Designing Our Systems

Last week, I had the great pleasure of attending the report out session for our team that was redesigning our discharge process. Many patients come to us needing inpatient care. Frequently, we don't have a bed ready for them when they need it so.........they wait. Sometimes, we actually do have a bed for them, but it hasn't been cleaned yet. We knew that our process for getting a discharged patient on her way and then cleaning the bed for the next patient was not well designed. We also knew that it had too many steps......but we didn't know how many.


The wonderful team in the photo above found that the process had 109 steps!

The Team realized that the system was never really designed in the first place so there were many steps that were not necessary or were being done more than once. Until the Team got all the steps written down, we did not know what the whole process looked like. The Team then set out to remove all of the waste.....the steps that didn't help get the patient on his or her way and then get the room ready for the next patient. The Team redesigned a process that had about 40 fewer steps! They are now testing their changed system to make sure that it works well and then we will roll it out to the whole hospital.

We are now using the science of continuous improvement as the way we move GBMC forward toward our goal of being the healthcare organization that treats everyone, every time the way we want our own loved ones treated. Since we don't want our own loved ones to wait for a bed......no one should wait for a bed.

This science, whose fathers included W. Edwards Deming http://en.wikipedia.org/wiki/W._Edwards_Deming, and Walter Shewhart http://en.wikipedia.org/wiki/Walter_Shewhart, has four main components.

The first is a focus on the person you are serving. In our case, we are serving patients. We must make sure that our work stems from what our patients need and want and to be careful not to focus on our own needs and wants.

The second component is the notion of design. High performing organizations don't get closer to perfection by relying on hard work and good intentions alone. Every system is perfectly designed to get exactly the results that it gets. If our patients are waiting, exhorting our people to move faster is not very smart. Our Team pictured above knows this, so they redesigned the existing system to reduce waiting.

The third component of continuous improvement is the use of measurement. Measurement provides the answer to the question: "How will we know if our change is an improvement?" The team is measuring the time from when a discharge order is written until the room is ready for the next patient. They plan to display the data on our inpatient units so that our people can see how we are doing.

The fourth component is teamwork. The hospital is a complex set of interconnected parts with many people doing specialized roles......just like the Ravens. Imagine what would happen if the Ravens tried to win as individuals, without the planning, practice, camaraderie, and collaboration that is required to win. We need the same in our healthcare organization.

The last component is empowerment. In winning organizations, people come to work saying "Its interesting how well we did yesterday....how might we do it better today". They don't wait for the boss to tell them what or how to change...they see generating meaningful change as part of their job.

Our teams are using Lean tools in their improvement work. The tools help us to get the waste out and to make things better for us and those we are serving....our patients!

I am very proud of our discharge process design team! We should all thank them for making things better.

Verbal Orders

I have been on airplanes a lot since I came to Baltimore for my first interview at GBMC this spring and a few times recently to see my family (my college-age children have summer jobs in Massachusetts). When I fly, I don't worry about my safety. This was not always the case.

I am old enough to remember when NBC had a correspondent, Robert Hagar, who only reported on airline crashes when they used to happen about 4 or 5 times a year in the US. Mr. Hagar retired and NBC eliminated the position (I think) because it is now a rare event that someone dies in a commercial airplane. What happened to make airline travel safer than it used to be?

There are many reasons why its safer to fly now than before but one big reason is that the Federal Aviation Administration has had pilots and air traffic controllers designing the communication system for safety. Pilots and air traffic controllers are humans....and humans make errors.

Even though both groups are very smart, have had many hours of training, and want all planes to land safely, in the past sometimes they would miscommunicate and cause catastrophes. Their communication system was reliable but not reliable enough. Very rarely, a pilot would hear "land on runway 1 Right" when the command was actually being given to a different airplane. The pilots and air traffic controllers realized that a system that was 99%+ reliable wasn't reliable enough if someone they loved was on the plane (see my first blog posting "What if it was your daughter?" http://ahealthydialogue.blogspot.com/2010/07/what-if-it-was-your-daughter.html).

All reliability means is "What should happen....happens and what should not happen.....doesn't. So, pilots and air traffic controllers now use a designed communication system called hear-back. The air traffic controller announces herself to the pilot and gives a command like "USAir 1006 ascend to 30,000 feet over" and the pilot announces himself and then repeats the command as he has heard it, like "Roger, USAir 1006 ascending to 30,000 feet, over". In this way, the air traffic controller "hears back" the precise instruction that she has given the pilot to assure that he has received the message correctly.

This week, I was with our wonderful planning team for the implementation of CPOE, Computerized Provider Order Entry. The team was discussing our on-going challenge of making sure that when a doctor gives a nurse or therapist a verbal order, that the order that the nurse "hears" is the order that the doctor intended to give. The computer system will give the physician the ability to directly put orders into the system from anywhere that he or she can get an internet connection. This will eliminate the handoff that exists in the paper world where a written order must be transcribed by a clerk. However, there will still be occasions like in an emergency, or when the physician is in the middle of a procedure, or when the physician is speaking with a nurse on the phone and is not near an internet connection, when verbal orders will be required. So the team was discussing our use of read-back where the nurse who has entered the order will read it back to the physician to assure that the correct care is delivered to the patient.

Medical care is a high risk endeavor just like commercial aviation. Its great to see us learning tools and techniques from another industry to make our care safer. If it was your daughter who was the patient, you would expect us to be doing this to protect her.

Collaborators in Care

This week, I had the great experience of having lunch with members of our Geriatrics/Palliative Care/Hospice team. Their work is inspiring to me as we figure out how to give outstanding care to very sick and often elderly patients in the last phase of their lives. You may know that our hospice company Gilchrist Hospice, recently had a Joint Commission survey and had no findings of deficiency! In my experience, surveyors always find some areas for improvement even if they are minor. Gilchrist got a perfect score. I am very proud of them.

Yesterday, I was given a tour of Sheppard Pratt Hospital http://www.sheppardpratt.org/ by the system's president, Dr. Steve Sharfstein. Dr. Sharfstein was very kind and he took me on a tour of the facility and educated me about the rich history of his hospital. I will spend more time on this blog in the future talking about care for our patients with mental illness, but it is a wonderful gift to have such a marvelous organization as our "sister hospital" and colleagues on the hill.