Friday, July 31, 2009

Finding our way forward...

All staff message:


Being named as Chief Executive Officer of CCRMC has been a humbling experience. I will sorely miss Jeff Smith who has been my friend and mentor since the beginning of my career here. He leaves big shoes to fill. We are also saying farewell to Miles Kramer, Program Chief of Psychiatry and Detention Services – we will miss him, his breadth of knowledge and his unique ease of leadership. We wish them the very best as they pursue new opportunities.

My immediate priority is to create a smooth transition for the Operations Team, so together we can continue to fulfill our mission to care for and improve the health of all people in Contra Costa County with special attention to those who are most vulnerable to health problems, without interruption. We are fortunate to already have a strong Operations Team in place– Larry Carlson, Jaspreet Benepal, Linda Bates, Shelly Whalon, John Stanger, Olivia Stringer, and Julie Kelley. I am happy to announce that I will be adding Lynnette Watts who is taking a lead role in creating a Patient and Family Partnership to dynamically include the voice of those we serve in an advisory capacity. She will report directly to me, signaling the significance of this nascent and very important partnership. In addition, I have asked Julie Kelley to take on a portion of Miles assignments as the Interim Director of Communications and Program Chief of Detention Mental Health and CCRMC Psychiatry.

Finally, I am happy to welcome Lance Mageno (Ma-hay-no) into the role of Chief Operations Officer effective September 1.

Lance comes to CCRMC with an impressive background including his most recent assignment as the Senior Program Associate for Quality at the California Health Care Safety Net Institute (SNI), where he has served as a quality improvement partner of the California Association of Public Hospitals and Health Systems (CAPH). Currently, Lance directs programs that improve the quality of care and services provided by California’s public hospitals and health systems with a focus on performance measurement and systems infrastructure, public reporting and transparency, pay-for-performance/value-based purchasing, patient loyalty and experience of care. Lance also holds credentials in Lean methodology – a healthcare management tool used as a system-wide strategy for eliminating waste, creating reliable and coordinated delivery systems, and increasing value to patients and their family members. Lance served for ten years at the University of Michigan Hospitals and Health Centers (UMHHC), where he helped build a world-class quality improvement program and was the Senior Administrative Manager of Quality Improvement. Before that, he worked as the Director of Patient and Family Relations, and Manager of Customer Satisfaction and Patient Experience, also at the University of Michigan Health System.

There has never been a more exciting time to work in health care nor a more challenging one. We are on the precipice of national health care reform while forced to work with a state budget that threatens medical coverage for the most vulnerable – those individuals served through our mission.

I look forward to working with all of you. I welcome and expect your feedback as I take on this challenging position. I do not fly solo and I want you to know that you don’t either.



Saturday, July 25, 2009

"She was at home" reflections from Maureen Bisognano on end-of-life care

Here you'll find a Boston Channel segment on end-of-life care where Maureen Bisognano, Executive Vice President and Chief Operating Officer, Institute for Healthcare Improvement (IHI), and Jim Conway Senior Vice President, Institute for Healthcare Improvement (IHI) appear.

Learn more about what Contra Costa Health Services is doing to enhance Palliative care and end-of-life care.

Wednesday, July 22, 2009

Anne Pato Chosen For The AHA's Patient Safety Leadership Fellowship!!

Message from Miles....

It is my honor to recognize the exceptional efforts of Anne Pato offer her my fondest congratulations on her selection!! One of a leader's proudest moments is to witness the growth and success of nearby talent. During a period where I desperately needed some help, a friend in personnel services mentioned to me a highly talented colleague of hers was looking for a change of pace and a growth opportunity. I was up to my ears in the alligators of a struggling system with some serious surplus of regulatory problems and a serious shortage of analytical horsepower. I interviewed Anne and despite her lack of experience in health care, her can-do attitude and wealth of real life experience made her just the sort of stabilizing presence I was looking for!

Anne joined the department of psychiatry and began helping with the myriad of quality and compliance challenges we were facing at the time. After about three weeks, I remember distinctly looking at my medical director after a meeting and saying, "Can you believe we were stupid enough to try and run this place without her?" We both had a laugh and marveled at our previous foolishness.

