in the healthcare industry often dedicate articles to covering the latest news on health leadership, promoting upcoming leadership conferences, and sharing advice that administrators can use to improve the efficacy of their organization."

Indeed, one of my hoped-for audiences is current and future health care administrators, and I am honored to be included.

Patty Skolnik adds "author" to her credentials

Congratulations to patient advocate Patty Skolnik in her new role as co-author in an international journal, Teaching and Learning in Medicine.  The title of the article is "Patient Safety Education: What Was, What Is, and What Will Be?" You can find it here.

The abstract:

Patient safety is an important topic that has been receiving more attention in the current health care climate. Patient safety as a curriculum topic in medical schools has only become apparent in the late 1990s, and much more needs to be done. This article summarizes patient safety curricular content as it occurred (or did not occur) in medical education circles in the past (pre-1990s), and present. It also makes some recommendations for the future of medical education curricula in the area of patient safety, using a framework for the development of expertise using the Dreyfus educational model.

Schwartz Center brings all together again

Petra Langer reminds us of an event that has become a mainstay of the New England healthcare community.  This may be one of the few places where the intensely competitive actors in the region join forces in total unanimity!

More than 150 doctors, nurses and other hospital staff who treated those injured in the Boston Marathon bombings will be honored at the 18th annual Kenneth B. Schwartz Compassionate Healthcare Dinner on Thursday, November 21, at the Boston Convention Center. Adrianne Haslet-Davis, a professional dance instructor who lost her lower leg in the bombings, will speak at the event beginning at 7pm. More than 2,000 people are expected to attend. 

“The Marathon bombings seven months ago cast a bright spotlight not only on the courageous first responders and volunteers at the scene, but also on the extraordinary people who work in healthcare in the Boston area,” said Julie Rosen, executive director of the Schwartz Center for Compassionate Healthcare, a Boston-based nonprofit that works to strengthen the relationship between patients andtheir healthcare providers. “We’re thrilled to honor them. Their professionalism and compassion have been critical to the collective healing of our community.”

The Schwartz Center will also celebrate the 15th  anniversary of its prestigious Schwartz Center Compassionate Caregiver Award®. The award was established in 1999 to honor healthcare providers who display extraordinary compassion in caring for patients and families. Past recipients will be in attendance, and this year’s recipient will be announced at the dinner.

A modest proposal

I’m going to offer an idea that is so outrageous it might actually have merit.  This concerns the Boston area health care market, but my readers from other regions might also find it of interest.

There are two health care entities in Massachusetts that face uncertain futures.  One is Tufts Medical Center, a relatively small but highly respected academic medical center with a notable history, going all the way back to its antecedent’s founding by Paul Revere and other patriots. The other is Steward Health Care, a chain of hospitals purchased from the Boston Archdiocese several years ago by a private equity company, which converted it into a for-profit organization.

Not withstanding superb executive and board leadership over the past dozen years and a dedicated medical staff, Tufts remains trapped by the lack of an extensive referral network of doctors and community hospitals.  It suffers, too, from some bad luck going back to leadership decisions made several decades ago.  For example, although located in Boston’s Chinatown neighborhood, the community health center serving that densely populated neighborhood decided to affiliate itself with another academic medical center several miles away.  When people in Boston say, as they sometimes do, that there are too many academic medical centers in town, Tufts is the one that is most often suggested for elimination.  Such facile comments are, of course, unfair, in that the quality of clinical care, teaching, and research at Tufts is excellent: Were this institution to close, the community and the world would suffer a true loss.

Nonetheless, in the changing world of healthcare, a lonely academic medical center surrounded by other such centers with large (and growing networks) is at a disadvantage.  Tuft’s inability to keep and create significant strategic alliances with physician groups and community hospitals is a major vulnerability going forward.

Steward Health Care presents a totally different performance problem.  Owned by a private equity firm, the hospital system’s leadership has done what private equity managers do.  Assets have been stripped away to create cash flow for the owner. Actions have been taken to increase the top line performance of the company: Acquire, at high price, physician practices to increase referrals; sign front-ended loaded global payment contracts with the largest insurance company; sell (and lease back) real estate; sell clinical laboratories (and enter into a long-term vendor relationship with the purchasing firm); and minimize capital investment in the system, to produce earnings before depreciation that look robust.

But even those steps cannot hide the fact that actually running a hospital system in the Massachusetts market is not a highly profitable enterprise.  Payment increases from private insurers, Medicare, and Medicaid seldom rise at rates greater than overall inflation. Meanwhile, service worker unions expect wage and salary increases to exceed that rate of inflation. Renewal and replacement of capital facilities and medical equipment by far exceeds the original cost of such investments. A for-profit firm faces the additional challenges of relying on taxable debt rather than tax-exempt debt; having to pay sales tax, local property taxes, and the like; and being unlikely to attract philanthropy to support its programs.

