This is not my main blog

Hi and welcome!

You can find my main blog here.

I am gradually copying posts related to transparency and Lean process improvement to this blog to serve as an archive and resource to people in hospitals who might want to review the experience at Beth Israel Deaconess Medical Center and other hospitals and apply lessons to their own institutions.  (You can also search "Lean" and "transparency" on my main blog and find most of these, but the search engine is not always complete, so you might find this a more useful place to review those posts.)

Our early version of Lean was called BIDMC SPIRIT, so you will see a number of blog posts that refer to that.  We came up with the concept of SPIRIT in November of 2007.  All of the stories during the "SPIRIT" era had the logo atop, to provide a touchpoint for our staff.  I've left some, but not all, of those logos on these reprints to give you a sense.  Eventually, by July of 2009, we let SPIRIT die away as a program "brand," but the lessons we drew from that stage in our institutional development were extraordinarily helpful as we rolled out a philosophy more directly based on Lean principles.

People often ask me how many staff members read my blog during the period covered by many of these posts.  It is impossible to tell exactly, but the likely range is between 1500 and 2000 each day, out of the 6000+ FTEs and 900 doctors on staff.  Some people regularly went to the blog link daily, others subscribed through Feedburner or another aggregator service, some read it on Facebook or Twitter, and others were referred to it by the clipping service published electronically each day by our media services department.  I know, also, that when a specific staff member was mentioned in a blog post, s/he would circulate it widely to family, friends, and co-workers.  This, in turn, led many people to send me story ideas about programmatic successes and setbacks, whether in clinical care or logistical or administrative arenas.  It is hard to overstate the importance of this medium as a leadership, team-building, and institutional communications tool; but a very important aspect of that was that I wrote the posts myself, keeping them current and in my own voice.

But blogging is really not the main point here.  What you see documented is a consistent and decided institutional commitment to transformational change.  It takes a long time and with constant reinforcement from the top folks to fight inertia and entropy and build sustained momentum for this kind of change.  While the senior management has to work really hard to make this work, my personal involvement and interest as CEO and that of the Chiefs was essential.

Another lesson is that personalizing the stories of success and setbacks is extremely important.  You cannot overdo the recognition of individuals, whether formally or informally.

Finally, this approach really works on many dimensions of quality and efficiency, as Steve Spear, John Toussaint, Gary Kaplan, Jim Conway, Bruce Hamilton, Jim Womack, John Shook, Peter Pronovost, Brent James, Mark Graban, Jeff Thompson and the others say.  If there is any path for a general hospital or academic medical center through what is coming down the pike in terms of government and private payer revenue restrictions, and demands by the public for more personalized medical care, this is it.  The attached scatter diagram from The Leapfrog Group is one indication of the kind of results that are possible.

(I have not transferred all the many thoughtful comments from these blog posts.  You will need to go back to the originals to read those.)

I have also transferred a blogroll here of useful resources in this field.  You will find some of the world's experts listed therein, but also real-life people reporting on the work in their hospitals.

Best of luck to you as you make health care safer, higher quality, and more efficient!

UNM residents start to go Lean

Following Dr. Kaplan's talk, UNM the residents retreat broke into work groups.  I attended the one about emergency department patient flow.  The UNM hospital handles 90,000 emergency room visits per year but suffers from major congestion problems.  The number of hours of boarding patients as they await rooms on the medical floors has grown, and there are also a substantial number of patients (14%) who leave without being seen because of the waiting times.  This is not an unusual problem in American hospitals, particularly the safety net hospitals, which face financial limitations in increasing capacity.

As we all know from our Lean training, though, there are process improvements that can be made in virtually any setting.  The purpose of our work group was to introduce residents to some of the Lean concepts.  We focused in this session on sketching out a process flow diagram, or map, indicating the steps taken in caring for a patient.  The idea is to identify all the steps and then determine the amount of time required to carry out each step.  Two metrics are used:  The net time is the actual time taken in carrying out a step; and the gross time is the fully elapsed time within which the task is accomplished, including all delays, re-work, and the like.  In most organizations, the net time is a small fraction of the gross time.

