DOING COMMON THINGS UNCOMMONLY WELL

Into 2012

2011-12-31T20:01:00.000-08:00

Welcoming a new year filled with possibility

It’s hard to believe it is already a new year. The fact that many of us have spent time in the last few weeks reflecting on the past year and making resolutions for the new, speaks of the hope that we hold for the future. As Chief Executive Officer of Contra Costa Regional Medical Center (CCRMC) and the Health Centers (HC), it has been my privilege to support the compassionate work performed by all of you this year. Together we have faced unprecedented upheaval in our national, state and local economies. Trying times expose our values because they force us to make critical choices.

This year will be no less trying. Economic crisis continues to clench much of the world. Initially centered on the financial sector, this crisis has caused business failures and job losses and, ultimately, an increased demand for service from the safety net. I will not downplay the fact that once again we will most certainly face another year of immense challenges – because, indeed, much hard work and hard choices are ahead. Yet, before us lies an even bigger opportunity to renew and recommit to our mission in response to the urgency of challenging times. Throughout our county’s history, tough times have seen us not lower our sights but raise them. We need to display an ambition equal to our future. We are in a time of profound change. We must continue to improve and invigorate our system as one that goes beyond a “place of last resort”, to a system that exists within a community where no one is left out.

Together, and in partnership with our community, we will achieve:

• Better Care: Improve overall quality, by making health care more patient-centered, reliable, accessible, and safe.

• Healthier People and Communities: Improve the health of the population by supporting proven interventions to address behavioral, societal, and environmental determinants of health in addition to delivering higher-quality care.

• Affordable Care: Reduce the cost of quality health care for individuals, families, employers, and our county.

We must rise to these challenges because nothing less will do. I don’t expect that we will always agree with each other or with our colleagues across the public sector about the path forward. This is not a bad thing. Differences of opinion do not need to weaken us, they can make us stronger. Expressing divergent thinking, or raising a question often spurs introspection and brings daylight.

I am thankful that this last year provided the opportunity to deeply examine our system. After many months, the sustainability study of our Regional Medical Center and Health Centers was completed. The report described our strengths and the work we have underway to further improve and transform our system in order to continue to care for our community and help implement changes as part of Health Care Reform. The study summarized our current efforts to improve service delivery and patient experience, providing an excellent overview of our planned transition to Health Care Reform into 2014 and beyond. The findings validate that we have been - and continue to be - on the right path.

We are at a critical crossroads in health care in America and here in Contra Costa County. Together we will move forward on the basis on our shared ideals. As our community’s health system, we must continue to focus and prepare for the full implementation of Health Care Reform in 2014. Our goal is to provide care for our patients that is more coordinated and integrated, that will allow for earlier intervention, fewer avoidable emergency department visits and hospital stays and, ultimately, a healthier population while containing costs across our system and our community.

Contra Costa Regional Medical Center and Health Centers (CCRMC & HC) will expand access to health care and enhance quality through our Delivery System Reform program, also known as DSRIP. The improvements we are implementing as part of this plan are seen as key concepts of Health Care Reform. This critical effort builds on the extensive, innovative, work already underway at CCRMC & HC and contributes to important knowledge for our country.

We are also well into the implementation of our electronic health record (EHR): ccLink. Based on the Epic software system, ccLink, which will "go live" in July 2012, is more than a state-of-the-art health record technology — it will help further transform the care experience by linking patients with the best care and people. The implementation of ccLink, increasing access to our delivery system, shortening response times for appointment scheduling, integrating behavioral health and primary care, the realization of landmark health reform concepts and many other improvements are all well underway thanks to your efforts.

There is still much work to be done, but we should not forget how much we have accomplished this past year. Your commitment and partnership are making a difference. Please accept my sincere best wishes to you and your families for a happy, healthy and prosperous new year.

I look ahead with confidence and optimism.

Something to smile about

2011-12-26T11:31:00.000-08:00

If you can't see the slides below, click here to view the PowerPoint.
I wanted to share some results from what began as a “small test of change” to improve dental health in children here in Contra Costa County. Flouride application is one improvement in our health care system that stands out as having a positive and immediate impact.

The protective effect that fluoride varnish provides for kids is remarkable. Just one annual application is dropping the rate of dental cavities as much as 50% and two applications dropping it by 75%. In spite of the fact that this quick, painless procedure has been a covered Medi-Cal benefit for young children since 2006; less than five percent of eligible children received even one annual varnish application in 2009. Unfortunately, few low-income children see a dentist on a regular basis – if at all.

We realized that our young patients didn’t need to be sitting in a dentist’s chair to receive this treatment, but in fact could have it applied during their well-child visit at our primary care clinic. Physicians, nurses and certain other personnel are legally permitted to perform the varnish application, which only takes between 1-3 minutes. Contra Costa County, in partnership with UCSF School of Dentistry’s Center to Address Disparities in Children’s Oral Health (CANDO), embarked on a program to train staff to provide this very basic service to our youngest patients. What started as a pilot in two of our health centers has now been expanded to all eight.

The results have been impressive. More than 70% of eligible children have received the varnish through our primary care clinics. We’ve also increased our education on oral health for parents as well as all patients. Our Health Plan has begun to train community providers about the varnish application.

Although it’s gratifying to be able to make such a significant difference with this simple procedure, we know that it is not enough to protect children’s dental health. We are also moving forward with efforts to expand dental care for children in our dental clinics. There are many negative consequences as a result of not seeing a dentist. If you’ve ever suffered a toothache yourself or been with one of your children while they did, you realize how much children suffer from this pain that we know could be avoided in most cases. They also risk serious and chronic infections and along with the pain are major causes of school absences. I hope to be able to report on our progress in this area in the not-too-distant future.

More very soon.
Anna

The Morning Commute: Perintal Services at CCRMC

2011-12-22T06:06:00.000-08:00

I was told once that I am especially sensitive to anniversary dates. I think that's true.

Remembering my Dad on his birthday -

When I was growing up, my dad and I were always awake long before anyone else in the house and would use that time to have a good discussion. For years after starting my career, I began most days with a call to my father during my morning commute. I knew I could count on him for a good chat during the drive in. My dad was the chief engineer in charge of the water department. Though we were in very different lines of business, his goal was safety, quality and the continuous flow of a perfect product, ensuring its delivery to the customer every time it was wanted. Does this sound familiar? He instilled in me a strong sense of duty and pride in civil service. As my career evolved, the differences in our work became far fewer than the similarities. My dad seemed to have a story for every challenge I faced. This real life reflection from a veteran leader was a valuable part of our morning discussions. He would never give any direct advice. More often than not, he would share what he described as a failed or wrong decision. I, on the other hand, would describe it as wisdom.

I still catch myself making a list in my head of things I'd love to run past him during one of our discussions. Over the next few days (or weeks, depending on the pace of my posts), I'd like to share some of my thoughts during my "morning commute" with you.

I begin with how proud I was to see Contra Costa Regional Medical Center receive the Quality Leaders Top Honors Award from the California Association of Public Hospitals and Health Systems (CAPH) and its quality improvement affiliate, the California Health Care Safety Net Institute (SNI) for our Perinatal Unit’s innovative program, the “Vaginal Birth after Cesarean (VBAC) Improvement Project.” Judy Bliss, MD, chair of our ob/gyn department, and Brenda Stewart, RN, quality manager for Safety and Performance Improvement, accepted the award on behalf of the CCRMC team at the CAPH/SNI annual awards luncheon earlier this month.

The team developed this program more than two years ago to offer women who have had a prior C-section the option to avoid this surgery if it can be done safely. Although medical science supports VBACs and indeed acknowledges that in general C-sections carry a greater risk, some providers are reluctant to offer VBACs because of the challenges involved in assuring all safety measures have been taken. In collaboration with the Institute for Healthcare Improvement, we developed a series of interventions, known as a “bundle,” and other protocols so that we could ensure the safest outcome possible to our patients who chose a VBAC.

These efforts are an example of CCRMC employees putting patients at the center of their care experience. Our perinatal team was determined to respond to the needs and wishes of our patients while keeping safety as the number-one priority .

Rapid Improvement/Kaizen Event Reports are TODAY

2011-12-16T06:08:00.000-08:00

The Rapid Improvement Event (Kaizen) Report are TODAY at:

7:45-8:15 AM - Richmond Health Center Lobby
10-10:30 AM - CCRMC Hospital Lobby
12:15 - 12:45 PM - Pittsburg Health Center Lobby

Patient-Centered Health Homes Leaning ahead

2011-12-12T06:17:00.000-08:00

This week teams will begin to develop and refine work flows and standard work for behavioral health referrals from primary care. The integration of primary care and behavioral health is a high priority for those we serve. We know that far too many people in need end up in a complex pathway that can result in unnecessary delays or steps in the process.

The team is meeting at the Pittsburg Health Center, 2311 Loveridge Rd., Pittsburg 94565 on Dec 12-16th.

The rapid improvement event (Kaizen) orientation is being held in the Cypress Conference Room, 11-1 TODAY, Dec 12. All are welcome.

The Report outs on Friday December 16th are as follows:

7:45-8:15 AM - Richmond Health Center Lobby
10-10:30 AM - CCRMC Hospital Lobby
12:15 - 12:45 PM - Pittsburg Health Center Lobby

"connected"

2011-12-11T08:59:00.000-08:00

Being a mother of many of them, I'll admit there are days I just can't seem to understand the new generation. I've complained that when we were young we used to actually talk to one another rather than text, email or update our status on Facebook. I've mistakenly viewed this type of communication as superficial. This subgroup of young people are now referred to as "GenWorld: The new Generation of Global Teens." My daughter, one of these "superconnecters," did confirm that just like good-old-fashioned, face-to-face conversations, some of these interactions are less than deep. As an example of a contrasting type of communication she offered the video below of Jonah. I was deeply moved.

As some of you may know, suicide prevention is near and dear to my heart. Others may not know this, but bullying is also something I am quite concerned about. One of the most heartbreaking stories I can recall is that of a 12-year-old girl who took her own life after being bullied. I will never forget the horror and heartbreaking cries of her parents as we informed them in a quiet room outside of our emergency department. When I watch this video and just a few of the responses (there are too many to list), it's clear the new generation is still connecting with one another in a very powerful way.

The following video's are quite sad. Yet the connection and words of hope and support are inspiring and prevail. Although not in the same way we did, I am reassured the new generation are connecting with each other in meaningful ways. I have much to learn.

Thank you, Elena.
....always
Mom

"Now comes the choice. To change, or not to change."

2011-12-10T08:15:00.000-08:00

"Now comes the choice. To change, or not to change." - Don Berwick

Don Berwick joined the IHI Forum and outlined five principles to guide change in health care:

Put the patient first.
Among those, put the poor and disadvantaged first, “those in the beginning, the end, and the shadows of life. Let us meet the moral test.”
Start at scale. “There is no more time left for timidity. Pilots will not suffice.”
Return the money. “It is crucial that the employers and wage-earners and unions and states and taxpayers – those who actually pay the health care bill – see that bill fall.”
Act locally. Every community must mobilize

You can view his presentation here.

As he spoke I thought to myself, why can't this man run American health care? Then I remembered, a small group of senators obstructed his nomination, putting political interests above the best interests of the American people. Sadly, they got away with it.

Below are a excerpts from his remarks that appear in White Coat Notes, by Chelsea Conaboy :

The time at CMS has been a privilege. I got the chance to work with thousands of career public servants, and to learn how much these people do for us all, unsung and too often unappreciated. These are the people who translate laws into regulations and regulations into deeds. In CMS these are the people who keep the lights on – they see that providers get paid, they protect the public trust, they help the most vulnerable people in America, and make sure that they get the care they need.

And, I got the chance to help pilot toward harbor the most important health care policy of our time – the Affordable Care Act. A majestic law. I learned that a law is only a framework; it’s like an architect’s sketch. If it’s going to help anyone, it has to be transformed into the specifications that regulations and guidance documents. Only then can become real programs with real resources that reach real people. On my expedition, that, mostly, was what I was doing.

I would have loved to keep at that job longer. But, as you know, the politics of Washington, and especially the politics of the United States Senate, said, “No.” But, overall, I don’t feel an ounce of regret. What I feel is grateful for the chance I had to serve, and for the generous support I felt, including from so many of you.
I want this afternoon to share with you a little of what I learned on the expedition; and what I think it means for you – for all of us. It’s a sort of good-news-bad-news situation. The good news: the possibility of change has never been greater – not in my lifetime. The bad news: if it’s going to be the right change, the burden is yours.
. . . .
Cynicism grips Washington. It grips Washington far too much, far too much for a place that could instead remind us continually of the grandeur of democracy. . .

Cynicism diverts energy from the great moral test. It toys with deception, and deception destroys. Let me give you an example: the outrageous rhetoric about “death panels” – the claim, nonsense, fabricated out of nothing but fear and lies, that some plot is afoot to, literally, kill patients under the guise of end-of-life care. That is hogwash. It is purveyed by cynics; it employs deception; and it destroys hope. It is beyond cruelty to have subjected our elders, especially, to groundless fear in the pure service of political agendas.

The truth, of course, is that there are no “death panels” here, and there never have been. The truth is that, as our society has aged and as we have learned to care well for the chronically ill, many of us face years in the twilight our lives when our health fades and our need for help grows and changes. Luckily, palliative care – care that brings comfort, company, and spiritual and emotional support to people with advanced illness and their families – has grown at its best into a fine art and a better science. The principle is simple: that we can and should offer people the very best of care at all stages of their lives, including the twilight.

The truth is, furthermore, that patient-centered care demands that the ways in which a person is cared for ought always to be under his or her control. The patient is the boss; we are the servants. They, not others, should direct their own care, and the doctors, nurses, and hospitals should know and honor what the patient wants. . . It is one of the great and needless tragedies of this stormy time in health care that the “death panel” rhetoric has denied patients the care that they want, denied caregivers the information they need to give that care, and denied our nation access to a mature, open, informed, and balanced discussion of the challenge of advanced illness and the commitment to individual dignity. It is a travesty.

If you really want to talk about “death panels,” let’s think about what happens if we cut back programs of needed, life-saving care for Medicaid beneficiaries and other poor people in America. What happens in a nation willing to say a senior citizen of marginal income, “I am sorry you cannot afford your medicines, but you are on your own?” What happens if we choose to defund our nation’s investments in preventive medicine and community health, condemning a generation to avoidable risks and unseen toxins? Maybe a real death panel is a group of people who tell health care insurers that is it OK to take insurance away from people because they are sick or are at risk for becoming sick. Enough of “death panels”! How about all of us – all of us in America – becoming a life panel, unwilling to rest easy, in what is still the wealthiest nation on earth, while a single person within our borders lacks access to the health care they need as a basic human right? Now, that is a conversation worth having.

And, while we are at it, what about “rationing?” The distorted and demagogic use of that term is another travesty in our public debate. In some way, the whole idea of improvement – the whole, wonderful idea that brings us –thousands – together this very afternoon – is that rationing – denying care to anyone who needs it is not necessary. That is, it is not necessary if, and only if, we work tirelessly and always to improve the way we try to meet that need.

The true rationers are those who impede improvement, who stand in the way of change, and who thereby force choices that we can avoid through better care. It boggles my mind that the same people who cry “foul” about rationing an instant later argue to reduce health care benefits for the needy, to defund crucial programs of care and prevention, and to shift thousands of dollars of annual costs to people – elders, the poor, the disabled – who are least able to bear them.

When the 17 million American children who live in poverty cannot get the immunizations and blood tests they need, that is rationing. When disabled Americans lack the help to keep them out of institutions and in their homes and living independently, that is rationing. When tens of thousands of Medicaid beneficiaries are thrown out of coverage, and when millions of Seniors are threatened with the withdrawal of preventive care or cannot afford their medications, and when every single one of us lives under the sword of Damocles that, if we get sick, we lose health insurance, that is rationing. And it is beneath us as a great nation to allow that to happen.

And that brings me to the opportunity we now have and a duty. A moral duty: to rescue American health care the only way it can be rescued – by improving it. I have never seen, nor had I dared hope to see, an era in American health care when that is more possible than this very moment. . .We can do this, we who give care. And nobody else can. The buck has stopped. The federal framework is set by the Affordable Care Act and important prior laws, such as the HITECH Act, and, quite frankly, we can’t expect any bold statutory movement with a divided Congress within the next year or more.

The buck has stopped; it has stopped with you.
Now comes the choice. To change, or not to change.

Go with your gut

2011-11-28T19:20:00.000-08:00

To further improve the detection and response of people who are demonstrating signs of imminent clinical deterioration, we are beginning a medical center wide "Go with your gut" initiative. Although criteria for calling the "Rapid Response Team" (RRT) is defined in medical center policy, the various criteria cannot possibly cover all situations. We are asking front line nursing staff, physicians, patients, family members and ancillary staff to follow your gut instinct and call for help whenever you are concerned or when you feel things are not quite right.

The Rapid Response Team members hope to raise awareness of this critical safety net rescue team. According to Rapid Response Team nurses, "The RRT brings an extra pair of hands, a new set of eyes, assist in determining the patient's monitoring needs, and most importantly, brings critical care to the bedside"

You are the most important link in our safety system. I encourage you to trust your instincts and "Go with your gut."

Anna

Engage with Grace

2011-11-23T18:09:00.001-08:00

A group of bloggers have been conducting an Engage with Grace blog rally each Thanksgiving. I am posting a summary prepared by Alexandra Drane and others involved in this issue. It should be noted that I ran into this on Paul Levy's blog. I have posted about Engage with Grace before. Sadly, after watching dear friends face these very difficult conversations this last year, Engage with Grace has new meaning and importance to me.

Below is Alaxenadra Drane's post:

Occupy With Grace

Once again, this Thanksgiving we are grateful to all the people who keep this mission alive day after day: to ensure that each and every one of us understands, communicates, and has honored their end of life wishes.

Seems almost more fitting than usual this year, the year of making change happen. 2011 gave us the Arab Spring, people on the ground using social media to organize a real political revolution. And now, love it or hate it - it's the Occupy Wall Street movement that's got people talking.

Smart people (like our good friend Susannah Fox) have made the point that unlike those political and economic movements, our mission isn't an issue we need to raise our fists about - it's an issue we have the luxury of being able to hold hands about.

It's a mission that's driven by all the personal stories we've heard of people who've seen their loved ones suffer unnecessarily at the end of their lives.

It's driven by that ripping-off-the-band-aid feeling of relief you get when you've finally broached the subject of end of life wishes with your family, free from the burden of just not knowing what they'd want for themselves, and knowing you could advocate for these wishes if your loved one weren't able to speak up for themselves.

And it's driven by knowing that this is a conversation that needs to happen early, and often. One of the greatest gifts you can give the ones you love is making sure you're all on the same page. In the words of the amazing Atul Gawande, you only die once! Die the way you want. Make sure your loved ones get that same gift. And there is a way to engage in this topic with grace!

Here are the five questions, read them, consider them, answer them (you can securely save your answers at the Engage with Grace site), share your answers with your loved ones. It doesn't matter what your answers are, it just matters that you know them for yourself, and for your loved ones. And they for you.

We all know the power of a group that decides to assemble. In fact, we recently spent an amazing couple days with the members of the Coalition to Transform Advanced Care, or C-TAC, working together to channel so much of the extraordinary work that organizations are already doing to improve the quality of care for our country's sickest and most vulnerable.

Noted journalist Eleanor Clift gave an amazing talk, finding a way to weave humor and joy into her telling of the story she shared in this Health Affairs article. She elegantly sums up (as only she can) the reason that we have this blog rally every year:

For too many physicians, that conversation is hard to have, and families, too, are reluctant to initiate a discussion about what Mom or Dad might want until they're in a crisis, which isn't the best time to make these kinds of decisions. Ideally, that conversation should begin at the kitchen table with family members, rather than in a doctor's office.

It's a conversation you need to have wherever and whenever you can, and the more people you can rope into it, the better! Make this conversation a part of your Thanksgiving weekend, there will be a right moment, you just might not realize how right it was until you begin the conversation.

This is a time to be inspired, informed - to tackle our challenges in real, substantive, and scalable ways. Participating in this blog rally is just one small, yet huge, way that we can each keep that fire burning in our bellies, long after the turkey dinner is gone.

