Thursday, August 17, 2017

Are we following the standard work…the design?

Earlier this week, at the executive Lean Daily Management board, we learned of three cases of patient falls at GBMC where the individual sustained minor injuries. Our people, especially our nurses and nursing support technicians, have done a remarkable job at reducing falls within our system. I believe that frail elders are now safer at GBMC than they are in their homes. Let me make the statement that I don’t think we will ever get to zero falls because to do this we would have to rob patients of their freedom and we will not do that. But as smart, caring professionals we need to always be learning from falls and changing our systems to move closer to zero.

So when three falls get reported what should our first question be? Our first question should be “did we follow our standard falls prevention work?” That standard work includes assessing the patient’s falls risk, educating high falls risk patients about how we will act and how they should act to protect themselves, and then implementing measures, like red socks, to alert others to the high falls risk, and using the bed and chair alarms.

The Swiss Cheese Model of error informs us that we should not expect to find one cause of a fall. In large complex systems, it is usually a series of factors that result in the bad event. One category of “holes” in the Swiss Cheese is that leaders need to be aware of managerial failure. One type of managerial failure is knowing that the standard work (in the case of falls prevention it is standard safety work) is not being followed and not doing anything about it.

If you are a very busy nurse on a medicine unit caring for a number of sick elderly patients, you have a lot to do. Setting up the bed alarm and making sure that it is turned on is one of your tasks. It should come as no surprise that a very busy nurse will sometimes get called away to urgently help another patient and forget to turn on a bed alarm. At GBMC we have, as part of our every two-hour rounds, a safety checklist that is done in part to check that the appropriate safety measures are in place and turned on. But what if we are not doing the safety checks as designed? If we are not, then that is a hole in the Swiss Cheese that is waiting to line up with a busy nurse getting distracted and forgetting to turn it on that might then lead to a patient fall.

So, as leaders at GBMC, we owe it to our patients, our staff and ourselves to assure that those safety checks are being done correctly. As we work to improve our care and get to even higher levels of reliability, we accept the fact that people will make mistakes and we must be preoccupied in catching the mistakes before they might result in harm.  So, we set up audits or checklists, but if we don’t follow the standard work of the check itself we miss our opportunity to find the mistake and fix it.

All leaders at GBMC have to unite NOT on ‘re-educating’ our staff on the importance of not forgetting, but, unite on ways of making sure that the standard work is followed when we are doing the safety checklist.  Only after enrolling all of their team members in the standard work should leaders decide how to hold their people accountable.  Leaders must take ownership as well.  If we know that the standard work is not taking place, as leaders we can’t wait until there’s an event, we must immediately work to close the hole in the Swiss Cheese and prevent the event from happening.

Please share your thoughts with me. 

Thursday, August 10, 2017

The Affordable Care Act was not repealed. What next?

In light of the vote against repeal of the Affordable Care Act (aka Obamacare) two weeks ago in the Senate, it’s a good time to continue the dialogue about the successes of the Affordable Care Act, its problems, as well as reflect on what the future may hold.

While I won’t go into the politics of healthcare, I believe it is important that the public remain educated and informed on how we arrived at this major crossroads in the American healthcare system.

The Two Main Components of the Affordable Care Act
First, did you know that there are actually two major bodies of work within the Affordable Care Act? The first has to do with health insurance. By far, covering Americans with health insurance was the biggest draw of this healthcare bill. Before the ACA was enacted, roughly 50 million citizens were uninsured. Since the ACA was passed, that number has been cut roughly in half.

The other component of the ACA focuses on the actual health care delivery system. As you know, even though we don’t cover all of our citizens with health insurance, we still spend 40 percent more per capita on healthcare than every other advanced nation and we don’t have outcomes for chronic disease that are as good as those other countries. So the ACA began changing incentives to meet the triple aim of improved health outcomes, better care delivery, and lower cost. This part of the ACA has been successful. We’ve seen annual Medicare cost increases lower than ever before and new programs set in motion that incentivize hospitals, physicians, and nurses to drive better health care value that has also kept employer-based health insurance cost increases relatively low. We’ve been experiencing the success of the ACA and the incentive programs at GBMC.

Of course, no bill, no matter how well designed, is without its problems. Yes, the ACA significantly increased the number of low-income individuals and families who qualified for Medicaid coverage to the tune of about 20 million Americans. It also made it easier for middle-class Americans to buy individual policies when they did not receive employer sponsored insurance, accounting for about 15 million more Americans who could purchase and choose their own plans on the newly created healthcare exchanges.

Why was this a big deal? Because prior to the ACA, people could buy individual policies from insurance brokers – if they were healthy. Because only healthy people could qualify, the rates for these policies were relatively low. People who were sick or had a pre-existing condition (such as epilepsy, diabetes, or even cancer), however, were deemed uninsurable. The pre-existing condition clause in the ACA opened up health insurance to a whole new pool of individuals who were no longer discriminated against by the insurers. This was a great win for millions of people.

But, once you create a market for sick people to buy insurance, the healthy people must also be required to buy insurance to balance out the costs.

