Monday, January 22, 2018

What if it was your mother?

I have been reflecting this week about an incident that made it to the national news; a woman wearing a hospital gown was left by hospital personnel at a bus stop in our city. We don’t know all of the facts, but this has been reported not to be an isolated occurrence. Could this happen at GBMC?

Emergency departments are frequently under siege. I have been in healthcare for more than 30 years and through those years, I have seen how we frequently use the emergency department as the pathway of least resistance. Primary care office closed? Send the patient to the ED. Specialist unable or unwilling to deal with a problem in the moment? Send the patient to the ED. Hospital leaders not able to create a smooth system for admitting a stable patient to the hospital? Send the patient to the ED. No way to get an infusion done on the weekend? Send the patient to the ED. Mental health system is broken? Send the patient in crisis and his or her family to the ED. I have worked in the emergency department when it seemed that we were overwhelmed with many problems beyond our control. And of course when the emergency department is overcrowded, people wait and they get upset.

What if we assume for the sake of discussion that there is a patient for whom the emergency department has done its job of treating an acute problem? The staff believes it has done all it needs to do and the patient is not happy. The patient begins to act in a belligerent manner after being told that she is being discharged. Let’s also assume that the first reaction of the staff is to try and reason with the patient and calm her down. But what if the patient escalates her behavior and starts yelling and screaming and even threatening the staff? And what if this is the third angry patient of the evening who has gotten confrontational? Can you understand the urge of a physician, nurse, or security guard to have this patient leave the ED? Of course, you can.

And what if the patient in this not atypical situation was your mother? What should happen next? There is no perfect answer in this hypothetical situation, but of course, you want your mother treated with respect and kindness, even if she is out of control.

As the leader of the GBMC HealthCare System, it is my job to make sure that the ED staff members believe that we will not leave them on their own when they are confronted with problems beyond their ability to fix. They must also believe that people like me mean it when we say that everyone must be treated the way we want our own loved ones treated. But we can only hold people to this standard if we are ready to give them the help and support that they need to carry it out.

Could this happen at GBMC? It is my duty to assure that our incredibly hardworking physicians, nurses, advanced practitioners, other clinicians, and support staff teams have the equivalent of a safety button that they can push which will bring other leaders to help when they feel overwhelmed. I have shared this commentary with Dr. Jeff Sternlicht, medical director of our ED, and Monica Goetz, assistant nursing director, who oversee the emergency department, to have them assure our staff members that we will not leave them to deal with episodes like these on their own. What do you think?

Friday, January 12, 2018

What if it was Your Loved One in the Bed? The Absence of Alarm Fatigue in our MICU!

Back in July, I wrote a blog about “alarm fatigue.” In that blog I discussed my experience as a pediatric resident in a Neonatal Intensive Care Unit with alarms that constantly went off. We had become oblivious to them, unconsciously assuming that they were false alarms. In that blog I also commented that in highly reliable high-risk systems, like in an airplane cockpit, the alarms are minimized to those that are critical and that in those systems everyone responds immediately to them.

This morning I was on our Lean Daily Management walk in the MICU. Stacey Klingler, RN, the charge nurse, was presenting the Board accompanied by her manager, Rachel Ridgely, RN. Stacey was in mid-sentence explaining something to us when a patient alarm went off. Stacey immediately stopped and started to move to the patient’s room as did Rachel. I turned and looked towards the source of the alarm to see that other staff members were on the move as well. A staff member gave a thumb’s up “all clear” and everyone went back to what they were doing. Without missing a beat, Stacey finished her explanation. I was so proud of Stacey, Rachel and the entire team. If it is your loved one who is a patient in our ICU, you don’t have to worry about an alarm being ignored.

We thanked Stacey and Rachel for exhibiting the “preoccupation with failure” that all high reliability teams exhibit and for not assuming that the alarm was false or would be dealt with by someone else. Afterwards, I reflected on how quiet the unit had seemed before the alarm went off even though the unit was very full. We are making excellent progress in eliminating alarms that are not helpful and in presuming that all alarms are real until proven otherwise.

Drift

Rachel also told us that she was meeting with the leaders of our equipment hub. A few years ago we created the hub to remove clutter (and eliminate blocked corridors in the event of a fire) from our patient care units and also to have a system where we always knew where our equipment was. This way it could be moved quickly to where it was needed. At that time, we realized that hard-working, well-intentioned physicians and nurses were hoarding equipment because they were afraid that they would not get it back when they needed it…in other words, they knew that the system for removing equipment from and returning it to the units was unreliable.  Well, our system has worked pretty well since we created it but Rachel was seeing some drift away from our standard work. The physicians and nurses were beginning to hoard things again after one or two episodes where they had called for things that could not be found.

It is not a surprise that workers in unreliable systems begin to work around the system. They are not doing it for malicious reasons. They do it because they believe it will help them get their work done. But, as students of systems, we need to point out that when a system starts to fail and people stop following the design, it actually makes the system worse! Rachel is taking the correct step to meet with the hub leaders and ensure that we continue to follow our standard work to make sure that everything is in its place and moves according to need.

What do you think? Do you see other examples of drift away from standard work? Please comment below.

Friday, January 5, 2018

On Becoming a Learning Organization: 8 Employee Injuries

Today, I met with Simon Freyou, our new Director of Occupational Health, and discussed the GBMC HealthCare System’s progress in making our environment safer. Back in 2011, as we started becoming aware of the magnitude of this problem, we had as many as 40 injuries per month, many of which were lifting injuries, injuries due to slips on wet floors and sprains.


Last month we had “only” eight injuries. I use the quotes because if you are one of our eight colleagues who was injured, you deserve to be annoyed if the CEO says “only eight injuries.” I was telling Simon that the good news is that there were no sprains, strains, slips, and falls or chemical exposures this year.

How did this improvement occur? Was it by wishing and hoping? Or by paying better attention? I am sure that paying attention to wet floors or to how we lift patients did help; but most of the improvement came from studying the causes of the injuries, learning from them and making real changes. We now have “spill stations” throughout corridors where we often have spills or wet feet. We no longer place full trash bags on the floor, instead, we place them directly into carts because many contain liquid and may leak. We have placed lifting devices in most rooms or near where the care is delivered to aid in lifting patients.

With “only” eight injuries we still have work to do. All eight were in the category of potential blood-borne pathogen exposure- needle stick or other sharps injuries and splashes of body fluids. This category is probably the worst for our people. It is very unlikely that someone will get a serious pathogenic exposure from a sharps injury or a splash, but can you imagine going home after your work as a physician, nurse or other clinician and telling your spouse that you just converted to Hepatitis C positive because you stuck yourself with a needle? We owe it to our people to learn from every injury to make changes to eliminate injuries from our workplace. While we will never achieve perfection, we must always be working to reduce harm to our patients and our workforce. I am proud to report that we are becoming a learning organization and we are making progress. Let’s keep learning and testing changes on the basis of what we learn.