Since then, Anne has showed repeatedly her flexibility, work ethic and strength of character. This year when I was given the opportunity to appoint an internal fellow to assist the organization implement our LEAN health care grant, and lead innovation throughout the organization, Anne was the obvious choice. Some two years after I somehow convinced her to get involved with health care quality, I'm thrilled that she has been accepted into the Patient Safety Leadership Fellowship for the 2009-2010 program!!!

This fellowship is sponsored by the American Hospital Association and the National Patient Safety Foundation to develop the next generation of leaders in quality care and safe practice.

I have no doubt that the additional experience of the Patient Safety Leadership Fellowship will position Anne to take a leadership role in the coming years of rapid innovation and improvement. These are truly exciting times in American Health Care. The current financial crisis coupled with the tremendous attention in Washington makes this the time to innovate . . . I'm so proud that Contra Costa will have Anne to help us along the way. We as a leadership group will all soon know how foolish we were to try and run this place without her!

Sunday, July 19, 2009

"Status Quo Is Not an Option" President Obama Speaks on Health Reform

What we do matters, we must succeed. If not us, then who?

Take a look again- That's our Rep., Congressman George Miller, 7th District of California, Chairman of the House Education and Labor Committee, standing with him.

What we do matters.

"We are here to make another world" ~W. Edwards Deming

Saturday, July 18, 2009

Articles and Links on Lean: Is anybody else doing this?

Leading Lean: A Canadian Healthcare Leader's Guide (Fine, Golden, Hannam and Morra, 2009)
An article about the application of Lean in the Canadian Health System posted by Paul Levy President and CEO of Beth Israel Deaconess Medical Center (BIDMC) in Boston.

Here are some links to Paul's blog that highlight the application of Lean at BIDMC:

Clicking through Lean
Interns Learn Lean--They get it in two days!
Pig--Part 1
Pig--Part 2
Pig--Part 3

The rest is up to you. Hint...try typing the word "Gemba" into his blog's search engine.

In addition, don't pass up Tom Jackson's A3 Post. If you have time read his book Hoshin Kanri for the Lean Enterprise: Developing Competitive Capabilities and Managing Profit (2006)

Live feeds to the blogs can be found on my right side bar under "Blogs I Follow"

Additional Articles you may like:
Lean Thinking for the NHS (Jones and Mitchell, 2006)
Fixing Healthcare from the Inside, Today (Spear, 2005)


Igniting "A Campaign of Hope": Kaizen 3 Team Report Out with closing comments from Teresa Pasquini

Here are some highlights from this week's Kaizen 3 report out at CCRMC.

The session began with David Kahler, Treasurer of the National Alliance of Mental Illness of Contra Costa (NAMI), telling us to "sit back and buckle your seat belts." He showed us a preview of the upcoming NAMI newsletter, which will present ‘Lean’ and other innovations being implemented in our system. Included will be the story of the design and opening of the Patient and Family Healthcare Partnership Center, dedicated to improving the experience of care of patients and families. The center was opened this week on a test basis and will ramp up operations in the coming weeks with a plan to rapidly expand the hours and services.

The Kaizen team report had some very special moments as they described the development and testing of multiple streams of standard work and communication methods. In recent weeks, many have asked why we are implementing ‘Lean’ and does this mean we are no longer pursuing the Insititute for Healthcare Improvement (IHI) initiatives and the other innovation and improvement work? The Kaizen Team asked this question as well. We talked at some length about inclusion and how other teams are not only part of the overall improvement and innovation engine in our system, but that they along with the innovative work and vision of many others over several decades here at Contra Costa Health Services are what brought us to where we are today.

The Kaizen Team noted that the feedback loop concerning continuous improvement and the change necessary to accomplish it should be open and comprise all stakeholders, recognizing that we all have the same aim - To provide safe, effective, timely, efficient, patient-centered and equitable care to every patient every time.

