Welcoming a new year...

"And now let us welcome the new year, full of things that have never been.”
—Rainer Maria Rilke

Greetings,

It’s an exciting time to work in a safety net hospital. We are privileged to serve the residents of Contra Costa County and it is my privilege to work with all of you. This year Contra Costa Regional Medical (CCRMC) begins a three-year planned cycle of ongoing quality improvement using a number of new approaches. CCRMC has seen promising results in clinical system performance with our initial redesign efforts. We are now well into the next phase of system redesign and performance improvement using leadership systems and tools like ‘systems engineering’ and ‘lean management’ to accelerate the transformation of our health system.

Fulfillment of our mission is a dynamic and ongoing process. In order to “do common things uncommonly well,” we need objective information to support us. The heart of the work ahead must focus not only on science, but also on action. Quality must be at the heart of all operations. Our efforts must be directed toward specific areas of work to assure no needless pain or suffering, no helplessness in those served or serving, no unwanted waiting, no waste and no one is left out.

Currently, health care makes up about 17% of our nation's gross domestic product (GDP) and is climbing at a steady and 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’s clear we will change course nationally and we must do the same here at the local level. Our mission is being challenged by the current economic downturn. The number of people who are struggling to meet their most basic needs is increasing in our community. It’s during these difficult times when safety net hospitals are called on to stretch already tight resources making quality, evidence-based practice, teamwork and communication the keys to success.

The debate will continue in our nation’s capital about what reform legislation will look like. Yet it is here, at the local level, that the actual impact of health reform will be determined. Just as an individual's experience of our system is determined at the point of care delivery and not in a conference room, health reform will be realized at the local level, not far away in the halls of Congress.

Together, in partnership with those we serve, we will continue to provide quality care to all people in Contra Costa County with special attention to those who are most vulnerable to health problems. We recognize and stand ready to embrace our responsibility to engage as active members of America’s Health Care Safety Net and as participants in the nation’s movement toward health for all.

Now let us welcome the new year.

Anna

Contra Costa County Health Services: Improving Surgical Care -Kaizen 3

What? First Kaizen Event of 2010.

When and Where?

Improving Surgical Care-Kaizen 3 Overview/Introduction:
Monday January 4, 2010 at 11:00 AM to 1:00 PM at Contra Costa Regional Medical Center (CCRMC) in Building One, Conference Room One.

Improving Surgical Care-Kaizen 3 Report-Out:
Friday January 8 at 10:00 AM to 10:30 AM at CCRMC in Building One, Conference Room One.

Note: The introduction and report-out for each Kaizen Event is video-taped and placed on CCHS-iSite.

I look forward to seeing you there.

Be well,
Anna

Remembering my Dad on his birthday...

Striking a balance between between celebration and acceleration.

Recently, I've been thinking a great deal about pacing. When I recall CCRMC's efforts with System Redesign which began in 2005, I remember many of the crucial lessons learned from our participation in the IHI 100k lives Campaign. One year ago today I wrote about our redesign efforts and again today my thoughts drift to System Redesign, an important anchor in our transformation efforts.

Although System Redesign is no longer a group, rather a set of coordinated efforts aimed at transforming our system for the better, the lessons learned remain with us. We learned to challenge the status quo by centering our efforts on real time observation and proven science. We learned that although we are very similar to others and can adopt proven strategies from them, in general, local adaptation based on our unique culture remains essential to realize meaningful and enduring change. We learned how important it is to not only involve, but to tirelessly support, those on the front line being actively engaged in design and improvement teams. We learned you cannot improve that which you cannot measure. By listening to patients and families, we learned how much we don't know. We learned what we thought was important to those we serve was not always the same as what was really important to those we serve. We learned the importance of shared vision and aims. Did I say anything about measurement? I know I already stressed measurement, but I thought I would throw it in once more for good measure! We learned how important it is to acknowledge and celebrate all efforts - even what seems the smallest accomplishments - and to accelerate our efforts to assure no needless pain or suffering, no helplessness in those served or serving, no unwanted waiting, no waste and no one left out. Celebration and acceleration, do you remember?