Wishing you and yours a happy and healthy holiday season. Let's Engage with Grace together.

To learn more please go to www.engagewithgrace.org.This post was developed by Alexandra Drane and the Engage With Grace team.

Giving thanks

2011-11-22T11:59:00.000-08:00

Dear Contra Costa Colleagues and Partners,

Thanksgiving is upon us. It is a time to stop, share a meal and precious time with family and friends, and, in the midst of whatever challenges we may be facing, reflect on what is right and good in our lives. It is a time for blessings to displace our burdens.

As health care professionals, we give special thanks to those among us who cannot stop what they are doing on Thanksgiving Day -- whose commitment to our community has them assisting those in need. We also know that many are not able to celebrate due to their personal circumstances.

They will be in our thoughts, as all of you will be in mine. I could not be more thankful for the privilege of working with such a dedicated and caring community of professionals and partners. Each day you bring your skill and spirit, contributing to our mission, making us one of the finest health systems in our nation.

I am grateful for your service and wish you and all your family and friends a safe and peaceful holiday.

Anna

Near Poor

2011-11-19T07:37:00.000-08:00

I was not surprised to read of the new measure of poverty, "near poor," released last week by the US Census Bureau. In the NY Times these people are described as, "down but not quite out." So often overlooked and under quantified, the NY Times goes on to report, "this new count suggests they are far more numerous than previously understood."

Although the government study has not yet been released, it is suggested that the new measure may find that, "100 million people — one in three Americans — are living either in poverty or in the fretful zone just above it."

Those of us in the public sector know far too well that this story is playing out across our communities. The unrelenting nature of this recession is unique and hitting California with great force. Although the legislative analyst said a double-dip recession was not likely, it did downgrade its forecast for employment growth and housing permits. It projects California's jobless rate will remain above 10 percent through the middle of 2014 and above 8 percent through 2017. That means that although we may face another devastating round of "trigger cuts," California's safety net will be required to further step up to meet the growing need of those in need.

The Women’s Summit – Education and Health Care are Everyone’s Issue

2011-11-18T06:41:00.000-08:00

Assemblymembers Joan Buchanan, Susan Bonilla, and Nancy Skinner hosted a Women’s Conference this week to discuss the impact of the economic downturn and the state budget crisis on services affecting women and children. I was honored to serve as one of the panelists.

The Summit was held against the backdrop of the 100th anniversary of the women’s right to vote in California. I joined panelists from the fields of education, safety and health care to address issues impacting local constituencies and encouraged the Assemblymembers to continue their strong advocacy on behalf of the safety net. Over a 200 women including local officials, leaders and residents attended the November 14th event at the Lesher Center in Walnut Creek.

I discussed the one-third increase Contra Costa Health Services has seen in people seeking health care over the past two years. People in our county are faced with difficult choices, sometimes between basic provisions for themselves and their family or health care. People who wait too long to seek service can end up sicker, experiencing personal suffering and may need more extensive – and more expensive – care. Some patients come to us in the middle of cancer or other life-saving treatment and have lost their work-based insurance. We’ve responded to the crisis by ratcheting up our already significant work to increase efficiency and access to care -- leading to multiple improvements. For instance, by implementing an automatic reminder call system for mammogram appointments, we have reduced the no-show rate from 18 percent in one health center to almost 50 percent in another. In spite of our work and improvement, the need for support is still great.

Cutting funds during this crisis is not only unwise; it will only cost us more down the road. With state revenues lower than anticipated and additional cuts looming, we must remain vocal in letting our legislators know how great the need is during these difficult times.

Even our strongest supporters – such as the three Assemblymembers representing our county in Sacramento – need to hear from us so that they can continue to fight on behalf of our patients.

Moving forward with Patient- and Family- Centered Care: IPFCC

2011-11-08T20:55:00.001-08:00

What an amazing group I am working with at the Institute for Patient- and Family- Centered Care Seminar, "Hospitals and Communities Moving Forward with Patient- and Family-Centered Care."

It's a privilege to work with such a diverse group. Today we explored the power of story. I was blown away by what I heard. I'm excited to reconnect with the group tomorrow.

I want to tell Dr. Tim Rutledge, President & Chief Executive Officer of North York General Hospital in Toronto, that I am truly inspired by your team and your committment to PFCC. As faculty, I am working with twenty people from North York General Hospital! This is clear and visible committment on your part.

Also on our team are Patient and Family Advisors from Fox Chase Cancer Center, and a leader from Hospice of Cincinnati. What an extraordinary story of partnership shared by Dan about his half marathon run, in which he was joined by his doctor. You can read about it here.

Message to Jim Conway- Martha Hayward, IHI Lead, Public and Patient Engagement and I have found each other!

PCHH Rapid Improvement Event

2011-11-06T06:07:00.000-08:00

Greetings,

The Patient Centered Health Home, Rapid Improvement/Kaizen Event, will be conducted at the Pittsburg Health Center this week. The team will focus on "flow" and efficiency in the clinic. I encourage those who want to learn more about Rapid Improvement Events to join the open session from 11am to 1 pm on Monday, November 7, at the Pittsburg Health Center.

The Report Out will be held Thursday, November 10th, from 5:00- 5:30 PM at the Pittsburg Health Center.

Please support the work of your colleagues and our patient and family partners as they draw on science and the energy and creativity of each other to continuously improve our health system.

Anna

CCRMC and HC's, Patient Centered Health Home

2011-10-30T09:57:00.002-07:00

If they don't load, please find Friday's slides here.
Presented by this weeks improvement event team, here is the future vision of the Contra Costa Regional Medical Center and Health Centers, Patient Centered Health Home (PCHH).

I was happy to see the migration from the term "medical" to the term "health." This is an example of the critical thinking that went into this vision and the push to move toward a model that goes beyond care only and focuses on health.

The team drew from the The National Committee for Quality Assurance's (NCQA), Patient-Centered Medical Home (PCMH) guidelines as a foundation for design. The NCQA describes the PCMH as,

"a health care setting that facilitates partnerships between individual patients, and their personal physicians, and when appropriate, the patient’s family. Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner."

In a set of standards that describe clear and specific criteria, the program gives practices information about organizing care around patients, working in teams and coordinating and tracking care over time.The NCQA PCMH 2011 program’s six standards are:
• Enhance Access and Continuity
• Identify and Manage Patient Populations
• Plan and Manage Care
• Provide Self-Care and Community Support
• Track and Coordinate Care
• Measure and Improve Performance

The team arrayed some (not all) of CCHS and community services as they relate to each of these standards. The key will be developing and maintaining meaningful connections
As we pursue seamless transitions through the health and health care experience we will become increasingly reliant on the ability to move information reliably. Below is the vision of standard movement of information.
I chose to present drawings rather than the electronic version of the forms here. I have received feedback by some that the forms can feel a bit off putting and intimidating. I am testing use of multiple forms of communication. For those who are counting on seeing the A3, you can find it and the entire presentation on Picasa here.

Exciting times are ahead of us. The first rapid improvement event for the PCHH is in just two weeks!

More, very soon.
Anna

Patient Centered Health Home: Value Stream Mapping Report Outs are Today

2011-10-28T05:39:00.000-07:00

The Patient Centered Health Home:Value Stream Mapping Report-Outs are happening today, Friday, October 28th as follows:

7:45-8:15 AM Richmond Health Center

10-10:30 AM CCRMC Hospital Lobby

12:15-12:45 PM Pittsburg Health Center

Please support the work of your colleagues and our patient and family partners as they draw on science and the energy and creativity of each other to continuously improve our health system.

Anna

Observance in Cynthia Palomata's memory - October 28th

2011-10-24T13:11:00.000-07:00

Dear Contra Costa Health Services Community,

This week marks a year since we lost one of our own in a brutal assault at the Martinez Detention Facility. Cynthia Palomata, a longtime nurse working at the facility, was violently attacked by an inmate whom she was treating. She succumbed to her injuries three days later.

In Cynthia’s memory, I invite you to observe a moment of silence on Friday, October 28th, at 3:30 p.m. Please feel free to gather with your colleagues at that time if you are able.

As we go through this painful period, I also want to remind you that you may contact the Contra Costa Crisis Line for confidential counseling anytime at 1-800-833-2900. Employees can also call our Employee Assistance Program at 1-925-930-3661 to make an appointment for counseling if needed.

I know you join me in sending your thoughts and prayers to Cynthia’s family at this difficult time.

Sincerely,
Anna

"No one left out"

2011-10-23T07:43:00.000-07:00

I thought some of you may like to read this Contra Costa Times article, Public hospitals carry burden of charity care despite big tax breaks for nonprofits. The article examines the distribution of care provided for people who are under-insured or uninsured in our region. For those who have followed the cantankerous discussion around Contra Costa Regional Medical Center and whether we need such a hospital in our community, I think you will find it worth the read.

"In Contra Costa, the county hospital alone accounted for more than 75 percent of the countywide charity care total in 2010." Sandy Kleffman, Contra Costa Times

Click on the images to enlarge
Image Source: Bay Area News Group

Many people continue to have a limited understanding of the essential role public hospitals and health systems. California ’s 19 public hospital systems make up the core of the state’s medical safety net – delivering care to all who need it, regardless of ability to pay or insurance status.

Though just 6% of all California hospitals statewide, public hospitals:
• Serve 2.5 million Californians each year
• Are located in counties where 81% of all Californians reside
• Deliver 10 million outpatient visits per year
• Operate more than half of the top-level trauma centers
• Operate almost half of the state’s burn centers
• Are teaching hospitals, training 43% of new doctors in the state
• Provide nearly half of all hospital care to the state’s 6.7 million uninsured (in some regions like Contra Costa County it's even greater than half)
• Provide 69% of their care to patients who receive Medi-Cal benefits or are uninsured; all other hospitals together provide 25% of their care to this population
• Deliver 30% of the state's inpatient care to the Medi-Cal population
• Serve a diverse patient population that is 48% Hispanic/Latino, 29% White, 12.5% Black, 6.5% Asian and 3.9% Other
CAPH.org

Although there are many differing perspectives, we all look to the future of health care in our nation with great hope. For me, my hopes for our nation's health care system, and for our community, are summarized in the Institute for Healthcare Improvement's (IHI) "No Needless List":
• No needless deaths
• No needless pain or suffering
• No helplessness in those served or serving
• No unwanted waiting
• No waste
• No one left out

...No one.
Anna

Lean Forward

2011-10-21T17:04:00.000-07:00

In November 2008, the California Health Care Safety Net Institute (SNI) launched its Lean Core Measures Improvement Initiative.The program introduced the use of Lean/ Toyota Management System (TMS) as a 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. Over the last two years we have been working with deliberate focus and speed to integrate Lean/TMS as our leadership system. Many of you have participated in improvement events (rapid/kaizen), and/or had the opportunity to learn of the ongoing efforts at one of our many monthly “report-outs.”

As a next step CCRMC was selected as one of five public hospitals to participate in the Embedding Lean initiative. This ambitious two-year initiative aims to support system-wide Lean transformation by increasing the number of staff who are trained in performance improvement, and the Toyota Management System (TMS).

  What's happening here?  

Mike Rona and Patti Crome from Rona Consulting provided the first of a series of Lean Intensive workshops for partners (users and providers) across our county involved in the delivery of health care. 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 CCRMC 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? 

Lean manufacturing or lean production, which is often known simply as "Lean", is a production practice that considers the expenditure of resources for any goal other than the creation of value for the end customer to be wasteful, and thus a target for elimination. 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 always defined by the external customer and in our case it's always the patient. Lean is centered on creating more value with less work. Lean manufacturing is a generic process management philosophy derived by and large from the Toyota Management System (TMS). It focuses on reduction of the original Toyota seven wastes in order to improve overall customer value.    

Why Lean/ TMS 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. 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/ TMS offer a systematic way of improving efficiency, while improving- not compromising- quality.   

What's Next?

 On October 24, 2011, a team of key stakeholders will perform an exercise called value stream mapping focused on the Patient Centered Medical/Health Home (PCMH). The team will examine steps in our processes and assign value to them from a patient’s perspective. We will then 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, that's because it 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. If you have questions so please don't hesitate to ask.  

More very soon... 
Anna

CCRMC and HCs Delivery System Reform Update

2011-10-12T22:37:00.001-07:00

Dear Contra Costa Health Services employees and partners,

As many of you know, Contra Costa Regional Medical Center (CCRMC) and Health Centers (HC) is involved in a major effort under a new five-year Medicaid (Medi-Cal) Waiver that will allow us to make significant, widespread improvements in access and care throughout our system. The project, entitled the "Delivery System Reform Incentive Payments (DSRIP)" program, is designed to build on the improvements and innovations we've already accomplished and to help us prepare for the full implementation of Health Care Reform in 2014.

This major effort involves the time and dedication of everyone at CCRMC & HC, and will continue to do so throughout the project. However, most staff are involved in only a portion of the plan, and thus we wanted to give you some details about all the work we are undertaking as part of the Incentive Program. To that end, we have created a short summary that describes the improvements we've achieved thus far and those in progress, as well as what we hope to accomplish by the end of the five-year period.

I am pleased to share this information with you, and also want to take this opportunity to say thank you for all the tremendous work you've achieved thus far and for your continued commitment to providing the best quality care for our patients. Please let Shelly Whalon or me know if you have any questions.

Sincerely,
AnnaIncentiveProgramfour-pagesummary

Go and See

2011-10-05T22:58:00.000-07:00

Thanks to Mark Graban for his post “Management By Walking Around” vs. “Gemba Walks"

I agree, leaders must go and see what is really happening.

Without knowing what you are watching for, "stand in the process and think for yourself," The Toyota Way, on Ohno circle.

For those who feel uncomfortable with the emphasis on Lean or TPS, Graban shared this quote from Deming.

"Management by walking around’ is hardly ever effective. The reason is that someone in management, walking around, has little idea about what questions to ask, and usually does not pause long enough at any spot to get the right answer.”–W. Edwards Deming, Out of the Crisis

We know you

2011-09-28T07:08:00.000-07:00

I thought you might enjoy this clip which highlights patient-centered design thinking. Keep an eye out for Dr. John Krueger, who joined us this last year to talk about innovation. Dr. Krueger will be here next week to visit the change agent fellows and innovation team. You are welcome to listen in. Cal students, not to worry, he'll be joining you as well!

Insights from the ER from Worrell Design on Vimeo.

2011-09-23T13:22:00.000-07:00

A few pictures from today's report. Slides and my comments are coming soon.

Kaizen Report-Out This Friday

2011-09-21T15:39:00.000-07:00

Improving Access, Kaizen Report-Outs will occur on Friday, September 23rd as follows:

7:45-8:15 AM Richmond Health Center

10-10:30 AM CCRMC Hospital Lobby

12:15-12:45 PM Pittsburg Health Center

Please support the work of your colleagues and our patient and family partners as they draw on science and the energy and creativity of each other to continuously improve our health system.

Anna

The Choice is Ours

2011-09-19T21:29:00.000-07:00

Today, along with other public hospital and health system leaders across the nation, I had the opportunity to hear our CMS Administrator, Don Berwick, speak concerning our options when considering the rising cost of health care. He noted that there are two choices before us that will result in cost savings:

we can cut services and care, or we can improve them.

While cutting services and staff, or withholding benefits may seem like an easy way to reduce costs, Berwick discussed a "better" approach: remove defects, duplication, inefficiencies and rework from our health care systems; provide the care that people want and need; produce health. He urged health leaders to pursue continuous improvement and innovation. Pointing to a cell phone in the room, Berwick noted that personal communication devices have not only vastly improved in functionality over the last five years, they have decreased in cost at the same time. In contrast to cutting service as a cost containment strategy, improvement, isn't easy: it takes time, it can be difficult identify which specific changes led to improvement and it requires skill and discipline in improvement methods.

We are at a critical crossroads in health care in America. We can pursue the historically unsuccessful and unsustainable approaches to cost containment we have typically applied in health care, or we can become better. We can cut service in our country, increasing human suffering and despair, or we can improve our health systems and provide the care our communities want, need and deserve.

The choice is ours.

Sustainability Study - Support for Our Course

2011-09-16T14:44:00.001-07:00

This message is from CCHS Director, Dr. William Walker and CCRMC/HCs CEO, Anna Roth

All Staff Message: Sustainability Study - Support for Our Course

After many months, the sustainability study of our Regional Medical Center and Health Centers is complete.

The report describes our strengths and the work we have underway to further improve and transform our system in order to continue to care for our community and help implement changes as part of Health Care Reform.

The County Board of Supervisors (BOS) asked for the sustainability study as part of the budget process in 2009 to look at how we provide care and how we can optimize services while controlling costs. The consultant, Health Management Associates, was awarded a $390,000 contract in January of this year to do the study. The final report has been posted on the county website (http://ca-contracostacounty.civicplus.com/index.aspx?NID=2728)and will be presented to the BOS CCRMC Joint Conference Committee on September 28 and then to the full Board of Supervisors on October 4.

We worked closely with the consultants on this study. In their findings, they point to how our integrated health system is well positioned for Health Care Reform and how we are fully accessing federal funding streams to continue to be the safety net provider of choice for our community.

The study describes our current efforts to improve service delivery and patient experience. Many of these efforts are underway, including implementing an Electronic Health Record, which will "go live" in July; increasing access and improving response time for appointment scheduling; and integrating behavioral health and primary care among many other efforts. In addition, the report highlights our long-standing commitment to quality improvement, applauding and calling for further support of the unique and innovative improvement work we are doing.

The study identifies the critical need to increase capacity and the importance of our current efforts to expand primary care capacity in both our system and in the partnerships we are developing in the community. Information on options for governance structure is presented but no specific recommendations are made. The study also identifies several external factors we do not control that have significant financial impacts on our ability to operate as a health system, such as personnel processes, and the cost of health and retirement benefits.

We view this study as an excellent overview of our planned transition to Health Care Reform in 2014 and beyond. The findings validate that we have been, and are on the right path. We all can be proud of the crucial work we do in caring for and improving the health of our community.

Thank you for your hard work and dedication to the people we serve,

William B. Walker, M.D., Director and Health OfficerContra Costa Health Services

Anna M. Roth, Chief Executive Officer, Contra Costa Regional Medical Center and Health Centers

Message from Alaska

2011-09-07T06:42:00.000-07:00

One of the fun things about blogging is the connections one can make. Find a message here about your work from a Lean leader in Alaska. His post is about the work you are doing and how you and your efforts are contributing to the growing swath of knowledge about the application of Lean as a leadership system in health care organizations.

For some time I have followed the blog, "Lean in Alaska." It's written by Patrick Anderson, Executive Director of Chugachmiut, Inc., an Alaska Native Tribal consortium. They too are on a Lean journey. I encourage you to take the time to read his blog as you will find many similarities and strategies to overcome many of the same barriers we face. Each organization has their particular spin on the application of Lean management. What I find of particular interest is that Chugamiut uses Lean as their leadership system much like we do. This is very different than the application of a simple veneer or focus/emphasis on the tools rather than the leadership discipline itself. Could this be the common connection between us that is Rona?

Keep an eye out. More very soon...

2011-09-05T08:54:00.000-07:00

Below are the slides from Friday's Report Out

Lean moves out of the box: CCRMC, Pittsburg Health Center and Richmond Health Center-Kaizen Report Out's Friday September 2

2011-08-31T14:05:00.001-07:00

The Kaizen Report Outs will occur on Friday, Sept 2nd as follows:

7:45-8:15 AM Richmond Health Center

10-10:30 AM CCRMC Hospital Lobby

12:15-12:45 PM Pittsburg Health Center

The improvement team has organized into three groups after generating improvement ideas related appointment access.

Team one is focused on appointment scheduling. They are examining current system issues surrounding distribution and sorting. They are conducting a trial giving advice nurses access to at least half of all "short notice" appointments. The team hopes to understand better if there is a difference and any improvement if these appointments are distributed through the advice unit.

Team two is exploring the virtual Provider visit. The team is currently testing using two physicians who are providing phone visits with patients referred from the advice nurse unit. Our hypothesis is that a significant number of patient needs can be met without an on site visit. These Providers are occupying unused clinic space at Pittsburg Health Center during the trial.