The session ended with closing comments from Teresa Pasquini,
Contra Costa County Mental Health Commission, Vice Chair
NAMI Contra Costa Board Member
CPAW Stakeholder

Her closing comments demonstrate the power of partnership with patients and family members and, with her permission, they are posted below:

When a parent watches a law enforcement officer escort their mentally ill, adult child to an ambulance, and sees them strapped onto the gurney and driven away….there is a pain that is so deep, and a powerlessness that can take you to your knees. A Mother needs to trust that their child will be received with kindness and dignity on the other end. As the result of this Kaizen experience, I have that trust.

When I challenged this group to eliminate the trash talk, about the mentally ill patient and their family members, and to consider it the same as a racial slur, you heard me. When I suggested that we create a vision of hope, and introduce the concept of customer service into the care of our mentally ill and their families, you heard me. You not only heard me, but you validated what I was feeling and thanked me for sharing. It means everything to have our lived experience respected.

It should not be so difficult to help desperate people. The mental health system is characterized by complexities. But, through this Lean Process, you have all simplified it for our County patients, families, and the health care providers. This effort was huge and it will change lives.

This week, NAMI Contra Costa and the Contra Costa County Health System, forged a partnership, that will be very low cost, but has worth beyond measure. It is real and it must be nurtured and protected because lives are depending on us. I am deeply grateful to have taken this waste walk, to eliminate some of the muda that has kept us at odds.

I have spent hours volunteering, over the past three years, hoping to shine a light on a system that has been infected with hopelessness and despair. During these four days together, we have broken down barriers that will ignite a campaign of Hope in the Mental Health Community. It will be change making!

I will carry this experience into all forums, including the Mental Health Commission and the Consolidated Planning and Advisory Workgroup. This model must be replicated in the outpatient mental health system of Contra Costa County. Although we do not need a funding stream to be kind, we do need a funding stream to teach LEAN. So, I will be proposing, that we use a portion of the MHSA Innovation funds to support this concept in the Mental Health Division.

I have been thrilled and honored to work with each of you. These past five days have filled my uncongested heart with hope and pride. Thank you….

Teresa Pasquini
Contra Costa County Mental Health Commission, Vice Chair
NAMI Contra Costa Board Member
CPAW Stakeholder

Tuesday, July 14, 2009

"Customers, Cars and Culture" what can Contra Costa learn from GM?

What causes an organization to fail to see the signals for change?

GM emerges from Bankruptcy-
"Today marks the beginning of a new company, our company, one that will allow every single employee, including me, to return to the business of designing, building and selling the best vehicles in the world"
~Fritz Henderson, President and CEO of General Motors

We've heard the story of GM's fall including massive layoffs, bankruptcy,and a government bailout. Google(verb) GM's misfortune and you'll yield thousands of opinions about what brought the company to its knees, but there seem to be a few vital take-aways we can all consider to avoid a similar fate?

Make investments that directly lead to increased quality
In the 1980s, instead of strengthening it's pension fund or invest in development of best in class automobiles, GM spent 80 billion dollars on automation that did not correct GM's quality problems.

Respect the customer: Produce 'Zero-Defects'
Toyota who is known to be prooccupied in 'seeing' defects and immediately correcting them, focused on making cars in line with market and customer needs. GM vehicles were too often viewed as poorly designed and built and outdated.

Innovation and Risk-Taking
Toyota introduced environmentally friendly cars and moderately priced vehicles for emerging countries when they aimed to take the industry lead. GM, stuck to producing SUVs that helped it dominate in a low-oil-price era but caused trouble as fuel prices increased.

In a recent article Yu states "that among the many factors that contributed to GM's bankruptcy filing, its failure to innovate may have been the most harmful.Even without such problems as staggering debt and health and pension burdens, it was still almost impossible for GM to rise to its previous glory because of that lack of innovation.

Today's GM does not have the economy vehicles that could help it win back the mass market nor does it possess the new energy technology needed to lead the car industry in the future. A new GM reborn after the bankruptcy of the old GM, then, carries the hope that the automaker will emerge as a smaller but more competitive company.
" (Yu,2009)

Contra Costa: Using Lean to lead the way forward

The following is a bit winded and I am repeating some of what I said in "Going Lean" originally posted in April, but I thought it important to start at the beginning as we enter our final Kaizen Week of Wave 1 (CHF).

