Monday, July 28, 2014

Excitement about Change and Improved Outcomes

I started my day on Friday at the Partnership for Patients leadership team meeting. Cathy Hamel, our Vice President for Post Acute Care and Cate O’Connor Devlin, our Administrative Director for Nursing Patient Safety and Bed Flow lead this team and they have done phenomenal things! Partnership for Patients is a collaborative effort sponsored by the Centers for Medicare and Medicaid Services to get hospitals to learn from each other to improve care. Our P for P team has overseen the creation of more reliable care that has significantly reduced pressure ulcers, patient falls, catheter associated urinary tract infections, and surgical site infections, among other things. I sat at this meeting so proud to be involved with this outstanding group of leaders who are delighted to be in action and moving us toward our vision.

I asked the Team what I could do to make their work go even faster and they really struggled to come up with anything. They did say that they want my support as they are studying adding hand wipes for patients to help us reduce our hospital acquired infection rates even further. These wipes will add an expense to the budget and they are searching for the best, most cost-effective product. Otherwise, they didn’t need my help…and that is the way that it should be!

Sometimes things don’t go as well. I had a couple of interactions last week where local leaders were struggling to get something “fixed” when it involved more than one department. I encountered a couple of very frustrated individuals who were pushing problems up the chain of command and were accepting answers from colleagues that, in my mind, were unacceptable instead of calmly and respectfully working on the solution.

Hierarchy Vs. Bureaucracy

The larger an organization is, the greater the tendency to have multiple levels of authority. Everyone gets it that someone has to be ultimately responsible for the organization. These multiple levels of accountability are called hierarchy. The Merriam Webster dictionary defines this as Hierarchy (noun): A system in which people are placed in a series of levels with different importance or status.

A hierarchy becomes part of the problem when the levels require non-value added communication or when it leaves people lower in the hierarchy with the impression that they have no power to change or fix things. They then wait for someone above them to fix problems for them. Or even worse, hierarchies can leave the option for silos to be obstructive to change, waiting for the leader above multiple silos to step in and get through an impasse.

When the hierarchy becomes an impediment, it is then a bureaucracy.  The Merriam Webster dictionary defines this term as: Bureaucracy (noun): A system of government or business that has many complicated rules and ways of doing things; a system of administration marked by officialism and red tape.
The leaders of the P for P Team are working beautifully across boundaries. They are making offers to and requests of each other continually and they are creating meaningful change. They are never going to their bosses unless there is a barrier that they cannot overcome. We need more of this. The larger an organization becomes, the more managers it needs (hierarchy), the harder it is to keep everyone on the same page and have all line managers feeling like they have the power to generate change.

And, in large, complex organizations with many departments often spread over vast areas, there is a temptation to not work manager to manager and push problems up the hierarchy. (Yesterday, a manager thanked me for getting a problem fixed when he had been given a silly answer as to why the problem couldn't be fixed. I felt really bad that I had to intervene.)

Here is a great example of managers working together across departments to identify a problem, create a plan for a solution and obtain great results:

  • When U45 went through an expansion in December 2012, it created two sides – Unit 45A and 45B. The staff quickly realized that the new U45B was not a mirror of 45A including the supply set-up. They quickly found that U45B did not have the general supplies readily available to them and staff was continually going back and forth from one side to the other just to find supplies and equipment needed to provide patient care. Nurse manager Eileen Skaarer recognized that the staff was becoming increasingly frustrated and decided to put metrics in place that provided incredible data – U45B had up to 30 missing pieces of supplies and equipment every day, causing staff to constantly have to search for the tools needed to provide care.

    Armed with this significant information Eileen and her team, along with Jim Duerr, Director of Materials Management, and his team, developed a solution to the supply problem on her unit. An Omni Cell and bulk cart storage that mirrored the existing supply storage on U45A was put into place on 45B. The result? According to Eileen, her team is now only searching for one or maybe two missing pieces of equipment/supplies per day compared to close to 30 missing items per day before the two department leaders took action to find the right solution. 

"It's Your Right to Fix What's Not Working..."

As managers and leaders in the organization, it is your right to question decisions or answers that don’t make sense; it’s your right and obligation to work together with other department managers in a calm, respectful yet direct way to fix things that aren't working for the benefit of our patients.