Like so many of you, I too am eager for a new day. I still haven't come to any definitive position on pacing other than action is needed for change. I acknowledge "soon is not a time." However, I do believe that big change begins with a bold aim and a small test. It starts with us, transforming our system, one test at a time.

It looks to be exciting days ahead.

More very soon...

Celebrate and accelerate- do you remember?

Remembering my Dad on his birthday...

Striking a balance between between celebration and acceleration.

Recently, I've been thinking a great deal about pacing. When I recall CCRMC's efforts with System Redesign which began in 2005, I remember many of the crucial lessons learned from our participation in the IHI 100k lives Campaign. One year ago today I wrote about our redesign efforts and again today my thoughts drift to System Redesign, an important anchor in our transformation efforts.

Although System Redesign is no longer a group, but rather a set of coordinated efforts aimed at transforming our system for the better, the lessons learned remain with us. We learned to challenge the status quo by centering our efforts on real time observation and proven science. We learned that although we are very similar to others and can adopt proven strategies from them, in general, local adaptation based on our unique culture remains essential to realize and embed real and enduring change. We learned how important it is to not only involve, but to tirelessly support, those on the front line being actively engaged in design and improvement teams. We learned you cannot improve that which you cannot measure. By listening to patients and families, we learned how much we don't know. We learned what we thought was important to those we serve was not always the same as what was really important to them. We learned the importance of shared vision and aims. Did I say anything about measurement? I know I did but I thought I would throw that in for good measure! We learned how important it is not only to acknowledge and celebrate all efforts even what seems the smallest accomplishments, but also to accelerate our efforts to assure no needless pain or suffering, no helplessness in those served or serving, no unwanted waiting, no waste and no one left behind. Celebration and acceleration, do you remember?

Like so many of you, I too am eager for a new day - hence, my original question about pacing. How big do we design and how fast do we go? If I draw from the original lessons learned I would look to real time observations and proven science. What would Deming say if we could ask him? It is well documented that he did believe and teach that all transformation begins with the indvidual. Many of the tests we designed began with one patient, one doctor, one nurse, one day, one shift, one time...you get the idea. You can learn more about the Model For Improvement and how we at CCRMC have used it in our improvement efforts here.

What do people mean when they talk about disparity in health? You can find a powerful graphic display published by the Contra Costa Times of life expectancy by zip code here.

New York Times article on errors, safety and accountability.

This article highlights much of the tension that exists in creating a culture of safety.

Learning from others

I was looking at the work done by those tackling other social issues that are, in fact, our issues as well.

Note: By his courage to relentlessly pursue what he believes in, Joe McCannon, Vice President at the Institute for Healthcare Improvement (IHI), inspires me to challenge my own thinking. It's just so easy to find safety and comfort "inside the box" isn't it?

Here is a link to the 10 year plan to end chronic homelessness in our communities, published by United States Interagency Council on Homelessness. I find the diffuse leadership structure of particular interest. In addition, the "Cost Implications" (#5) seem very familiar.

The video below focuses on homelessness in California, specifically Ventura County. Unfortunately, Contra Costa County looks no better. Each year, an estimated 15,000 people experience homelessness in our County, and on any given night, more than 4,800 people are homeless. 23,861 calls were received by the Hotline last year from homeless families and individuals seeking shelter in our communities. You can find the link to Contra Costa County Homeless Services here.

Shifting from "having more to being more"

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.

Recently, I 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 me/you.

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 stinky if one can siphon off the new and exciting parts of an innovation/new thing AND keep what they already have. Where do I/you fall?

Marshall Ganz...
First let me say I just saw him speak at the IHI National Forum (my favorite event of the year) and he was inspirational, frankly he was downright moving. I found his plenary address so much more than a speech. Were you there? Did you hear it? He refers to movements and feeling a calling. He speaks not of having more but of being more.

You can find Marshall Ganz's web module on Organizing here.

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 psycho-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/convergence of ideas 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.