In November, the California Health Care Safety Net Institute (SNI)launched its Lean Core Measures Improvement Initiative. Funded by the California HealthCare Foundation, the program will introduce and spread the use of Lean as a management strategy to streamline processes and create a more patient-focused environment that supports timely delivery of treatment and other healthcare services with optimum quality at the least cost. CCRMC, along with three other public hospital systems was awarded a grant to bring 'Lean' thinking to our system.

Why Lean and why now?

"The future is already here…it’s just not evenly distributed yet." *

For many of us it's difficult to hear our system described as "financially unsustainable," but that's how our system was described at a recent board meeting. This shouldn't surprise any of us. As a government owned and operated system, we are in fact a reflection of the US Health Care system. I understand many would argue that industry is a better description than system. However you prefer to describe it, we do offer a glimpse of what the nation faces.

Currently health care makes up about 17% of the GDP and is climbing at a steady and very unsustainable rate. In America, we hear daily debates about bailouts, stimulus packages and health reform. Although the solutions are still in the development phase it is clear we must change course nationally and it is just as clear we must do the same here at the local level. Lean Management offers a systematic way of improving efficiency while improving not compromising quality.

Where are we now?

I can't believe we have made it to the halfway point already. It has been an amazing journey up to this point and we look ahead with excitement.

We are heading into our last Kaizen event related to CHF. This process has been challenging and rewarding. Our work has taken us to all areas of our integrated system. We began with a three day intensive of 25 executives and leaders throughout the system to learn the about Lean and the Toyota Way.

We followed our Lean Executive Session with a Value Stream Mapping event involving 16members of our system. We then engaged in a series of 3 Kaizen events each one week long with approximately 20 members from CCHS and the community. These events have taken our teams from the patients home through our system and back to the community.

We have learned that patients do not discharge from our care but that they are transitioning through an experience and out of respect for those we serve we are striving to understand the experience of care patients receive from us and provide the highest value for the patient.

Some signs of change...

• We now have a group of fellows who have participated in every step of the process and are an integral component of the system of Continuous Improvement for CCHS. -the fellows speak throughout the system and in the community and are requested on a regular basis.

• There are 2 patients/family members participating in this weeks Kaizen event.

• We are conducting multidisciplinary rounds on the inpatient medicine unit and including patients and families in the process. These are very well attended.

• Piloted a CHF nurse in one outpatient setting and are spreading to a second clinic site.

• Use of the A3 reporting process and have developed a revised CHF dashboard with key measures. This measurement methodology is now being considered for spread to all of our projects in the Performance Improvement Portfolio (PIC)

• Redesigned multiple processes and forms to reflect standard work based on best known evidence and patients preference.

In times of great uncertainty Lean lends a sense-making approach to unearthing the hidden capacity within our system. Buried in wasteful processes lies desperately needed resources we will need as we face even more challenges in the coming months and perhaps even years. The work of our Kaizen teams has resulted in a greater understanding of the power of quality, the power of a deep respect for our customers, and the power of Lean.

In summary, in a time many systems are feeling helpless to determine their own destiny Lean has unleashed the true creativity and might that lies with our system itself.

I am grateful to SNI, The California Healthcare Foundation and The California Association of Public Hospitals(CAPH) for supporting our system on this transformational journey. Mike Rona, Pattie Crome and Tom Jackson continue to impress me week after week with their expertise in the application of Lean and it's philosophy as well as their relentless hands-on approach to the work. If you get the chance to participate in a Kaizen I warn you now, dress comfortably because your going to Gemba!

It is at this important milestone that I also want to acknowledge all of you for actually taking us on this journey. There have been many twists and turns since we began our intentional efforts toward critical introspection and system transformation with System Redesign. Our results thus far are a direct reflection of the skill and spirit in our system. I am thankful for your creativity, your skill and your dedication to serving our community. I am deeply moved by the changes I see daily as I walk through the halls of the medical center.

