Great dance

A new auction item has just come in, a dance performance by the Trey McIntyre Project at the ICA theatre on Friday, November 20. It is courtesy of World Music/CRASHarts and is available here at my auction to benefit Bowdoin Street Health Center.

Cooley-Dickinson vanquishes VAP

About a year ago, I wrote about the great progress made by Cooley-Dickinson Hospital in Northhampton, MA with regard to eliminating ventilator associated pneumonia. I now hear from Daniel J. Barrieau, RRT, CPFT, Director of Respiratory Care Service, that "we are now counting our time between incidences of Ventilator Associated Pneumonia in YEARS instead of days. This week we passed the 2 year mark and took a moment to celebrate the milestone. Here is a pic of the cake. . ."

Congratulations!

Zip-a-Dee-Doo-Dah

Find custom made jewelry made from zippers! Really. Courtesy of ZipBling's owner and designer, Louise Loewenstein. Check out my auction to benefit Bowdoin Street Health Center.

Working with a family advisory council

The concept of patient and family advisory boards to hospitals is gaining currency. The idea is to integrate the perspective of patients and families into decisions about clinical practices, space, priorities, and the like. We have had a Family Advisory Board for our Neonatal Intensive Care Unit (NICU) for some time. Here is its mission statement:

The mission of the BIDMC NICU Advisory Board is to touch the lives of each NICU family in a positive and lasting way. Our goal is to complement the NICU's outstanding clinical care and embrace the hospital's commitment to Family-Centered Care with programs and initiatives that acknowledge and support the family in a time of crisis, and to extend the relationship between the family and hospital well beyond discharge. The NICU Advisory Board will support this mission through representative feedback on existing and future programs, facility and policy enhancement, staff/family relations, development and fundraising, and other issues related to the needs of NICU families.

If you are going to create an advisory body like this, you need to share key information with them. I am showing here a few slides of a presentation delivered yesterday by Dr. DeWayne Pursley, chief of service. Among other things, the presentations contained a full exposition of progress on the metrics by which the NICU judges its success with regard to family interactions, along with a statement of initiatives in the various dimensions of care. This kind of transparency leads to a greater sense of involvement, and it also prompts discussions that often lead to good ideas.

In a post below, I wrote about some recent success in our adult ICUs. That success was dependent on involvement by a similar patient and family advisory council. Our experience with the NICU council helped us design the adult council, but it also gave the medical staff some confidence that the effort involved in creating and meeting with the council would be worth the effort. Clinicians and hospital administrators are often skeptical on this point. Let's hope that such skepticism gradually erodes as the good work of these councils becomes more widely known.

Feeling the need to wine?

A limited edition, new California wine from Je Suis is available at my auction to benefit Bowdoin Street Health Center.

Help for migraines

Here's a short and excellent discussion about migraine headaches on the FOX25 Morning News with Dr. Carolyn Bernstein, a headache expert with BIDMC's Arnold Pain Management Center. She is the author of The Migraine Brain: Your Breakthrough Guide to Fewer Headaches and Better Health.

Need inspiration?

Planning a meeting for your company or civic club? Hire one of three great inspirational and informative speakers at my auction to benefit Bowdoin Street Health Center. Look under "Unique Experiences."

Want to see a masterpiece theatre?

WGBH is offering tours of its studios in my online auction to benefit Bowdoin Street Health Center. Look under "Unique Experiences."

Interlocking circles and cycles

Still relatively new to the medical field, I am often struck by the interplay among generations of patients and doctors, and between doctors themselves. I have not seen it to this degree in other industries with which I have been associated. It makes the field intensely personal, with constantly interlocking circles and cycles of life.

Here's a microcosm. Dr. Harold Solomon learned about hypertension from one of the leaders in the field, Dr. Norman Kaplan, Clinical Professor of Internal Medicine, University of Texas Southwestern Medical Center at Dallas. Dr. Kaplan's book, Clinical Hypertension, is the standard in this area. Harold built a practice with an emphasis on this field, but also focused on delivering high quality primary care in general.

One of Harold's patients, Harvey ("Chet") Krentzman, died a few years ago. In recognition of the excellent care provided by Harold to her husband, Chet's wife Farla decided to lead an effort to fund a lecture series at our hospital in his name. One of the guest lecturers invited by Harold was Dr. Kaplan, in appreciation for his stature in the field and for his influence on Harold's own career.

Tonight, on the eve of tomorrow's lecture, a group of Harold's patients and physician colleagues joined to express their appreciation and affection for all three people. You see them above.

The gold standard

Our pathology labs receive accreditation from the College of American Pathology and the American Association of Blood Banking. Inspections are every two years and cover about 3000 separate standards. The reviewers are pathologists and technologists from other participant organizations.

We just completed an inspection conducted by a 15-member team, a group with very impressive qualifications.

I am proud to say that, not only did we pass with flying colors, but one surveyor said, "I have been doing inspections for 30 years and if any place has a gold standard, this place is It"!

As noted by Dr. Jeffrey Saffitz, our Chief of Pathology, "In more than 35 years in academic pathology, I have not witnessed such an extraordinary level of commendation and praise from a team of peer reviewers. Almost without exception, these seasoned, experienced inspectors indicated that they learned a great deal from us and they intend to implement many of our policies and practices in their own institutions. Many also expressed a desire to take some of our people back to their home institutions! The cooperation, trust, work-ethic, dedication and commitment to excellence by our lab personnel is absolutely unparalleled."

Congratulations to the entire team!

Hallelujah!

Craving culture? Check out Boston Baroque's Messiah and also their New Year's Eve concert at my auction to benefit Bowdoin Street Health Center.

And, why not combine it with a one night's stay at Boston's most romantic inn, the Charles Street Inn? Look for this newly arrived item under "unique experiences" on the auction site.

Urine my thoughts

I am always on the lookout for water saving techniques . It comes from having focused on this while running the metropolitan area's water system.

I, er, encountered this at MIT -- along with the handy sign that you can read while....

