Sunday, November 28, 2010

Perinatal Rapid Improvement Event # 1 begins Monday November 29

“Whatever you do, or dream you can, begin it. Boldness has genius and power and magic in it.”
-Johann Wolfgang von Goethe
The Perinatal Rapid Improvement Event (Kaizen) #1 begins Monday, November 29th at 11:00 AM at CCRMC Building One, Conference Room One. The overview session which is open to all is 11:00 AM - 1:00 PM.

We have learned from other public systems such as Denver Health and New York City Health and Hospitals that Lean Management can yield tremendous results in a public system.

What's happening here at CCRMC?

Mike Rona and Patti Crome from Rona Consulting provided a three-day Lean Intensive for some members of our leadership team. You may have seen some of the teams out in the medical center and clinics participating in an exercise called a waste walk.

This was an eye opening experience for those of us who went. We went out to the clinics and hospital in search of waste. We wrote down our examples on sticky notes and placed them on a wheel based on what type of waste they were. At times it was almost laughable, until we began to see the waste literally falling off our waste wheel. Some of us did what is called a spaghetti diagram. We followed the path of workers to see where they go to get their work done. The movement was phenomenal to watch. In summary, although it was a fun and very easy exercise, it was also quite sobering.

What is Lean?

Basically, lean is centered on creating more value with less work. Lean Management is a generic process management philosophy derived mostly from the Toyota Production System (TPS). It 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." *

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's Next?

Mike Rona and Patti Crome are back at CCRMC. Work with teams of key stakeholders teams last month conducted a value stream mapping event for Perinatal Services. This mapping examined steps in our processes and weighted them in value from the patients perspective- thank you to the users of our system who gave their time to help us better understand what patients want. We will now follow this up with a series of rapid improvement events or kaizen events (also known as kaizen blitz). I know this seems like a foreign language, but that's because it is!

It feels like so much to learn, but we will learn together. Please join us tomorrow for the Rapid Improvement Event learning session from 11 am to 1 pm.

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.

More very soon...

Saturday, November 27, 2010

Eliminating harm: The science of delivery

What would Deming say about this?

Two studies released back to back this month found a lack of significant change in eliminating harm due to medical error within the samples studied.

A study of 780 Medicare patients discharged from hospitals in October 2008 found that 12 died as a result of hospital care. The HHS report estimated that 15,000 Medicare patients die each month in part because of the hospital care they receive. Temporary harm occurred in another one in seven patients whose care-related problems were detected in time and corrected.

In a second study conducted over a six-year period at 10 randomly selected hospitals in North Carolina using the IHI Global Trigger Tool, internal reviewers identified 588 instances of patient injury among 2,341 admissions, for a rate of 25.1 per 100 admissions. Of the 588 instances of harm identified by internal reviewers, 63.1% were classified as preventable. Injuries involved procedures in 186 cases, medications in 162, nosocomial infections in 87, other therapies in 59, diagnostic evaluations in seven, and falls in five; other causes accounted for the rest. Most of the adverse events were temporary, requiring either intervention or initial or prolonged hospitalization, although 8.5% were life-threatening, 2.9% were permanent, and 2.4% caused or contributed to death. Researchers concluded there were no significant changes in the rate of overall harms identified by internal review, or in the rate of preventable harms, over time.

Medical mistakes are "an enormous public health problem," said Peter Pronovost of Johns Hopkins University, co-author of the book Safe Patients, Smart Hospitals.

Although this may feel discouraging, I believe there is a unique opportunity before us. We are, without question, at a point in history where change is not only possible, it's inevitable. These studies point to the gap in what is known about "how to" deliver evidenced-based health care reliably to the public. "We spend two pennies trying to deliver safe health care for every dollar we spent trying to develop new genes and new drugs," Pronovost told USA Today earlier this month. "We have to invest in the science of health care delivery." I agree that there is more we can do with a systematic approach. We can and should look to other countries who have taken on such efforts on a national scale. I believe we are better positioned than we have ever been to transform the experience of care in our nation. We must let go the old ways of thinking and challenge the self imposed limits we have come to accept and believe about what is possible.
"It is not necessary to change. Survival is not mandatory." -W. Edwards Deming
To my first question, what might Deming say to us? Although we will never know, we needn't look far to find clues to what his position might be.


Here are the studies below:

Landrigan C, et al "Temporal trends in rates of patient harm resulting from medical care" N Engl J Med 2010; 363: 2124-2134.

US Department of Health and Human Services. Office of Inspector General. Adverse events in hospitals: National incidence among medicare beneficiaries.

Engage with Grace: Do you know the answers?

Last year I participated in a “blog rally” to promote Engage With Grace – a movement aimed at making sure all of us understand, communicate, and have honored our end-of-life wishes. I'm thankful to participate once again.

From Alexandra Drane:

The rally is timed to coincide with a weekend when most of us in the United States are celebrating Thanksgiving and are with the very people with whom we should be having these unbelievably important conversations – our closest friends and family.

At the heart of Engage With Grace are five questions designed to get the conversation about end-of-life started. We have included them at the end of this post. They are not easy questions, but they are important -- and believe it or not, most people find they actually enjoy discussing their answers with loved ones. The key is having the conversation before it’s too late.

This past year has done so much to support our mission to get more and more people talking about their end-of-life wishes. We’ve heard stories with happy endings … and stories with endings that could have (and should have) been better. We have stared down political opposition. We have supported each other’s efforts. And we have helped make this a topic of national importance.

So in the spirit of the upcoming Thanksgiving weekend, we’d like to highlight some things for which we’re grateful.

Thank you to Atul Gawande for writing such a fiercely intelligent and compelling piece on “letting go” – it is a work of art, and a must read.

Thank you to whomever perpetuated the myth of “death panels” for putting a fine point on all the things we don’t stand for, and in the process, shining a light on the right we all have to live our lives with intent – right through to the end.

Thank you to TEDMED for letting us share our story and our vision.

And of course, thank you to everyone who has taken this topic so seriously, and to all who have done so much to spread the word, including sharing The One Slide.

We share our thanks with you, and we ask that you share this slide with your family, friends, and followers. Know the answers for yourself, know the answers for your loved ones, and appoint an advocate who can make sure those wishes get honored – it’s something we think you’ll be thankful for when it matters most.

Here’s to a holiday filled with joy – and as we engage in conversation with the ones we love, we engage with grace.

To learn more please go to This post was written by Alexandra Drane and the Engage With Grace team. Please feel free to join our blog rally by copying this post and putting it on your own blog for this holiday weekend.

Monday, November 15, 2010

CCRMC Improvement Academy: Opportunities and Challenges in Health Care Reform

Please join me for this week's Improvement Academy as Jim Conway walks us through challenges and opportunities ahead with Health Care Reform.