Team three is focused on the patient access line. They have reviewed other health system's access lines and plan to trial a system utilizing improved human interaction and a more patient centered phone tree. The team believes that these system improvements will increase patient satisfaction and direct calls to the appropriate resources in an efficient manner.

Please join me in supporting the work of your colleagues and our patient and family partners as they draw on science and the energy and creativity of each other to continuously improve our health system.

Anna

Sea Level

2011-08-28T07:46:00.000-07:00

In past discussions I have often likened the unprecedented change we are experiencing in health care, here in Contra Costa County and nationally, to a tsunami. I was wrong. This change is not a series of unrelenting waves. The sea itself is rising and so must we. There is no more waiting. Change is here. We must lean directly into the wind with active pursuit of continuous quality improvement at every level of our system. Adoption of Lean Management and the Model for Improvement throughout our system offers a systematic way of improving efficiency and improving, not compromising, quality.

This should be considered the first in a brief series of posts aimed at providing an overview of our primary strategy to transform our system. I will begin with Lean. In the next post I will discuss The Model for Improvement. I hope to link these discussions to what is happening in your work area and/or experience of our system.

What is Lean anyway?
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.

What are we doing at CCRMC and the Health Centers?

Teams of key stakeholders perform an exercise called value stream mapping (VSM). 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 members, teams then imagine/dream the ideal future state and present that to the system.

To begin developing and testing changes that are aimed at realizing this ideal future state 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. 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.

The table below displays upcoming events dates

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

There is much to learn. 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.

Anna

Got Tdap?

2011-08-20T09:40:00.000-07:00

Get a free Tdap (whooping cough) vaccine

TODAY only at the Richmond Recreation Complex, 3230 MacDonald Ave. from 11 a.m. - 2 p.m.

A new State law requires all 7th-12th graders get a Tdap booster to stay in school this fall.

Learn more at Contra Costa Health Services

Visit from LAO, CHEAC and CAPH

2011-08-19T00:27:00.000-07:00

Greetings,

Today (Thursday), I had the opportunity to help share the exciting work we have underway in our health system to implement health reform with some special guests from the California Legislative Analyst’s Office (LAO), County Health Executives Association of California and the California Association of Public Hospitals. The LAO provides fiscal and policy advice to the Legislature, serving as its "eyes and ears.” We were one of only three counties in California that the group visited this summer to gather information on efforts around the Medi-Cal Waiver, health care coverage expansion initiatives and other issues facing systems like ours.

CCHS Director Dr. William Walker, Contra Costa Health Plan CEO Patricia Tanquary, Assistant to the Director Wanda Session and I presented an overview of the comprehensive services we provide to our community- from our hospital, 10 primary care federally qualified Health Centers, nationally recognized family practice residency program and Health Plan to our extensive network of mental health and substance abuse providers and array of public health outreach, education and disease management programs. I was excited to talk about our innovation work and Lean Management System to continuously improve our system.

As we covered the array of critical services we provide, I was struck yet again by the groundbreaking work we do every day. I am so proud to work with colleagues committed to excellence and to doing common things uncommonly well. The work we are undertaking now to prepare for 2014 is the most thrilling challenge of my 18-year career here. The work you are doing is remarkable and we are well on our way to achieving our goal of the better health, better care and lower costs.

Thank you for all that you do.
Anna

Thank you to Senator Mark DeSaulnier and California Legislature for honoring Sergeant Paul Starzyk

2011-08-16T20:02:00.000-07:00

Thank you to Senator Mark DeSaulnier and California Legislature for honoring Sergeant Paul Starzyk. Today SCR 21 (DeSaulnier) was approved, naming the Martinez Pine Street overcrossing in Paul's memory. Sergeant Starzyk is a hero who made the ultimate sacrifice to keep our community safe and is greatly missed.

As a member of the Martinez Police Department family you have my deepest gratitude.

Anna Roth

Released today:

Police Sergeant Paul Starzyk Memorial Overcrossing” Approved by Legislature

Tuesday, August 16, 2011

Senate Concurrent Resolution 21(DeSaulnier) names the Hwy 4 Pine Street Overcrossing for a Martinez Hero

The State Senate has approved SCR 21 (DeSaulnier) to name the Pine Street Overcrossing that crosses State Highway Route 4 in Martinez as the “Police Sergeant Paul Starzyk Memorial Overcrossing.” Martinez Police Sergeant Paul A. Starzyk served as a full time police officer for 14 years and was tragically killed in the line of duty while protecting those he was sworn to serve. Sergeant Starzyk also served as a member of the SWAT team, he was a Range Master, and ultimately became an instructor for the SWAT team.

“Sergeant Starzyk died a hero,” said Senator Mark DeSaulnier (D-Concord). “Naming this overcrossing in his honor will serve as a constant reminder to all of us that we owe a great debt to this fine officer and his family.”

On the morning of September 6, 2008, Sergeant Starzyk responded to a domestic disturbance. A man armed with a handgun terrorized patrons at a beauty salon and then forced his way into a second story apartment where his estranged wife’s cousin had sought refuge.

When Sergeant Starzyk and his cover officer arrived, they approached the apartment and heard women screaming and gun fire. Sergeant Starzyk knowingly and willing placed himself in harms way by confronting the suspect who was threatening the lives of five occupants of the apartment after shooting and killing his estranged wife’s cousin as Sergeant Starzyk and his partner approached. Sergeant Starzyk was immediately fired upon by the suspect and was critically wounded, but he was able to return fire and fatally wounded the suspect.

Sergeant Starzyk’s decisive and heroic actions saved the lives of two women and three children who were hiding in the apartment. Sergeant Starzyk did not survive his injuries making the ultimate sacrifice to protect the five occupants of the apartment. Sergeant Starzyk was awarded the Medal of Valor posthumously for his extraordinary and heroic actions. The community will forever be indebted for his sacrifice. He left behind a wife and three children.

In honor of Sergeant Starzyk’s service, the City of Martinez Police Department asked that this overcrossing be named for Sergeant Starzyk. SCR 21 requests that Caltrans determine the cost of appropriate signs showing the special designation and upon receiving sufficient donations from private sources, erect the appropriate markers. The resolution need not go to the Governor for consideration as approval by the Legislature alone is sufficient.
# # #

Sen. Mark DeSaulnier (D-Concord) represents the Seventh Senate District, which includes most of Contra Costa County.

Michael Miiller, Communications Director
(916) 651-4007 or (916) 204-0485
michael.miiller@sen.ca.gov

2011-08-14T06:46:00.000-07:00

Worth the read-
http://leaninalaska.wordpress.com/2011/08/13/moneyball-by-michael-lewis/

July 4, 2011 ~ A Roth

Two reasons I love this:

1. The message to health care exec's (the real reason)

2. It's about my team (a happy coincidence)

Simple rule - get to the base!

2011-08-07T08:13:00.000-07:00

Many thanks to Patrick Anderson, Executive Director of Chugachmiut, Inc., an Alaska Native Tribal consortium, for taking the time to read about our efforts to improve access to our system. He notes that, " Chugachmiut went from waiting for up to 4 weeks for appointments to same day appointments in a short period of time. While our demand is not as great as Contra Costa’s, and we are nowhere near as big, the tools work the same in both our cultures."

You can read the full post here as well as many other interesting posts on Patrick Anderson's blog, Lean in Alaska.

CCMRC /CCHS July 22 Kaizen Report Access Value Stream/ Advice Unit

2011-08-06T09:53:00.000-07:00

Jeff Selberg speaks to the team

Click on the slide to see the full slide set

I am posting a long overdue summary of the July 22 Kaizen Report out which focused on access to our system with an emphasis on the role of the Advice Unit.

I'd like to thank the team which included employees from across our system and patient volunteers/Healthcare Partners. Without you we could not accomplish what we have thus far. I also want to extend my gratitude to Jeff Selberg, Executive Vice President and Chief Operating Officer of the Institute for Healthcare Improvement (IHI), and Mike Rona, President and CEO of Rona Consulting, who joined us at the report out. Jeff commented that he was "wondering how we will accomplish all that we have to do" he went on to say, "now I know."

I have attached the slides which should be posted both above this post and within this post. If the slide show is not working you can click on the picture above and it will take you to the slides. I will post the rest of the pictures from the report out this week.

In summary, the team formed three work groups:
1. Flow

2. Patient Centered Medical Home

3. Advice Unit

Teams identified areas in need of improvement and in some cases began to cost out the opportunity. Each team developed proposed tests of change and began testing this week.

The Flow team tested use of a triage system for MD access and sorting of calls.

Several ideas were considered around creation of truly patient-centered medical homes. The team has planned to test the proposed standard work with one physician in the first week of October.

Other test conducted this week included utilization of a MD in the Advice Unit. Based on national standards and protocols the team tested directing calls to an MD for intervention.

This is complex work and work that is now reaching far outside the walls of the medical center (CCRMC) into the health centers (clinics) and the health plan (CCHP). This is not easy work. It takes willingness, courage, caring and honesty to engage in a change effort [*]. Additionally, it takes constancy of purpose and discipline.

There are many distractions along the way and the force of the status quo is strong. Many have mastered the current state and their perceived power, position, and in some extreme cases, their identity can be based on that mastery. To seek a new order, to resist the urge to settle and to lead a transformation effort is indeed the work of the courageous. The first step is to change ourselves, which may be the most frightening step of all. Many will retreat to the status quo. Many will settle. We will not.

My deepest gratitude to the team and to all of you for your commitment to our mission and our community.

Anna

"You See"

2011-08-05T23:38:00.000-07:00

PH 290.6 bSpace is now open!
I'm looking forward to a great semester.

Jeff Selberg and Mike Rona to join CCRMC Access Kaizen Report Out this Friday, July 22

2011-07-21T00:15:00.000-07:00

Greetings,

I'm excited to have joining us this Friday at the CCRMC report out, Jeff Selburg, Executive Vice President and COO of the Institute for Healthcare Improvement, and Mike Rona, President and CEO of Rona Consulting. Please support the work of your colleagues and our patient and family partners as they draw on science and the energy and creativity of each other to continuously improve our health system.

As a reminder, in June a team of representatives from across our system and the community mapped the appointment process to observe and quantify how much time is seen as “value” for the patients when they are seeking an appointment. Ideas were then generated from the team about improvements that could be made to create an ideal “future state.”

Using the future state as a guide, three one-week long rapid improvement events (Kaizens) were planned. A recurring premise throughout the three planned improvement events (Kaizens) is creating a system that delivers the right care, in the right place, at the right time. The plan is presented on the A3 here. You should be able to click the A3 to better view it.

This week, your colleagues have been working with the Advice Nurse Unit. They are testing alternative models of service. One idea being tested is an Advice-Nurse-referred phone call from a virtually-embedded physician using evidence-based, national standards. Teams are also testing a revised message for incoming callers with clear direction for calls that are unrelated to the Advice Nurse Unit. A third area of work is focused on the Patient-Centered Medical Home model. In one clinic, the team will test a virtual liaison for a number of roles. These roles include; primary care providers, advice nurse, medical social worker, appointment unit representative, and care coordinator. Several other possible roles are also being considered for testing.

In summary, your colleagues are bringing together ideas from across our system and from science to test alternative models of care with three aims;

Better Care: Improve the overall quality, by making health care more patient-centered, reliable, accessible, and safe.

Healthy People and Communities: Improve the health of the population by supporting proven interventions to address behavioral, social, and environmental determinants of health in addition to delivering higher-quality care.

Affordable Care: Reduce the cost of quality health care for individuals, families, employers, and local government.

You are invited to attend one of the three Kaizen Report Outs that will take place on Friday, July 22, 2011, as follows:
7:45 am Richmond Health Center lobby
12:15 pm Pittsburg Health Center lobby
1:45 pm Contra Costa Regional Medical Center lobby

Hope to see you there.
Anna

2011-07-07T10:06:00.001-07:00

Just plain good.

Access to Care: Value Stream Mapping Report-Out Friday, June 24 in Richmond, Martinez and Pittsburg

2011-06-23T06:18:00.000-07:00

See the slideshow here.

Contra Costa Regional Medical Center and Health Centers
Mapping the Appointments Value Stream

On Friday, June 24, 2011, a Value Stream Mapping team will report on a week of analysis focused on improving access to Contra Costa Health Services’ Appointments. Staff and the public are invited to attend a presentation at one of the following locations:

Richmond Health Center 7:30 am
Contra Costa Regional Medical Center 10:00 am
Pittsburg Health Center 12:15 pm

Staff and community members are mapping the current state of Appointments from the perspective of the patient’s experience. During subsequent Rapid Improvement Events (Kaizen) over the next few months, synergistic teams will plan, test and launch innovative solutions to improve access to care throughout our health system. Results will be measured against the current state to provide powerful evidence of actual improvement.

Please join me to hear from the team this Friday as they present the results of their work.
Anna

CCRMC and Contra Costa Health Centers Epic Kick Off

2011-06-14T07:47:00.000-07:00

Happy Birthday MHCC

2011-06-12T08:01:00.000-07:00

I was honored to spend the evening celebrating the 35th Birthday of Mental Health Consumer Concerns, the nations oldest consumer advocacy organization. It was a night filled with stories of courage and hope. I was humbled as I listened to accounts of amazing people overcoming what seemed impossible barriers. Far too many of these barriers come from the healthcare system itself. We have much to learn from those who use our system. Happy Birthday, MHCC.

Mental Health Provider of the Year, John Allen with John Gragnani

Contra Costa Health Services Mental Health Director (retiring), Donna Wigand with CCC Senior Deputy County Administrator, Dorothy Sansoe

Mother, Patient and Family Advocate and CCRMC Healthcare Partner, Teresa Pasquini, Dorothy Sansoe, myself and MHCC Executive Director, Consumer Advocate and CCRMC Healthcare Parter, Brenda Crawford

John Gragnani, Brenda Crawford

Wonderful to see Donna and Dorothy

The founders of the Contra Costa Regional Medical Center Healthcare Partnership! Teresa Pasquini, Patient and Family Advocate and NAMI member, Dave Kahler and Brenda Crawford

Loved the Big Band

California State Senator, Mark DeSaulnier, a fierce and unyielding advocate for health for all

It was fantastic to run into Stan. Stan is one of the community members who redesigned and painted the entry to the Psychiatric Emergency Services.

2011-06-09T20:12:00.001-07:00

All employees and partners,
Hear what others are saying about the amazing work you do every day.

2011-05-30T09:56:00.001-07:00

2011-05-29T07:41:00.000-07:00

Atul Gawande talks about "shifting from corralling cowboys to producing pit crews," in his most recent New Yorker publication.

Brilliant and well worth the read.

Are you prepared?

2011-05-22T07:29:00.000-07:00

My hat is off to the CDC. Below is a great example of a very clever use of social media. Way to get your point across and have a little fun! Click the picture below to find out what the CDC is saying about zombie preparedness.

2011-05-15T08:30:00.000-07:00

I'm excited to join others this week to talk about Sustainable Solutions to Homelessness. You can learn more about the Saffron Strand Annual Conference here.

Leading a public hospital - thoughts from a CEO

2011-05-07T08:47:00.000-07:00

As the nation transitions toward some version of a reformed health system, one might ask what the role of public hospitals will be. In addition to serving as the primary back-up-plan for America’s failing health care system, public hospitals are faced with a conundrum. They are caught between the eroding health care system and the eroding public services sector. There is an increasing awareness that both are unsustainable as they exist today. States like Indiana and Wisconsin who eliminated collective bargaining for public employees may offer a glimpse of additional changes and serious challenges on the horizon. Sitting directly in the middle of these endangered systems are public hospitals.

Currently, health care makes up about seventeen percent of our nation's gross domestic product (GDP) and is climbing at a steady and unsustainable rate. In America, daily debates continue about bailouts, stimulus packages and health reform. Although potential solutions are still in a very nascent and fragile phase, it is clear there has been a sea change. There is a unique opportunity before leaders in health care, as well as leaders in the public sector. We are, without question, at a point in history where change is not only possible, it is inevitable.

Public hospitals are being challenged by the economic downturn. The number of people who are struggling to meet their most basic needs is increasing in communities across the nation and locally. According to California Association of Public Hospitals (CAPH), in California, the number of uninsured people seeking care in public hospital emergency rooms, increased by nineteen percent. In the San Francisco bay area, Santa Clara Valley Health System reported a one-third increase in the number of new patients in its emergency room. Contra Costa Regional Medical Center saw a twelve percent increase in the number of patients in its emergency room. The surge in demand is being replicated throughout the state of California. Los Angeles County also saw a twelve percent increase for its four hospital’s emergency rooms. Though these data are based on a 2007 survey, there is no indication of a significant shift in trends.

CAPH further notes that though they represent just six percent of all hospitals statewide, the nineteen public hospitals are located in counties where 81 percent of Californians live. They provide nearly half of the hospital care to the state’s 6.6 million uninsured. I think it is safe to say that providing care for the uninsured is what most people believe is the purpose of public hospitals. Yet in California, a state many would argue has an abundance of health care available, public hospitals also operate 54 percent of all top-level trauma centers , 43 percent of all burn units, train over half of the new doctors and operate robust outpatient operations that total over 10 million clinic visits a year.

It is during these difficult times when safety-net hospitals along with others in the public sector, are called on to further stretch already tight resources. To add to the challenge, local budgets at the county and municipal levels are dwindling, leaving leaders and society to face difficult choices. Recently a public leader in Contra Costa County published an opinion piece calling on the County Board of Supervisors to eliminate funding for the local public hospital. They urged the public to contact their elected officials and support safety over public health subsidy.

Moving away from either position one may be tempted to take, it should be noted that there is nothing new about vying for a bigger piece of the pie. In 1968, Garrett Hardin, presented this complex dilemma in his seminal publication, The Tragedy of the Commons. In his essay, Hardin explores problems arising from population growth and the finite availability resources on the planet. He winds through a labyrinth of ideas that ultimately and inevitably lead to the conclusion that a human solution, not a technological solution, will need to be applied to the challenges of the sustainability of shared resources.

To illustrate this, Hardin presents a fable which takes the reader to a pasture used by the local farmers. The pasture, full of lush green grass in the center of the region, is not owned by an individual, but rather by the entire community. He calls this shared resource “the commons.” Each farmer, looking out for his own interest, attempts to expand his herd. The farmer receives all the proceeds from the additional animal. However, each animal also causes slight degrading of the pasture. Ultimately, the pasture is overgrazed and degraded, rendering it no longer a viable resource for the community. The end result, everyone loses.

One premise of the story is that recognizing or identifying resources as “commons” in the first place, acknowledges they require management. Hardin concludes that a human solution was needed to escape the “tragedy of the commons.” It would require people to come together to create a plan to sustain the commons.

More recently, Elinor Ostrom shared the 2009 Noble Prize with Oliver Williamson in Economic Sciences when she revisited the concept of the commons. She defined the commons as collectively owned resources. Her work explores governance schemes of collective resources. She argues against a single governance structure for management of commons and instead supports shared governance. Simply stated (embarrassingly simply as her work is so much more), her research forwards that collective resources can and should be managed by the people who actually use them. Both Hardin and Ostrom identify people themselves must seek shared solutions for management of collective resources.

So how might the concept of the commons apply to this discussion? At its core is the underlying reality that there is only so much public good (space on the commons-tax dollars-call it what you like) to go around. Public services are not free. The public leader who called on the Board of Supervisors understands that the public good is allocated, or parceled out, to support public service. Many factors are considered when making these very hard choices. Use and manipulation of provocative language and tugging at social values, pepper the debates over the division of resources. In the end it will come down to hard choices - rationing of the public good – rationing of the commons.

In general, people hate the concept of rationing. Particularly, as it relates to health care. It strikes at the heart of our fears. We are Americans and have been bombarded with the notion that everyone has the same chance to succeed. It is called the American Dream, made up of opportunity, self-determination, independence and choice. At its foundation, the American Dream promises that we are all equal. Again, moving away from particular position on equality, as I know there are diverse opinions on this, I think it's important to understand what influence these belief systems might have.