The private equity business model calls for a sale (or flip) of purchased companies within a short time frame. Indeed, the investors in private equity funds are promised such terms.  In general, two types of sales are envisioned: An initial public offering, in which the company’s shares are offered to the general marketplace; or a secondary sale to another firm in the private equity market. In either event, the selling entity needs to create a colorable story that the enterprise has a high chance of financial success, meeting the hurdle rate of the new investors.

From reports I see in the media, it is unclear to me that Steward has much to offer to new investors.  As mentioned, its financial strategy seems to have been tied to stripping cash out, leaving questionable value for the next investor. Profitability seems difficult to achieve. Indeed, we can imagine the current firm seeking concessions from its labor unions and perhaps even asking for property tax relief from municipalities if its earnings deteriorate significantly. Such actions would be a precursor to a loss of political support.

There is talk of selling Steward to one of the large American private hospital companies.  But what can Steward’s owners truly expect such a company to offer in the way of a purchase price, when the likelihood of the system meeting a private market’s hurdle rate is so small? If I were the current owner, I would be searching for a way to get out—to take solace in the cash I have been able to extract, and to avoid the possible future costs of running the system.  Indeed, I might even be willing to give away the investment to cut future losses and report a reasonably successful investment result to my private equity fund participants.

It is that thought that swiftly leads me to today’s modest proposal. I suggest that Tufts and Steward would both be better off if they reach an agreement under which Steward sells itself to Tufts for $1and in which the hospitals in the Steward network are re-established as non-profit institutions within a greatly expanded Tufts network of physician groups and community hospitals.  Overnight, Tufts would become the second or third largest health care network in the state, with outposts throughout the Boston metropolitan area.  It would thereby enhance its ability to negotiate with the private insurance companies.  Steward’s tertiary referrals, which today go to the high-priced Partners Healthcare System, would instead be treated at Tufts’ main campus in Boston, offering lower priced care of equal quality. As non-profits, the community hospitals could again return to their tax-exempt status, saving millions in costs over the coming years and benefitting from the generosity of local donors. And, by the way, the two hospital systems are already part of the Tufts Medical School training program, so there are benefits of better coordination for graduate and undergraduate medical education.

How crazy is this? If you think through the alternatives for the two parties, the approach I outline doesn’t look so bad—and could look quite good.  The public policy ramifications are also positive: Beyond solving the sentimental problem of keeping Paul Revere’s legacy alive, the proposal offers the potential for the entry of a third vibrant competitor in a health care marketplace that is looking more and more like a duopoly.  Contestability in this sector requires at least three competitors.  This proposal could help make that scenario more likely.

A normal day at the NHS

Those of us in the US who have been overwhelmed lately by overly excited health care stories in the media look fondly across the Pond. We are confident that we can find a much calmer discourse about these issues in the UK.  After all, a single payer system, well established, and held in fond regard by the populace can’t be very controversial.  Well maybe.

Here’s a synopsis of one day’s news coverage about the NHS from The Times and The Daily Telegraph.  Make sure you read all the way to the last one.  My head is spinning.

•A hospital trust whose staff were allegedly forced to alter waiting times of cancer patients has been put in “special measures” by Monitor, the health regulator.  An “improvement director” will be appointed by Monitor to ensure the [Colchester Hospital University NHS Foundation Trust] turns itself around. “The leadership of the trust will be reviewed as part of our scrutiny of the trust’s governance arrangements and, if necessary, further regulatory action will be taken.”

•Hundreds of teenage girls have had genital cosmetic surgery on the NHS, prompting doctors to call for an end to state-funded “designer vaginas.” Internet pornography has driven a five-fold increase in female genital surgery in the past decade and more than 2,000 women a year now have the procedure on the NHS.  Ruptures are reported in up to a third of cases and NHS surgeons report seeing women with complications caused by surgery in the private sector. There is no evidence that the surgery improves women’s lives.

•Nine of the world’s biggest pharmaceutical companies have warned that innovative new medicines are being blocked from use in the NHS and are calling for an overhaul of the commissioning process.  They said that, since 2005, the National Institute for Health and Clinical Excellence (NICE), the body that selects drugs for use in the NHS, has approved “fewer than one-in-three medicines” and needs to be given a new mandate to make the UK a world leader in innovation. In a statement, NICE said the companies had “wildly underestimated” the proportion of drugs approved and it “supports more than 80pc of the drugs appraised. The NHS needs to be confident that the treatments it buys with its increasingly stretched resources are both clinically and cost effective.”