Here you see chief psychiatric resident Peggy Rodriguez keeping track as the group outlined the steps between when a decision is made to admit a patient and his or her arrival on a medical floor.  Each discrete step is itemized, and two numbers are assigned.  The one on the left is the net time for the task, and the one on the right is the gross time.

Were we doing this for real, all participants in the ED process would be engaged in creating this process flow diagram.  As the University of Michigan's Jack Billi would remind us, when a map is constructed to enable all to all aspects of the value stream, "it's not the map that's valuable.  It the process of mapping, which produces a shared understanding of the value stream and which enables the front-line team to design improvement experiments together."

This map, though, was being set forth for instructional purposes,  next you see Dr. Marc-David Munk, one of the leaders of the session, reading off the summary chart.  Peggy kept track and prepared the following summary chart.  Our rough analysis -- just based on perceptions of people in the room -- yielded 853 minutes of gross time spent per patient for work that had a value of 71 minutes.  This is remarkably close to the 14 hour average delay that the ED has documented.  The next step, if we were actually doing this in the hospital, would be to identify measures that could be taken to redesign the work flow and conduct experiments to see what would be helpful in extracting waste out of this overall process.

Dr. Kaplan addresses GME patient safety retreat in New Mexico

I am in Albuquerque, New Mexico, for a series of events related to patient quality and safety and process improvement in hospitals.  We are starting this morning with a graduate medical education retreat  entitled "Residents and Patient Safety" being run by the University of New Mexico School of Medicine.

The keynote speaker is Dr. Jay Kaplan, who practices emergency medicine in northern California and also works with hospitals throughout the country on clinical improvement matters.  I'll try to summarize key points as he talks.  His theme is "Driving Hospital Quality."

In his introductory moments, Jay noted that a rule of his department is bedside change of shift report.  He presented a recent example from his own last shift of such a handoff to show that this protocol can help identify a patient's problems that would otherwise be missed.

His major point is that customer service and quality of care are intimately related.  Quality is often viewed as the "hard stuff," while service excellence is viewed as "fluff stuff."  This is not accurate and misses the degree to which the latter affects clinical outcomes.  Quality gets you in the game; service lets you win.

One obstacle is that doctors have not been trained to be team players.  They need to learn how to collaborate.  Trained as craftsman, likewise, they are often not conversant in process improvement.

We have to focus on both systems and people.  We need people to buy into well designed systems.  Likewise, though, systems have to be designed to support great people.

Efficient patient flow requires aligned behaviors and cooperation between emergency departments and inpatient floors.

He asks the residents to ask themselves, "What do you do every day to bring quality and patient safety to your patients?"  Integrate service provision into this question.

Think bakery.  What does a customer notice upon entering?  The smell.  Do bakers notice it?  No, because they are used to it.  The analogy is:  When people first walk into your practice, clinic, or hospital, what do they notice?  What patients see, feel, and hear is different from what you and I see see, feel, and hear.  We are used to the environment.  They are not.  View your workplace from the point of view of the patients.

Here are some ideas.  Take a fresh look:  Change the signs.  Sit down when talking with patients, so they don't think you are in a hurry.  People will not hear all of your words:  Use key words that will be remembered.  As you pause to wash your hands, mention that you are doing so for their safety.  At the end of the visit, ask "What questions do you have for me?" instead of "Do you have any questions for me?"  They will always say, "No," to the latter.

Here is another set of ideas, based on the acronym ICARE:  Introduce yourself and Inspire confidence in the patient; Connect with the patient and family; Acknowledge what the patient has said; Review the plan of care and how long the various stages will take; Educate about what to expect and Ensure their understanding.