Do not accept what doesn't make sense. Get in action, work together, and cut across silos. Find appropriate solutions to work across departmental lines to fix what is not working and improve things.

Communicate openly and directly. Like the process owners on the P for P Team and Eileen and Jim, take ownership and get in action testing change. And only when the plan isn't being worked by both managers should you escalate it up the chain of command.

I am very grateful for everything that our leaders are doing to get the outstanding improvement that we are seeing. Please keep it up!

Friday, July 18, 2014

Summer Heat and Storms, an Unreliable Electric Grid, and Resilience

GBMC has once again shown its ability to rise above adversity and meet its mission over the last few weeks. The summer has brought high temperatures, thunderstorms and our local electric grid has not been able to supply GBMC with a reliable flow of electricity. We had three significant events where our campus had power interruptions.  During the most recent event with the added dilemma of an electrical storm, lightning struck one of our main feeders causing a power interruption.   Approximately one hour later, the second feeder on to our campus was incapacitated.  Power was then restored 45 minutes later. St. Joseph’s was also affected by this event.

The good news is, over the past few years GBMC has installed three new emergency generators so that we do not go without power. The bad news is these generators do not backup everything.  Our priorities for emergency power include: life support devices, emergency lighting, fire protection systems, patient communications devices, critical computer systems and clinical equipment. Our chilling system, which among other things cools the air in our buildings, is not connected to emergency power. So, when the power goes down, the chillers shut off. The fans continue to run as they must for ventilation and pressurization, but they are then pulling high humidity air from the outside into the building, thereby increasing the internal humidity.

Our operating rooms and our surgical instruments must stay within a narrow band of humidity to keep them sterile. During the summer, with high external humidity, the chillers keep the internal air within acceptable temperature and humidity levels. But when the chillers go down, the humidity can quickly get too high, and the rooms need to be re-cleaned and the surgical instruments need to be re-sterilized. There is a renewed emphasis on humidity and temperature control by CMS/Joint Commission to prevent healthcare acquired infections.  We can clean the operating rooms fairly quickly but it takes many hours to re-sterilize all surgical instruments.  For this reason, GBMC has had to delay or cancel many operations during these events.

I want to thank all of our staff who have risen to the occasion over the past few weeks to help us get things back in order. Our operating room nurses, technicians, central sterile staff, anesthesiologists, administrators and environmental service workers have done an outstanding job under very difficult conditions. I want to also thank our surgeons for understanding the problem and for having done everything to get their patients what they need.

Our management team has realized that we did not have the emergency designs in place to communicate well with our patients, our surgeons, and the rest of the GBMC team. I apologize to all for this. Over the past few weeks we have learned from each event and we have developed better systems of communication, but we need to do even better - and we will.

As for preventing future events, we are working with vendors to see if we can install emergency air conditioners that we can connect to the generators to better protect our sterile supplies.  We are also exploring back-up systems and emergency power connections for our Sterilizers. The long range fix is to connect the chillers to the emergency power. This is a very expensive proposition and will take a significant amount of time, but we are presently studying this with our engineers.

GBMC is an excellent healthcare system and we will grow stronger as we learn from these events and make the required changes. Thanks to everyone who is helping us.

Thursday, July 10, 2014

Learning from Near Miss Events to Avoid the Catastrophe

In my April 3 blog post, I discussed the notion of preoccupation with failure and that accepting a defect by working around it may eventually lead to a catastrophe. High reliability organizations demonstrate a zeal to fill holes in the Swiss cheese before they can line up to create a bad outcome. When they find a defect they do work around it but they also identify the root cause and redesign it so that the problem doesn't occur again. They don’t fall into the trap of working around the problem over and over again until eventually other defects line up and a patient gets hurt.

On Lean Daily Management rounds last week one of our units reported a missing dose of insulin from the day before. A nurse went to give a patient insulin at 6:00 a.m. However, the insulin, which had been ordered more than five hours earlier, was not there. The nurse, concerned that the patient was about to eat breakfast and the risk of hyperglycemia quickly called the pharmacy who raced to deliver the medication. Further problems were averted and the staff breathed a proverbial sigh of relief. 