Back at the hospital, I inquired of our facilities folks whether we should have these in public restrooms at the hospital. A rather lengthy stream of information ensued from Mark Lutisch, our utility manager. I'll include most of it, for those of you who might be interested as you consider this in your own facilities.

Waterless urinals can save a lot of water and be fairly clean, with minimal odor. As waterless urinals don’t flush, there may be a reduction in bacteria or pathogens that are transported in aerosols to users. However, waterless urinals are not a set-and-forget plumbing fixture.

Prior to a waterless urinal retrofit project in older facilities, it is highly recommended that facilities 1) ensure that the slope of the drain line is ample, and 2) route drain lines to avoid problems such as sediment build up and 3) check drain heights are appropriate to the brand to be purchased. 4) Heavily corroded pipework should be replaced with PVC pipes. Facilities are far less likely to encounter problems with retrofit projects if these preparations are made.

A special and often-patented trap assembly that requires a special lighter-than-urine liquid must be added to the regular bathroom maintenance schedule. The trap assembly and the trap liquid must be added to the list of consumables that need to be purchased and resupplied for the life of the fixture. Maintenance staff require training in the proper care and feeding of all waterless urinals. Once the plumbers are gone, it’s up to the building staff to maintain the fixtures, and they still need daily cleaning and disinfecting, waterless or not. It may be necessary to clean urinal pipework before installing waterless urinals.

Toilets account for about 20% of BIDMC's water usage, urinals about 1%. A study by Water Management Inc. in 2007 recommended a focused fixture replacement program that zeros in on the fixtures with “the most bodies per potty”. They proposed to replace fixtures that have high per use flows and receive consistently high usage. These fixtures are generally located if common area and staff restroom facilities. Some plumbing fixtures would be excluded from the project scope based on low usage profiles. The cost was estimated at $380K with a 4.5 year payback. Because the energy budget did not have $380K for this measure, and the 4.5 year payback was not as good as other projects, toilet and urinal replacement was excluded from the water conservation project.

Instead of installing waterless urinals, Water Management Inc. recommended simply modifying the flush valves on 50 high use urinals to reduce the volume used per flush to 0.8 gallons per flush, saving about 282,000 gallons and $4K per year. Replacing the flushometers (possibly with infrared no touch sensors) is a cost effective way of reducing urinal wastewater.

In FY12 the energy plan will request funding for toilet and urinal replacement, along with a study on rainwater harvesting, greywater harvesting, and irrigation scheduling. However, we may pilot low flow toilet fixtures sooner in several high use bathrooms.

Thanks for your support,
Mark Lukitsch
Utility Manager, BIDMC

Sleepy? Amorous?

Which side (of the river) do you prefer? Win a hotel room in Boston or Cambridge for a visiting friend or relative . . . or for that romantic night out. Courtesy of the Four Seasons and the Courtyard by Marriott. Bid at my auction for Bowdoin Street Health Center.

Tom Sellers --->> DC

My friend Tom Sellers has fled Boston and taken a new position as President & CEO of the National Coalition for Cancer Survivorship. (Locals here will know that Tom led the fundraising, community relations, and development activities for a $30 million American Cancer Society project to build a 50,000 square foot Hope Lodge in Boston to provide free lodging to over 1,000 cancer patients annually. Before that, he worked at the United Way and in the MA state government.)

He is very excited about this and tells me that there are nearly 12 million cancer survivors living in the United States and that NCCS is the oldest survivor-led cancer advocacy group in the country. This group advocates for quality cancer care for all Americans and provides tools that empower people affected by cancer to advocate for themselves. It was founded by and for cancer survivors more than 20 years ago. Its governance requires at least half of the Board members to have had a cancer diagnosis some time in their lives, and many staff members are cancer survivors, so they speak from experience.

Tom says, "One of our newest initiatives is the Journey Forward program, which is targeted to health care professionals and patients. Upon completing treatment, many cancer survivors find themselves wondering, “What’s next?” The Journey Forward program, is a collaboration of the NCCS, Wellpoint, UCLA Cancer Survivorship Center, and Genentech. It helps survivors with the transition from uncertainty to the next stage of survivorship through the use of treatment summaries and follow-up care plans that summarize cancer treatment and give clear steps for follow-up care and monitoring.

"Cancer care plans put survivors in a better position to advocate for themselves, monitor their health, and participate in decisions about their future care. Journey Forward’s custom-made Survivorship Care Plan Builder is available to any oncologist, and the electronic Medical History Builder allows patients to easily record their own health history. Journey Forward’s survivorship toolkit currently offers templates that include information specific to survivors of breast and colon cancer, and a generic model that is applicable to survivors of many cancer types will soon be available.

"The program is completely free, and more information about how you can develop a plan is available here."

Hungry?

Head downtown for a great lunch or dinner at the Chinatown Cafe on Harrison Street, courtesy of proprietor Hing Soo Hoo. First, though, bid on a gift certificate at my online auction to benefit Bowdoin Street Health Center.

Who cares if it is off-season?

Take 10 friends for a tour of Fenway Park, courtesy of our Red Sox partners. Or have lunch with Executive Vice President Sam Kennedy. Bid at my auction to benefit Bowdoin Street Health Center.

If you visited yesterday, check out some new items today.

GRACE: Will it be amazing?

Our folks are working on an important new project. It derives from a number of adverse events, cases in which elderly patients fell and were injured. Our review process often indicated that the staff had done just the right things with regard to fall prevention and supervision of patients. Using the "5 Why" process of Lean, they kept digging into the cause of these falls. A hypothesis emerged: Perhaps we were contributing to the likelihood of falls by over-medicating geriatric patients or missing important parts of their supervision and therefore causing them or allowing them to be disoriented.

Our group began to construct a new "geriatric bundle" of care. (You have seen this be tremendously effective in other arenas, like avoiding Ventilator Associated Pneumonia.) But what should it look like, and what should it include? Well, we have just started rolling it out on an experimental basis, and we will report the results as things progress. Here's a summary from the staff:

The Geriatric Bundle now has a new name - GRACE (Global Risk Assessment and Careplan for Elders). This program is designed to improve the care of all hospitalized elders admitted to the BIDMC, with the hope that we will reduce the risk of delirium, falls, pressure ulcers, functional decline, etc.