Another key strategy is to have follow-up phone calls to check on adverse reactions from drugs, to check on patient understanding, the patient's condition, etc.  This will also increase customer satisfaction.  The average time it takes to do this is two minutes and will result in some of the most rewarding feedback you will get from patients.

Reverse the expectation of punishment

An article in amednews.com reports:

[D]ata released in February by the Agency for Healthcare Research and Quality show that most physicians, nurses, pharmacists and other health professionals working in hospitals believe their organizations are still more interested in punishing missteps and enforcing hierarchy than in encouraging open communication and using adverse-event reports to learn what's gone wrong.

These findings underlie the tragedy in medicine that results in thousands of preventable hospitals deaths each year and untold harm to other patients. Correcting this problem is a matter of leadership, plain and simple.  The clinical and administrative leaders of hospitals need to set a different standard.

I note this in my new book, Goal Play! Leadership Lessons from the Soccer Field:

You can see this philosophy in action through an event that happened at Beth Israel Deaconess Medical Center in July of 2008. A patient woke up after orthopaedic surgery and asked her doctor, “Why is the bandage on my right ankle instead of my left ankle?” It was at that moment that the surgeon realized he had operated on the wrong limb. It is impossible to know who was more distraught, the patient or the doctor who realized that he had violated a life-long oath to “do no harm.”

It was quite clear that the hospital’s “time-out” protocol, which was designed to avoid precisely this kind of error, had not been properly carried out. In the weeks following this disclosure, a number of people asked me if we intended to punish the surgeon in charge of the case, as well as others in the OR who had not adhered to that procedure. Some were surprised by my answer, which was, “No.”

I felt that those involved had been punished enough by the searing experience of the event. They were devastated by their error and by the realization that they had participated in an event that unnecessarily hurt a patient. Further, the surgeon immediately reported the error to his chief and to me and took all appropriate actions to disclose and apologize to the patient. He also participated openly and honestly in the case review.

. . . [A] wise comment by a colleague made me realize that I was over-emphasizing the wrong point (i.e., the doctor’s sense of regret) and not clearly enunciating the full reason for my conclusion. The head of our faculty practice put it better than I had, “If our goal is to reduce the likelihood of this kind of error in the future, the probability of achieving that is much greater if these staff members are not punished than if they are.”

I think he was exactly right, and I believe this is the heart of the logic shared by our chiefs of service during their review of the case. Punishment in this situation was more likely to contribute to a culture of hiding errors rather than admitting them. And it was only by nurturing a culture in which people freely disclose errors that the hospital as a whole could focus on the human and systemic determinants of those errors.

Jonathan Byrnes on inventory optimization

MIT's Jonathan Byrnes presented a terrific webinar last week.  His topic -- inventory management -- has a lot to do with all kinds of businesses, including hospitals.  I want to summarize some key points for you.  (For those who want learn more, Jonathan has his own blog, which I highly recommend.)

The major point of the webinar was that there is a huge difference between inventory optimization and inventory management.  Jonathan puts this in terms of a paradigm shift:

In the past, the job of the supply chain manager was to optimize the flow of goods into and out of the storeroom.  For example, reducing the inventory of a SKU that lost money was viewed as success.  But as Jonathan puts it, "If you optimize something that is stupid, the result is still stupid."

He urged us instead to consider the earning power of inventory, to change from minimizing inventory cost to maximizing its earning capacity.  Inventory represents a significant portion of a company's invested capital, and you want to put that investment to its most productive use.

If you look at your task as maximizing the return on invested capital that is represented by inventory, many other aspects come into play.  Look at this comparison of the factors which would be considered in the standard model and the one for which he advocates.

In the old model, all those factors in the right-hand column were "somebody else's job."  If, instead, you take a broader view, you realize that those factors must be considered, especially relationships with suppliers and customers.  Each stage of that value chain should be analyzed.

There is a historical context for this transition.  Markets have evolved over the years.