•Wider use of statins will have minimal benefit and could needlessly expose thousands to severe side-effects, a leading doctor has claimed following a change in US prescription guidelines. Dr. Aseem Malhotra, a cardiology specialist registrar at Croyden University Hospital, south London, said he would be “disturbed” if Britain followed America in changing prescription guidelines to widen use of statins. Side-effects experienced by up to one in five patients include severe muscle aches, memory disturbances, sexual dysfunction, cataracts and diabetes.

•And here are two presentations of the same story:

The Daily Telegraph story, headlined, “Return of ‘proper family doctors:’”

A new contract for GPS will see the return of “proper family doctors” responsible for out-of-hours care for the elderly, Jeremy Hunt, the Health Secretary, announced today.  The deal agreed with the British Medical Association reverses changes introduced by Labour that allowed family doctors to abandon responsibility for care outside office hours. Mr. Hunt says that the changes are crucial because the failure to care for older patients is behind a crisis in NHS emergency care, with millions of patients admitted to hospital because they cannot get help in time from their GPs.

The Times headline was, “GPs told to reveal their pay:”

Family doctors will have to reveal their salaries from next year, under changes to be outlined today by the Health Secretary. Jeremy Hunt said that he had secured the agreement of the British Medical Association to publish the pay of GPs, in return for waiving a series of targets and handing nearly £300 million of performance-related pay directly to doctors.

[Hunt said,] “Transparency is always uncomfortable. People will get used to it, but it needs to be linked to outstanding performance.”

Both stories talk about the elimination of 40 percent of GP performance targets.  Here’s the Telegraph quote:

Under the targets framework, doctors have been paid for improving their handwriting, or ensuring staff undergo training, or for asking their patients how often they take part in activities such as DIY, cooking or gardening.

And the Times quotes Dr. Chaand Nagpaul, chairman of the BMA’s GP committee, applauding the change as:

Freeing up resources for GPs to use their clinical judgment—not a checklist—when treating their patients.

And finally:

•GPs are seeing up to ten patients a day who are lonely rather than ill, according to research. Three quarters of GPs questioned said it was usual to see between one and five patients a day in their surgeries primarily because they were desperate for human contact. However, some doctors had even higher rates of patients suffering loneliness with one in ten saying that they saw up to ten patients a day who came in for the company. Half said they were not confident about whether they could help their lonely patients.

What's your QI IQ?

Here's an excellent program for residents and attending physicians in the New York City area who are interested in enhancing their quality improvement skills.  It is offered jointly by CIR/SEIU Healthcare.

A summary:

This is a great educational opportunity for residents and attendings who are interested in taking their QI project to the next level and plan for publishing their work. Publication of a manuscript is a process that starts when you think of a QI topic, and requires thoughtful planning and execution. You will learn from leaders and national experts in the field of QI how to plan, execute and publish. Interactive and hands-on activities comprise a large part of this conference. 

What:  What's Your QI IQ? How to be Scholarly in Quality Improvement
When: Saturday, November 23rd, 2013 from 9:00am - 3:30pm
Where: New York Academy of Medicine
  1216 5th Ave, New York, NY 10029
Who: Housestaff, Faculty, Administration
Cost: Complimentary
Register here: bit.ly/QIIQNov23

Sportsmanship supreme

You don't have to be a soccer fan to enjoy this video clip.  Summary:

Al Nahdha's goalkeeper Taisir Al Antaif was about to make a clearance early in the second half with the score still at 2-2 but noticed that his shoelace had come undone, and was clearly nervous about his boot coming off as he kicked.

The opposing striker bearing down on him, a Brazilian by the name of Jobson, noticed what was going on - but instead of trying to take advantage, he ran up to his opponent and did his shoelace for him.

Al Antaif slapped his new friend on the back as thanks, and gave him a high five afterwards before getting on with the game.

But, here's where it turned sour, with the referee penalising the keeper for taking too long with his clearance.

He awarded an indirect free kick inside the area, and the home side lined up, clearly fearing the worst as Al Ittihad's strike force discussed their attacking options.

But in one of the most subtle and greatest insults given to a match official, Al Ittihad did the decent thing and merely passed the ball safely off the pitch. Even the supporters cheered at the gesture.

In a single stroke, the players managed to endorse a magnificent moment of sportsmanship between two opponents, while highlighting what an idiot the referee had made of himself.

Different priorities

A thought for the day from the world of coaching girls soccer, with thanks to a colleague at Northwestern Medicine in Chicago.

After a soccer game between two teams of seven-year-old girls:

Frustrated coach:  Your heads were just not in the game! Where were they?

