Wednesday, June 30, 2010

CCRMC Improvement Academy and Noon Conference Thursday July 1

I wanted to remind everyone the CCRMC Improvement Academy meets today, Thursday July 1 at 9:00- 10:00 am at CCRMC in Building One Conference Room One. The academy is meeting for one hour this week and we will be discussing Atul Gawande's commencement speech at Stanford’s School of Medicine last week, The Velluvial Matrix, New Yorker, June 16 2010.

I'm also excited to attend Jon Stanger's Noon Conference today/Thursday in Building One, Conference Room One entitled "Beyond Right and Wrong: Six Parables for Medical Ethics."

Next up: Food for Thought
I will send along another reminder but for those interested Dr Stanger also facilitates an ethics discussion entitled Food for Thought which meets monthly and is always interesting and provides a wonderful environment to begin to think through many ethical dilemmas we face daily in our work. This months Food for Thought is
Wednesday, July 14
5:30 - 7:30 PM
Building One Conference Room One(i.e. "noon conference room")

For this session, watch the movie Departures some time before the date. It won the Oscar for "best foreign film" in 2009, amongst many other awards. You should have no difficulty finding it at a movie rental store. It is also available from Netflix, either via mail or by "instant viewing" download. Jon will bring the DVD to our discussion in case we want to watch a scene, but please try to watch it ahead of time, as we won't have time to watch the whole film.

Please send Jon Stanger an RSVP. You are wanted - even if you haven't been to one of our discussions before, mark your calendar and send Jon a "yes" RSVP. I think you will enjoy watching this movie and the discussion should be interesting.

Next week on July 7th we will continue our summer break discussions at the Improvement Academy. In preparation for this discussion, please read Don Berwick's Yale School of Medicine Graduation Address given last week.

We will return to continuous improvement and advanced measurement at the Improvement Academy on July 14.

Be well,

Tuesday, June 29, 2010

I received message from my dear friend and mentor Jim Conway that Polly Arango, a nationally known advocate for children, died on Saturday, June 26. Although too brief, my encounters with Polly made a lasting impression on me.

I met Polly while I was at the IHI. Among the many other things she was involved in, she was faculty for the IHI Triple Aim. As a fellow and from Contra Costa's work on Triple Aim, I had several opportunities to encounter Polly. Co-founder of Family Voices, she was a committed and gracious advocate and true leader who never stopped reminding us of the power of patients and families. A mother who set out to make a difference and did. I think her friends and colleagues from Family Voices said it best when they said "Polly's impact on families and children in New Mexico, the United States, and around the world is difficult to measure or match."

Saturday, June 19, 2010

Closing the door: A Father's Day gift

I have been asked to share the story I told of the last Father's Day my dad and I shared and the precious gift a nurse gave us. It's posted below.

Anyone who’s heard me speak about the CCRMC System Redesign has heard me speak of my father. In my blog entry on his birthday, I disclosed how disorienting the experience of being a ‘daughter at the bedside’ was for me.
“I tried to keep up as the teams rounded on him. I began to realize 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 seemed in just a few short weeks my father went from being a strong independent man who always knew best, to a person reduced to a diagnosis, a set of complicated and ever-changing presentations. He became a man who was dependent on a system of care surrounding him that didn’t seem to truly grasp how far away he was from himself. After knowing him my entire life, experts began to redefine him in terms I would have never considered using to describe my father: the Acute Renal Failure (I even heard them say ARF); the pancreatitis in 12; confused, demented and elderly. Sometimes (I believe in an attempt to reassure us) we were told “for his age this is common.” It was anything but common. It was absolutely unique for him and for us as a family.

I remember my dad’s last Father’s Day. He was in the hospital and I gave him a collection of CDs. It was an audio collection of mystery radio. When I was a young girl, my mother went to law school at night. My dad and I would drive 30 minutes to the school and sit in the car waiting for my mother to get out of class. We would listen to Radio Mystery Theater with E.G. Marshall. It was an attempt at radio show revival during the 70's. During the show, we would try to guess who committed the dastardly act. I would "rest my eyes" in the last 15 minutes but I would pretend I was awake the whole time and my dad always played along. The show would end about 15 minutes before my mother actually came out. My dad and I would explain our rationale for choosing the suspect and almost always our conversations would wander.