More very soon.
Anna

Community Health Centers get much needed support- Primary Care leads the way to better health

Golfing With Friends

With his permission I am posting a short essay written by my esteemed colleague Dr. Jon Stanger. I asked him to reflect on his experience at our last Kaizen report out.

I deeply respect Jon's perspective and hope you enjoy his comments as much as I did.

Anna

The following is his response:

Golfing With Friends
Jon Stanger

(Dr. Stanger is clinical and organizational ethics consultant at CCRMC. He is a member of the hospital Operations Team. His passions include family, medicine, literature, moral philosophy, and – recently – golf.)

We’ve all heard the expression, “A bad day on the golf course beats a good day at work.” Who’s going to argue? It’s not so much that I disagree but, in the wisdom of my maturity (i.e. as I get older), increasingly I find that experience has an irksome way of challenging categorical pronouncements. Here’s the deal. Somehow, one day last week I canceled a golfing date with good friends to attend a meeting at the hospital – and came out feeling, well, OK about it. This requires some explanation.

I successfully resisted golf for years. Even though advancing age and receding cartilage made it a natural for this erstwhile sportsman, I thought Mark Twain pretty much had it right when he described a day on the links as “a good walk spoiled.” Anyone with that much time on his hands needs to get a life. Besides, it’s not a real sport, is it? And “the physician golfing” calls to mind all the wrong associations – of plaid pants, power politics, and privilege – for this affirmed county doc.

About a year ago, trusted friends lured me onto the fairways for my first time. Start-up can be a painful experience for the novice. We can all remember our first times, right? Talk about performance anxiety. It takes a special mix of courage and humility to step up to that first tee, a gallery of aficionados on the clubhouse veranda feigning indifference while in fact watching you … judging you … smirking at you behind a foamy veil of Bud Light. That drive off the first tee is one of those rare certainties in life. You can be pretty much certain that it will be every bit as humiliating as you had imagined. Then, safely down the fairway at last, the searing pain of ego laceration gives way to a dull throb of frustration. This is when you realize the marketing genius behind the exorbitant green fees you just paid. Only such substantial investment, combined with primordial arrogance, keeps you from taking the shortest path from the fairway bunker directly back to the parking lot.

I have to believe that none but the delirious and demented would make it past the clubhouse turn of that first round were it not for a mysterious seduction that takes hold around the sixth or seventh holes. Stirring poetry has been (or should be) written about the power of that moment when the golfer, looking up from the Swoosh™ for the first time, finds herself painted onto a canvas of natural beauty and transcends preoccupation with her own situated particularity to embrace oneness with the cosmic universal. [Note: Italics here are employed to denote the author’s erudite use of technical philosophical terminology.] And there is something more I never anticipated – some alchemy of four friends, now comfortably distant from adolescent preoccupations with “winning,” sharing the disappointment of the slice into the woods along with the joy of the forty-foot chip that improbably finds the hole.

Certainly, golf has the challenge of personal improvement, and old-fashioned competitive drive has its place, but for me the appeal of golf is ineluctably social – friends come together for these few hours in a common pursuit, supporting each other, calling one another to the twin virtues of humility and courage as circumstances and individual dispositions require. We are in this together. We have learned together from the misadventures and triumphs of the last hole. Now the next tee is waiting, and beyond that another before we take our turn on the veranda to sip our beers and critique the next foursome. Stories will be squared, sins will be forgiven, hope renewed, fellowship affirmed, and a tee time booked for next week.

Where was I? Oh yes, last week I had a golfing date scheduled with good friends. Unfortunately, a conflict had arisen with work. On this same day there was to be a “reporting out” of a “kaizen event” that had been under way over the past week. I was not so isolated in my semi-retirement as to have no inkling what this involved. Kaizen is all the rage within hospital management circles these days, and my work in the field of organizational ethics requires that I have some basic understanding of these sorts of things. I had read the required texts, attended a few lectures.

The word “kaizen” is from the Japanese, meaning “improvement.” In common usage today it refers to a philosophy and practice of continuous improvement in the workplace. Pioneered in the Toyota production line, kaizen has gained popularity in a wide range of manufacturing, business, and, more recently, healthcare settings. A “kaizen event,” then, is a weeklong multi-disciplinary effort focused on improvement in a particular area of service. Surgical care had been the focus for this week’s event.