Before mass production, the "market" was how much you could deliver on your horse or in a cart.  With mass markets, full-scale and wide-ranging production and distribution became the norm.  Now, though, precision markets exist, with finely grained purchase and consumption decisions intimately tied to the needs of suppliers, intermediaries, and consumers.  This requires a new view of value creation, one that leads outside the boundaries of the corporation to include the real-time needs of customers.

Jonathan followed with a number of case studies that dramatically illustrated these points.

Really, the most significant?

Medscape Today has an article featuring "The Most Significant Medical Advances and Events in 2011."  The list includes things like some FDA drug warnings; the fact that the Supreme Court will review the health care reform law; some finding about cellular phone use and brain activity; withdrawal of propoxyphene from the market; and new listings of top hospitals.

To which I say, "Bah, humbug!"  Most of the things mentioned have had and will have little or no impact on you, me, our relatives and friends as we seek to get care or avoid care.

What are the most significant advances and events?  They are the ones that have occurred by communities, patients, and clinicians in their home towns or their home regions that demonstrate the potential for real improvement in clinical care.  These are the ones that save lives now.  These are the ones that empower patients to be true partners with their caregivers and vice versa.  These are the ones that have nothing to do whatsoever with government mandates, accreditation actions, and the like.

These are the ones that occur because, by strategy or opportunism, well intentioned and thoughtful people modestly work together to reorganize the work in hospitals and other settings.

Examples from this blog are:

1 -- A patient named Christian who persuaded a nurse to allow him to administer his own dialysis, and who then trained others, transforming care in a Swedish hospital.

2 -- Peter Pronovost and colleagues document that reducing central line infection rates in Michigan also lowered costs.

3 -- Glen Cove hospital achieves 1223 patient days without a central line infection.

4 -- The one million people of Saskatchewan allocate $5 million per year of government funds to establish and maintain a Health Quality Council, an independent agency that measures and reports on quality of care in Saskatchewan, promotes improvement, and engages its partners in building a better health system.

5 -- The University of Michigan Health System demonstrates the power of adopting a Lean process improvement philosophy and generously shares its experience with the world.

6 -- Jeroen Bosch Hospital in the Netherlands celebrates the opening of a new building by enthusiastically endorsing transparency of clinical outcomes.

7 -- Aided by the Vermont Oxford network, thousand of neonatologists create state consortia to to set statewide targets and objectives, compare best practices, and understand the variability in clinical practices across and within institutions. 

8 -- The SCAD ladies band together and influence the direction of medical research.

9 -- The Sepsis Alliance presses for greater awareness of this deathly clinical syndrome.

10 -- The Manukau District Health Board in New Zealand propounds the following philosophy: 

What we need to do if something goes wrong is pull back from the instinct to place blame and instead think more deeply about the contributing factors. We need to think about how the system got us to where we are and where the faults in it lie.

More on Lean from Michigan

I want to add a couple of more items to the post below about John Billi's MIT-sponsored webinar about Lean at the University of Michigan Health System.

When the Lean approach was first adopted at UMHS, there were some notable successes which I would term "projects."  For example, a rapid improvement event was held to redesign the carts used for blood draws, using the 5S approach that I have often referenced on this blog.  Here's the "before" view:

And here's the "after" view:

This is all good stuff, but it is not a full-fledged implementation of an organizational philosophy.  What UMHS found out  is that the cultural change inherent in Lean takes a long time to become embedded in the firm.  At BIDMC, we used to talk about "tortoise not hare" when we described that.  In essence, the process of adopting Lean becomes a Lean process itself.  It is one of modesty and constant learning.  Look, for example, at what John presented for the coming agenda for his institution.

The other point John made is when a map is constructed to enable all to all aspects of the value stream, "it's not the map that's valuable.  It the process of mapping, which produces a shared understanding of the value stream and which enables the front-line team to design improvement experiments together."