We traveled very little, we were a big camping and hiking family. I always wanted to see the great cities of the world, so my dad would tell me a story about a place he had gone when he was in the military. He would recall little details which didn’t often reveal very much about the place of interest, but revealed a tremendous amount about his experience of being there. He would describe how warm or cool the wind was, the smell in the air, colors people were wearing, what the food tasted like, and the feel of the ground under his feet. His stories were always my favorite part of the day. If ever I asked for him to tell me about a place he had been, he would always, without fail, deliver. He was a great storyteller.

If the truth be told the radio show CD's were probably more for me than him, but as always, he played along. I placed the CD in the portable stereo I had brought from home. I think he quite liked the idea, but didn’t really listen, because I don’t think he felt well enough. He drifted in and out of sleep. His nurse peeked in the room and motioned to me she would come back. She softly shut the door and at that moment every monitor, hall conversation, ringing telephone and supply cart rolling by faded into the distance. It was as if we were sitting in the dark parking lot in our family car, me and my dad and Radio Mystery Theater, just as I remembered. When the show was over my dad opened his eyes and said “I knew who did it the whole time.” He smirked because we both knew he had no clue, he was fast asleep. He asked me how school was going and I told him all about Parnassus Campus (one of my favorite places). I shared little details about Millbury Union, the beautiful fog that seemed to linger all day, and the great library. He said he remembered the library well, calling it “the crossroads of the world.” He complained that no one goes anymore and soon young people will not understand the silence of the great rooms of knowledge and the smell of old books. The nurse came and went and my dad drifted off to sleep. I did too, I was exhausted.

While walking through the medical center I reflected on Don Berwick’s plenary speech at the 2009 International Forum on Quality and Safety in Health Care in Berlin. He said that he believes we would all be better off "if professionals (us) would behave with patients and families not as their hosts in our care system, but as guests in their lives.”

We can count how many patients are in our hospital, but how many lives are we really touching? So many people make up our experience of living: people whom we can delight just by slowing down from our hurried pace and taking a moment to listen to them with an aim to understand what they are telling us; people whom we can disappoint, because too often we assume we know what is right and we define them relying on our experience as a professional, rather than on their experience as a unique and vibrant individual with stories and experiences that far exceed anything we will have the privilege of knowing.

I thought about the nurse who shut the door for my dad, a gift from her to us. No more monitors, no more call lights, no more ringing telephones, just me and my dad and Radio Mystery Theater, just as I remembered. She took the time. She gave us respite from the unsettling experience of being in a hospital. She gave us a moment of peace and quiet on our last Father’s Day. On that night, that nurse not only cared for my father, she touched my life too.

Happy Father's Day

Friday, June 18, 2010

Behavioral Health at CCRMC Gets Lean: Kaizen Report-Out

It never ceases to amaze me when I go to the report-outs just how powerful these events are. I've stopped bringing paper and writing down numbers and achievements during your reports, because I have come to cherish the time spent listening and watching everyone report. I have learned to take the time to take it all in and celebrate with you. This means I don't have the exact numbers from the report-out, but I'll try my best.

Behavioral Health Kaizen Two Headlines

The Documentation Team: You can guess what this means! The team went piece by piece through all of the documentation. Even those working on the unit never realized how much time was being spent "nursing paperwork" instead of patients.

The Stay Team: Aiming to reduce lead time for individuals on the unit by reducing redundancy, non-value-added movement and re-work. The process for belongings was unbelievable.

The Disposition Team: Reducing lead time and creating a seamless transition home or to another placement. I assumed I had a pretty good understanding of this process having come from a background in bed control and operations. I learned, as did others, I really had no idea just how many moving parts were involved in this.

The Pathway Team: Getting the right care to the patient in the right place at the right time. The team began assessing the feasibility of a behavioral health Emergency FastTrack (urgent care). Through experimentation (yes I mean actual testing) the team determined that the volume is likely too low to support this service. At that time the team switched their focus from developing Fastrack to developing a Pathway, creating standard work for medication support and other frequently needed (and predictable) service.

Highlights...there are so many I haven't listed them all. If you're interested in the improvements made, and I hope you are, you can find the complete report on iSite.
• In all, over 60 hours per week of nursing time will be saved and redirected to patient care. Several forms were eliminated and in one case three forms were reduced to one - all agree (all being front-line staff and consumers and family members) that the single form is much better than the three put together.

• Mike Rona reiterated that he has done hundreds of Kaizen events and never has he seen so many community members (consumers, family members, advocates and other agencies) directly involved in the actual improvement work.