There are clear implications for leaders of public hospitals when considering the complex social drivers and influencers of decisions as they relate to what Ostrom and Hardin refer to as the commons. Myths that depict substandard, low quality, government-run health care systems persist. These myths change form in order to survive and thrive in environments consisting of fragmented snapshots of knowledge rather than the entire landscape. Much like a virus that mutates evading the grasp of those who pursue it, the myths that surround public hospitals as places of substandard care continue to persist.

With the increasing demand for public service, those working to preserve and enhance the safety-net will need new levels of leadership skill. Knowledge of improvement science and systems-thinking will be needed to face the significant operational, policy and political challenges that lay ahead. Too often, when thinking of the safety-net, the “last resort” image prevails rather than a place of excellence, hope and recovery and as a place where no one is left out. To add to the challenge, it is increasingly difficult in these difficult fiscal times to achieve alignment among public leaders themselves.

Hence, the perfect storm has arrived.

In order to achieve sustainable solutions, there is need for a shared framework not only among public hospitals, but also across the public sector. The challenges leaders are facing will only increase if they move forward alone. Public leaders, and specifically public hospital leaders, will face ongoing political realities with local, state and national fiscal crisis. They must meet the needs of today while pursuing a sustainable system that provides:

• Better Care: Improve the overall quality, by making health care more patient-centered, reliable, accessible, and safe.
• Healthy People and Communities: Improve the health of the population by supporting proven interventions to address behavioral, social, and environmental determinants of health in addition to delivering higher-quality care.
• Affordable Care: Reduce the cost of quality health care for individuals, families, employers, and government.
-National Quality Strategy, HHS.gov

I believe that key to achieving this will be ceding individual control in order to develop shared aims that are meaningful to those we are here to serve.

A sky filled with clouds of change offers the perfect opportunity. It truly is a perfect storm and should not go to waste. Leaders should not run for shelter, nor resort to tearing each other down in order to protect the status quo. They should look to the legacy and long history of innovation in the public sector and instead seek collective solutions, embracing the opportunities before them to continue to serve their communities.

CCRMC Improvement Academy: Special Session Thursday, May 5th at 10am with Dr James Mountford, Teresa Pasquini and Anna Roth

2011-05-04T06:44:00.000-07:00

"Involving Patients as a Path to Achieving the IHI Triple Aim"
Presented around the globe by The Institute for Healthcare Improvement Fellows.

Dave, I see you taking pictures. If you send them my way I can post them.

All teach, all learn - The IHI Fellows present the lecture heard around the world

The IHI Fellows are conducting an international experiment May 1−15. We will all be delivering a jointly developed presentation about the IHI Triple Aim to as many diverse audiences as possible across the US, England, Ireland, Scotland, Wales and New Zealand.

The first session at CCRMC in Building One, conference room one will be Thursday, May 5 at 10:00 am.

The presentations will encourage attendees to learn about the IHI Triple Aim and will enable all attendees to implement the IHI Triple Aim “By next Tuesday!”

Dial-in across Contra Costa County using the noon conference lines. To our valued partners both in the safety-net and beyond, we welcome your participation. Please contact my office for dial-in detail, or better yet, feel free to join us!

The presentation is scheduled for one hour. Presenters will be available for discussion for those interested. Room will be cleared promptly at 11:45 am.

About the presenters:

Dr James Mountford:
Dr James Mountford is Director of Quality for University College of London (UCL) Partners, one of five Academic Health Sciences Centers in the UK. UCLP’s mission is two-fold: first, to bring research through to routine clinical practice more rapidly; second, to drive a step-change in the quality and value of care for the population of North London through changes to both community-based and hospital care. UCLP was formed in October 2009, with five founding partners: University College London, UCL Hospital, the Royal Free Hospital, Great Ormond Street Children’s Hospital and Moorfield’s Eye Hospital.

From 2005-07, James was a Commonwealth Fund/Health Foundation Harkness Fellow in Health Policy, based in Boston at the Institute for Health Policy, Massachusetts General Hospital and at the Institute for Healthcare Improvement (IHI) where he led the early work on the “Business Case for Quality” with Maureen Bisognano and Don Berwick. Before joining UCLP, James was a consultant in McKinsey’s London Healthcare practice where he led McKinsey’s work on clinical leadership.

James’s background is as an NHS doctor. He has a medical degree from Oxford and an MPH from Harvard. In 2009 he co-edited the UK’s first book on clinical leadership Clinical Leadership: Bridging the Divide. He has written and spoken on this and other topics related to quality and value both in UK and internationally. He sits on the board of Diagnosis, a healthcare social enterprise.

Teresa Pasquini:
Teresa Pasquini is a full time community volunteer and advocate for improving the mental health system of our county, state, nation and world.

As a family member representative of the Contra Costa County Mental Health Commission, she works with all layers of the community to provide insight, oversight and to help improve and transform the mental health system. She is a Commission Liaison to the Mental Health Services Act Consolidated Planning and Advisory Workgroup (CPAW) and the Contra Costa Mental Health Coalition.

As a family member of two mental health consumers, her 35 year personal experience drives her passion to improve care for those consumers and families who suffer without treatment and recovery. An outspoken champion for all of the disenfranchised and underserved, she was a founding member of the Healthcare Partnership at Contra Costa Regional Medical Center, bringing family/consumers/patients to decision making tables to transform the way healthcare is delivered.

Teresa also serves as a patient and family advocate on the Executive Leadership team of CCRMC. She is a strong voice for change and instilling a vision of hope to make healthcare welcoming and accessible for all.

Anna Roth:
(it feels odd to post my own bio - I'll keep it brief)
Chief Executive Officer of Contra Costa Regional Medical Center, Contra Costa Health Centers and Contra Cost County Detention Health Services.

I am privileged to work shoulder to shoulder with dedicated professionals and amazing community partners to provide quality care to all people in Contra Costa County with special attention to those who are most vulnerable to health problems.

Watch "Food Stamped" this Thursday, May 5 at 6:00 pm in the CCRMC lobby

2011-05-02T21:03:00.000-07:00

Food Stamped: May 5th at CCRMChttp://www.foodstamped.com/

Join us in the Contra Costa Regional Medical Center lobby on May 5th at 6:00 pm for a screening of the new documentary, “Food Stamped.” The film follows a nutrition educator in low-income neighborhoods and her filmmaker husband as they attempt to eat a healthy, well-balanced diet on a food stamp budget. We will be joined by the director of the film, Yoav Potash, as food justice advocates, nutrition experts, politicians, and people living on food stamps share there perspectives on the struggles low-income Americans face every day. You can learn more by going to the Food Stamped website here.

I hope you will consider joining us for this very important screening. A panel discussion to directly follow.

Panelists:
Yoav Potash, Film Director, Food Stamped
Anna Roth, CEO, CCRMC and CCHC
William Walker MD, Director, CCHS
Alan Seigal MD, CCRMC and CCHC
Tracy Rattray, Director of Community Wellness and Prevention Program

If you want to go far, go together: Contra Costa Safety Net Summit

2011-04-29T21:53:00.000-07:00

If you want to go fast, go alone. If you want to go far, go together.
~Contra Costa Safety Net Summit, April 2011

What a great day of collective thinking and learning with an amazing group of people. I spent the day the Contra Costa Safety Net Summit which brought together stakeholders from across the safety net.

Jeff Kutash gave a thought provoking presentation on Collective Impact to drive large-scale social sector change. He presented fascinating examples from across the world ranging from the juvenile justice system to Strive, which is increasing high school graduation rates- reading and math scores and increasing the number of children in preschool to prepare for kindergarten. One example illustrated a community solution related to poverty. Farmers had a fixed amount of space and they could grow a fixed number of crop. By focusing on development of a better seed they were able to grow four times the crop in the same space. Farmers now earned four times the money. The community now had four times the resource. At one point it was suggested that a new system is within reach of safety net leaders. He summarized by noting that this sort of change requires the "usual suspects to work in unusual ways" - that's us!
He noted that in each example of collective success there were five conditions found:
1. common agenda
2. shared measurement
3. mutually reinforcing activities
4. continuous communication
5. backbone support organization

The picture below provides an illustration of his talk. I have to add here that Emily Shepard did such a great job capturing the day in picture and summaries. Click on the picture for a closer view.

I loved the map on the wall. We placed ourselves on the map. I learned a great deal by being able to see what the safety net looks like from this perpective. To my delight and surprise, I also found Matt Steifel from Kaiser (and a fellow IHI Fellow)at the map!

Wanda Session and Patricia Tanquary

The group identified gaps in the safety net as well as strengths.

The group set out some next steps, one of which will be forming a time-limited task force made up of cross sector representatives. The day closed with Supervisor John Gioia who grounded us in reality with the sobering facts and figures we all know too well. Health is not being experienced equally in our county. We know because it is our mission and our promise to leave no one out. We are dedicated to caring for all in our community with special attention to those most vulnerable to health conditions.

Supervisor Gioia closed with a quote from our 38th Vice President, Hubert Humphrey.

It was once said that the moral test of government is how that government treats those who are in the dawn of life, the children; those who are in the twilight of life, the elderly; and those who are in the shadows of life, the sick, the needy and the handicapped.
Hubert H. Humphrey

Perinatal Report Out today in the CCRMC lobby at 10:00 am

2011-04-29T06:44:00.000-07:00

In "Healthy People 2020" released in December of 2010, the U.S. Department of Health and Human Services released the new 10-year goals for our nation's health - and supporting breast-feeding is prominent among them. By 2020, the goals call for increasing the percentage of Baby Friendly Hospitals to 8%. Contra Costa Health Services is committed to providing quality patient-centered care.

As a review, in October 2010 a team of physicians, nurses and social workers from the medical center, health centers, Healthy Start and public health performed approximately 50 patient observations and time studies of the patient experience from the prenatal visits, through delivery and ending with the first post partum visit. From these observations, the team created a current state map of what our patients experience during their care across the entire care experience. The current state was critically evaluated to determine a vision of our future state.

Please join us this morning in the CCRMC lobby at 10:00 am to learn more about the work of your colleagues and our patient and family partners as they draw on science and the energy and creativity of each other to continuously improve our health system.

Anna

HHS Region IX Launch of Partnership for Patients at Contra Costa Regional Medical Center

2011-04-22T22:56:00.000-07:00

Dear Contra Costa Regional Medical and Health Center Community and our valued partners:

Thank you all for joining us today for the Region IX launch of the Obama Administration new initiative, Partnership for Patients. I was honored to introduce our organization and our accomplishments to our local, regional and national leaders. As a public hospital, we play a critical role in our community’s health and we are proud to join hospitals across the nation pledging to improve care and save lives. Here is the Contra Costa Times story that highlights the event.

It is an honor to pledge our support for this ambitious new intiative and to have our achivements recognized by our nations leaders.
Speakers included:

Congressman George Miller,7th District of California
Herb K. Schultz, Regional Director, HHS, Region IX,
David Sayen, CMS Regional Administrator, HHS, and
Joseph McCannon, Senior Advisor, Centers for Medicare & Medicaid Services, HHS

We were joined by consumers, industry representatives, and other key health care stakeholders to highlight the historic reforms of the Affordable Care Act. The new initiative, Partnership for Patients, will help save 60,000 lives by stopping millions of preventable injuries and complications in patient care over the next three years, improving quality and containing costs.

Already, more than 1300 hospitals, as well as physicians and nurses groups, consumer groups, and employers have pledged their commitment to the new initiative.

Our commitment to patient safety has been longstanding. As the people who are working on behalf of our community to continually improve our great health system, you should be proud of the work and the many milestones achieved at Contra Costa Regional Medical Center.

Above are just a few examples of what we have accomplished. You can find them posted on the walls of your work areas. Your achievements are many. You have opened doors that were once closed and welcomed in patients and family members as part of your teams. You have learned to have meaning discussions and shared-decision making with out partners. You have embraced the science of improvement and you are making a difference.

As science and our knowledge of how to create sustainable change continues to advance, we now know we can achieve results that were once thought to be - by hospitals nationwide - out of our reach.

It’s time to challenge ourselves. We can do more.

This isn't an easy conversation for health care providers to have. We go into healthcare to help and heal those in need. It can be difficult to talk about being part of, as Joe McCannon so poignantly stated, a health care system across our nation that is "rife with waste, harm and in urgent need of improvement." Even though this is difficult, we can’t let that deter us. The time has come. The conversation must take place and the Partnership for Patients offers the opportunity to have that dialogue.

At Contra Costa Regional Medical Center and Health Centers we will:
• decrease by 40%, preventable hospital-acquired conditions by the end of 2013
• reduce by 20% hospital readmissions by the end of 2013.

We will look to science and to our partners. Along with others across our region and our nation we will design systems of care that provide the care that our communities want need and deserve free of preventable complications.

U.S. Department of Health and Human Services, Partnership for Patients: To Improve Care and Lower Costs, Regional Launch at CCRMC Friday, April 22 at 10am

2011-04-20T10:01:00.000-07:00

Greetings-

I am excited to extend an invitation to you to the regional launch of the U.S. Department of Health and Human Services' Partnership for Patients: To Improve Care and Lower Costs Initiative to be held at CCRMC this Friday April, 22 at 10am. As you know, CCRMC has had a longstanding commitment to providing the highest quality care to those we serve. We are deeply honored to be chosen as the host for the regional launch of this national collaboration. I hope you can join us.

Please feel free to contact my office directly if you have any questions.

Sincerely,
Anna

Lean(ing) into it: Update on Budget, Sustainability Study and Redesign

2011-04-13T06:57:00.000-07:00

I will be joining the Improvement Academy tomorrow, Thursday April 14th, to provide an organizational update on the following:

1. Budget hearings and process
2. 1115 Waiver/ Delivery System Reform Incentive Pool (DSRIP)
3. Planned upcoming leadership changes and next steps at CCRMC and CCHC's
4. Our commitment to the "Partnership for patients to improve care and lower costs for Americans"

Noon conference phone lines will be open

Anna

Did you know that 1 in 10 Americans are trying to eat on $1 per meal?

2011-04-11T22:38:00.000-07:00

When the student is ready, the teacher will (re)appear

2011-04-07T17:49:00.000-07:00

Posted by guest blogger, Charles Saldanha MD

“When the student is ready, the teacher will (re)appear”
-variation on a Buddhist proverb

Just prior to starting internship, my classmates and I received a gift. It was a book called Through the Patient’s Eyes: Understanding and Promoting Patient Centered Care. I regarded it as a kind token intended to remind us, as we filled our heads with scientific and technical knowledge over the years upcoming, that patients came first. That’s what we’re about as physicians, right? I didn’t read it. I had plenty else to read and not enough time to sleep. Making sure that I was “up to date” felt far more important and urgent.

In subsequent years, the book found a cozy home on bookshelves in various apartments, homes, and offices. It made three cross country trips. In the meantime, I was trying on different professional hats, unconsciously seeking to reconcile diverse and at times divergent ideas of what it means to be a physician.

On a weekend morning a few months ago, the spine caught my eye as I sat in our living room. I extracted it from between old textbooks and paperbacks and opened it. The binding cracked like a new book. I smiled to find that the contents I dismissed as so obvious and straightforward as to not warrant reading, I now recognized as addressing the most fundamental and challenging parts of our work.

Today, we apply more scientific knowledge, technology, and financial resources toward restoring health than any other civilization has at any time in human history. Yet, even with this relative embarrassment of riches, we struggle and all too often fall short of providing the health care that patients want and deserve. The challenge of our time is harnessing resources and scientific advance in a way that moves health care forward, principally from the perspective of the patient. Our patients and their loved ones have need us to recognize the situation and take it seriously; certainly, the crisis is immediate and real for those we serve.

Like unread books, the people who come to us for care are waiting to be asked for their knowledge and guidance. We need to have the humility to invite them and courage to overcome mistrust and check our professional pedantry at the door. By opening and sustaining that conversation we can become who our patients need us to be.

Charles Saldanha MD

Perinatal Kaizen Overview Monday March 28th at 11:00 AM

2011-03-27T07:24:00.000-07:00

“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) #4 begins Monday, March 28th 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.

CCRMC Noon Conference/ Improvement Academy welcomes Thomas Burke, MD, FACEP

2011-03-23T07:05:00.000-07:00

Photo source: http://fojailnohel.wordpress.com/2009/04/26/global-health/

Please join me at CCRMC's Noon Conference/Improvement Academy
Restructuring Health Care in Southern Sudan

Presented by:
Thomas Burke, MD, FACEP,
Chief, Division of Global Health and Human Rights
Department of Emergency Medicine, Massachusetts General Hospital
Associate Professor, Department of Surgery, Harvard Medical School

Thursday, March 24, 2011
12:15 - 1:00 pm
CCRMC, Building One, Conference Room One

National Quality Strategy

2011-03-22T19:18:00.000-07:00

I will certainly write more on this very soon!

From Healthcare.Gov:
HHS released it's Report to Congress: National Strategy for Quality Improvement in Health Care

The National Quality Strategy will pursue three broad aims that will be used to guide and assess local, State, and national efforts to improve health and the health care delivery system.

•Better Care: Improve the overall quality, by making health care more patient-centered, accessible, and safe.
•Healthy People/Healthy Communities: Improve the health of the U.S. population by supporting proven interventions to address behavioral, social and, environmental determinants of health in addition to delivering higher-quality care.
•Affordable Care: Reduce the cost of quality health care for individuals, families, employers, and government.

Find the full report here.

Team Stats

2011-03-19T11:30:00.000-07:00

For my husband on his birthday...

It begins with a story I have posted before. I have only changed one word. Instead of "eight" years, today marks "ten."

Even though today marks ten years, I can remember it so clearly. It was just a few hours before the clock struck twelve and it would be my husband’s birthday. He loves presents, but always makes it difficult for me to get the right thing. He acts as if his birthday doesn’t matter to him, but I do think he likes a bit of a fuss.

The message on my phone wasn't very clear. There was a great deal of background noise. I could hardly hear him say, “Call me now, it’s an emergency!” I tried calling several times, but he wasn’t answering. Finally, I called my father-in-law and I could have never predicted what would come next. His voice was different; it was slow and soft as he calmly explained to me that my husband’s brother had just killed himself. He was 26 years old. It was incomprehensible. I couldn't make sense of it. Even after years of working in mental health, I could not even begin to grasp what I was hearing.

There isn’t a day that goes by that I don’t think of him. He and my husband were best friends. Al was always there. He did everything with us. I remember he would come out on the boat with us. He never got out on the ski or wake board. He never drove either. He just liked to come along for the ride. He liked to spend time with his brother. The feeling was mutual. They were very close. Where you found one, you would very likely find the other.

It only takes a momentary glance to see the sadness in my husband’s eyes. I have come to know this silent sorrow all too well, because it dwells in our family. I have experienced other family members dying. I have talked about my father's death, which had a profound effect on me but this is different; there is a silence that accompanies suicide. The silence is deafening. Each December we are quiet, our conversation subdued, as his birthday passes and the holidays come and go. Then there is today’s date, and even though we rarely speak of the night he killed himself, we are all thinking about it. I don’t really know how to say it other than directly. I miss Alfred. I really miss him. There is so much silence. I wish we could talk about him more.

When speaking about her experiences with the National Alliance for Mental Illness (NAMI), Teresa Pasquini wrote, "We were on the same team that nobody wanted to be picked for..." I never told her at the time, but it is a brilliant description.

The team nobody wanted to be picked for.

As I put together the list of stats below I had a shocking and painful realization. I am on this team! It's amazing how I never noticed before. It's been ten years and it never dawned on me that the list below applies to me and my family. I never wanted to be on this team, no one does. Worse yet, because of the stigma and silence that surrounds suicide, excluding a relatively small number of people, one knows very little about others on the team.

Like me and my family, about 3.7 million people in the U.S. currently mourn a loved one’s death by suicide, and the number grows by 190,000 each year.

So as you read the numbers below, I'd like you to consider this not as simply a list of bad news. Sadly, these are my teams stats.

Some facts about suicide from the World Health Organization (WHO)

•In the year 2000, approximately one million people died from suicide: a "global" mortality rate of 16 per 100,000, or one death every 40 seconds.
-It's 2010 now! How many have been lost? Read the next line--too many

•In the last 45 years suicide rates have increased by 60% worldwide. Suicide is now among the three leading causes of death among those aged 15-44 years (both sexes); these figures do not include suicide attempts up to 20 times more frequent than completed suicide.