There are three main components of the initiative:
- Provider Order Entry (POE) enhancements
- Improved Pharmacy/Medication safety
- Bedside care protocol

The bedside care component is a major piece and through the diligent work of many is well on its way to implementation. A tool is a GRACE bedside flow sheet that will be used for all patients 80 and older each day. You can see it and the other elements at this link to Slideshare, where you can read the entire presentation that was shared with our clinical staff on several floors.

Online Auction to Benefit Bowdoin Street Health Center

I am starting a new feature on this blog. I hope you enjoy it and participate.

Some friends of mine are involved in a new company called BiddingforGood. What EBay brings to the world of auctions in general, B4G brings to the world of charity auctions. It is a consolidator, facilitator, and operator of on-line auctions for charitable causes and organizations.

With the help of B4G and some of the BIDMC staff, I will be holding an on-line auction each month to benefit one of the BIDMC's affiliated community health centers or another worthwhile health care-related cause.

This week's auction will benefit BIDMC's owned Bowdoin Street Health Center, a wonderful place providing primary care, specialty care, and many support functions to a section of Dorchester in Boston. I am trying to raise money for an ultrasound machine, so pregnant women can have ultrasounds in their neighborhood setting rather than having to spend time and money to travel to BIDMC for this service.

Just click here to enter the auction site. There are some great items -- travel, food, concerts, sport events, art, and memorabilia. Also, some very special people are offering to provide inspirational and informative presentations at your civic organization or company. Finally, there are a couple of special items from our partners, the Boston Red Sox.

Bid early, bid often, and bid high! You have until 8pm on Monday, November 9, to submit bids.

Also, if you would like to offer items or services for this or future auctions, please click here or on the "Donate" button on the right side of this blog.

In the interest of total disclosure, I want you to know that bidding in this auction will place you on a mailing list for future auctions, both mine and others around the country. You can have yourself taken off that list at any time.

Please let me know what you think about this idea and the B4G site.

And, good luck!

Out of line

Depending on your point of view, competition is either the strong point or the underside of Boston's spectacular collection of hospitals and physicians. It does produce an exceptional desire to succeed, to deliver the highest levels of clinical care. But it also has the potential to be rather juvenile and wasteful of resources. But here is an unusual case where it got downright ugly and out of line.

The story is documented yesterday in a Boston Globe article written by Liz Kowalczyk. The case involves a request for a restraining order against their former hospital physician organization by two doctors who chose to join another hospital's network. Why would they need a restraining order? I have seen the court complaint. Here is a representative part:

Defendant Caritas Christi Physician Network, Inc. ... has failed and refused to send a timely notice to patients presently under the Plaintiffs’ care with respect to the change in affiliation and Plaintiffs’ new contact information. Notwithstanding this failure, Defendants have further refused to agree to remedy the situation by permitting the Plaintiffs to maintain temporary custody of their active patient files until such time as patients have been fully informed of the change and given the opportunity to continue care with Plaintiffs. Without regard to the needs of Plaintiffs’ aged and chronically ill patient population, Defendants propose to remove forthwith ... all active patient files, with the exception of those patients who have a scheduled appointment with Plaintiffs in the next two weeks. Defendants also have failed and refused to agree to ensure that Plaintiffs’ new contact information will be provided to everyone who calls that number, notwithstanding that Defendant is keeping the phone number Plaintiffs have had for over thirty years.

The judge granted the restraining order. The legal standard for a restraining order is that the moving party has "a likelihood of success on the merits of its claim and, without the requested injunction, risks suffering irreparable harm." I'll leave you to read the story, but I want to respectfully disagree with Liz's characterization in one part of it.

She notes, "The disagreement highlights the intense competition among hospitals in the Boston area to hire and retain established physicians, especially primary care physicians." Not so! This is something altogether different.

This is out and out cruelty to patients by attempting to restrict their doctors' access to them and their medical records. I can't recall any other hospital system behaving in this manner when a doctor chooses to join another network, no matter how competitive the environment.

Newton and the Countefeiter

I'd like to suggest a book to you, entitled Newton and the Counterfeiter, by Thomas Levenson (Houghton Mifflin Harcourt). Levenson is a professor in Writing and Humanistic Studies at MIT.

We are all familiar with Isaac Newton's outstanding contributions to science and mathematics, but how many know about his career after 1695? In that year, tired of university life at Cambridge, he moved to London to become Warden of the Royal Mint.

There, he ran into another very bright person, in the form of William Chaloner, an accomplished counterfeiter, who was rising through the ranks of the underworld. As he had in other fields, Newton invented methods of investigation and proof, but these were designed to catch criminals.

Mr. Levenson's writing style is engaging, and you find yourself turning pages quickly. The book reads more like a novel than non-fiction, and the factual basis for the story makes it even more intriguing.

Pumpkins @ BIDMC

Here are some of the winning entries from the BIDMC annual pumpkin carving contest.

Lead cases studies will be available

We just finished our presentations at the BCBS conference. The full case studies will be available on the BCBS of MA sites mentioned below, but also on the IHI website.

Berwick jumps in, too

Following up on the post below, Don Berwick, CEO of the Institute for Healthcare Improvement is offering the keynote address at the BCBSMA conference. I'll try to pick up his major themes as he goes along.

Don offered stage-setting remarks for the CEO presentations to follow. He noted that the MA universal coverage law is being used as an example by people in Washington, DC, even though there remains lots to do with its implementation. He termed that law a "moral commitment," but one that requires lots of attention to the offshoots and results of that kind of commitment.

Don said that the work of the Lead group is also path-finding in its own way.

Regarding the current debate in DC, Don suggests that most of what seems to be playing out is an oscillation between two kinds of alternatives: Spend more or do less. The political process has the means to get through this kind of dialectic. But what the CEOs here know is that there is actually a third option: Redesign the care. The quality movement is formed by a kind of optimism. It always can be better; therefore we should stive. "Better is the option: Redesign is the plan."