I confess to having cultivated a degree of skepticism toward this whole kaizen thing. From an ethics perspective, medicine is, or should be, the most teleological of disciplines. This means that the health professional must have a single-minded devotion to the end or purpose or “telos” of providing quality care for the vulnerable patient. To my view, many of the sins of medicine today can be laid at the feet of those who would betray this orthodoxy for the false idol of marketplace economics. Should we really be looking to Toyota Corporation for enlightenment? In this all-too-competitive world of health care qua market commodity, where efficiency has become the salient virtue, the last thing we need is for our administrators, let alone our clinicians, to be flitting across the continent from conference to conference genuflecting at the altar of business school dogma.

I knew that our organization was in the midst of just such a conversion. My reservations notwithstanding, the spread of this heresy within our hospitals and clinics is plainly evident in the new hallway vernacular of kaizen novitiates. “Lean”, “hansei”, “5 Whys”, “value stream mapping”, TPS, CQI, TCAB, TWI … Do you speak Kaizen? Do you have your Six Sigma black belt?

This was not the first time that the conference room had been invaded for a kaizen event. I had stolen glimpses of friends, colleagues, and fellow employees – physicians, nurses, clerks, administrators, housekeepers, pharmacists – all gathered together, cooing and pecking like a flock of pigeons in the park on a spring afternoon, before winging off to the wards at the behest of some unseen external threat. Surely, I was missing something. This had none of the feel of the muscular command and control management that we needed in these tough times. I mean who was in charge here? Who was calling the shots? Who was making the tough decisions? Just when we most needed an eagle, we had a flock of pigeons.

It was time I learned a little more about this whole undertaking. I was just plain curious, and the word itself – kaizen – seemed to suggest a spiritual imperative that could be ignored only at risk of soul damage. I also felt some responsibility, as organizational ethics consultant and a member of the operations team, to better understand the kaizen phenomenon. Besides, the morning broke cold and drizzly, so I called my buddies to say that I couldn’t make it for our golfing date.

I found a spot standing against a wall in the back of the conference room near the exit, ready for a quiet getaway. What followed was quite unlike any hospital meeting I had experienced, and I am a veteran of thousands. The executive sponsor gave a one-minute – really, one minute – welcoming statement of support for the activities of the past week. The balance of the session consisted of fifteen individual reports from various participants in the event. Each report was brief, perhaps two to three minutes long, and each told a story. Some of the reports addressed seemingly minor, though not unimportant, issues. “The FAX to Nowhere”, for instance, told of how a simple hardware cable connection lay at the root of a longstanding delay in getting post-op medications from the pharmacy. Other reports dealt with major systems issues such as reduction of surgical suite “turnover time” and elimination of a long waiting list for routine surgical cases.

The narrative structure of the reports was unmistakable: the protagonist of each story is the patient and the story is told from the perspective of the patient’s experience; a problem area or “conflict” is identified; paths to potential resolution of the conflict are tried; and the outcomes, good and not so good, are described. It may be that this narrative structure was unintentional on the part of the kaizen participants, but the effects are important nonetheless. Narrative ethics is one of the most exciting and productive areas of inquiry in the fields of both clinical and organizational ethics today. At the heart of this model are the observations that we humans are meaning-seeking and meaning-forming creatures, and that story is our most effective and engaging means of communicating meaning. Just as four duffers come to understand the day’s events on the golf course in terms of the stories they rehearse on the veranda, we shape and share the meanings attached to our professional work through narrative.

The narrative frame for our discussions of problems within the hospital, then, goes a long way toward determining the solutions we will imagine. It really is important that the stories told by the kaizen folks keep the patient’s point of view center stage and that frontline hospital workers are given roles as active agents for change within these stories. All too often the narratives we have customarily told under the rubric of performance improvement have been told from the perspective of the hospital, or the county budget, or the clinical department, or the employee. And all too often the casting call for agents of change has been limited to the pool of “stars” within the administrative and clinical hierarchy.