•Suicide worldwide is estimated to represent 1.8% of the total global burden of disease in 1998, and 2.4% in countries with market and former socialist economies in 2020.

•Although traditionally suicide rates have been highest among the male elderly, rates among young people have been increasing to such an extent that they are now the group at highest risk in a third of countries, in both developed and developing countries.

•Mental disorders (particularly depression and substance abuse) are associated with more than 90% of all cases of suicide; however, suicide results from many complex socio-cultural factors and is more likely to occur particularly during periods of socioeconomic, family and individual crisis situations (e.g. loss of a loved one, employment, honor).
- WHO

Unfortunately the list goes on.

There are however so many amazing people working to change these stats. I'm inspired by Contra Costa Crisis Center. When I read their Strategic Plan I noticed the number one objective listed was to "help people at risk for suicide stay alive." I recall reading the newsletter they sent out earlier this year about perfect depression care. I love the bold aim. I believe in bold aims. I also noted that they looked to The Henry Ford System's Depression Care Program for inspiration. What a great model. The rate of suicide in Henry Ford's patient population decreased by 75 percent from 89 per 100,000 patients to 22 per 100,000 in the first four years of the program's implementation, significantly lower than the annual rates for suicides in similar patient populations. For the last two and a half years, that rate has been zero per 100,000!

So many lost, so many left behind, all preventable...and with bold leaders like these, there is hope.
~Anna

2011-03-18T18:01:00.000-07:00

Many thanks to Hive Strategies for the generous comments about my blog. I'm humbled to be included in this group of bloggers.

I found the Hive Strategies Blog very interesting and inspirational as well. The Core Values are fantastic. Well worth the read!

http://www.hivestrategies.com/2011/03/sometimes-you-need-a-little-inspiration/

Perinatal Rapid Improvement Event (Kaizen) Overview

2011-03-08T23:37:00.000-08:00

Many thanks to Kandy Heinen and Michael Roetzer for providing an overview of the Perinatal Improvement Events.

When the Perinatal Value Stream Map was developed several months ago, the complex process that includes Pregnancy through Post Partum was divided into segments for opportunities for Rapid Improvement Events or Kaizens.

The Kaizens to date have covered:
Kaizen #1, November 29-December 3 included Post C-Section/Newborn
Kaizen #2, January 31-February 4 included Post Partum Inpatient (Including Tubals)
Kaizen #3, February 28-March 4 included C-Section and Induction (Scheduled Deliveries)

As with all Rapid Improvement Events, each one builds on the successes of the previous Kaizens and Kaizen #3 was no exception.

The team that assembled on Monday included a Pediatrician, Doctors from the Perinatal Services and the clinics and a cross section of Nurses and other staff from Perinatal to the Operating Room. This was a relatively small but high power team of nine members that was able to focus on Scheduled Deliveries from the patient’s perspective from the clinic through birth, including processes around the Operating Rooms. The Executive Sponsors for this team, Dr. David Goldstein and Jaspreet Benepal were active and engaged throughout the process and met almost daily to assess progress, provide encouragement, and offer suggestions for areas to analyze.

The A3, the tool used to provide structure to the problem solution process, identified non-value added time as a problem for patients, before and after scheduled C-Sections. The goal, as defined in the Target Statement, was to “Reduce the wait time for new patients so that they are seen when they want to be/need to be seen.”

Upon analyzing the work, three teams were established to go to the various work places and assess how the work is being performed. These teams visited clinics, the Perinatal unit and Surgery and also contacted other Departments within CCRMC to gain insights into how processes now work and where streamlining might occur.

The team quickly identified two issues with lead time. First, there was a significant issue with the time between arrivals to incision times for C-Section patients and second, about 7% of induction patients were sent home without being induced because the gestational dating was not correct.

In early discussions, team members knew there were delays for scheduled C-Section patients and based on their experience, believed the delays might have been an hour or slightly more. After review of records, it became clear that the average delay in approximately two thirds of our cases was around three hours.

The team efforts, reported out on Friday, March 4 were impressive.
Here are some highlights:

• A new form that will be used by doctors to standardize gestational dating information, and assess the patient for readiness for delivery. This should ensure that patients who arrive at the Perinatal Unit are ready and will not be sent home.
• Education for doctors and nurses on the standard work developed by the Kaizen team to externalize some of the work to cut lead time and ensure patients are ready to deliver.
• Educate O.R. staff on a new process to ensure on time starts.
• Standard work to level load C-Section and Induction patients to spread scheduled cases across available times.
• Do patient education on topics such as skin-to-skin and breast feeding while the patient is in a prenatal visit and prior to admission whenever possible and in a private room otherwise.
• Test a process to pre-register to speed up registration and to have labels and other things delivered before the patient comes in.
• Enhancing patient privacy through the use of private rooms rather than the multi-bed triage room.

The success of this and previous Kaizens is in the work done during the Kaizen week followed by relentless follow up. The Process Owners, Dr. Judy Bliss and Margee Dean will continue to meet to review progress and to ensure that testing is carried out and appropriate adjustments are made.

This Kaizen was led by two of our 2010/2011 Change Agent Fellows, Kandy Heinen and Michael Roetzer. The Fellows, in addition to Kandy and Mike, include Miles Kotchevar, Wendy Katchmar, and Vernita Travis. These Fellows will be leading Kaizens 4, 5 and 6 which are scheduled over the next three months.

Thursday February 17: CCRMC and HC Town Hall Today at Noon

2011-02-17T06:09:00.000-08:00

Greetings,

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 and local budget that challenges us to find new ways to meet 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.

It is with this in mind that I invite you to a Town Hall meeting at CCRMC in Building One, Conference Room One at 12:00 noon tomorrow, Thursday February 17. I will open phone lines to all Health Centers across the county using the Noon-Conference dial-in numbers.

I plan to provide updates and time for discussion on the following:

• Proposed budget submission

• CMS "bridge to reform," delivery system reform incentive pool (DSRIP)

• Contra Costa County Board of Supervisors ordered Sustainability Study of Contra Costa County Regional Medical Center (Hospital) and Health Centers (Clinics), which is currently under way

Please join me for this important discussion.

More very soon,
Anna

Doing Common Things Uncommonly Well...one more time

2011-02-09T00:36:00.000-08:00

Why do we do common things uncommonly well? I've been asked several times recently about the origins of the statement I so often use "doing common things uncommonly well." I have done a brief post about this in the past and decided to post it again for those who are interested.

Without actually asking George Degnan we can’t be sure what may have inspired his association of Contra Costa County Hospital with his prophetic and simple statement:

“We do common things uncommonly well”

George Degnan, M.D., Chief Surgery, Founding Residency Director, County Health Director, Contra Costa County: 1950 – 1980.

Here is an excerpt from a interview conducted by Caroline Crawford, University of California Berkeley (1997) with Henrik L. Blum M.D., M.P.H., champion of public health, social justice and considered to be one of the true fathers of health planning. He served as health officer of the Contra Costa County Health Department from 1950 to 1966.

Not only do I find these interviews fascinating, I find it reveals a great deal about today to read these historical recounts.

EQUITY FOR THE PUBLIC'S HEALTH: CONTRA COSTA HEALTH OFFICER; PROFESSOR, UC SCHOOL OF PUBLIC HEALTH; WHO FIELDWORKER

Crawford: Did the two of you (Degnan and Blum)reinforce each other in the community?

Blum: "In a sense, yes. Yes. I mean, we were constantly friendly enemies or friendly competitors, or something. I remember when the Easter Seal Society came around and wanted us to do something. They were going to put on a big campaign, and the campaign was to state that our county health department had the best crippled children's service in the state. Well, it probably did, but that's nothing to put into a campaign which is going to tell my board that their health department is the
best in the world therefore it won't deserve any significant new funding. I mean, one just can't say stupid things like that.

George was at the meeting. It was in my office, I remember, he was this big handsome guy, and he was listening to these ladies who were driving me nuts. They just could not be talked out of it. I said, "Look here, it's our county, and you're coming from San Francisco and are telling me how to play ball here. We'll get you whatever you want, because we want the same things, but don't come out with this kind of propaganda, like it's the best program in the world. It's insane." They just couldn't hear me. So I got up and walked out, slammed my own door, and left. George, they tell me afterwards, turned to look at these people and he hadn't said a thing all this time and he said, "Well, I think that settles that, doesn't it, ladies?" He was a good ball player, a good card player, a good poker player, and it worked. They came around and did what we wanted. It all worked out very well our way without our telling the world we had the best health department. If you do something like that, you're crazy."

I am drawn to this story when I look at the address plaque of Merrithew Memorial Hospital that hangs on my wall. It underscores the perverse incentive/disincentive-based-system we call American Health Care. American Health Care, like all systems, is designed to get the results it gets; needless pain and suffering, needless death, unwanted waits, helplessness, waste and health care inequity. This design rewards settling for less than the best and reinforces perceptions that county/government owned and operated medical centers are a place of "last resort." This design supports a prevailing cautionary note that whispers (or screams, depending on the day), "Don't tell the world you are great. If you do you something like that you are crazy."

I recognize and am truly grateful that we stand on the shoulders of these great and visionary leaders. I also believe that it no longer serves us to downplay what our system can and does do for our community. A "last resort" is not what I see when I look at our publicly owned and operated health system. I see an integrated health system based on primary care and prevention. I see a dedicated team comprised of employees and members of our community working together, drawing on science and the energy and creativity of each other to continuously improve our great health system. I see a place of hope. I see a place where no one is left out.

I see a place where we do common things uncommonly well.

Anna M. Roth RN, MS, MPH, Chief Executive Officer, Contra Costa Regional Medical Center

Below are some potential sources our Residency Director, Dr Jeremy Fish sent (not clear who said it first as they lived amongst each other) that Dr Degnan may have drawn on.

GEORGE WASHINGTON CARVER
“Learn to do common things uncommonly well; we must always keep in mind that anything that helps fill the dinner pail is valuable.”
George Washington Carver quotes (American. Started his life as a slave and ended it as horticulturist, Chemist and Educator, 1864-1943)

JOHN D. ROCKEFELLER
The secret of success is to do the common things uncommonly well.
- John D. Rockefeller 1839- 1937 , Founder Shell Oil

ORISON SWETT MARDEN
Doing common things uncommonly well.
Orison Swett Marden 1850-1924, American author and founder of Success magazine.

As Jeremy points out, it is interesting and noteworthy that these three men’s lives overlapped.

Thanks for sharing Jeremy.

Perinatal Kaizen Report Out

2011-02-04T18:40:00.000-08:00

Thank you for joining me at the Perinatal Kaizen Report Out this morning in the CCRMC lobby. This was the second of six monthly Kaizen/Rapid Improvement Events targeted to improve processes throughout the perinatal experience in the medical center and health centers.In "Healthy People 2020" released in December of 2010, the U.S. Department of Health and Human Services released the new 10-year goals for our nation's health - and supporting breast-feeding is prominent among them. By 2020, the goals call for increasing the percentage of Baby Friendly Hospitals to 8%. Contra Costa Health Services is committed to providing quality patient-centered care.

As a review, in October 2010 a team of physicians, nurses and social workers from the medical center, health centers, Healthy Start and public health performed approximately 50 patient observations and time studies of the patient experience from the prenatal visits, through delivery and ending with the first post partum visit. From these observations, the team created a current state map of what our patients experience during their care across the entire care experience. The current state was critically evaluated to determine a vision of our future state. Attached below is an A3 which describes the plan for improvement over the next year.This week representatives of the Post Partum Inpatient Care Experience, which includes patient partners, are working together to develop and test improvement strategies for the inpatient Post Partum Patient Experience, including medication safety, education, and tubal ligations.

I will post a summary of the report in the next few days so you can learn more about the work of your colleagues and our patient and family partners as they draw on science and the energy and creativity of each other to continuously improve our health system.

Anna

A mother's lessons: Reflections from Teresa Pasquini

2011-01-30T18:35:00.000-08:00

Presented by Teresa Pasquini
Mother, Advocate, Partner
When invited by Anna Roth, CEO of Contra Costa Regional Medical Center to participate in a Lessons Learned reflective writing activity with a group of local, national and international leaders of healthcare improvement I hesitated. How could my experience with the healthcare system compare to the important work of these great leaders? I had earned a BA in Liberal Studies back in 1977, but I never really used my education in a formal capacity. I had no letters like RN, MA, MD, or PHD behind my name. I was just a mom. But, I forced myself to reject the feelings of insecurity caused by my inexperience, lack of higher education, and professional degrees. I remembered that I was in fact an expert on navigating the chaos of the mental health system and my life experience earned me a PHD in system survival. That lived experience brought me to a Kaizen Event at Contra Costa Regional Medical Center in July of 2009. Before I share my life changing experiences at CCRMC, I need to go back to the beginning of this story.

I became a mom on August 22, 1982. I had a beautiful boy with ten fingers, ten toes, and all of the indications of a healthy baby. My son had 15 visitors on his first day of life. Grandma and Grandpa, Nonie and Papa, Aunts, Uncles, Cousins, and good friends welcomed his birth. A family joined together by the hopes and dreams of new life. It was my first time in the hospital as an adult. The care I received was amazing. The labor and delivery nurses were unbelievable. My husband brought them flowers as a token of gratitude for the care of his wife and newborn. I received a diamond pendant from my husband that I wear to this day commemorating our son’s birth, the day before our 2nd Wedding Anniversary. We were so proud and hopeful for our new family.

After a five month maternity leave, I returned to work briefly, but soon became a stay at home mom. I had secretly always wanted to be a stay at home mom even though this was the new era of the working woman. I had a promising career in business but left it eagerly and I was privileged to stay at home and care for our new son while managing our newly formed construction business.

From the beginning of my pregnancy I received excellent healthcare. Throughout our son’s first couple of year’s life was good. Then little things started happening that now I realize were clearly red flags. A serious speech dysfluency at age 3, too immature to start kindergarten, and failure to read in first grade. All of these warning signs brought special education supports and therapies through 3rd grade. Our request for testing of the school district failed to indicate a severe learning disability which was a relief. Behavior and defiance issues in 5th grade prompted immediate family counseling. Sleep problems began in 6th grade and by 7th grade there were serious emotional issues at play combined with the beginning signs of drug use. We sought immediate help from the pediatrician who had treated our son from birth. We began to navigate a maze of services in one of the most integrated healthcare systems. It was a nightmare. Balancing a business, a marriage, a family, and a serious mental illness was overwhelming at times. The memories are traumatic to recall these many years later.

The reality of our son’s symptoms wreaked havoc on our family which also now included a daughter. I had to take control and become my son’s case manager, a mental health system expert and special education advocate to save his life. I had the resources and ability to do this although not all families are so lucky. Although we were told when our son was diagnosed at 16 with Bipolar Disorder that we would be lucky if he lived past the age of 25, he is still alive today. After multiple involuntary holds, numerous hospitalizations, conservatorships, and several suicide attempts, my son’s mental illness and the mental health system have changed who I am and taught me that I needed support and partnerships to survive.

I joined the National Alliance on Mental Illness, NAMI, a non profit advocacy and education organization of family members of seriously mentally ill consumers. For a couple of years I went to monthly meetings and shared my grief with other families experiencing the same nightmare. We were on the same team that nobody wanted to be picked for and we helped each other and our children survive.

I remember one point in time when I was taken to my knees in pain. It was following one of numerous hospitalizations where I was ignored, my son was ignored and I felt defeated and broken. I knew that I could not control the current system and all of its injustice, but I realized that I could control how I spoke out and fought against the ignorance and discrimination toward families who have loved ones with serious mental illness. I had a Scarlet O’Hara moment from one of my favorite movies, Gone with the Wind. Just like Scarlet cursing the ravages of the War and her pledge to save Tara, “As God was my witness…” I was going to change the mental health system.

I applied for a Family Member position on our local Mental Health Commission. I had no clue what I was getting into or that my life would change profoundly as the result of this volunteer position. After a couple of meetings, I recognized that there was very little public recognition of the harm being perpetuated on families and their loved ones in a very broken system of care. There was mostly talk of the “positive” things being done. I began speaking of the negative things that my family had experienced by the mental health system. The negative versus positive dynamic created a tension that challenged my advocacy work early on as a Commissioner. In order to encourage the benefit of direct action, I wrote an open letter to the Commission in 2008 on the differences of positive and negative tension. That letter read in part as follows:

Dear Commissioners,

…As a mother who has also fought to save my son's life in the mental illness war, I do know the heartache and grief of which our Chairwoman speaks. We have shared our pain and struggles. We share a desire to serve our community and improve the lives of those who suffer, as our son's have suffered. We share a desire to "...influence the system toward positive change even in this tough economic situation."

As human beings, we often share substance, but not always style. It is that distinction that creates the beauty of a group who comes together to solve such an enormous task. It is that distinction that creates the challenge of a group who comes together to solve such an enormous task.

I recently re-read Martin Luther King Jr’s, famous April 16th, 1963, "Letter from a Birmingham Jail," about the importance of confrontation. It is a brilliant piece. The theme is the difference between positive and negative confrontation and their purpose in solving crisis. The letter discusses King's disappointment in the response from the white moderates to his direct-action program. He stated that the "...white moderate, who is more devoted to order than to justice; who prefers a negative peace, which is the absence of tension, to a positive peace, which is the presence of justice..." King wrote, "Actually, we who engage in nonviolent direct action are not the creators of tension. We merely bring to the surface the hidden tension that is already alive. We bring it out in the open, where it can be seen and dealt with. Like a boil that can never be cured so long as it is covered up but must be opened with all its ugliness to the natural medicines of air and light, injustice must be exposed, with all the tension its exposure creates, to the light of human conscience and the air of national opinion before it can be cured.”

Like King, I am not afraid of tension. My deep moral concerns, for the mentally ill and their families, cause me to challenge the power structure and systems that prevent their rightful justice. I don’t believe that tension prevents people from working together productively. I don’t believe that tension prevents progress and change.

As a Commissioner, I seek hope and change. I believe the tension that may arise, from seeking answers from those in power, and expecting accountability, can be constructive. I can not operate as a rubber stamp for those systems that continue to defend minor improvements, for a few, when so many others suffer deeply. Balancing negative peace and positive peace is the challenge before our commission. These are drastic times. Tough questions must be asked. The people we represent deserve the answers. It is the responsibility of our community service to accept that challenge.

Sincerely,
Teresa Pasquini

This letter created drama and further division on our Commission. The pull of the status quo was mighty and I was encouraged to be more collaborative and not use my personal story so much. I took that advice to heart and rejected it in part. This was personal. I would not be silenced about the harm caused to my family, but I sought to find a more respectful way to challenge the status quo and consider the bigger picture. That led me to the July 2009 Kaizen event at CCRMC.

In July of 2009, I was one of two family members asked to participate in a one week rapid improvement event for congestive heart failure. The team wanted to explore the risk factors of CHF for behavioral health/psychiatric patients. As a family member and mental health advocate, I was asked to participate. There was concern about me whispered around the tables and behind closed doors. Cautious warnings were shared about my outspoken, even radical, direct action approach. Fortunately, the Administration of CCRMC took a risk and opened their doors and minds and even encouraged me to push them forward. The first Kaizen was the beginning of a partnership that ignited our shared vision of hope.

We started off strong, excited, with the creation of a mission statement to “transform healthcare to be accessible and welcoming for all” We ventured into discussions that were previously reserved for internal staff meetings. We were now speaking freely of access, safety, errors, and improvement. We were teaching and learning together and laying down the tools that had been failing. We were challenging the status quo and embracing the tension that comes from change. And there was tension.

The tension was often whispered offline or subtly felt in meetings. The staff was not trained to be open with “outsiders” in the room. The patients and families were not familiar with “medical speak.” But, through determination, courage, and leadership, the comfort level increased and lessons were learned. The main lesson learned is to respect each others lived experience and assume good intentions. Remove blame and shame and establish a just culture mentality based on equity of ideas balanced with regulatory demands. If there are tensions, embrace them and fight through them in order to find the benefits for the patients, the families, and the staff who serve them both.

