Wednesday, December 31, 2008

2009: Open Letter to Medical Staff Department Heads

As we enter this new year I resume my former role of Chief Medical Officer (CMO) which I had from 1987-2000.

(Trivia: What do I have in common with President Cleveland?)

In this role I will be the point person for staffing, contracting and union negotiations. I will work under the direction of Dr. Smith and collaboratively with him and with Dianne Dunn Bowie.

2009 is going to be a tough year for money. Nevertheless, I plan during the month of January to meet with each of you to better understand your current state staffing, vacancies and needs. I will then assemble this into one document. Jeff, Dianne and I will discuss it and will make decisions about how to prioritize and deploy the few vacant positions we have, and if, when and how to obtain additional ones.

Aina Wirthlin will be contacting each of you to set up an individual one hour meeting with me. Please bring written info to describe your current staffing and data to support any requests for additions. (Deming wrote: "In God I trust. Everyone else bring data.")

More that you can expect in 2009:

In addition, Jeff and I will be working to formalize the contracting structure and process to create more predictable and transparent outcomes. Any suggestions you have regarding this would be appreciated.

I expect all clinical department heads will be involved in issues regarding the continued need, contraction, or expansion of certain contract specialties. I do not plan to meet with any contractor without having the department head in the loop.

It is likely that I will desire standing meetings with each medical staff department head individually either monthly or quarterly to maintain open channels of communications and to create an established forum for constant engagement regarding physician services. We will talk more about this at our January meeting.

Given the severe budget shortfalls that will face the county (both state and local budget issues) we have no choice but to scrutinize exactly how we assign physicians. Our principle assignments as stewards of the public's money and health are to provide quality and access. In order to do so this year we may have to challenge long held paradigms.

And finally and most important: I expect each of you to be the "local experts" for your specialties. But I expect you to transcend that allegiance to be advocates for the system as a whole and the populations that we serve. I have utmost confidence that you will.

We can make lemonade.

Steven Tremain, M.D., A.B.F.P, F.A.C.P.E.
Chief Medical Officer & Chief Medical Information Officer

Monday, December 22, 2008

Where is System Redesign?

For my Dad on his birthday…

On June 9, 2005 the first annual Hospital Redesign Summit was held in San Diego. How much more perfect could this get, since I was charged with helping lead System Redesign? Like everyone else, I wasn't quite sure what that meant. I arrived late that night to San Diego after a very full week of long hours in the hospital dealing with what seemed to be an expanding list of issues. My week was not consumed by the halls of Contra Costa but spent in other hospitals sitting at the bedside of my father who had fallen quite ill. After what seemed to be weeks of sleepless nights, my father was transferred to a large tertiary medical center. It was a welcome reprieve as the drips and lines seemed to be increasing with each day. With him safely tucked in at one of the finest centers in the world, I could now get on a plane to learn more about “Redesign.” To be honest, I was tired and needed a break.

My day started off with a video from Sorrel King, mother of Josie. To this day I will never forget her words, the words of a mother who lost her child to a chain of errors and system failures.
~Josie King Story~
She challenged hospitals to think about having a team that was available to bring care quickly to people who were deteriorating before they went into a cardiac or respiratory arrest. She called it a medical emergency team or rapid response team.

I went from session to session and could not escape the realization that our system was broken. It wasn’t about the hospital, but rather the whole system of health. I also found others who were trying to learn ways to improve their systems through ‘redesign.’ I came home energized and full of ideas about improvement methods and reliability, and concepts like ‘spread.’ I also came home to find my father sicker than when I had left.

The days following the Summit were filled with ideas scribbled on paper while sitting at my father’s bedside. I tried to keep up as the teams rounded on him. It seemed so odd that after all the time I had spent in a hospital, I hadn't a clue how it all worked. I couldn't figure out who was in charge of which part of his body. I couldn't keep up with his deteriorating health and growing amount of health care intervention. It was truly a mess but in just a few more days he was discharged to my home for what would surely be a very long but full recovery. It was four days later I had come back to work for a meeting about the digital diagnostic imaging system (PACS) when the call came in about my Dad. It wasn't good news…

As I drove home that night from the mortuary I wondered. Did he experience any harm due to error? He took high-risk medication, what if it was the insulin? Was it a postoperative complication or infection? Was it sepsis? I wondered what might have happened if there were some mechanism like the rapid response team that Sorrell King had described. I wondered about the people we serve.

When I returned to work, the System Redesign Team approached the most senior leadership and the Performance Improvement Committee with a request to endorse and actively participate in the IHI 100k Lives Campaign. In the months to follow, leaders all over the system stepped forward. Tools and how-to-guides were brought to life by teams that had already been working in many aspects of the 100k Lives Campaign interventions. We heard stories of steady improvements that began to take the form of breakthrough improvement. The energy was palpable.

As I read through the email responses to my ‘small test’ in communication and was stopped in the halls this last week, I realized that many people are wondering, "What ever happened to System Redesign?" It's a reasonable question, and it points to how redesign elements have been integrated into the current system. System Redesign was never occurring in a conference room but rather in improvement teams on your unit. 'System Redesign' wasn't a committee making sweeping changes and impersonal decisions that shaped the experience of the individuals we serve: you were, one decision at a time, one experience at a time, one patient at a time. The team located tools from experts to share with you. Tools that others across the nation had found, if used reliably, made it easier to do the right thing for your patients.