Until now, it has not been necessary to do this in the health care system, and many parts of the system are still delivering care based on old models. Congress and the Administration don't get this because they don't deliver care. They don't know what the potential is and how to achieve it.

Don suggests that there are other elements in achieving this potential. The first domain of care is inherent in the Institute of Medicine list: Safe, effective, patient centered, timely, efficient, and equitable. He notes that we have gotten better in this domain, and he presented lots of examples across hospitals. "We know a lot, and it can be done."

The second part of the story has to be based on value, a system that we can afford. "I do not regard it as ethical that health care takes up 16% or more of the national economy." This steals wealth from other important causes like education, culture, and infrastructure. The health care system is way overbuilt. "Health care is not entitled to the growth in GDP that it demands." This will not be solved by focus on the IOM domains. We have to use scientific knowledge about process improvements and knowledge of systems to achieve the IHI triple aim: Better care, better health, and lower per capita costs.

There are some high value areas of the US. We brought together 10 of those regions and did a debrief. These places have broken the back of supply-driven demand. They also evidence high degrees of cooperation between medical groups and hospitals, among hospitals, and with payers. In every one of those communities, people in positions of responsibility both inside and outside of the health care system have chosen to exercise that responsibility. The attributes of the executives in the successful markets include: Confidence in possibility; appeal to the heart of the work force; constancy of purpose; alignment of resources for achievement of the long-term aims (money and time -- use a low discount rate in evaluating investment choices); review and reflection; translation into finance (bridge between the world of improvement and the world of money -- the CFO is at the table); management of spread (take pockets of excellence and help them be be pervasive); formats for cooperation ("not love, not even peace, but some way to get together") -- move good news from one place to another; celebration at the community level.

Jumping In

I'm currently attending a conference organized by Blue Cross Blue Shield of MA entitled, "Jumping In: Learning from CEOs about driving health care quality improvement." This conference represents the summation of a BCBS program called Lead, in which five MA health care institutions created a community of practice to learn about ideas, concepts, and implementation of meaures to improve the safety and quality of care.

My colleagues in crime in the Lead program are (seated): Vinod Sahney, SVP at BCBSMA; Jeanette Clough, CEO of Mount Auburn Hospital; Helen Streider, CEO New England Baptist Hospital and Maureen Broms, VP of Health Care Quality and Patient Safety at NEBH; and (standing) Eugene Lindsey, CEO of Atrius Health; Craig Melin, CEO of Cooley Dickinson Hospital. Yup, that's Don Berwick standing to Gene's right: More on him in a second.

All of the program materials are, or will be, available online here for providers and here for employers. There are some impressive stories, including how Mount Auburn virtually eliminated medical errors over a period of several months.

The keynote presentation will be given by Don Berwick in a few minutes. I'll try to pick up highlights and get back to you.

Auction item reminder

Please don't forget to donate to my collection of auction items to benefit Bowdoin Street Health Center. Thanks!

Thanks for nothing

I was excited to see that our Boston transit system, the MBTA, had installed these LED signs on the line I take to and from work. I eagerly anticipated messages saying, "Next train in 8 minutes" or "Green Line delay because of track repair."

But, no. The sign remained dark for the half-hour I waited for a train tonight.

Well, not totally dark. There was the message, simulcast on the public address system and the LED sign, warning us that fare evasion was a crime and that we could be punished mightily for it.

But not a word about the actual train service.

I have to give the MBTA something for truth in advertising. It describes this capital improvement project (or one like it) as follows: This project will install new LED information signs on the platforms and lobbies of busy subway stations. These signs will provide visual equivalent of audio information on train arrival times and destination information.

In that sense, the signs are the visual equivalent of the public address system on this line, which for years has also failed to give audio information about delays or train arrivals.

Brava, Helen!

I don't usually post emails from other hospital CEOs to their staffs, but this one is so kind and thoughtful that it presents a model for others to emulate. Helen Streider stepped in from a lay Board position to be Interim CEO of New England Baptist Hospital when there was an unexpected vacancy in the job. This, in itself, was generous act. Now, as her term ends with the arrival of a new CEO, she bids farewell to the staff in an incredibly gracious manner.

This will be my final Reflections as Interim President and CEO. It has been a remarkable year (actually 14 months). To this day, I am proud that the Trustees asked me to take on this responsibility and humbled by the honor. It has been a great privilege to work at the helm of this extraordinary institution where the values of respect, ownership, superior service and excellence result in legendary service being a prominent part of the culture.

These values are some of the reasons that my father, a thoracic surgeon, loved the Baptist, and the reason why I have enjoyed working at this institution, from the time I had a summer job during college, through my service on the Board of Trustees.

I knew as I started to work last August that I would be supported by a talented Executive Team and helped along the way by all who work here, and this proved true. I am proud that we were able to go beyond just holding the fort and accomplish so much together this year.

First and foremost, we continued our journey toward keeping our patients safe by reducing complications such as infections, skin breakdowns and medication errors. All of nursing, health care quality, infection control, environmental services and everyone who washes their hands regularly contributes to this progress. The pharmacy, nursing units, and the PASU learned to solve problems to root cause, reducing medication errors that reached the patient by 33%. To be successful with this process means that we must not blame each other for mistakes, but instead figure out how to change systems to avoid errors. We have learned to be transparent and now know it is safe to call out issues as they arise.

When the economy failed, and we, like so many, lost value in our investments and our pension assets, and our volume declined, the entire staff pulled together and made sacrifices to enable us to make, and even exceed, our budget. Special kudos go to the patient care teams who cooperated in continuous, precise flexing of staff and closing units when volume levels required.

And then there was the horrible winter, when Security roared into action getting folk up the hill for their shifts, and the wonderful patient care team spent overnights here and did everything in their power to make sure that they were here to care for their patients (including one nurse who walked up the icy hill in her socks).

We have renewed our alliance with our medical staff by coordinating negotiations with insurers and, in the process, aligned our quality goals with the medical staff metrics.