With the creation of our mission statement came the realization that a previous hospital policy was considered to be non accessible and non welcoming for approximately 600 psychiatric patients each month. The consumer and family voice was strong and challenged the administration to consider re-opening the door to the Psychiatric Emergency Service that had been closed five years earlier in order to re-direct psychiatric patients through the regular ER. By working as a team of change agents, the Heatlthcare Partnership helped push this idea forward by electing two of its members to attend the weekly Executive Operational team.

One of our community partners and I, representing consumer and family voices, joined the inner circle of the hospital leadership to further the opportunities to unite in innovative, strategic, operational change. The first outcome of this effort was the decision to convene a Value Stream Mapping Event for Behavioral Health. The Executive Team supported and teamed with its community partners to explore this idea through science. This effort resulted in the re opening of the Psychiatric Emergency entrance in May of 2010 for direct access to medical and psychiatric care. This has recently been acknowledged by the Joint Commission as an example of excellent patient care.

Opening doors and opening minds to the possibility of systemic improvement through the use of patient and family member advisors has been a primary aim of the Contra Costa County Healthcare Partnership. Since July of 2009, a small group of patient, family and staff have met weekly to develop a shared vision that would transform the delivery of healthcare in our local public system and beyond. We have learned that it is not possible to transform, improve, or integrate our system if we continue with hospital/clinic centric, hierarcachael or territorial thinking. We discovered that we must look behind the doors of our homes, homeless shelters, hospital floors, clinics, ERs, Board rooms, other health divisions, and the CEO’s office in order to prepare ourselves for the cultural shift. We have been doing that in Contra Costa these past months.

It is my honor to share my story and reflections of my journey. I thought back on our family experience during a recent visit to our son while my husband and I drove a total of 5 hours round trip. Psychiatric patients are not often treated near their community, but in far away placements. When we arrived, our 28 year old son came running with such happiness at the sight of our car and stopped at a high wire fence, waving to us. It reminded me of when he was in kindergarten and he used to run to the school yard fence to greet me. The fence reminded my husband of a prison and it took him a while to get out of the car and head into visit with our son in this locked psychiatric facility. My husband still struggles with his inability to rescue his son from his symptoms and the system. They have stolen his son’s freedom, dignity, and often the will to live. How do we hold on to hope when our son continues to suffer by a broken, fragmented, under funded mental health system? I choose to seek partnerships with other change agents who believe that all deserve the right care at the right time. Contra Costa Regional Medical Center and Clinics have offered our patients and families a trusting, authentic, shared learning experience and partnership.

I have exposed my life and story, to the community, in order to help make positive systemic changes. I have interfaced with all layers of the system to teach and learn. I have committed to the Healthcare Partnership with Contra Costa Health Services because of its focus on the whole person and the whole system. I believe in a systemic view when considering transformation. We must unify and empower all who intersect in the care of our most vulnerable patients.

My family has had the misfortune of being exposed to every level of care provided on the continuum of mental health services. I have been to the dark corners of the system. Some were in my own home. Some services were private based care, others were public. I have challenged the hierarchical cultures of both systems, not to be rude or disrespectful, or radical, but to shine a light. I have seen too much and know too much to ignore the realities that cause consumers and families to destruct and die. As JFK said, “We are not here to curse the darkness, but to light a candle that can guide us through that darkness to a safe and sane future. For the world is changing. The old era is ending. The old ways will not do.”

We need to speak the truth, hear the truth and go and see the truth. Constancy of purpose and focused direct action will create a system where the consumers, the families and the providers work in a true partnership. No politics, no discrimination, no special interests, no egos, just pure ethical healthcare based on the needs of the patient. I have seen it happen. It is possible.

Paul Batalden's idea, "virtually" speaking: A tapestry of lessons and reflections

2011-01-28T05:17:00.000-08:00

I am responding to a suggestion presented by Paul Batalden in the recently published Lessons Learned in changing healthcare... and how we learned them. He notes that we are surrounded by leaders who have lessons to share. He states that we too could engage in a process much like they did and learn together. Below you will find a slightly modified version of an email invitation I sent to some colleagues. It's self-explanatory so I will move to my point. I hope you will reach out to those in your network. Please feel free to take my invitation and modify it for your own use or write your own. Additionally, I hope you will engage in this virtual test. Please feel free to join in and comment or send something you would be willing to share.

Here is the email invitation I sent:

I am writing you today because each one of you has inspired me. Your support and the lessons you have shared with me have made a difference to me and in my life’s work, to serve those most vulnerable and to stand up for what I believe in - to never settle. I have turned to you when I needed guidance and I have tried to offer the same in return. It is in this spirit that I reach to you now. While reading Lessons Learned in changing healthcare... and how we learned them 2010: 9-12 edited by Paul Batalden I was moved to action. In his Introduction: Moving Forward Together through Reflection and Sharing, Batalden addresses the pressures we all face in the ever changing environments in which we work. I don’t need to list them out to you as I know you are all too familiar. He notes that there are people all around us leading change and learning lessons. It’s a relatively quick and highly relevant read which I have linked here.

I loved reading the lessons from the amazing leaders that Paul brings together so brilliantly. Presented are succinct stories that present practical lessons that we can all apply in our work environments.

Here is an excerpt from his Introduction:

"When all the authors had submitted their chapters, we collated the learnings across the speakers and recognized that, together, they form a "tapestry" of lessons. We kept probing for the underlying threads that seem to weave themselves through the presentations, and we explore some of the most prominent in the last chapter.

.... step back from these presenters and their lessons and realize that in your own community, in your own network, a process similar to this one could be undertaken, allowing you and your colleagues to inquire of each other about the lessons that have been helpful to you. Explore how your particular setting contributes to the way change is learned and how it happens.

… Through introspection, we can recognize that each change leader has had to create a personal frame of understanding to make sense of what he or she faces as the processes of building knowledge, taking action and reviewing and reflecting become real. Naming the lessons and reflecting on how they were learned is an exercise in contemplation and self-discovery. Sharing these thoughts in conversation with others allows them to be examined, refined and further developed. The opportunity for learning about leading change in today's healthcare is all around us.

The collected lessons and how they were realized offer significant counsel for these times of change. But of potentially equal value is insight into the process of eliciting them. What we did in our local setting, you can do in yours. Everywhere that leader are at work, there is the potential for a "learning laboratory" to help others develop their own leadership knowledge and skills. This is a book about leading from within the frames of personal experience and, through conversation and interaction, across them.

Whom should you invite? We asked physicians who are active as leaders; you could ask nurses, administrators, laboratorians, therapists, social workers, nutritionists, pharmacists – any healthcare professionals working as leaders. The key is the process of reflecting on the experiences: naming the lessons and exploring the means by which they were learned. Sharing them publicly enables others to see the real journeys involved in becoming a leader and, through conversation and interaction, to form communities of individuals engaged in that practice. Watching the process allows us to see that we are all immersed in the phenomenon of leadership development."

As I read the insights presented I thought of you. I recall your stories and your words of wisdom. Some of you used theory to teach me, while others offered a story about your experience. In every case you offered a genuine and thoughtful lesson in the spirit of sharing what you have learned along your journey in the hopes it would be of help to me. I know I may not have always gotten back to you, but I want you to know you did help me and you made a difference.

Here is the real purpose of my email:

I would like to extend an invitation to you to share a lesson with me and others about something you have learned while leading change in your setting. I would also like to do as Paul Batalden suggests and share it publicly. In the past, I have had guest authors on my blog “Doing Common Things Uncommonly Well” and I received positive feedback from both the guest authors and readers.

My specific ask: Please consider writing a one (preferable) or two pages (shorter seems to go over better in the blog world and I know how busy you all are) about a reflection or something you have learned on your journey. It could be something you have already written or something new. I will then post your entry on my blog, with you as the author (or, for those who wish, I can open the blog and you can self-post). Of course I hope you would consider placing the shared lessons and reflections on your blog, Facebook page, Linkedin site, Ning, etc… as well. The aim is to allow others to share in the privilege that I have had, to learn from you. Most importantly, we can learn together!

I end my invitation with a one final quote from Batalden, “There is no claim of a magic five realizations – only the recognition of the truth that emerges from reflecting, listening, having conversations and connecting to the experiences of others within our own lives.”

Please join me. I will start by sharing a reflection I once wrote. You can find it below.

With my deepest respect and gratitude for your support, friendship and all you have taught me.

Anna

Shifting from “having more” to “being more.”
Presented by Anna Roth
CEO, Contra Costa Regional Medical Center and Health Centers

In a call to action, Tim Brown, CEO of the Global Design and Innovation Consultancy IDEO, asks if we could shift our thinking from having more to being more*. A curious question don't you think? He further asks if this question only has relevance to those who "already have lots?"

We don’t have to look far to see possible applications of this thinking all around us. Rather than look for more resources, what if we could get more productivity out of the resources we already have? This is very much aligned with Lean thinking and supports engagement in process redesign. The principle of accomplishing more with the same amount of resources or inputs (simpler still, be of more value with less), or thinking leaner, has been well accepted. Yet if it's such an easy concept, why is change so slow and so difficult? Why do we have experts - whole departments in some cases - dedicated to leading change? The answer may be a bit more personal than we like. What if we are part of the problem? Could this be why W. Edwards Deming and Taiichi Ohno (大野耐) stressed that in order to make real change we must first change ourselves? They said - and they are well supported by many others - that all change begins with the individual. More explicitly, all change starts with me/you.

I once gave a talk with my esteemed colleagues Dr. Jason Leitch and Dr. Peter Lachman on transformation. We presented a common theory, The Model for Improvement. We then provided three distinct examples of the application of our theory in transformation efforts taking place on very different scales: a hospital, a county, and a country. The take-home message was that all change, no matter how big or small, occurs at the point of the individual experience. In short, no matter how many policies or change events you engage in, if it doesn't result in a change at the point of the actual experience you are trying to alter (in this case at the point of care), it isn't change, it's simply activity. In order to determine if the change you are making is in fact an improvement, you must have a measurement method (measurement is a topic for another post altogether.) My point is that the examples we presented support the idea that all change, whether on a single unit or spanning a nation, begins with changing ourselves.

Let's think about the idea that we as individuals are the target of change. In your setting, who is it that is most likely to NOT let go of what they have? Looking at it another way, who is deriving power or authority in your environment/context from institutional inertia - commonly known as the status quo? Whose identity is coupled with mastery of the current state? Are they likely to give it up? I'm not targeting any particular person or group. I'm simply asking. Who do you think is open to change and who is least likely to really change (the haves or have-nots)? This can get particularly tricky if one can siphon off the new and exciting parts of an innovation/new thing AND keep what they already have. It's a tough question, but I do try and ask myself, where do I fall? Perhaps it's easier to draw on someone else to think this through?

Marshall Ganz...
I saw him speak at the IHI National Forum year before last (my favorite event of the year) and he was downright moving. I found his plenary address so much more than a speech. Were you there? Did you hear it? He speaks not of having more, but of being more.

On the uncertainty of change and the pull of the status quo - the safety and comfort of what we know - he writes the following:
"When we face uncertainty, we often feel conflicting emotions. On the one hand, we may be fearful - things will go wrong, we will fail, others will see. We then retract, metaphorically at least, to protect ourselves from danger. On the other hand, we may be curious - the unexpected can be exciting, bring new opportunities and new growth. So faced with the challenge of learning to act in new ways, we may retreat into the security what we know, or, at least, what will reduce our anxiety; or we may risk leaning into the uncertain. We may learn best when we can do both: secure ourselves in enough certainty that we have the courage to risk exploration. Learning to balance security and risk is not only key to our own learning, but to the learning of those with whom we work, for whom security may be more elusive and the risks greater."

I understand and believe that change is scary. Many will retreat. Our perception of ourselves, whom we believe others approve of and depend on, is often that which we spend most of our time being. But what about our dreams? I know this sounds like a bit of starry-eyed-babble, but what if we try and see ourselves as what or who we really want to be? Better yet, what if we could be that which we are capable of? Do we even know what that is? What if everything we think we are supposed to be were washed away? Dr. Robert Schuller asks, "What would you attempt to do if you knew you would not fail?" What would I do? I'll admit I don't have the answer. I have many questions. Is what I do based on being something or having something? Do I seek knowledge or mastery of the current state in order to understand how to change it fundamentally for the better? Or do I seek understanding of the current state in order to better know how I can achieve rewards from it? Aren't these awful questions? Is it possible I choose superficial success, such as having more because it's too scary to try and be more? Is it possible that the barriers I impose on myself serve a very important purpose: protection from the risk of failing or experiencing pain?

For today that's enough of what Tim Brown describes as "head-hurting thinking." If the answer is to come, it will only be through synthesis of all those divergent ideas and belief systems surrounding what it means to move beyond "having more" to actually "being more." Who knows, maybe having a little fun is part of it? I already confessed I had no answers. I only have starry eyes filled with hope.-

Workforce Safety and Vitality: Request for your input

2010-12-26T08:35:00.001-08:00

Greetings,

Workforce safety is a growing concerns facing health care systems across the nation. The need for a safe environment for all is paramount. For an environment to be safe, we must listen and respond to those who have their feet on the floor -- the employees.

I am seeking your ideas and feedback to design and build the necessary structure for continuous improvement of your work environment. I am proposing a dedicated Center for Workforce Safety and Vitality. The Center would develop a transparent and accountable process to support and amplify the voice of employees and meet their identified needs. For the Center to be truly employee-focused, I need your help

Below, or in your email, you will find a draft of a proposal for the Center. Please consider this document as a draft only as I am eager for your feedback. Please send your suggestions to Tess O'Riva, either by email at teresa.o'riva@hsd.cccounty.us or transmittal to my office directly by 1/10/2011.

As we look to a new year and new opportunities to improve, I welcome your prompt feedback and creative thinking.

With respect,

Anna
Center for Workforce Safety Proposal for Employee Review

Reflections

2010-12-24T08:41:00.000-08:00

“A line has been drawn in our lives and there is no going back to the time before the line – we can only move forward or stay stuck.” Dr. Joel Fay

Each of us is charged with making meaning out of the events that happen to us. Our experiences greatly influence our subsequent actions for a lifetime. On October 25, 2010, the unthinkable happened. On of our own was assaulted during the course of her work and succumbed to her injuries. During the debriefing which occurred in the days following, Dr. Joel Fay reminded us all – “A line has been drawn in our lives and there is no going back to the time before the line – we can only move forward or stay stuck.”

I have watched as we try in each of our own ways to make sense of this senseless act. Deputies and health staff have established an even deeper respect and team spirit. The deputies are now defined as part of the treatment team. We have examined our joint practices to begin re engineering how the work flow moves through the detention facility. Deputies and health staff sat together in Critical Incident debriefings. There is a difference in the way we treat one another.

Although in very early stages, we are in conversation about how to design a safer workspace for all staff. The Sheriff’s Office and Contra Costa Health Services have forged a stronger and more united bond not only to ensure there is safety and respect, but to reestablish where the two departments have common goals. We have begun discussions with the labor representatives and Risk Management to provide feedback in our process as we move along. In the next year, we will be developing a Center for Workforce Safety and Vitality. Still in the design and feedback stage, this is an essential step to new and redesigned patient care while ensuring that our system is a safe and rewarding place to work.

“I now know Cynthia through your stories.”Jim Conway

Jim Conway joined us for some of those conversations. He came to assist us in problem-solving and to provide his expertise on ways we could continue to provide safe and excellent service without compromising quality of care. As the detention staff and others met with him over the course of two days, he was struck by the deep respect they had for each other and their work. Evident was a committment to move forward in a meaningful way creating an enduring legacy to honor Cynthia and all who are committed to our mission. Before he left he thanked the detention nurses commenting “I now know Cynthia through your stories.”

There was outpouring of concern by the inmates. That such a grievous act could be performed by a fellow inmate was unacceptable. They, too, mourned her loss. They rallied together to contribute to the fund set up in her memory and created a work of art that will hold a prominent place at Martinez Detention Facility.

It was moments such as these, and many others, that spirit and strength of our great system shined through.

During this time of the year, my heart extends to Cynthia’s family who are without her. I can not imagine their loss. They are in the hearts and minds of many people. We will not forget Cynthia, nor will we forget you. Like her, you have chosen to offer your skill and spirit in service to our community and I am honored and privileged to stand with you as we welcome a New Year and new opportunity.

Anna

System Redesign

2010-12-22T14:30:00.000-08:00

I have been asked several times to post this again and have been waiting for today to do so. Remembering 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 and the teams you are on in your local work areas. Some of you call it the IHI work. Some of you may know it as the work we have done on Lean. Others still may not call it anything specific, but it is the output of the team efforts you are all engaged in across our great health system. Redesign can be found everywhere. I found a number of people who said you didn't need more resources but you need to find different ways to do the right thing, a viewpoint supported by Steve Spear 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 better, 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.

Perinatal Kaizen 1 Report Out

2010-12-17T11:28:00.001-08:00

The most recent Kaizen was aimed at eliminating the gap that exists for mothers and babies who are delivered by cesarean section. The goal was to ensure at least 15 minutes of skin-to-skin time for mothers and babies in the first 60 minutes of life. The average time for mothers who delivered vaginally was less than 15 minutes to skin-to-skin, as opposed to mothers who delivered via cesarean who on average waited more than 3 hours for 15 minutes or more of skin-to-skin with their child. Increased skin to skin has been shown to reduce hemorrhaging and anxiety, increase the likelihood of breastfeeding, increase the maternal-child bond (we learned that fathers feel more bonded as well), and reduce pain.
In other words, the team focused on much more than health care, they focused on HEALTH!
I found it interesting and refreshing that teams spent an entire week trying to get "us" (health care delivery) out of the maternal-child experience and instead support health, which we we have learned is best accomplished not by us, but by us supporting the mother and child.

I will be posting a video on the most recent work and what patients are saying very soon.

WIHI on The Patient Activist

2010-12-13T06:46:00.000-08:00

The Patient Activist
Thursday, December 16, 2010, 2:00 PM – 3:00 PM Eastern Time
Guests:
Bill Thatcher, Executive Director, Cautious Patient Foundation

Barbara Balik, RN, EdD, Senior Faculty, Institute for Healthcare Improvement

Tricia Pil, MD, Medical Writer, University Health Sciences Project Coordinator, Patient Activist

Charles Maclean, PhD, Founder, PhilanthropyNow

When you think of a patient activist, what sort of individual comes to mind? Someone who has been harmed by health care or who has a loved one who’s experienced an error? Someone who’s filed a lawsuit against a hospital? Someone who’s angry and still waiting for answers... and an apology? If these are your impressions, OR your experiences, OR the experiences of someone you know, they are indeed features of what’s motivating a new “army” of individuals and groups to insist on a far safer and more patient-centered health care system – both in the US and internationally.

What may be less well understood is how sophisticated this loose network of “fellow travelers” has become. Many groups now work directly with health care organizations, especially hospitals, on the redesign of care, on shared decision making, and on far more reliable ways of communicating vital information to patients and families. The mushrooming of patient advisory councils is also another sign of active engagement with providers and administrators on what’s working, what’s not, and how to improve.

Some 50 patient activist leaders travelled to IHI’s National Forum in Orlando, Florida, to share experiences and to consider ways to combine forces to be that much more effective. Come find out what happened at this first-ever summit by tuning into WIHI on December 16 and hearing from Bill Thatcher, Barbara Balik, Tricia Pil, and Charles Maclean. Each has a story to share and a role to play, as do you, to make health care safer and more effective. WIHI host Madge Kaplan invites you to come learn and add to the ideas and the blueprint for change.

To enroll, please click here.

About WIHI
WIHI is an exciting "talk show" program from IHI, connecting you to the cutting edge of health care improvement. It’s free, it’s timely, and it’s designed to help dedicated legions of health care improvers worldwide keep up with some of the freshest and most robust thinking and strategies for improving patient care. A 60-minute program is offered live every other week, or you can listen to recordings of the broadcast later at your convenience. WIHI is your opportunity to meet up with colleagues who want to improve patient care and shape a true health reform agenda.