Player: I was thinking about princesses and puppies.

Northwestern Medicine learns from patients and families

I had the pleasure of making a presentation at a leadership meeting at Northwestern Medicine today. Afterwards, while sitting through some other business sessions of the team, I saw this simple graphic representation.  It is emblematic of the types of changes that can occur when patients and families help set a health system's priorities.  Northwestern has convened a patient-family advisory council and was discussing with them the various metrics the hospital uses to portray progress on several clinical fronts.  The PFAC members made a persuasive case that the evaluative framework employed by the health system, and the corresponding set of metrics to measure progress along that framework, had a number of gaps. What evolved was the new framework shown above.  Over the next couple of years, NW will design and add metrics to their corporate scoreboard to fill in the gaps noted by the PFAC.

This is a fine example of the kind of partnership that can develop between a health care system and the people it serves.

Chutzpah

The classic definition of chutzpah is provided by the man who kills his parents and then pleads for mercy from the sentencing judge on the grounds of being an orphan.

Now, we have a story by Julie Donnelly in the Boston Business Journal about the CEO of a hospital system who bemoans the fact that "any savings from layoffs in the health care industry are constrained by labor agreements that often force hospitals to lay off the youngest, cheapest workers."

Let's recall that it was this CEO who aceded to a neutrality agreement to facilitate the ability of the SEIU to organize his hospital system back in 2009 and who then was responsible for negotiating and approving the collective bargaining agreement with that union.  Such an agreement contains the seniority rules that govern the order in which layoffs occur.  At the time, some of us thought of these as steps along the way to ensure that union's support in front of state officials when the non-profit system's acquisition by a for-profit entity required state approval.

But now, the gentleman pleads for mercy.

The word from Mt. Sinai

There’s some good stuff happening at Mt. Sinai Hospital in downtown Toronto, and I thought I’d take a moment to share examples with you. I was there because the folks at the hospital had invited me to give grand rounds and also to participate in some sessions with senior leadership and with their quality improvement champions. As is often the case, I learned more than I imparted, and I walked away impressed with the organization’s commitment to quality and safety improvement, transparency, and staff engagement.

Here’s one example. While I had heard about the concept of a patient navigator before today, including at my own former hospital, the navigator service was usually designed to help people of different cultural backgrounds maneuver through the complicated labyrinth of the tertiary care system. At Mt. Sinai, they have taken the concept to its logical conclusion, providing patient navigators for all general internal medicine, surgical oncology, and inflammatory bowel disease patients.

Here, for example, is Heather Siekierko, a navigator assigned to the “D” group of doctors and nurses serving patients in the general internal medicine area. When a patient arrives on the floor from the emergency department, Heather is already on the case, handling a multitude of tasks that previously would have taken time away from nurses or other clinical staff. Heather’s academic training? Fine arts!

With one navigator assigned to each of the four clinical teams, there used to be some confusion as to which person was assigned to which team. A doctor might spend time asking, “Are you in our group?” The problem was solved when a doctor suggested creating simple badges indicating each navigator’s group affiliation.

This program is supported by philanthropy, as the payment regime from the province of Ontario does not include funding for this kind of service. It is so effective, though, in terms of patient satisfaction and clinical improvement, that the hospital is working on a way to provide sustainable funding.

Here’s a second example, implementation of the Releasing Time to Care™ approach developed by the UK’s National Health Service. The focus is on team huddles, design of work flows, and attention to key clinical indicators--most importantly characterized by empowering front line staff to identify concerns and drive improvements themselves. As folks at Mt. Sinai have noted:

RTC is about changing the way we manage and do our work--it is not an "add-on" improvement initiative but rather a fundamental strategy that is embedded in the core works of our units and our team.

The program is supported and enhanced by a remarkable degree of transparency. Take a look at these charts—presented for all to see—on the walls of the clinical care floors. There’s no holding back when things do not go according to plan. Everyone is aware.

As you can see from these two falls-related pictures from two different floors, these presentations are not necessarily high-tech computer-generated graphs working off sophisticated databases: They are filled out by hand or constructed by the staff on the floor. People’s participation in creating the visible displays of key metrics is part of the process. They own the numbers, and when the numbers indicate problems, the team swarms on the issues and creates experiments of possible solutions. The feedback on the effectiveness of those experiments is quickly and clearly displayed to all in real time.

So that’s it for now. Two examples of thoughtful attention to the issues facing many hospitals. To the Mt. Sinai folks, this is a good start, but they are modest in their assessment of what has been accomplished. From my vantage point, this is truly front-line driven process improvement, enhanced by support from the senior leadership and from members of the Toronto community. The momentum has been building, and I, for one, expect to see great things in the future.