Wednesday, April 28, 2010

Wednesday, April 21, 2010

First, do no harm: Then, measure to be sure.

The President of the Medical Staff, Dr. Keith White and I have decided to share a conversation we had related to measuring harm and our use of the IHI Global Trigger Tool (GTT). We've been testing its use at CCRMC for almost two years.

The context: I had just left a Medical Staff Leadership meeting where we had a spirited discussion around measuring harm using the GTT. Following the meeting I sent out some information on the GTT. Below is the exchange of email and ideas between Dr. White and myself further exploring the issue. We're sharing this here because we're assuming we aren't the only Hospital CEO and Medical Staff President having this sort of conversation.
If nothing else, you may find it amusing.
Dr. White:
Thanks for the articles Anna. I read them all. Good discussion with the Medical Staff yesterday. I'm intrigued by the Trigger Tool and I'd like to use it, but I'm not certain that it directs us to the truth. Doctors have gone down all sorts of blind alleys in the past and we're skeptical (that can be a good thing).

• Is there evidence that the Trigger Tools are reproducible from month to month at a particular hospital? One would assume that problems would continue to follow the same trends. (Dr. Bliss brought that up)
• Is there any published evidence that using Tools helped bring about improvement? Can you demonstrate that they are practically useful?
• What grade of evidence would you give the Tool if you used Oxford Evidence-Based Medicine or USPTF standards? http://www.dbpeds.org/articles/detail.cfm?TextID=672? These are sacred to Doctors.
Thanks for the info. I'll see you at the Academy tomorrow.

Anna:
Hi Keith,
Great questions! I don't claim to be a safety expert like many of my esteemed colleagues but I will give this a go and answer generally and to the best of my ability.

Question 1. Is there evidence that the Trigger Tools are reproducible from month to month at a particular hospital? One would assume that problems would continue to follow the same trends.

Reproduction speaks to inter-rater reliability or repeatability. As you know several factors can effect repeatability. These include: power, effect-size, sample size etc. There is indication in our own data that we are seeing stability in our data (as evidenced by the graphic I provided yesterday). This type of display of data shows random variation, aka no significant trend in increased number of incidence of harm, but no improvement either. Additionally, we know some problems may not be detectable without trending their occurrence if the volume is very low, as is the case with perinatal events which occur at a very low rate. This makes detection tools with a higher degree of sensitivity even more important to identify areas in need of improvement. This is a form of "active surveillance" not to be confused with process measurement that monitors and drives interventions aimed at improving.

How do harm and mortality come into play at the oversight level for your department? What tools are used now and when are trends analyzed?

Question 2. Is there any published evidence that using Tools helped bring about improvement? Can you demonstrate that they are practically useful?

Surveillance in and of itself does not drive improvement, people do. People need to measure in order to understand whether the intervention is leading to an improvement. I have a copy of The Improvement Guide in my office and am happy to share that with you. It’s pretty much Deming packaged up for healthcare and a very easy read. It has lots of story!


Question 3. What grade of evidence would you give the Tool if you used Oxford Evidence-Based Medicine or USPTF standards? http://www.dbpeds.org/articles/detail.cfm?TextID=672? These are sacred to Doctors.

The levels of evidence tables are applied in the broadest sense to research and unfortunately improvement work has been left out of this loop so often. The Squire Guidelines, which are becoming more widely accepted to use for publication may assist those engaged in improvement better ready their studies. I think research and academia will get there in a decade or two and recognize quality improvement as legitimate science!(of course I'm kidding, but you get my point)

As I said yesterday, there is a dearth of evidence related to the use of Trigger Tools beyond those that are process specific- for example there are several systematic reviews with homogeneity (meta-analysis) of randomized control trials (RCTs) that study the use of Trigger Tool methodology related to medication adverse event surveillance. This may have been driven by increased use of computerized physician order entry (CPOE) and the cry for decision support and may only become more compelling as we are all held to the meaningful use requirements.

The use of Trigger Tools for adverse drug event (ADE) surveillance is standard practice in pharmacies nationwide and in ours. There is also strong evidence behind individual triggers and I would suggest a literature search per trigger could best yield answers to your specific questions as your questions can be applied to a wide swath of literature.

Thanks for your interest.
Hope this helps…
Anna


Dr. White:
Hi Anna,
Thanks for the thoughtful reply. I understand the issues and want to read more. I'm curious to use the Global Trigger Tool (GTT) and trying to anticipate medical staff objections.

• "Harm" is a loaded word. We've taken an oath not to cause any, and some of the kinds described aren't reducible. This is a whole different uncomfortable kind of review
• I understand because of sample sizes that we might not get coherent results. Wandering causes of harm might be very frustrating.
• Some will argue that requiring capital "E" evidence for medical research and small "e" evidence for improvement is playing with the rules (did IHI really prevent 5 Million cases of harm?).
As you point out, we don't really have broad oversight of harm and death. Let's give it a try. Seismology is a lovely science even though it doesn't prevent earthquakes!
See you tomorrow
Keith

Anna:
Hi Keith,

I'm not suggesting we accept small "e," evidence. I am suggesting there is a dearth of evidence as of yet. I believe more will come and certainly adoption of electronic medical records will accelerate such monitoring and reporting.