This is the part of the ACA that is not working.
The incentives for healthy people to buy coverage were just not enough for many. Every time a healthy person decides to forgo health insurance pays the penalty, and takes their chances that they won’t wind up with a major illness or accident, the cost of insurance goes up…and up, and up.  And every time the cost of healthcare insurance goes up, more and more young and healthy people decide to roll the dice, take the risk, and not buy insurance, leaving a yet higher percentage of sick individuals in the insurance pool which drives costs up further. In some states across the country, this is causing insurance companies to stop selling policies to individuals. In these states, the exchanges are at risk of failing.

Going forward, we need to figure out how to make these exchanges work. We need a bipartisan effort to fix this part of the ACA, whether that means steeper penalties for healthy people who don’t buy health insurance, or more significant incentives for the healthy to enroll in coverage to keep costs lower for everyone. I am hopeful that the bipartisan work that started in Congress last week will come up with some good ideas to help fix this. Remember, the goal is better health outcomes with better care experience at lower cost. I don’t know anyone…Republican, Democrat or Independent…who is against this. 

As a result of this turmoil, many people are now considering a single payer system for the first time in our healthcare history. This would eliminate the problem of pre-existing conditions and differing policy costs because every citizen would be covered in the same huge pool of people.

This doesn’t mean socialized medicine or total government control of our healthcare system. This is the misperception that is hindering our efforts to even discuss this as an option.

Think about this: There is a single payer system in Canada. In Canada, it’s like Medicare for all, where Canada (like Medicare), is just paying all the bills, not providing the care. Actually, it is the U.S. government that provides more care than the Canadian government. The Veterans’ Administration is government-delivered care (is the VA socialized medicine?). Because of the single payer system, Canada spends about five cents on the dollar on insurance administration. In the U.S., we spend about  18 cents on the dollar on administrative costs and profit (which is actually lower than the previous 22 cents on the dollar the U.S. spent before the ACA). The difference between that 18 percent and five percent is billions of dollars! Many Americans believe this is pure waste.

A single payer system does not mean government provided healthcare. In all of the debates and discussions about the future of our healthcare system, Americans need to stay calm and listen to the dialogue about what single payer actually means.

There are pros and cons of all of the healthcare systems in the world. There is no perfect system…our goal as a nation should be to make our system better. We can make great progress even without a single payer system but we must come together to truly explore the evidence and our options.

We have a long road ahead of us to get to where we need to be with our healthcare system in this country. Staying educated and informed is vital to keeping a smart dialogue moving forward.

Thursday, August 3, 2017

Studying Defects to Learn and Improve at GBMC

I and other members of the senior team have really been impressed with what Kendrick Wiggins and Kevin Edwards and the materials management team have done to improve their work and make sure that our nursing units always have everything that they need to care for our patients. They have significantly reduced calls from nursing units for all types of supplies. Our nurses are spending much less time looking for supplies and calling to get things that they need that should already be present on the floor. At the same time Kendrick, Kevin and their colleagues have reduced the waste of having too much supply on the unit that can then expire and have to be discarded or reprocessed. Kendrick and Kevin have made their processes much more reliable.

This Tuesday morning on LDM rounds, Kendrick presented the learning on calls for missing linen from the day before. Kendrick had received a call that Unit 36 needed more linen. After directing the delivery of the needed things, he began to investigate. He asked the first why: Why did the unit run out of linen? He learned that the daily cart that replenishes the supply according to the predicted usage had not been delivered to the unit. He then asked the second why: Why had the cart not been delivered? And he learned that the vendor had not delivered the cart for that unit to GBMC. He then asked the third why: Why had the vendor not delivered the cart to GBMC to be brought to that unit? Kendrick called the vendor and found that they had not followed their standard delivery work. He asked them to problem solve and to create a final check of their delivery and to alert materials management when they did not deliver what was needed. The process that Kendrick followed is called the 5 Why process because it frequently takes asking the why question 5 times before you get to the fixable cause of the defect. Kendrick got all of the information that he needed in this case by asking just 3 why’s.

For LDM to be of value, the local leader must have a curiosity about how things are actually working. He or she must avoid the trap of assuming that they already “know” before going to study the actual event. On rounds when we hear people responding to the “what happened” question with “usually” or “sometimes” we know that the person has not actually investigated the event and done a 5 why’s. Tests of change that come from someone assuming what went wrong are not likely to be helpful. Engineers that are trying to improve something always start by going and watching the existing process. Only when they have observed and learned as much as they can about how a process fails do they test a change.

Another point that the leader must understand is to not stop the 5 why process too soon. On rounds we often hear “the chair alarm was not on.” The first ‘’Why was the chair alarm not on?” results in the answer, The nurse did not turn it on.” At this point we often hear that the leader has assumed education is the answer and that he or she is going to reeducate the nurse about the importance of turning on the chair alarm. If the leader had asked the second why, “Why didn’t the nurse turn on the chair alarm?” he or she may have gotten the answer that the nurse forgot. Very hard working and well trained people forget things from time to time, especially when they are under pressure and have many things to get done. Forgetfulness is better fixed by some kind of reminder in the moment (like a sign) or by some kind of constraint to make it impossible to get to the next step without completing the preceding step (you can’t order anything online until you have put in all of your credit card information) or by eliminating the step (like having the chair alarm reset itself). Leaders who stop the why process too soon don’t make as much improvement as those who learn as deeply as they can.

So the next time you see Kendrick, Kevin or anyone from the materials management team, thank them for being excellent learners and for helping us move closer to our vision faster!