Please join us in our final report out of Kaizen Wave One Results on Friday July 17th at 10:00 AM at CCRMC Building One, Conference Room One.

More on Kaizen Wave 2 very soon...


Tuesday, July 7, 2009

IOM releases Report on America's Uninsured Crisis

Not just for the Safety Net-
Please take the time to read this report.

It will take effort from us all to find the nation's way "Out of The Crisis."

America's Uninsured Crisis: Consequences for
Health and Health Care Committee on Health Insurance Status and Its
Consequences, Institute of Medicine

Friday, July 3, 2009

Kaizen 2: A message from Dr. Hinman

I received this letter written by Dr Priscilla Hinman. She describes her experience at the June Kaizen. With her permission I am posting it below.

For those of you who would like to learn more about Lean and CCHS, we have scheduled a two hour Lean/Kaizen introduction to Kaizen 3 for Monday July 13th at 11:00 AM at CCRMC in Building One, Conference Room One.

The report-out for Kaizen 3 is scheduled for Friday July 17th at 10:00 AM at CCRMC in Building One, Conference Room One.

These meetings are open to everyone. The introduction and report-outs for each kaizen event are also video-taped and placed on CCHS-iSite.

Be well,

Below is Dr Hinman's letter:

"I wanted to fill everyone in on this process that many of us just participated in. The process started some time ago in an effort to reduce CHF re-admissions. I believe the strongest driver of it is the specter of financial penalties for CHF re-admissions. There was a kaizen a couple of months ago which initiated changes, the most important of which from Am Care perspective was a CHF nurse case manager in Martinez. They also focused on coordinated patient education starting with admission and continuing every step of the hospitalization.

Our June group took up where they stopped, completing the transition from in-patient care to out-patient care. The first thing we did was a "waste walk". We went to the clinic and the inpatient floors and observed processes. We identified various kind of waste, from excessive walking, over inventory, over processing, etc. We then divided into 4 teams of 3 -4 people, in patient vs. Am Care (RHC represented Am Care) and develop ideas that came from the Waste Walk.

There was a multidisciplinary team which instituted multi-disciplinary rounds in the hospital, to initiate discharge planning at inception of admission, including social services, pharmacy, nursing, medicine. There was a Pharmacy/Meds team to help with drug interactions, etc. But also to help resolve insurance, formulary issues. There were out patient groups: Linda (Richmond clinic charge nurse) was part of hospital to home transition, and worked mainly on replicating the CHF nurse role for RHC and Pittsburg. The CHF nurse will get the patient information and follow up with the patient within 48 hrs of discharge, help the patient with pharmacy problems and transportation, etc.

Our out-patient groups produced a patient educator format for the CHF nurse, and patient instructions which divide clinical symptoms up into Green, Yellow, Red (like the asthma action plan form), and a clinic intake and discharge form for nursing. The nurse on intake will fill out the relevant data with expanded questions about the chief complaint and symptoms. The provider after the visit will check of boxes ordering any necessary lab, x-ray, and patient ed or dietician referrals, and can request an emphasis on home weighing, salt intake, activity, and contact instructions for Yellow Zone/Red zone. An LVN or RN will do the discharge.

Follow up appointments within AmCare were said to be fixed in the last Kaizen (May), Supposedly it is working, and I intend to follow this up with the Martinez FMC folks.

My role focused on the actual provider visit, and transfer of medical management information from in-patient to the FNP or MD seeing the patient post d/c. After watching a provider in our clinic spend 12 minutes with a DMC discharge patient, and 26 minutes with Up To Date, and calling consultants to determine a management plan appropriate to that particular patient, the problem was elucidated. With the help of Mitch Applegate I came up with the following remedy, at least for CCRMC: The new CHF Nurse referral form filled out by discharging resident was modified anew to contain specific reminders of information for the discharging resident to include in the discharge summary.