But what happened next? The staff, both on the floor and in the Pharmacy went back to their work. When I asked the person presenting the board what did they learn as to the reason why the insulin was not there the answer was that they did not know because no one as yet had investigated it. Now before you as the reader get upset with me and say “there he goes again, this guy doesn't know how hard the nurses and pharmacists are working…when did he expect them to study this?” - I accept your criticism. We leaders must create the capability to study these errors in real time if we are serious about fixing the “latent” errors that lead to near misses and then sometimes to full-blown catastrophes. We must create both the zeal to learn why the defect occurred and the resource to study it and fix it as quickly as possible. Eventually some patient may get hurt because we didn't learn why this patient dodged a bullet. 

We are making excellent progress toward our vision in our healthcare system. But the question remains what can we do to move faster? One answer is to be preoccupied that if we don’t learn why a defect happened someone could get hurt and be less likely to work around a defect in our system and go back to work.

I welcome your comments.

Saturday, July 5, 2014

Happy (Fiscal) New Year

This week marked the end of our fiscal year 2014 and the beginning of our new year. We set our goals according to the fiscal year so how did we do and what’s in store for this year?

Our system scorecard is not yet complete but it is clear that we had a great year. When we talk about our 4 aims, we always say that the goal of better health is the most important one. If the patient is your loved one, the most important thing is that she gets evidenced based care that gives her the best chance of returning to or maintaining her health. We finished the year with six serious safety events and beat of goal of 10. Two years ago we had 21. The only ethical stopping point is zero, but we have made great progress! GBMC has moved to higher reliability. We are now much more likely to be following standard designs to keep people safe. We use checklists because we know that we will get distracted and forget things and we are working better as a team. Our people are more likely to speak up when they see something that is not right. This is in part because of our work in creating a Just Culture. We continue to do well at reporting great catches and near misses and then learning from what we find.

In FY ‘14 our clinicians, especially our nurses, made marvelous improvements in reducing hospital acquired conditions like patient falls and catheter associated urinary tract infections. We went an entire fiscal year without a stage 3, 4, or un-stageable pressure ulcer! In fiscal ‘15, we will continue to improve by focusing on more of the Maryland Hospital Acquired Conditions, MHAC’s.

In the area of better care, we are making very good progress even though we will not achieve our inpatient HCAHPS goal. For this metric, the patient is asked to rate their hospital stay on a scale of 0-10, with 10 being the best. The percentage of patients giving us a 9 or a 10 is what is measured and reported. The attached graph shows that we have made progress through the years but we still have work to do.

GBMA has made exciting improvements in care over the past few years. They have achieved their annual overall satisfaction goal. They have become much more responsive to their patients’ needs as they have implemented the patient-centered medical home.

Lean Daily Management has been a wonderful success story to help us drive out waste especially in helping us get to get to better patient flow. We achieved our goal for ED throughput; the average admitted patient now waits 90 fewer minutes to get to an inpatient bed! And, it appears that we achieved our system operating margin in a very difficult financial environment.

Under our aim of More Joy, we have come a long way in keeping our people safe. In FY ‘14, our executive team studied employee injuries on a daily basis and we reduced them significantly. I am most pleased by our efforts to reduce blood-borne pathogen exposures. We have nearly eliminated splash injuries to the eye because we are now reliably wearing protective eyewear when we should. GBMC leaders have done much to respond to both the employee satisfaction survey and also the physician survey. These surveys will be repeated soon and I believe that we will achieve those goals. We will talk about these when the results are in.

So, it was a great year. We are progressing well toward our vision of being the community-based healthcare system where everyone gets the care always that we would want for our own loved ones. We are safer and more patient-centered. We are more efficient and our patients are reaping the benefits. Let me thank everyone in the GBMC family for your hard work and well-earned accomplishments. 

Happy Birthday to Us!

July 4th marked the birthday of our great country…the land of the free and the home of the brave. Let's take some time to reflect on what we can each do to make our country even better than it is today.

July 4, 2014 was also the 75th anniversary of Lou Gehrig’s remarkable retirement speech. Gehrig was a wonderful example of a very talented and hard working individual who in a moment of major adversity, as he was retiring from baseball due to having been diagnosed with a terminal illness that now bears his name, found the courage and grace to call out his joy for having  been given so much in life. You can hear Mr. Gehrig’s speech here.