Take-aways from Maureen Bisognano's Keynote at IHI's 22nd Annual Forum

2010-12-11T08:19:00.000-08:00

"Together, our destination is the Triple Aim. It won’t be easy. It’ll take courage, new leadership skills, new care models, new business models, a commitment to equity, and new assumptions:

• Health care systems can be sustained with modest annual cost increases; and
• There is enough capacity in the systems to provide equitable, high-quality care to all; and
• Solutions to national problems will be designed and implemented at the local level"
Maureen Bisognano, President and CEO, Institute for Health Care Improvement

With ease and grace that I have come to associate with Maureen and her leadership, she called on us to listen. Listen to those we serve, listen to the workforce and listen to ourselves. The theme of this years forum was to 'Take Care.' I was honored to join my colleagues and fellow IHI Fellows in learning and collaboration. I love the forum because you are truly surrounded by amazing people who are actually changing the world for the better.

I was particularly excited about the patient and family delegates who joined the conference this year and the focus and challenge to us all to look to the single greatest untapped resource in health care, patients and families. They included a morning devoted to bringing together over 50 Patient Activists and Partners in Quality and Safety. The aim was to bring together activists to tell the healthcare system (us) how it (we) must change to lower cost, reduce waste, and improve their care without harm, and not mince words doing so. Many hospital chiefs say they are now preparing to put patients on their boards and executive teams.

Just imagine the possibilities....I think I like where this is going!

CCRMC and HC Perinatal Value Stream Mapping- blog post from NAPH

2010-12-11T07:38:00.000-08:00

Here is a post from Lindsey Marshall at NAPH, who recently joined us at CCRMC to learn more about our improvement efforts.

"During the week of October 25, I had the opportunity to visit Contra Costa Health Services in Martinez, CA, to observe a week-long “Kaizen” quality improvement event focusing on perinatal care. The Kaizen method, derived from Japanese management concepts, means change (“Kai”) to become good (“Zen”).[1] Above all, the Kaizen method focuses on helping employees learn to spot and eliminate waste in business processes.[2] Over the past year, Contra Costa has adopted the Kaizen method to support them in improving key service lines, including psychiatric care programs and perinatal care. While attending this event, I learned how Contra Costa is using Kaizen to identify waste and strategies for improvement in perinatal care. I also came away with observations about the value of this type of work for safety net hospitals...." Continue reading the entire post on the NAPH blog Safety Net Matters.

Joint Commission Survey

2010-12-03T18:59:00.000-08:00

Contra Costa Regional Medical Center and Health Centers: Caring for and improving "the health of all people in Contra Costa County with special attention to those who are most vulnerable to health problems."

I am pleased to share with you that The Joint Commission completed their week-long survey of the hospital and health centers. The findings are remarkably positive and the surveyors noted many times that your commitment to quality and safety was extraordinary.

I want to thank all of you and our community partners for your commitment to our mission. The strength of our system is grounded in the shared vision of the Contra Costa County residents, leadership, dedicated and skilled staff, and our governing board, the Contra Costa County Board of Supervisors.

Please take a moment to accept my sincere praise and gratitude. I am proud to work with you all as we continue our journey of continuous improvement to safe, effective, patient-centered, timely, efficient, and equitable care for all.

Today we celebrate, tomorrow we accelerate.

Anna

Perinatal Rapid Improvement Event # 1 begins Monday November 29

2010-11-28T08:00:00.000-08:00

“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...
Anna

Eliminating harm: The science of delivery

2010-11-27T18:16:00.002-08:00

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.

Anna

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?

2010-11-27T18:16:00.001-08:00

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 www.engagewithgrace.org. 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.

CCRMC Improvement Academy: Opportunities and Challenges in Health Care Reform

2010-11-15T11:56:00.000-08:00

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

Sad News

2010-10-28T13:20:00.000-07:00

It is with a heavy heart that I share the tragic news that one of our own has been killed in a senseless act of violence. Cynthia Palomata, a longtime and dedicated member of our nursing staff, was brutally attacked by an inmate she was trying to assist at the Martinez Detention Center. She suffered a severe head injury and succumbed today.

As we all struggle to cope with this tragedy, we keep Cynthia and her family in our thoughts and prayers. We know that her family will need our support so I will update you as soon as possible with information on how we all can help.

Staff safety is critical to our mission, and we are working closely with the Sheriff’s Office to evaluate safety procedures.

In the meantime, we also need each other’s emotional support, and I encourage staff to call the Contra Costa Crisis Line for confidential counseling anytime at 1-800-833-2900. Employees can also contact our Employee Assistance Program to set up an appointment for counseling if needed at (925) 930-3661.

As I learn more information, I will share it with you.

With deepest sympathy,
Anna

Anna M. Roth RN, MS, MPH
Chief Executive Officer
Contra Costa Regional Medical Center
and Health Centers
333 C Street
Martinez, CA 94553

A call to action in the perfect storm

2010-10-22T14:49:00.000-07:00

This week for National Quality week I had the wonderful opportunity along with other safety net leaders to guest blog for the National Association of Public Hospitals.

The following is an excerpt from my post:

The Perfect Storm
Anna M. Roth CEO, Contra Costa Regional Medical Center and Health Centers

With increasing demand, those working to preserve and enhance the safety net will need new levels of leadership skill, improvement knowledge, and systems-thinking to face the significant challenges that lay ahead.

Frequent changes in leadership and direction - as well as inaction when change is clearly needed - have resulted in a culture of mistrust in health care and hierarchical control rather than shared decision making and participative improvement. Too often, when thinking of the safety net, a “last resort” image prevails rather than a place of excellence, hope and recovery and as a place where no one is left out. To add to the challenge, there appears to be a lack of emphasis on the acquisition of continuous quality improvement skills among the safety net workforce...Read the full post at http://www.naph.org/Main-Menu-Category/Newsroom/Safety-Net-Matters-Blog/The-Perfect-Storm.aspx

Have you had your flu vaccine yet?

2010-10-15T08:52:00.000-07:00

Did you know that only about half of all health care workers get a flu shot? We can do better.

Flu Vaccination information is available at cchs.org

Here is Dr. Alan Siegel and his band "Rhythm Method" performing at CCRMC a novel version of “Bad Case of Lovin’ You,” re-purposed with a familiar and important message: get a flu shot before symptoms start to appear.Syria T. Berry (vocalist), Alan Siegel (guitar), Duane Campbell (bass), Michael Greene (drums), Bruce Reingold (trumpet)

This year, there is one flu vaccine available which protects against 3 flu viruses including H1N1. Everyone 6 months and older is recommended to get vaccinated. Children under 9 years of age will need 2 doses of flu vaccine, one month apart IF this is the first time that the child is receiving flu vaccine, or if the child did NOT receive any H1N1 vaccine.

Where to Get Vaccinated

Flu vaccine is beginning to be available throughout Contra Costa County. To get a flu vaccine:

Check with your regular health care provider
•Kaiser members can call the Kaiser Flu Hotline: 1-800-573-5811 (1-800-KP-FLU-11).
•Community clinics are also offering flu vaccine - call the clinic for details.
Flu vaccines for Contra Costa Health Center patients (must bring cranberry colored card)
•Walk-in Flu Clinics will be held from October 18 - October 22, 2010
Tdap (whooping cough) and pneumococcal vaccine will also be available to those who are eligible.

◦Antioch Health Center: Monday-Friday 12-1 p.m., Health Center Hallway
◦Pittsburg Health Center: Monday-Friday 1:30-4:30 p.m., Health Center Lobby
◦Concord Health Center: Monday-Friday 12-1 p.m., Health Center Lobby
◦Martinez Health Center: Monday-Friday 9 a.m.-12 p.m., Health Center Lobby (2nd floor)
◦Richmond Health Center: Monday-Friday 9 a.m.-12 p.m., 1st Floor Conf Room 1603A
◦For Bay Point, Brentwood and North Richmond Health Centers - Appointment Required, call 1-800-495-8885

•Scheduled flu clinic appointments will be available October 25 - December 3, 2010 (As supplies last)

Call 1-800-495-8885 to schedule an appointment.
cchs.org

Links of interest:

•flucliniclocator.org (check clinic for details)

•Free Public Health Clinics - Wednesday, November 10th from 1pm-7pm at locations throughout the county. Tdap and pneumococcal vaccine will also be offered at these clinics. See locations (PDF).

CCRMC Improvement Academy: 5s Reports Thursday, October 7

2010-10-06T07:13:00.000-07:00

You may have seen teams in the medical center who are applying 5S in their work areas.

Improvement Academy Participants will report on their results on Thursday October 7 at 9 AM at CCRMC Building one, Conference Room One. All are encouraged to join.

Of note: Next week we are merging the medical staff noon conference learning sessions with the Improvement Academy. The academy will meet every Thursday at noon at CCRMC Building One, Conference Room one.

More very soon…

Here’s a review of what 5S is.

Seiri (整理) Sorting
Going through all the tools, materials, etc., in the plant and work area and keeping only essential items. Everything else is stored or discarded.

Seiton (整頓) Straighten
A key distinction between 5S and "standardized cleanup" is Seiton. Seiton is often misunderstood, perhaps due to efforts to translate into an English word beginning with "S" (such as "sort" or "straighten"). The key concept here is to order items or activities in a manner to promote work flow. For example, tools should be kept at the point of use, workers should not have to repetitively bend to access materials, flow paths can be altered to improve efficiency, etc.

Seisō (清掃) Sweeping
Systematic cleaning. At the end of each shift, the work area is cleaned up and everything is restored to its place. This makes it easy to know what goes where and have confidence that everything is where it should be. The key point is that maintaining cleanliness should be part of the daily work - not an occasional activity initiated when things get too messy.

Seiketsu (清潔) Standardizing
Standardized work practices or operating in a consistent and standardized fashion. Everyone knows exactly what his or her responsibilities are to keep above 3S's.

Shitsuke (躾) Sustaining
Maintaining and reviewing standards. Once the previous 4S's have been established, they become the new way to operate. Maintain the focus on this new way of operating, and do not allow a gradual decline back to the old ways of operating. However, when an issue arises such as a suggested improvement, a new way of working, a new tool or a new output requirement, then a review of the first 4S's as appropriate.

If you would like to get involved please let your supervisor know.

Kaizen Report-Out Today in the CCRMC Lobby at 10 AM

2010-09-24T06:51:00.001-07:00

Behavioral Health and Safety System Kaizen teams will report back to the organization today at 10 AM in the CCRMC Lobby.

At the report-outs, teams made up of staff and community members will share with you the progress they continue to make to streamline operations and improve the patient experience at Contra Costa Regional Medical Center. I believe that the effects of these improvement efforts will have a lasting impact on the health of our community.

Please support the work of your colleagues and our patient and family partners as they draw on science and the energy and creativity of each other to continuously improve our health system.

Anna

A new day in American Health Care

2010-09-23T05:36:00.001-07:00

“We will go through the gate. If the gate is closed, we will go over the fence. If the fence is too high, we will pole vault in. If that doesn’t work, we will parachute in. But we are going to get health care reform passed.”
-House Speaker Nancy Pelosi, March 23, 2010

Many of the provisions of The Patient Protection and Affordable Care Act take effect today. The provisions contain protections for consumers and for many of the nation's most vulnerable and in need of health care. I realize there are mixed feelings about the reform legislation. Many may feel this is too little, while others may disagree with health reform altogether.

I'm grateful we've moved from recognition of the problem and talking, to acceptance of responsibility and action to improve our nation's health system. Like most change, I believe we will test and iterate our way forward. I'm relieved the work lies before us and that the time for action is now.

More very soon,
Anna

In case you missed it from my earlier post this week:

For Plan Years Beginning On Or After September 23, 2010, Privately-Insured Consumers Will Have The Following New Protections:

1. Your health coverage cannot be arbitrarily cancelled if you become sick
Up until now, insurance companies had been able to retroactively cancel your policy when you became sick, or if you or your employer had made an unintentional mistake on your paperwork. Under the new law, health plans are prohibited from rescinding coverage except in cases involving fraud or an intentional misrepresentation of facts.

2. Your child cannot be denied coverage due to a so-called pre-existing condition
Each year, thousands of children who were either born with or develop a costly medical condition are denied coverage by insurers. Research has shown that, compared to those with insurance, children who are uninsured are less likely to get critical preventive care, including immunizations and well-baby checkups. That leaves them twice as likely to miss school and at much greater risk of hospitalization for avoidable conditions.

The new law prohibits insurance plans both from denying coverage and limiting benefits for children based on a pre-existing condition. This protection applies to all health plans, except “grandfathered” plans in the individual market. These protections will be extended to Americans of all ages starting in 2014.

3. Your child up to age 26 can stay on your health plan
Young people are the most likely to be uninsured – with currently one in three young people having no health coverage. One reason is that young people are less likely to be offered coverage through their jobs. Under the new law, insurance companies are required to allow young people up to their 26th birthday to remain on their parents’ insurance plan, at the parent’s choice. This provision applies to all health plans. (For employer plans, only those young people not eligible for their own employer coverage receive the benefit, until 2014, at which time all young people up to age 26 are eligible.)

4. Your health plan cannot put a lifetime limit on your health coverage
Millions of Americans who suffer from costly medical conditions are in danger of having their health insurance coverage vanish when the costs of their treatment hit lifetime limits. These limits can cause the loss of coverage at the very moment when patients need it most. Over 100 million Americans have coverage that imposes such lifetime limits. The new law prohibits the use of lifetime limits in all health plans.

5. Your health plan’s annual limits are phased out over three years
Even more aggressive than lifetime limits are annual dollar limits on what an insurance company will pay for health care. Annual limits are less common than lifetime limits – but 19% of individual market plans and 14% of small employer plans currently use them. The new law phases out the use of annual limits over the next three years. For plan years beginning on September 23, 2010, the minimum level for the annual limit will be set at $750,000. This minimum is raised to $1.25 million in a year and $2 million in two years. In 2014, all annual limits are prohibited. The protection applies to all plans, except “grandfathered” plans in the individual market.

Beginning September 23, 2010, Consumers Purchasing NEW Plans Will Have The Following Additional Protections:

6. You have the right to key preventive services without deductible or co-payments
Today, too many Americans do not get the high-quality preventive care they need to stay healthy, avoid or delay the onset of disease, and lead productive lives. Nationally, Americans use preventive services at about half the recommended rate.
Under the new law, insurance companies must cover recommended preventive services, including mammograms, colonoscopies, immunizations, and pre-natal and new baby care, without charging deductibles, co-payments or co-insurance.

7. You have the right to both an internal and external appeal
Today, if your health plan tells you it won’t cover a treatment your doctor recommends, or it refuses to pay the bill for your child’s last trip to the emergency room, you may not know where to turn. Most plans have a process that lets you appeal the decision within the plan through an “internal appeal” – but there’s no guarantee that the process will be swift and objective. Moreover, if you lose your internal appeal, you may not be able to ask for an “external appeal” to an independent reviewer. The new law guarantees the right to an “internal appeal.” Also, insurance companies will be prohibited from denying coverage for needed care without a chance to appeal to an independent third party.

8. You have the right to choose your own doctor
Being able to choose and keep your doctor is highly valued by Americans. Yet, insurance companies don’t always make it easy to see the provider you choose. One survey found that three-fourths of the OB-GYNs reported that patients needed to return to their primary care physicians for permission to get follow-up care. The new law: 1) guarantees you get to choose your primary care doctor; 2) allows you to choose a pediatrician as your child’s primary care doctor; and 3) gives women the right to see an OB-GYN without having to obtain a referral first.

9. You have the right to access out-of-network emergency room care at in-network cost-sharing rates
Many insurers charge unreasonably high cost-sharing for emergency care by an out-of-network provider. This can mean financial hardship if you get sick or injured when you are away from home. The new law makes emergency services more accessible to consumers. Health plans will not be able to charge higher cost-sharing for emergency services that are obtained out of a plan’s network.

Kaizen Report-Outs are Friday September 24th at at 10 AM in the CCRMC Lobby

2010-09-22T07:25:00.000-07:00

Behavioral Health and Safety System Kaizen teams will report back to the organization this Friday at 10 AM in the CCRMC Lobby.

At the report-outs, teams made up of staff and community members will share with you the progress they continue to make to streamline operations and improve the patient experience at Contra Costa Regional Medical Center. I believe that the effects of these improvement efforts will have a lasting impact on the health of our community.

Please support the work of your colleagues and our patient and family partners as they draw on science and the energy and creativity of each other to continuously improve our health system.

Anna

Consumer Protections take effect Thursday, September 23- United States Representatives Miller and Giramendi at CCRMC

2010-09-21T05:57:00.000-07:00

U.S. Representative George Miller (D-Martinez) and John Garamendi (D-Walnut Creek) joined Bay Area residents today at Contra Costa Regional Medical Center to announce major new health care consumer protections that take effect this week under the historic health care law enacted this spring.

For example, no longer will insurance companies be able to cut off your insurance just because you are sick, or set annual or lifetime caps on your coverage, or deny coverage to children with so-called pre-existing conditions.

The nine new protections in a Patient’s Bill of Rights were designed to put patients and their doctors in charge of medical decisions – not insurance companies. They will take effect for plan years that start on or after this Thursday, Sept 23rd.

This means that these consumer benefits will be in effect during the next insurance ‘open season’ for consumers who receive coverage through an employer or the next time a consumer re-enrolls in or purchases a policy from an insurer.

“These are real protections against insurance company abuses,” said Miller, who co-wrote the Affordable Health Care Act. “Just six months after our historic health insurance reforms were signed into law, important consumer protections are going into effect. These protections mean that never again will your insurance run out or be taken away from you when you need it the most. And never again will a sick child be denied insurance because of a so-called pre-existing condition.

“Not only do consumers need to be aware that these new protections will take effect starting later this week – they need to know that these new protections and all the other provisions of our new law are at risk being taken away. Republican leaders in Congress and the Tea Party movement have made it clear that repeal of the health insurance law is one of their top priorities. They would put insurance companies back in charge of health care decisions for average Americans. They are once again standing on the side of the special interests, not on the side of consumers and patients.”

Rep. John Garamendi, who voted in favor for the health care and served as California Insurance Commissioner, said the new provisions taking effect later this week are critical for patients and their families.

For Plan Years Beginning On Or After September 23, 2010, Privately-Insured Consumers Will Have The Following New Protections:

1. Your health coverage cannot be arbitrarily cancelled if you become sick
Up until now, insurance companies had been able to retroactively cancel your policy when you became sick, or if you or your employer had made an unintentional mistake on your paperwork. Under the new law, health plans are prohibited from rescinding coverage except in cases involving fraud or an intentional misrepresentation of facts.

2. Your child cannot be denied coverage due to a so-called pre-existing condition
Each year, thousands of children who were either born with or develop a costly medical condition are denied coverage by insurers. Research has shown that, compared to those with insurance, children who are uninsured are less likely to get critical preventive care, including immunizations and well-baby checkups. That leaves them twice as likely to miss school and at much greater risk of hospitalization for avoidable conditions.

The new law prohibits insurance plans both from denying coverage and limiting benefits for children based on a pre-existing condition. This protection applies to all health plans, except “grandfathered” plans in the individual market. These protections will be extended to Americans of all ages starting in 2014.

3. Your child up to age 26 can stay on your health plan
Young people are the most likely to be uninsured – with currently one in three young people having no health coverage. One reason is that young people are less likely to be offered coverage through their jobs. Under the new law, insurance companies are required to allow young people up to their 26th birthday to remain on their parents’ insurance plan, at the parent’s choice. This provision applies to all health plans. (For employer plans, only those young people not eligible for their own employer coverage receive the benefit, until 2014, at which time all young people up to age 26 are eligible.)

4. Your health plan cannot put a lifetime limit on your health coverage
Millions of Americans who suffer from costly medical conditions are in danger of having their health insurance coverage vanish when the costs of their treatment hit lifetime limits. These limits can cause the loss of coverage at the very moment when patients need it most. Over 100 million Americans have coverage that imposes such lifetime limits. The new law prohibits the use of lifetime limits in all health plans.

5. Your health plan’s annual limits are phased out over three years
Even more aggressive than lifetime limits are annual dollar limits on what an insurance company will pay for health care. Annual limits are less common than lifetime limits – but 19% of individual market plans and 14% of small employer plans currently use them. The new law phases out the use of annual limits over the next three years. For plan years beginning on September 23, 2010, the minimum level for the annual limit will be set at $750,000. This minimum is raised to $1.25 million in a year and $2 million in two years. In 2014, all annual limits are prohibited. The protection applies to all plans, except “grandfathered” plans in the individual market.