• Joining us today were representatives from Alameda County Psychiatric Emergency Services, California Healthcare Safety Net Institute, Ambulatory Care Behavioral Health, Mental Health Consumer Concerns, NAMI, Anka Behavioral Health, Inc. Nierika House Community/Behavioral Health, Employment and Human Services and staff from all departments of CCRMC.
To those who came,
On behalf of CCRMC I would like to thank you for joining us today. Your interest in and support of the work of the CCRMC improvement teams means a great deal and offers us the opportunity to learn and improve together.

To the teams,
I am grateful to all of you who generously share your skill and spirit in order to make the experience of care better for those we serve. You are making big change, one small test at a time.

Consumers and Families/our partners in transformation

Additionally, it was a wonderful day full of celebration and collaboration today at the Contra Costa Consumers and Families 21st annual picnic. I will admit that when Dave asked me to say a few words and chuckled when he said I would have to stand on a table and use a very BIG voice I thought he was joking. He was serious! My heartfelt appreciation for the warm welcome. Thank you for including CCRMC.

What a great day.
It is truly a privilege.


Kaizen pictures to follow very soon.

Thursday, June 17, 2010

Behavioral Health Kaizen Two Report Out is Tomorrow/Friday at 10:00AM in the CCRMC Lobby

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

What is Lean?

There are many different variations of Lean in practice so I offer a very limited and generic overview that is consistent with the overall philosophy and reflective of CCRMC's Lean efforts.

Generally, Lean is centered on creating more value with less work. Lean Management is a process management philosophy derived mostly from the Toyota Production System (TPS) and grounded in W. Edward Deming's System of Profound Knowledge. Lean focuses on reduction of the original Toyota seven wastes in order to improve overall customer value.

Working from the perspective of the customer who consumes a product or service, "value" is defined as any action or process that a customer would be willing to pay for. Value is defined by the external customer and in our case it's always the patient.

Lean manufacturing is a variation on the theme of efficiency based on optimizing flow; increasing efficiency, decreasing waste, and using empirical methods to decide what matters, rather than uncritically accepting pre-existing ideas.

Why Lean and why now?

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

For many of us it is difficult to hear our system described as "financially unsustainable," but that is how our system was described at a board meeting earlier this year. 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.

What are we doing at CCRMC?

Teams of key stakeholders perform an exercise called value stream mapping. This mapping examines steps in our processes and determines how much value these steps add to the patients experience of care from their perspective. In partnership with users of our health system/community partners, teams then imagine/dream the ideal future state and present that to the system. To begin developing and testing changes to take our system to this ideal future, a series of rapid improvement events or kaizen events (also known as kaizen blitz) are conducted. In these improvement events several small tests and simulations are performed where changes are developed and tested with front-line staff and users of our system. Teams in the site where the work actually occurs then implement changes and continue to refine them on an ongoing/continuous basis, pursuing the ideal future state.

I know this seems like a foreign language, and that's because it actually is!

It feels like so much to learn, but we will learn together. We will take one step at a time. If we fall down seven times, we will get up eight. Please ask questions and keep an eye out for updates. Anyone from the Operations Team can answer your questions so please don't hesitate to ask.

I hope to see you tomorrow.
More very soon.

Click here to go to the Daily Kaizen Update learn more about what this week's team is doing.
Continuous Information for Continuous Improvement...

Sunday, June 13, 2010

Take a stand against suicide today, Sunday June 13 at noon at the Golden Gate Bridge

Here is a heartbreaking post that was placed on last week.

In seven days over 50,000 people have joined an online community offering encouragement and help.

Today (Sunday June 13) at noon hundreds are meeting on the Golden Gate Bridge to take a stand against suicide at the very place where it happens most in the world. (You're invited, look for the yellow balloons and ribbons).

This hopeful story has received international press coverage including this first report on Time Magazine's NewFeed.

En siete días más de 50.000 personas han unido un ánimo en línea de ofrenda de comunidad y ayuda.

Hoy (13 de domingo junio) a mediodía centenares encuentran en el Puente Dorado de Puerta para tomar un soporte contra suicidio en el muy lugar donde sucede la mayoría en el mundo. (Es invitado, busca los globos y las cintas amarillos).

Esta historia optimista ha recibido cobertura periodística internacional inclusive este primer reporte en La Revista del tiempo Es Newfeed.