We reached a milestone in our Master Facility Plan in September as we opened the beautiful new Central Sterile Processing Department and a leading edge OR. The remarkable thing about the construction and facilities team was not only that they accomplished these goals, but met them while keeping disruption to operations to a minimum, and Environmental Services kept us clean and shiny throughout. What a great team!

By the end of the fiscal year our surgical admissions, outpatient visits and radiology volume actually exceeded that of 2008, despite the economic downturn and various other challenges. The increase in volume is due in large part to the efforts of our medical staff to increase their work, and to the incredible efficiency in the OR and perioperative teams. We also were fortunate to have several Harvard Vanguard orthopedists join our ranks in a testimony to their belief in our quality and that this is a place where their patients will have better outcomes. And now, as we are blessed with greater volume, all departments are rising to the challenge of caring for more patients while holding to our high standard of care.

And through all of this, our Food & Nutrition team fed us, catered events with panache, and comforted out patients with room service. They sustained us with that vital coffee and snacks as we dragged into early morning or evening meetings ready to put our heads on the conference table. How would we survive without them?

And what a beautiful tea party they orchestrated for us yesterday. Thanks to all for a lovely afternoon of smiles and to everyone who came to wish me well. And special thanks for my beautiful new chair.

So now Trish arrives on November 2^nd . . . and I will be sleeping in! We all are excited about her leadership and look forward to helping her help us be the very best we can be.

Thank you all for a wonderful, exciting and challenging experience and for all that you do for this Hospital.

Helen

Dan Jones at Medical Grand Rounds

Dan Jones continued his visit as our Judith and Robert Melzer Visiting Professor in Health Care Quality and Patient Safety with an appearance at Medical Grand Rounds. You see Dan here with his friend and colleague Jim Womack.

The topic was "Realizing the potential of Lean thinking in healthcare." I'll try to hit the highlights.

Joking that, after visiting our hospital, "I'm encouraged because your problems are the same I see everywhere else," Dan set forth the challenge as one of delivering more and better service to patients for less money. He noted that progress in the quality movement can be viewed an complimentary to implementation of Lean approaches. Whereas the quality movement strives to define best practice interventions and to eliminate variation and errors, Lean focuses on the context of the flow of work to eliminate delays for patients, wasted effort for staff, and unnecessary costs. The two movements share a common sceintific-evidence based methodology.

Lean, says Dan, begins with engaging the staff in improving work, liberating the potential to take action. But, he warns, point improvements are hard to sustain without an end-to-end perspective and management systems to support them. There is a need to manage an interdependent process throughout an organization. This requires a different level of engagement, in that making the system more "fragile" and subject to interruption is an inherent characteristic of the lean approach.

Dan illustrated the hospital environment as a set of processes (see above). Usually, nobody can see the whole set of interactions, "but we need to be able to do that," or each segment will just react to events rather than working on the greater good. In the example he gave us, he showed an analysis of patient flow from the emergency room through to discharge. "If demand is generally predictable, why are there so many delays" he asked, "both at the front end in the ER and at the back end, waiting for discharges?"

Based on his work at many hospitals, he noted that there are pioneers who have make progress in each segment of the care process. "Yet, the big opportunity is leveraging the gains of that work by linking the entire system together. The challenge, now that we see the hospital as a collection of processes, and we know how to improve most of them, is to connect all the pieces together."

After a detailed review of one particular case, Dan laid out the conditions for successful implementation of this kind of integrated approach:

There has to be a will to act.
Someone has to be the value stream manager, the person who takes end-to-end responsibility.
That person works to establish the foundations of progress: stability and visibility.
That person has to gain agreement from the team on the right actions, based upon the facts on the ground.
That person has to have the backing from senior officials to resolve conflicts that arise between departments and the overall value stream objectives.
That person, has to be able to deliver results, and yet has to do so with no authority over resources (just like the engineers at Toyota.)

Our doctors and students were engaged and very interested in all of this. Many had been primed by previous activities and instruction from Mark Zeidel, our Chief of Medicine. But, I think the fact that this is a whole new way of thinking about care delivery was evident to the audience. It is an approach that will take lots more practice and thoughtful planning and priority setting for hospital-wide implementation.

Figures lie

The old adage about "figures lie" takes on a new meaning when you are the target of an SEIU corporate campaign. In a recent mailing sent to the homes of our staff members (accompanied also by voice mails left on home phone lines), SEIU cites the rise in the cost of insurance benefits to our employees and notes that a number of our staff relied on "taxpayer funded health insurance."

Well, it turns out that many employers in the state, including unionized organizations, have employees who rely on taxpayer funded health insurance. Indeed, that was part of the design of Chapter 58, the universal health care coverage law passed a few years ago (the one being used as a model for national health reform). Here is the chart published by the Commonwealth of Massachusetts on this topic. Let's see a sample of which governmental organizations and nonprofits are included: The Commonwealth of Massachusetts itself, City of Boston, U Mass, Salvation Army, City of Springfield, Brigham and Women's Hospital, Bay State Medical Center, Boston University, Boston Globe, Catholic Charities, Action for Boston Community Development, U Mass Memorial Health Care, City of Cambridge, Boston College. As you can see, there is a mix of both unionized and non-unionized organizations included.

The SEIU mailing also decries the fact that our workers last year had cuts in earned time, retirement benefits, and raises. Absolutely true. As has been documented in national and local news coverage, BIDMC was a national example in avoiding hundred of layoffs by asking workers to make a sacrifice for the greater good. And all the while protecting the lowest wage workers by ensuring that they would continue to get raises. This is what happens when workers care for one another. In contrast, how many stories have you heard about where unions have refused to consider this kind of shared approach, resulting in layoffs of their most junior members.

A benign infection

We are honored to host Dan Jones, Chairman of the Lean Enterprise Academy in the UK, to be our Judith and Robert Melzer Visiting Professor in Health Care Quality and Patient Safety. He will spend a full day at BIDMC addressing Board members, conducting grand rounds, going to gemba and out-briefing with residents and others. You see him here with the Melzer's.