Beginning September 23, 2010, Consumers Purchasing NEW Plans Will Have The Following Additional Protections:

6. You have the right to key preventive services without deductible or co-payments
Today, too many Americans do not get the high-quality preventive care they need to stay healthy, avoid or delay the onset of disease, and lead productive lives. Nationally, Americans use preventive services at about half the recommended rate.
Under the new law, insurance companies must cover recommended preventive services, including mammograms, colonoscopies, immunizations, and pre-natal and new baby care, without charging deductibles, co-payments or co-insurance.

7. You have the right to both an internal and external appeal
Today, if your health plan tells you it won’t cover a treatment your doctor recommends, or it refuses to pay the bill for your child’s last trip to the emergency room, you may not know where to turn. Most plans have a process that lets you appeal the decision within the plan through an “internal appeal” – but there’s no guarantee that the process will be swift and objective. Moreover, if you lose your internal appeal, you may not be able to ask for an “external appeal” to an independent reviewer. The new law guarantees the right to an “internal appeal.” Also, insurance companies will be prohibited from denying coverage for needed care without a chance to appeal to an independent third party.

8. You have the right to choose your own doctor
Being able to choose and keep your doctor is highly valued by Americans. Yet, insurance companies don’t always make it easy to see the provider you choose. One survey found that three-fourths of the OB-GYNs reported that patients needed to return to their primary care physicians for permission to get follow-up care. The new law: 1) guarantees you get to choose your primary care doctor; 2) allows you to choose a pediatrician as your child’s primary care doctor; and 3) gives women the right to see an OB-GYN without having to obtain a referral first.

9. You have the right to access out-of-network emergency room care at in-network cost-sharing rates
Many insurers charge unreasonably high cost-sharing for emergency care by an out-of-network provider. This can mean financial hardship if you get sick or injured when you are away from home. The new law makes emergency services more accessible to consumers. Health plans will not be able to charge higher cost-sharing for emergency services that are obtained out of a plan’s network.

For more details, consumers are urged to contact their individual provider or human resources department. Consumers can also visit www.healthcare.gov

http://www.healthcare.gov/widget/healthcare_widget.html

Contra Costa Regional Medical Center and Health Centers Chief Operations Officer Appointment

2010-09-14T12:28:00.000-07:00

Greetings,

On September 1, 2010, I assumed the role as Chief Executive Officer of Contra Costa Regional Medical Center and Health Centers. This integration of the medical center and ambulatory care system provides the opportunity for improved integration and redesign across the continuum of care and service in our delivery system.

To further our ability to improve operations across our system, I have been engaged in a search for a Chief Operations Officer of Contra Costa Regional Medical Center and Health Centers and am pleased to announce the appointment of Michael Anaya as the Chief Operations Officer of Contra Costa Regional Medical Center and Health Centers.

A 30-year veteran of health care management, Mr. Anaya has directed healthcare operations worldwide and held senior leadership roles in for-profit and not-for-profit hospitals where he has improved quality and safety, operating performance, as well as patient, physician, and employee satisfaction. Most recently, Michael served as the Chief Operating Officer/Vice President, Healthcare Operations for Mystikal Solutions, an information technology services company based in San Antonio, Texas. Previously, he served as Chief Executive Officer of Colorado Plains Medical Center, a diversified rural health system; CEO of the 297-bed dual campus Doctors Hospital of Laredo; and COO of 203-bed SouthPointe Hospital, a St. Louis specialty hospital. A 22 year military veteran serving in the Medical Service Corps, Mr. Anaya held management positions at Naval Hospitals in the U.S., Japan, Italy, and Middle East as well as U.S. Naval Ship Mercy, Bureau of Naval Personnel, and TRICARE Management Activity.

Active on national, state, and community levels, Mr. Anaya served as President & Chairman of the National Forum for Latino Healthcare Executives, Commissioner on Colorado’s Minority Health Advisory Commission, and Trustee of the Colorado Hospital Association. He has been a Fellow of the American College of Healthcare Executives since 1989.

I’m excited to bring someone with Michael’s tremendous experience to our health system. Most important, he is committed to our mission and will provide leadership to continue our path toward a model for the new American system of health care.

As Michael transitions to his new role this coming week, please join me in welcoming him to our health system.

Sincerely,
Anna

Anna M. Roth RN, MS, MPH
Chief Executive Officer
Contra Costa Regional Medical Center
and Health Centers

Pround Knowledge: Appreciation for a System

2010-09-08T17:26:00.000-07:00

“A [man-made] system is a network of interdependent components that work together to try to accomplish the aim of the system. A system must have an aim. Without an aim, there is no system. The aim of the system must be clear to everyone in the system. The aim must include plans for the future. The aim is a value judgment.”
-- W. Edwards Deming, New Economics for
Industry, Government, and Education

Please join us tomorrow, on Thursday September 9 at the CCRMC Improvement Academy in Building One, Conference Room One at 9:00 AM for our next session of Deming's System of Profound Knowledge:

Session II: Appreciation for a System

Presented by Marc Miyashiro, Information Architect / Documentation Manager Health Services - Information Technology

I'm excited to see what the teams begins this series. Thanks to all of the teams who have stepped forward to teach us. All teach, all learn (IHI.org)...

Hope to see you there.

Exploring Ethics at "Food For Thought"

2010-09-07T07:09:00.001-07:00

I'm really looking forward to the upcoming "Food For Thought," a monthly ethics discussion facilitated by Dr Jon Stanger. This is a thought provoking evening and provides a wonderful environment to begin to think through many ethical dilemmas we face daily in our work and in our lives.

Here is the detail:

Food For Thought
Wednesday, September 15
5:30 - 7:30 PM
CCRMC, Building 1 Conference Room (i.e. the "noon conference room")

For this session, our topic will be "WORK". What do we want from our work? What is the meaning of work in the lives of individuals? Rewards? Disappointments? What, if anything, is special - or should be - about work in the field of health care? How does our work experience affect the care we provide? .....

We will review selections from Studs Terkel's classic book, Working: People Talk about What They Do All Day and How They Feel about What They Do. Terkel interviewed >100 people, asking about their work lives, and transcribed their stories. I think you'll find that they make fascinating reading. As always, no pressure – particularly this time, since all told it's fairly long. Read whatever parts you have time and inclination for. If you can't get to the reading - come to our session anyway. We all have our own work stories. You can find NPR's revisit of Terkel's 'Working' here.

As decided by the group, someone kindly volunteers to bring the food for this gathering (this rotates and is not required and by attending you will not be expected to do this). Please send Jon Stanger or Peter Delfiorentino an RSVP if you haven't already, so that we have a rough idea of how much food will be needed. Please try and remember to bring $5-10 to the session to cover the food costs as decided by the group. There is no charge for residents, students, and anyone with student loans.

So, mark your calendar, send in your RSVP, and enjoy as much of the reading as feasible.

Hope to see you there.

Remembering Sergeant Paul Starzyk

2010-09-03T21:55:00.001-07:00

Remembrance Event for Sergeant Paul A. Starzyk on Monday, September 6, 2010

Martinez Police Department will host a public remembrance to honor Sgt. Paul A. Starzyk, who was killed in the line of duty, September 6, 2008

Tentative Schedule for September 6, 2010

7:00 AM- Uniformed personnel form up in front of the fountain near the flag pole.

7:10 AM - Honor Guard to present flag and memorial flag at half staff in front of City Hall

8:00-11:00 AM - Council Chambers open to public for public memorial; small guided tours of the memorial wall inside the police department

11:35 AM - Police Chief's comments

1139:17 AM - Moment of silence

"The wicked flee when no man pursueth: but the righteous are as bold as a lion."- Proverbs 28:1

"You are not alone"

2010-09-02T08:28:00.000-07:00

The dream team from the Behavioral Health Kaizen is checking back in at today's CCRMC Improvement Academy. They've formed a rapid response (for lack of a better term) called the "You Are Not Alone" (YANA)Team. The team's aim is to ease the collateral suffering experienced by those close to major medical and psychological crisis. Team members are be trained in peer to peer crisis management, community resources, and organizational fluency to allow facilitation of visiting and to offer immediate support to the family and friends of our patients. Codes are predicted to last approximately 15 - 20 minutes for the purpose of assisting families in activating their own support systems for longer term support, orient them to the medical center and/or unit, and the provision of resources (local food, hotels, and support groups/crisis lines). The YANA design team plans to also work w/ medical center volunteers to create "comfort packs" for both children and adults (consisting off nonperishable food & water, and entertainment such as newspapers and activities for children).

Please join your colleagues and hear of the work they've been doing to ensure that when facing a crisis "you are not alone' at CCRMC.

Additionally: Jon Stanger continues his noon conference ethics discussions. Today Jon will present "Taking Suffering Seriously."

I hope you're seeing a theme here. and I hope you join today's discussions.

My best,
Anna

CCRMC Improvement Academy: Deming's System Of Profound Knowledge Session One

2010-08-25T21:52:00.000-07:00

"We have learned to live in a world of mistakes and defective products as if they were necessary to life. It is time to adopt a new philosophy...." -W. Edwards Deming

REMINDER:
CCRMC's Improvement Academy meets Thursday August 26th at 9:00 AM in Building One, Conference Room One. I will present an overview of W. Edwards Deming's System of Profound Knowledge.

This will be the first of a series of dedicated learning sessions on Deming's System of Profound Knowledge and transformation.

Please join us.
Anna

More on Forgiveness

2010-08-24T13:56:00.000-07:00

Posted by Jon Stanger, MD

[Five years ago, in the wake of a troubling case involving delayed diagnosis, a subgroup of our Ethics Committee was convened to consider and make recommendations for appropriate management of adverse patient outcomes and medical error within our system. The Subcommittee’s findings and recommendations led directly to the formation of our current Medical Error and Adverse Outcome (MEAO) Committee. I invite you read the final “Report of the Subcommittee on Disclosure of Medical Error.” It can be found in the “Ethics” folder on the desktop of any computer in our system, within the subfolder “3.0 – Policies and Reports,” and under the heading “Medical Error Disclosure Subcommittee Report.”]

Kudos to our CEO for having the courage, once again, to engage a very complex and critically important topic – without presuming to have all the answers. This time Anna has invited us to consider the painful reality of error within our professional practice and the prospect for forgiveness. Anna’s comments and references urge us to look beyond formal responses and institutional structures, to consider the personal, spiritual meaning of harmful error brought about by good people while trying to help others - and the potential for healing afforded by forgiveness.

Forgiveness is a tricky business and, I believe, it is important to resist facile formulations. Two possible conceptual traps in considering forgiveness I would call “cheap forgiveness” and “forgiveness denied.”

“Cheap forgiveness” comes into play when we see forgiveness as something we are entitled to. The reasoning goes something like this:

Medicine is a risky business from the outset. The patient comes to us for help and we do our best, but there can be no guarantees. Even in the best of circumstances, complications and mistakes are liable to occur. It is unreasonable for the patient and family to hold us morally or legally accountable for these unintended consequences... They owe us forgiveness.

It’s not that there isn’t some validity to this line of reasoning. Indeed, I think this is a powerful rebuttal to the current system of medical malpractice liability in our country. The error here is that this depiction, just like the legalistic remedy it seeks to counter, reduces a complex human reality – the specter of a vulnerable patient coming to harm at the hands of those trusted with his/her care – to a simplistic calculus of rights and obligations. This is a demand for “cheap forgiveness.“

Forgiveness – at least the kind of forgiveness that has a potential to heal – cannot be demanded or won as matter of rights or entitlement. Forgiveness is never an obligation of the aggrieved. It must be freely given, if it is to be authentic. And it must take account of the human dimensions and relational realities of the situation – realities like suffering, guilt, and perceived betrayal of trust. It must be earned.

What are the elements of “earning” this kind of forgiveness? Anna refers us to the wise counsel of the Reverend Victor Carpenter on the occasion of honoring Nelson Mandela at Harvard University. In this speech, Rev. Carpenter alludes to the work of Archbishop Desmond Tutu and the Truth and Reconciliation Commission in South Africa. During my years in seminary at the Graduate Theological Union, I had the opportunity to study Tutu’s Ubuntu theology and the history of the T & R Commission in some depth. Principles pertaining to forgiveness and reconciliation that have emerged from international experiences like that of South Africa include:

· Never ignore or trivialize the victim’s suffering.

· Causes must be uncovered and confronted.

· Repentance comes from the perpetrator, but reconciliation and forgiveness must come from the victim.

· Reconciliation involves construction of a new narrative of meaning that acknowledges the trauma while recognizing the humanity of the offending party and daring to trust and commit to relationship again.

· Forgiveness and reconciliation are processes that often take time.

I don’t think that it’s a stretch to see the relevance of these principles to our consideration of forgiveness and reconciliation in the setting of medical error. Here as well, forgiveness of the patient or family cannot be presumed, and reconciliation has certain prerequisites to re-establish the trust required for a therapeutic relationship. “Earning” reconciliation in the medical setting requires:

· Prompt discovery and honest disclosure of causes, to the extent possible.

· Sincere expression of regret or apology.

· Time taken to answer questions and to listen to the patient’s story.

· Demonstrable commitment to learn from the error and to prevent future recurrences.

Any expectation of forgiveness or reconciliation that side steps these elements of the process would be evidence of “cheap forgiveness.”

The second trap of forgiveness I call “forgiveness denied.” “Forgiveness denied” applies when the clinician, having taken the steps to facilitate reconciliation, remains unable to learn from the mishap and move ahead without the patient’s explicit forgiveness – which may not be forthcoming.

This concept raises the question, “Whose forgiveness am I seeking?” I would argue that there is not a single answer to this query. Certainly, our first reaction must be to say that we are seeking (or hoping to earn) the forgiveness of the patient and/or family. I have seen the transformative, healing power of this experience – when the care-giver’s honesty, sincere expression of regret, and demonstrated commitment to prevent future recurrences are met by acceptance, understanding, and forgiveness on the part of the patient and family. No one who has been involved in such a case will ever question the healing power of the experience.

However, I have also seen any number of instances in which the most earnest efforts of the professional are not followed by any expression of forgiveness by the patient. Here again, I think we are wise to avoid falling back into the trap of “cheap forgiveness” that assumes we are entitled to such a response. So, is the dedicated professional in such a circumstance left to merely hope for some future softening of the patient’s disposition? To a certain extent, yes – while maintaining compassionate contact and openness to being with the patient through the process.

But there is more to the dynamic of forgiveness than seeking absolution from the patient or family. Indeed, I believe that the primary moral valence of any expression of forgiveness by the patient is as an indication of healing of the patient himself. This is not to say that the effect on the caregiver is not profound – it certainly is. When the family says, “We forgive you,” the physician is granted permission … to what? To forgive herself.

This gets us back to the question I raised earlier, “Whose forgiveness am I seeking?” and my suggestion that “the patient’s or family’s” may not be the only answer. It is critically important to recognize that clinicians also suffer in these cases. The emotional toll upon clinicians involved in cases of medical error can be devastating. And the all-too-common “shame and blame” response has the potential for personal and professional destruction, even as it obstructs constructive efforts to help this, and future, patients.

When we compassionately consider the position of the care-provider, as well as the individualized reality of the patient’s response, it becomes unreasonable to require the patient’s forgiveness before the clinician can find some peace in the wake of a mistake. Provided careful attention has been paid to the elements of earning reconciliation as discussed above, we must guard against dependence upon “forgiveness denied” just as we have rejected the facile expectations of “cheap forgiveness.” In a very important sense, then, another legitimate answer to the question, “Whose forgiveness am I seeking?” may be “my own”, or for those with a religious faith orientation, “God’s.”

Let me close this overly long commentary by strongly recommending two films. The first is “Long Night’s Journey Into Day,” a moving documentary of the Truth and Reconciliation process in South Africa.

My second recommendation is Ingmar Bergman’s masterpiece “Wild Strawberries.” This film is a harsh, but ultimately warm and very human story of an elderly physician who has been chosen to receive an honorary degree in recognition of his 50 years of service. During his lengthy road trip to the site where he will receive his award, Dr. Borg reflects on his life course, both personal and professional, and strives to come to terms with the realization of his own shortcomings. His sleep is disrupted by a dramatic nightmare in which he is called into a medical lecture hall to take a clinical examination in front of a large audience. Filled with self-doubt, he is grilled by the examining professor in the same “callous, selfish, and ruthless” manner that he has adopted toward his own students over the years. Now in the role of student himself, he is unable even to focus the microscope for identification of a bacterium on a slide. His diagnosis of a patient’s clinical condition is egregiously wrong. And, in the final question of the exam, he is asked to complete the sentence, “The first duty of the physician is … …” His mind is a blank. He can think of nothing.

Final grade – “Incompetent.”

We think we know the answer, don’t we? I thought I did. You… we… are wrong. The answer in the film? “The first duty of the physician is … … to ask forgiveness.”

A Culture of Safety: Forgiving

2010-08-22T14:27:00.000-07:00

“The day is committed to error and floundering; success and achievement are matters of long range” ~ Johann Wolfgang von Goethe

I've been thinking about the "Safety Incident Detection and Response System Optimization" efforts and our culture. In reading about cultures in ultra-safe industry (airlines, nuclear power, European railways), as opposed to health care which is not considered to be, I have found that a relentless focus on learning and moving beyond the need to blame and the need for redemption seems to be a system attribute in each these industries. I should add that many others are thinking about this as well.

Thankfully, courageous leaders such as Lucian Leape, Don Berwick, Jim Conway, Maureen Bisognano and many more have advanced the discussions about how we respond to medical error and system failures into mainstream discussions and media publications. Here is a recent article the NY Times on disclosing medical error and apology. The Executive Director of Chugachmiut, Inc., an Alaska Native Tribal consortium recently posted in his blog "Lean in Alaska" Pointing Fingers, where he discusses a "no blame, no shame" culture. He points to W Edwards Deming's System of Profound Knowledge and Deming's focus on pride and joy in work. A simple Google query will yield thousands of related links on error, just culture, culture of safety, apology, blame, bad apple versus system response etc. There is no dearth of reading if you're interested.

A request for help. How do we move from blaming to forgiving?

I am not trying to minimize how complicated this is. To the contrary, I believe that too often this complex socio/cultural concept is oversimplified. The term "transparency" is tossed about as if it comes easy and as if it will save us. Please don't misunderstand, I am in favor of transparency. Yet I do believe there is a tension between transparency and for lack of a better term, a "need to know." There is a tension between an inclusive and democratic process and an autocratic process. Leading the system and providing service within it is a complex and humbling undertaking. I look to the words of one of the greatest change agents who ever lived, W. Edwards Deming who said, "All transformation begins with the individual." If we are to create safe, fair and just culture; if we are to create a culture of continuous improvement, we must begin with ourselves. With each new day and each new challenge we will continue to discover that those who came before us carried heavy burdens for us all. It's our turn now. We are here to make a new world.

I am not asking anyone to be perfect. I ask that we help each other and provide service to our community in the most respectful way possible. I don't pretend to have all the answers. I ask that we work together to lead our system forward and to recognize that sometimes, like those people we are here to support in carrying out our shared mission, we will make mistakes.

It's important that we all work together. It's important that we all learn together. That means all of us. Those we are here to serve are depending on us getting this right. We must learn to work through system failures and to work through mistakes.

I am not suggesting we forget harm or look away from difficult situations. I am suggesting we learn to forgive and not let it divide us as looking for blame will. I am not suggesting we be complacent in any way. I am asking that we draw on courage. Drawing on the same humility we require as leaders of our great health system, we must not allow mistakes to create permanent barriers between us. There will be times we must look beyond the mistakes of others and remember to be grateful they are participating. To better understand what I am saying I offer the speech Victor H. Carpenter presented at Harvard when Nelson Mandela was honored there. Please take a moment to read his very brief but powerful remarks on "Forgiveness: The Mandela Principle" and I believe you will understand what I am trying to say to you.

Change is here. With that, all that is possible lies before us.

Now, we move forward.
Anna

2010-08-21T07:28:00.001-07:00

Thanks to everyone who posted in my absence. The posts and comments are fantastic.

I'm delighted to tell you that some of the guests have agreed to come back from time to time.

Something wonderful to look forward to!

Anna