So where is System Redesign now? System Redesign has been diffused into structures such as Safety and Performance Improvement. Under the leadership of Dr. Tremain and many others, the County Board of Supervisors is learning more about safety and improvement and hearing stories from many of you about improvement efforts in your area. Redesign can also be found on every unit in the system. I have walked the units and found improvement emerging without exception in every site. I found a number of people who said you didn't need more resources but you needed to find different ways to do the right thing, a viewpoint supported by Steve Spear this last week in the New York Times (More for more? Spear, S.), where he notes that in health care, more is not necessarily better. Not necessarily more, but different, that is redesign.
Recently, I was on the fourth floor and a rapid response was called. I watched as the team delivered what appeared to be a seamless response that resulted in a rapid transition to critical care. I thought of his family. A few days later, I learned that the man had been discharged home. I thought of my Dad.

Tuesday, December 16, 2008

There is no wizard........

No, Dorothy, there is no wizard. We can't click our heels together and make patient care safer, and we can't click our heels together to balance the budget. Patient Safety, Quality Improvement, and all Financial Stewardship require hard work....every day.

I bundle these together for many reasons.

First, they are indeed intricately connected. We know that unsafe, ineffective, inefficient, or poorly timed care is not just bad care, it is wasteful care. Many of us grew up in the era where we were constantly told that more care = better care. We know better now. Better care = better care, and better care is often less care, especially if the "more care" comes from trying to get it right a second time.

Second, I recently was at IHI where Dr. Berwick eloquently talked about the two choices we all fight to continue to make care safer over the next twenty years, or to give up because it is too hard and because the returns on our hard work and emotional committment are often too elusive. And then I returned to Contra Costa and California where we are faced with astronomical budget deficits. We will need to answer Dr. Berwick's question within this economic context.

So what's my answer? Giving up is not an option. We will work together to continue to improve the quality of the care we give. It will not be easy, and there will be tough choices, but giving up is not one of them.

And clicking our ruby slippers is not an option either.

Monday, December 15, 2008

Hungry For Bread

The world is a challenging place right now--financial recession, upside down mortgages, high unemployment, dramatic inequities, wars, terrorism, global warming, etc. etc.

Sometimes it may seem overwhelming, maybe even an impossible situation.

How do we deal with all of this...and the need to improve health care, maintain safety in health care, and simply do our jobs in an efficient and effective manner?

That is what Dr. Berwick was talking about when he talked about "words" being the "bread" for a hungry person. As bread brings nourishment to our bodies, meaningful words bring purpose to our work and our mission.

Those words may be somewhat different for everyone, but they will almost always hold a few universal truths, such as....

The work we all do improves the world one step at a time! Many steps join together to make a journey. And, every journey toward quality and caring moves someone to a better place.

I think Dr. Berwick was simply saying that the strength to move to a better place is built by simple steps forward in the face of great challenge.

Good job, CCRMC and HC employees and staff!!!!


Sprint to the Summit

Greetings and Welcome
Just Back from The Institute for Healthcare Improvements 20th National Forum.

It was the twentieth anniversary of IHI. Once again the room was filled with a renewed hope for the future. In his plenary speech Don Berwick called for action to seek what is possible to achieve health for all.
He read two letters to his daughter Jessica who is training to be a doctor just like many of you who are training to serve as the healers of tomorrow. The letters are to be opened on the fortieth anniversary, in twenty more years.

One letter was filled with words of defeat and an apology to Jessica for letting her down. The letter said it was “too hard” to make things better. It was filled with the realities of the barriers we face every day while trying to do the right thing. It was a sad reminder of how easy it would be to turn away from what is possible and focus on mastering the current system.

The second letter was one of hope and told a story of vision, hard work, and perseverance. He told Jessica “it wasn’t easy…we almost lost hope that would have been easy to do…but we didn’t turn around, we went faster”. Letter to Jessica

He introduced the Improvement Map IHI Improvement Map and Dr Atul Gawande joined Dr Berwick asking us to “sprint”. Dr Gawande asked that hospitals try using the World Health Organization’s Surgical Checklist in the next 90 days and provide feedback. What a great concept to sprint toward a safer experience for the people we serve!
Three new interventions were added to the already twelve interventions in the five million lives campaign.

· WHO Surgical Safety Checklist
· Prevent Catheter-Associated Urinary Tract Infections
· Link Quality and Financial Management: Strategies to Engage the Chief Financial Officer and Provide Value for Patients

As I assume my new role as the Chief Operations Officer I ask that you join me in the ‘sprint’, to go faster toward improvement and transformation. When we are told we can’t be the best and create a system that will allow the young healers of tomorrow to fulfill our mission, we must understand that fear and status quo drive that belief. Join me in envisioning safe, effective, efficient, timely, patient centered and equitable health care for everyone. Together we can find ways to move from great ideas to action. Let us find new ways to reach those in the most need. Please share with me your thoughts on how we can best serve our community and how we can contribute and collaborate with our partners across the nation and around the world to ensure no one is left behind.

I look forward to the days ahead.


“People are hungry you know and one good word is bread for a thousand. We baked the bread Jessica. You’re welcome. Here’s one good word, Joy. Love Dad”
- Don Berwick. IHI 20th National Forum. Nashville Tennessee. December10, 2008