The GTT is a measurement instrument with an accompanying sampling strategy, not an intervention. Measurement does not "prevent," it attempts to quantify or describe as does story.

Wandering causes should not be responded to unless they declare themselves as more than random variation or even a one-off special cause variation (one data point exceeding three standard deviations from the mean). I agree lack of consistent sampling and trending has led to many change campaigns (tampering) that were likely unwarranted.

I’m not certain of the The 5 Million Lives Campaign count. I do know we lack national standards around harm measurement on any consistent basis. The complexity of that sort of count exceeds my abilities. However, I tend to think more than 5 million incidents of harm were prevented, but my sense doesn't count as "E" evidence does it? We do have reporting requirements and tools we consistently use to rate the severity of an event such as The National Coordinating Council for Medication Error Reporting and Prevention Index (NCC MERP). For harm it seems to get a bit more hazy. It was much easier to look at mortality in the 100k lives campaign because everyone counts that in some manner. Harm is much more elusive. Only the highest performers take on such a task.

I'm with you Keith. Let's proceed carefully and with a critical eye.
See you tomorrow. You can let me know how my presentation went.

Anna

Loaves and fishes, the commons and Hoshin Kanri

I wanted to draw your attention to a recent blog post Loaves and fishes and hoshin kanri written by our esteemed colleague Tom Jackson.

In his discussion of Hoshin Kanri, Tom Jackson draws on the parable of the loaves and fishes in which Jesus and his disciples feed five thousand with just five loaves of bread and only two fishes.

Read on and you might notice that this master economist and Lean expert also seems to touch on the work of Elinor Ostrom and Oliver E. Williamson, who were awarded the 2009 Nobel Memorial Prize in Economic Sciences. Ostrom was recognized for "her analysis of economic governance, especially the commons." The work draws on the influential original article by Garrett Hardin (1968) The Tragedy of the Commons, which refers to a dilemma in which multiple individuals, acting independently, and solely and rationally consulting their own self-interest, will ultimately deplete a shared limited resource even when it is clear that it is not in anyone's long-term interest for this to happen.

For those who are interested in how this might be adapted to health and health care resources, I encourage you to view Don Berwick at the 2009 IHI National Forum. In this talk, he explores the health care commons and challenges us all to rethink the way we do things.

I encourage you to learn more about the works of these great thinkers as we prepare to introduce Hoshin Kanri in our next phase of the Improvement Academy.

More very soon...
Anna

Friday, April 16, 2010

Change a mind: Our greatest weapon against stigma is our voice

Love this! From bringchange2mind.org who have partnered with the National Alliance on Mental Illness (NAMI) in walking together to raise awareness and eliminate the stigma surrounding mental illness.

You can find more information about NAMI in Contra Costa County here. Our local walk will be held on Saturday May 22 in San Francisco at Golden Gate Park. Will CCCRMC or the Healthcare Partnership have a team to sponsor?
Yes, it's a challenge!

Getting your message across

I've heard it said that "safety" has become an overused term and may no longer grab peoples attention. Sadly, I'm afraid there may be some truth to that perception. Below is a video Anthony Longoria, Director of CCRMC Emergency and Detention Nursing Operations, played at his talk on Team Building yesterday at the CCRMC Improvement Academy.

How do you build a team with engaged members in two minutes? Here's how a clever employee of Southwest Airlines did it. I did read more about this and it is reported that some passengers confessed they had never really listened to the safety instructions until they took this flight!

Tuesday, April 13, 2010

21st century tools for health leadership at University of California, Berkeley

I'm looking forward to the 2010 Leadership Conference at the University of California, Berkeley this week. Kate Fowlie and I will be speaking about the use of new media to move an organization into the future. In other words, it's a talk about blogging, tweeting and facebook!




Friday, April 9, 2010

Friday, April 2, 2010

The Future Waits No More-Behavioral Health Gets Lean

“Whatever you do, or dream you can, begin it. Boldness has genius and power and magic in it.”
-Johann Wolfgang von Goethe
It was a wonderful report-out today. I would like to thank everyone for your efforts. I am deeply moved and grateful for your willingness to contribute your skill, spirit and dedication to redesign our behavioral health service. The silence and darkness that has surrounded our behavioral health system is no more. You have brought us from silence to voice, from darkness to dawn. I look ahead with great excitement and anticipation. I encourage everyone to go and see (Genchi Genbutsu, 現地現物) the amazing work done by the team this week posted in the hospital lobby.

Keep an eye out for visible change in our behavioral health services, because it has arrived!

I want to share reflections from Teresa Pasquini. She is an amazing change agent and partner in our journey to excellence.
Here is her post-
On March 17th, a Behavioral Health Collaborative convened at Contra Costa Regional Center to begin a journey back to the future and on to a new frontier. This team effort was the dream of many Contra Costa County Community members who strive to change the way we treat one of our most vulnerable populations.