Dan and his US counterpart, Jim Womack at the Lean Enterprise Institute, are the instigators of a group called the Lean Global Network. This comprises sixteen organizations around the world that are promoting Lean thinking and leadership and helping organizations with their Lean transformations.

Dan had a great description for how Lean becomes a force in those organizations that carefully plan and design its implementation: "A benign infection for which there is no antidote."

Intelligent design?

My friends and I just didn't get it. We entered 1 Federal Street in Boston and found this very odd elevator system. You have to punch in the number of the floor to which you want to go on the outside of the elevator. Once you are inside, it takes you there. There is no inside panel of floor buttons. So, what if you made a mistake or want to change your mind after the doors have closed?

New blog feature coming soon

I am presenting a new feature on this blog on Monday, November 2. I hope you enjoy it, but I am also seeking your involvement now.

Some friends of mine are involved in a new company called BiddingforGood. What EBay brings to the world of auctions in general, B4G brings to the world of charity auctions. It is a consolidator, facilitator, and operator of on-line auctions for charitable causes and organizations.

With the help of B4G and some of the BIDMC staff, I will be holding an on-line auction each month to benefit one of the BIDMC's affiliated community health centers or another health care-related cause. You will have a chance to bid on neat items, knowing that the proceeds go to a worthwhile purpose.

The first auction will benefit BIDMC's owned Bowdoin Street Health Center, a wonderful place providing primary care, specialty care, and many support functions to a section of Dorchester in Boston.

Bowdoin Street Health Center was founded in the Bowdoin/Geneva neighborhood of Dorchester in 1972 by community residents to provide affordable, accessible primary care and public health services. The Bowdoin/Geneva community is a widely diverse population. 43% of the patients served at the health center are African American or Caribbean Islanders and 38% are Cape Verdean, while Latino, Vietnamese, Haitian and Caucasian populations make up the remaining base. The health center has experienced continued growth over the past 36 years, leading to several relocations to larger facilities. The current building opened in 1997, and we now care for more than 10,000 patients through 45,000 visits across a wide spectrum of care. Bowdoin Street also has a long history of working in partnership with residents, businesses and organizations on identified issues of importance to the community. A staff of 70+ employees makes Bowdoin Street the largest employer in the Bowdoin/Geneva area.

Specifically, I am trying to raise money to purchase an ultrasound machine for the health center. This would enable pregnant women to have ultrasounds in the community, rather than having to travel several miles to BIDMC for these screenings. I hope you will like the items I am offering and will bid vigorously for them for this cause.

But, wait, there's more. I mentioned that B4G is a consolidator and facilitator. You have the opportunity to offer items of your own to include in this auction. Just go here and click on the button entitled "Sign in to Donate," provide the requested information, and we'll tell you if your item will be included. (You'll need to consult your tax advisor to assess the tax deductibility of a donation.) Or use the blue Donate an Item button on the right side of this blog.

Sample items that typically do well that I’d love to include in the auction include:

Tickets to sporting events (from season ticket holders)
Tickets to entertainment events
Gift certificates
Weekend get-aways
Bottle of fine wine
Unique experiences
Lunch with a celebrity or a political figure (are you one?!)

This blog has a worldwide audience, so don't think your items have to be based in Boston. On the other hand, I do have lots of Boston-area viewers, so local items are also welcome.

The first auction will run from Monday, November 2 through November 9. I'm planning to run one during the first week of every month.

I hope that you enjoy this new feature and will choose to participate, as a bidder, donor, or both. Please pass along the word to others, too, OK?

CIMIT advances

The two young men above are Nevan Hanumara and Conor Walsh, Ph.D. candidates in Mechanical Engineering at MIT. You see them here at the current Innovation Congress of CIMIT, being held in Boston. CIMIT is a multi-institutional cooperative venture with the mission of improving patient care by facilitating collaboration among scientists, engineers and clinicians to catalyze the discovery, development and implementation of innovative technologies, emphasizing minimally invasive approaches.

Nevan and Conor work with Professor Alexander Slocum at MIT and Doctors Rajiv Gupta and Jo-Anne Shephard at MGH's Department of Radiology. They came up with a device to help interventional radiologists perform soft tissue probe insertions with greater speed and accuracy and reduced complications and physician strain. They explain more here.

This kind of project research is funded by the CIMIT member organizations, along with federal government and industry sponsors. To the right, you see some of our executive committee members getting a feel for this device.

Helping women get on corporate boards

I recently heard about an organization called WBL, or Women Business leaders of the U.S. Health Care Industry Foundation. It was founded in 2001 to provide its members with help to improve their businesses and grow professionally. The part I find especially interesting is the help that WBL offers to senior level executives (VP and above) to get positions on non-health care corporate boards.

The organization has published two books, Answering the Call and Advancing Women in Business. The first is a resource for considering the risks and responsibilities of governance. As WBL notes, "This book is a great place to start considering whether board service is right for you or to brush up on your governance-related knowledge." The second book is to help you understand how to get on a nominating committee's radar screen.

In addition, WBL holds annual Summits about serving on corporate boards and considering your first board seat.

This is a great resource for women health care professionals who want to expand their personal and professional horizons. Many corporate boards are seeking to diversify their membership, and the experience offered by health care people can often be applicable to other industries.

Not all fun and games, but they help

Following up on one of the recommendations in the item below, you may recall that I have written before about the use of games and other light-hearted events to promote better hand hygiene. That, plus a lot of hard work, has resulted in general improvement in the hospital.

A key part of the program, consistent with our transparent approach to process improvement, is that we share data about every floor with every floor, so there is an overall awareness of how we are doing. Our measurements are based on a combination of direct observation and keeping track of quantities of CalStat used on each floor relative to the number of patients on that floor. We are now at the point, as noted below, of increasing our goal.

Here's the form of the message that goes out from Linda M. Baldini, RN, CIC, CPHQ, Infection Control\Hospital Epidemiology, to each floor, all of the Chiefs of Service, Division Chiefs, and many other people at the end of each observation period:

The latest hand hygiene reports for all units are now available. Reports are available on the online Infection Control manual. The link may be found on the new portal.