I won't inflict all the details on you, but questions are welcome. It was a very worthwhile process, or will be if this particular method continues to roll out so all of us can participate at some point, this being the Continuous Quality Improvement aspect. We were empowered/encouraged to make actual changes while learning to work the method and the nursing part is to be rolled out Monday. Administrators and relevant staff such as patient educators came to meet with us on short notice when we had to work out a process or remove an obstacle, and in fact were very helpful. I think most of us managed to put aside our occupational cynicism (cultural (old) adaptation) to try to come up with good processes.

I did have an epiphany along the way: it felt uncomfortable at times because the provider role became quite narrow and specialized. We often think of ourselves as the center of a patient's care. However, in a system with "good value flow", nursing roles expand, and Social Service and pharmacy roles develop. Everyone plays a critical part. What is left is the actual clinical encounter. I then felt a sense of relief at the very thought of no longer having to play social worker, nurse, financial counselor, and pharmacist during the FM visit. And then I realized a provider freed from these roles could then focus on clinical issues. Boy howdy

I then became very interested in the occurrence of hospital bedside rounding, and aware that important clinical conversations take place, as collective wisdom develops into a patient specific therapeutic plan. We in the clinic often don't benefit from those discussions as we take over the management of the patient, but this is very complex information to transmit. So, although getting the dry weight, discharge weight, EF, etc., are really important, what I also want to know about are the details, the actual twists and turns of the hospital course: meds tried and why d/c'd, complications, how associated conditions such as CKD affect the management, why the patient was re-admitted and the plan to remedy the defect causing the re-admission.

The next Kaizen will be in July, and Jan will be a part of it. Although these improvements affect the care of a very limited subset of patients, improving care of CHF patients at least shows us what is possible. Please be supportive of the nurses as they implement these new processes. One thing that was emphasized over and over is that it is not about blame or assigning fault. 85-90% of the time it is a system problem that when fixed makes the work simpler and more productive. This requires that we give and receive feedback, none defensively, so the defects can be eliminated for the benefit of the patient."

American College of Physicians elects Rashad Massoud to the Fellowship

Bravo Rashad!

From URC/CHS News Website:

Dr. M. Rashad Massoud Elected to Fellowship of the American College of Physicians

The Massoud family at the convocation ceremony: Rashad, Karma, Fares, and Rami
April 23, 2009: University Research Co., LLC (URC) and the USAID Health Care Improvement Project (HCI) are pleased to announce that Dr. M. Rashad Massoud is now a Fellow of the American College of Physicians (FACP).

Fellows in the American College of Physicians (ACP) are a select group of doctors dedicated to continuing education in medical practice, teaching, or research. The honorary designation is given to recognize ongoing individual service and contributions to the practice of medicine. Direct election to Fellowship without prior ACP Membership is a singular honor conferred upon only a few outstanding physicians each year.

Dr. Massoud noted that the ACP’s recognition holds special meaning for him: “I feel truly honored to be recognized by the ACP in this way, and I am thrilled to see the value that the ACP is placing on quality improvement. This is also recognition for many colleagues around the world who are working to improve health care quality.”

M. Rashad Massoud, MD, MPH, FACP, a physician internist and an internationally recognized leader in improving health care, is Senior Vice President for the Quality and Performance Institute at URC, in Bethesda, MD, USA, and Director of the USAID Health Care Improvement Project—a centrally procured global contract currently active in 21 countries. Dr. Massoud served as Senior Vice President at the Institute for Healthcare Improvement (IHI) in Cambridge, MA, where he oversaw IHI’s Strategic Partnerships—the key customers working on innovation, transformation and large-scale spread. Before that, he led several URC improvement efforts around the globe including working on developing the World Health Organization’s strategy for design and scale-up of antiretroviral therapy to meet the 3x5 target and large scale health care improvement in the Russian Federation.

He also founded and led the Palestinian health care quality improvement effort. He was a founding member and chaired the multi-country Quality Management Program for Health Care Organizations in the Middle East and North Africa (QMP-MENA). He worked as a Medical Officer with the United Nations Relief and Works Agency. Dr. Massoud has also consulted for and collaborated with several NGOs, KPMG, UNICEF, the World Bank, and WHO.

Rashad is married to Karma Shaath, an artist; they have two boys. Fares, ten, and Rami, five and a half, who are both bundles of energy.