Born out of a vision of hope and the Healthcare Partnership, we brought together consumers, family members, law enforcement officers, ambulance drivers, nursing staff, medical staff, and administrative support to learn and teach about how to impact a Behavioral Health redesign at Contra Costa Regional Medical Center. We needed change agents to bring improved care and supports to all of our Community partners. That day was a gut level sharing of lived experiences that framed the work performed during the Behavioral Health Value Stream Mapping Event this week.

With stop watches and clip board in hand, this team of ambulance drivers, law enforcement, consumers, family members, nurses, therapists, psychiatrists, and clerks entered the ER and the CSU with the eyes focused on patient care only. We watched voluntary and involuntary consumers enter the ER, triage, medically clear, and move to the CSU. We watched what a consumer experiences as they enter the Crisis Stabilization unit from beginning, middle and end.

We watched the charge nurses and RNs scurry from one end of the unit to the next, the therapists arming the phones in search for beds, consoling and advising family members, and brainstorming with their colleagues on ways to get the services necessary for the patient as soon as possible. We timed the Psychiatrists assessment and consultation process to determine medical necessity to continue treatment and observed disposition orders given.

And we saw waiting, a lot of waiting. It was our job to find ways to reduce all non value time that was creating waste, duplicating efforts, and restricting patient care. After the Time Observations, data collection, and calculations were complete, we had our current state mapped.

Next, during our brainstorming session, we threw out old attitudes, debated and challenged the obstacles that exist in the current state, and made suggestions for building an ideal future state. We had become an amazing community team with open hearts and minds. We were told to think Big and Blow up the Box. Our ideas reflected our diversity of experiences and perspectives. No idea was excluded or judged.

The Report Out today in our hospital lobby demonstrated the power and magic that can occur when we lay down the tools that don’t work and pick up new tools that will help us bring improvement to the quality of care we provide our consumers. It was an awesome showing of humanity and social justice in motion.

Today the community celebrated the beginning of a one year Behavioral Health Improvement Process that will save lives. As the result of the Value Stream Mapping, more consumers and families are going to experience more value added care. The staff is going to feel more satisfied with their ability to provide care to their patients, and the community is going to move one step closer to healing. A community driven, consumer and family centered, collaborative process helped us dispel myths and rumors about the “mysterious” world of psychiatric care at Contra Costa Regional Medical Center.

A community team went to the Gemba (work place) and saw what the care of our psychiatric patients currently is at CCRMC. It really wasn’t mysterious; it was good medical care that is being provided in a system that needs improvement. On May 10, 2010 a new community team will convene to begin a rapid quality improvement event (Kaizen) that will take us one step closer to the future.

A week ago my son was a patient in the CSU. He has been there many times in the past ten years, but this time was different because of the consumer and family centered improvement efforts. He was only held for a couple of hours, this time. When discharged he told me that he was treated well. When I told him that I was coming to work at the hospital with a team of people who were going to make this process more accessible, accountable, and appropriate, he said, “Mom, my case manager told me that you believe in miracles.” That made him smile and proud of me. I love seeing my son smile. I don’t know about miracles, but I do believe in this process and I know that change is here.

Teresa Pasquini

Thursday, April 1, 2010

Contra Costa Regional Medical Center Honored for Cancer Care

Congratulations to all-

Contra Costa Regional Medical Center Honored for Cancer Care

Contra Costa Regional Medical Center’s (CCRMC) Cancer Program is one of only three California hospitals to receive the 2009 Outstanding Achievement Award from the American College of Surgeons’ Commission on Cancer.

The Chicago-based Commission on Cancer recognizes accredited cancer programs that “strive for excellence in providing quality care to cancer patients.”

CCRMC Cancer Program Medical Director Dr. Sharon Hiner said the recognition reflects the program’s commitment to quality.
“This is a great honor and it recognizes that we are a state-of-the-art facility. Not everyone knows that public hospitals like ours provide such excellent care,” Dr. Hiner said. “As the county health system, our mission is to serve the underserved and we believe our patients deserve the best care possible. This award shows that we are doing just that.”

For 41-year-old breast cancer patient Janet Morris the cancer program has been a godsend. She discovered a lump shortly after she had lost her job and health insurance last year.

“I was a little scared about going to a county hospital, but now I feel it was the most lucky thing to happen to me because I got such wonderful care,” said Morris, who lives in Richmond. “I felt very welcome. They are so caring, competent and loving.”
Not only is Morris receiving top notch care at CCRMC, she also is participating in clinical trials that give her access to some of the best new cancer drugs.

CCRMC’s cancer program was accredited in 1987 and is part of the Contra Costa Health Services county health system. “We are able to enroll more patients into clinical trials than some university hospitals, which means patients have access to cutting edge treatments. Over the past year, the cancer program has seen a 30 percent increase in patients likely due to more awareness about the program and a jump in the number of people losing their health insurance", Dr. Hiner said.
The CCRMC Cancer Program also recently issued its 2010 Annual Report. The annual report includes an in-depth look at breast cancer treatment at CCRMC. For the Commission on Cancer’s full award list, visit their site here.