The most recent report is for Period #25 (7/4/09 – 8/28/09) and is generated using data on usage (counting empty soap and CalStat containers) and census (patient days) for each unit. These data closely mirrors that obtained by direct observation of hand hygiene performance of health care workers during the same period. Note that L&D is considered an ICU in this report due to similar nurse:patient ratios.

The reports available include: ICU hand hygiene reports (all units on one graph) Non-ICU hand hygiene reports (all units on one graph) Average ICU and non-ICU hand hygiene performance over time Individual graphs for each unit over time

Congratulations to L&D, CVICU, MICU 7, 7 Feldberg, 6 Feldberg, 5 Feldberg, 5 Stoneman, Farr 10 for reaching goal this period of ≥80%!

An email reminder will be sent to you after each intervention period, approximately every 9-10 weeks. Please share these data and information with your unit-based staff at all levels and physicians. Feedback of data has been shown to help improve performance.

You can see the data, too, on our corporate website. As I have often mentioned, we believe that public presentation of our performance data stimulates internal improvement by helping to hold ourselves accountable to the standard of performance for which we stand.

But back to the game idea, here's the latest campaign, announced last week:

To: BIDMC Community

From: Ken Sands, MD, MPH, Senior Vice President of Silverman Institute for Health Care Quality and Safety

Sharon B. Wright, MD, MPH, Director, Infection Control/ Hospital Epidemiology

Subject: Raising the Bar on Hand Hygiene

Starting with the new observation period that begins Oct. 24, BIDMC will increase its hand hygiene compliance goal from 80 to 90 percent across the medical center. To help roll-out this new initiative we will introduce a fun new incentive program to help inpatient unit staff improve their hand hygiene compliance.

BIDMC Bowl-O-Rama (Knock Down The Germs) will use a bowling-themed scoring grid to communicate unit performance in each measurement period. Those units meeting the new goal will receive rewards such as bowling shaped cookies and coffee to winning units at the halfway mark (April, 2010), and a big party with raffles during Infection Prevention Week in October 2010.

Our grand prize will be a Wii game system, including the sports/bowling program, as well as other bowling-themed prizes, gift certificates to area bowling alleys, custom made bowling shirts (for select Hand Hygiene advocate champions), and movies such as and “The Big Lebowski.” Unit-based bowling trophies will also make the rounds to highlight and reward compliance.

To learn more about this new initiative, please join us at the Infection Prevention Week informational fairs in the east and west campus cafeterias on Oct. 21 and 22, from noon to 1:30 p.m. The fairs include free prizes and Wii bowling.

Amateur hour

Sometimes the "amateurs" come up with important observations. Samantha Sherman and Patricia Henderson (above) are two of our Sloane Fellows who took on an interesting assignment suggested by MIT's Steven Spear. Thinking through the issue of hospital acquired infections, Steve suggested that a couple people could go to gemba and watch how germs might invade the perimeter around a patient in the hospital. Perhaps this kind of observation could lead to process improvements or other changes that could reduce the rate of infection.

So that's what Sam and Pat did. They are not trained clinicians and have frankly not spent all that much time in clinical settings. But they have good eyes. For many hours, they sat in patient rooms and watched as people entered and left, keeping track of potential sources of infection.

Here's a short excerpt of what they noticed, just the part focusing on hand hygiene. Please remember this was not meant to be a statistically valid sample. Some of the observations have been helpful to our infection control people as they design changes to improve compliance with this important aspect of the hospital. In other cases, the recommendations might be deferred because different approaches have been found to be more effective. See the post directly above this one for an update on the entire issue.

Sloane Project
Observation Findings

Overview:

Over the course of 4 weeks, we spent approximately 25 hours observing interactions in inpatient rooms to evaluate what passes the perimeter of the infection zone. We were able to compare notes from our observations and categorize our findings into five categories.

They are:

1. Physical space
2. Equipment
3. Hand hygiene
4. Use of gloves
5. Outside visitors

Hand hygiene

Observation:
Major inconsistencies with staff using Cal Stat upon entering and exiting patient’s room.
This observation includes: nurses, co workers, food services, physical therapy, family members, couriers and Phlebotomist.

Recommendation:
Further training in targeted work groups and visitors (see list above).
All visitors must sign in at front desk before entering patient’s room at that time.
Educate or give visitor a hand hygiene pamphlet that explains the importance of this
requirement.
Involve the patient; include an antibacterial wipe/napkin on food trays along with an educational reminder to use before eating.

Observation:
Empty Cal Stat – people were still going through the motions even if nothing was coming out.

Recommendation:
1. Monitor Cal Stat usage
2. Install empty warning alerts
3. Flag – visual identifier
4. Blinking red light
5. Beeping sound

Gloves
Observation:
No standard protocol for when to wear gloves and when not to (medication delivery, checking wounds, etc.)

Recommendation:
Establish best practices; undergo refresher training for all staff.
Use educational humor, display slogans in certain areas of the institution, i.e.
“Spread the word not the Germs”.

Observation:
During our visits we observed that there is no designated work space for staff within the patient room. Caregivers are often observed using the soiled linen cart as a place to check and/or update the patient chart or they use the space to regroup before coming into the room, or moving on to the next patient room. Also, often times, equipment or charts would move back and forth from the clean bed to the patient bed increasing risk for infection. Floors, chairs, patient bed, and patient tray were used as work spaces to hold phlebotomist cart, charts, medications, and even urinals.

Recommendation:
One recommendation is to create a designated space in the room that gets sanitized – perhaps one of those tables that fold down from the wall? If there is no space within the room, it could exist immediately outside the room. In some situations such as the phlebotomist, a rolling work station might be appropriate.

Observation:
The cleanliness of the rooms also presented some risk. We observed dirty gloves on floor next to trash can; empty drain hanging out of trash can; and dirty paper towels on floor. Additionally, we observed a coworker who cleaned the patient’s belongings while wearing the same gloves used when she cleaned the patient.

Recommendation:
Perhaps an easy fix for trash could be to buy taller trash cans. The trash cans are quite short and are often placed in a far corner of the room. If the cans were taller, there might be less likelihood of missing the can. Additionally training is recommended for all staff that is responsible for cleaning and sanitizing the room to educate on the various ways that infection can be transferred.

Observation:
Some equipment is used on multiple patients – this includes tourniquet, stethoscope, and blood pressure cuff. Not all equipment was wiped properly before being used on the patient.

Recommendation:
Some of the items could be assigned to each individual upon arrival – such as a tourniquet or blood pressure cuff. Communication and education around the importance of cleaning stethoscopes may help with consistent cleaning prior to use on patients.

A note to other 89%: You are in the minority

A couple of weeks ago, I wrote about a Boston hospital that had shut down employee access to various social media sites and offered my view that it was not a productive thing to do. Here's a similar view from Socialnomics. The site notes that only 11% of companies do not put some kind of limitation on use of Facebook by their workforces.

I like this set of comparisons.

Banning social media in the work place is:

• Analogous to banning the Internet
• Analogous to banning the phone because you might make a personal phone call
• Analogous to banning paper and pens because you might pass a note that is not related to class or work
• Could potentially signal to current workers and future recruits that your company just doesn’t “get it”

Journal of Participatory Medicine has its debut

E-patient Dave informs me of a new venture, the Journal of Participatory Medicine, a peer-reviewed open access journal. It is the product of the Society for Participatory Medicine. Here's the lead-in to issue #1, along with other material from the Society:

Our mission is to transform the culture of medicine to be more participatory. This special introductory issue is a collection of essays that will serve as the 'launch pad' from which the journal will grow. We invite you to participate as we create a robust journal to empower and connect patients, caregivers, and health professionals.

This is free, online journal dedicated to documenting how healthcare encourages, supports and expects active involvement by all parties, and leads to improved outcomes. An interdisciplinary publication founded, written, edited, and reviewed by health professionals, patient advocates, and researchers, the journal will explore how participation affects outcomes, resources, and relationships in healthcare; which interventions increase participation; and the types of evidence that provide the most reliable answers.

Caller-Outer of the Month Award #8

Continuing our series, David Mangan, shown here, received this month's Caller-Outer of the Month Award from our Board of Directors.

Sometimes a call-out is just a sign of initiative and caring. It might not result in a new process, but it might help confirm that something that has been put into place is working well. Such was the case here.

Dave is a pharmacist who helps nurses and other staff learn to use our sophisticated medication-delivery pumps. During a pump's testing phase, he will sometimes distribute a few pumps to people in training and then collect them before the full roll-out occurs.

He did this recently and found one pump was missing, having disappeared. Previously, finding one pump on the dozens of floors in the hospital would have taken forever, during which time it might have been misused or create other problems. Here, Dave immediately called Pam Dicapua in our clinical engineering department. That group had recently installed an RFID system and labeled hundreds of medication pumps. This particular lost pump was located within 37 minutes of Dave's query to Pam. It had traveled downstairs from one floor on our West Campus, across the street three blocks away, and then upstairs to a floor on our East Campus.

In short, good heads up thinking and initiative by Dave, and excellent follow-through by Pam at clinical engineering, using the latest systems put in place by her and her colleagues.

Dave says he has renamed RFID to mean "Really Finds Infusion Devices"!

That's two in one day

And here's another excellent appointment, of Sarah Iselin as head of the Blue Cross Blue Shield of Massachusetts Foundation.

Welcome back, Betsy!

Brigham and Women's Hospital in Boston has a new President, Elizabeth Nabel, currently at the NIH. Read Rob Weisman's story from the Boston Globe here. A superb choice. It will be great to have her back in Boston.

Minorities in Boston

I just returned from a session for minority students at Harvard Medical School where I joined my Harvard hospital CEO colleagues in addressing the students on the topic of "Why Boston? Building your Career in Academic Medicine in Boston." You might be interested to know that, decades ago, Boston was considered one of the friendliest places in America for African Americans to live and advance professionally. Unfortunately, that reputation was tarnished greatly in the 1970s and 1980s (thanks in part to this image) when the controversy over school busing to integrate the public schools divided the city in so many ways. More recently, civic, academic, and corporate leaders in the region have reached out in an attempt to revive that older, more tolerant and friendly view of the city.

A lovely moment in tonight's program was the presentation of an "Excellence in Mentoring Award" to Dr. Johnye Ballenger (seen here). Johnye is a instructor in pediatrics at Children's Hospital, and she has spent the last 20 years tutoring and mentoring HMS students. In accepting the award, she said to the students, "It has been my passion to be part of your lives," and received a standing ovation.

Next year?

The season is over for the Red Sox, but they are scouting for talent for the future. BIDMC Chief of Neonatology DeWayne Pursley took batting practice at Fenway Park today in the hope of securing a better job.

DeWayne reports: "At the end of that session the head coach, assessing my season’s performance, told me that I could probably have a good career in medicine." Then, "I’ll be in a little late tomorrow. I’ve got a physical therapy appointment lined up."

Question for Glenn Steele and colleagues

Much has been rightfully made of the success of the Geisinger Health System in delivering high quality care at a lower cost. Here's an article from Philly.com that discusses the issue.

A pertinent quote:

"Medical care is more fragmented in most hospitals, with many doctors self-employed or working for independent groups, and insurance provided by separate companies. That pits those groups against one another economically. In a fully integrated system, like Geisinger's, everyone benefits more easily from holding costs down and improving care, experts said."

Question: How much is due to the common bottom line between the MDs and the hospital, and how much is owning the insurance company? Also, how much of this is transferable to other settings that do not have the dominant market position enjoyed by Geisinger?

Glenn and colleagues, can you please reply?

Making stairs fun

Watch this. I love the theory set forth: Can we get more people to use the stairs by making it fun to do?

OK, it's part of an ad campaign for Volkswagen, but who cares?