I was told that, during the week of this kaizen event, roughly one hundred empirical trials (“small tests of change”) had been implemented and that seventy-five of these were “successful.” To one who cut his teeth on a system in which a single change could take months to wend its way through the web of departmental and committee structures, often only to become terminally stuck, this seemed frankly unbelievable. The “trick” seemed to lie in a radical understanding of what is meant by “success” and a somewhat disarming comfort with giving new ideas a try. For the kaizen participants, success is always tentative. A change is not proven once and for all, engraved in the policies and procedures manual, and revisited again five years hence. There is no pretense to Ultimate Truth here. Rather, a new procedure is “standard” only until such time as an alternative approach is shown to be an improvement in meeting the ultimate goal of providing quality care for the patient.

So, there I was, against the wall, listening to this rather remarkable string of testimonials and thinking – thinking about medicine … and golf. As an affirmed intellectual, I need to read books and listen to experts when approaching any new discipline. This compulsion has lead me to pour over several golf texts authored by past masters of the game and to waste more than a few hours watching “tips from the pros” on the golf channel. I’ve learned that there are moments in the game that call for daring and panache, but the best results usually result from a steady routine, incremental improvement, and playing the percentages. Error and misadventure are inevitable and even the best of players must wrestle with the chimera of perfection. But this reality cannot excuse an, “Oh well, stuff happens,” attitude. It demands instead a discipline of error identification and management, and a commitment to incremental improvement so as to reduce the likelihood of repeating mistakes. There are breakthrough moments in golf … and in delivery of medical services … but improvement is mostly incremental, measured from season to season, the result of a disciplined dialectic of praxis and critical reflection. [More sophisticated ethics vocabulary.]

I have to say, however, that what struck me most about the kaizen report had little to do with tangible improvements in services. The stated goal of SCIP (“Surgical Care Improvement Project”) is a 25% reduction in surgical complications for certain target areas by the year 2010. That is nothing to scoff at, even if a one-week trial can’t be long enough to know whether changes have truly improved care. (Except maybe for that FAX cable.) But what really grabbed my attention was something about the demeanor of the people in the room. Call it enthusiasm … or engagement. It’s not easily labeled or measured, but there was a tangible sense of empowerment, purpose, collegiality, and community the likes of which I hadn’t felt in any committee meeting in recent memory.

My pigeon metaphor was off target. These weren’t doves, indistinguishable in the flock, driven by rote instinct and fear of external threats. A comparison to dolphins might be more appropriate. I don’t know a lot about dolphins, but they’ve always struck me as intelligent, inquisitive creatures, engaged in actively exploring their environment, each celebrating the freedom of its individuality yet always true to its social nature. Like our marine brethren, the kaizen folks behaved like empowered individuals united by a shared purpose and bound to one another by mutual respect.

And as for leadership, forget that eagle, alone and majestic on his rocky crag. A kaizen vision of leadership requires a humbler sort of majesty, wise but down to earth. Think owl or even turkey. This is the leader as sponsor, process expert, cheerleader and champion of the telos, less directive and more willing to trust and nurture employees’ shared commitment to the purpose that called them to this work.

Speaking of cheerleaders, I will own that the kaizen report felt a little like … well, a little like a high school pep rally. There was some applause and, at one point, I actually witnessed a high-five. I can see the eyebrows of my weathered colleagues rising at even the suggestion of such mawkish proceedings. But have we really become so cynical as to discredit an honest expression of enthusiasm resulting from an experience of working closely with colleagues to make things better for our patients? The feeling in the room was infectious. I found myself a little self-conscious, but also inspired – inspired and proud to call this group of dedicated professionals my friends and colleagues. Perhaps this is part of what organizational development experts mean when they say that the kaizen process can be “humanizing.”

Much of ethics boils down to theories of human nature. I side with those philosophers who argue that we humans fundamentally crave two things – meaning and community. It follows that the “good life” entails fulfillment of our nature through work that has an identified purpose greater than our own self-interest – work undertaken with our fellows in a spirit of radical respect for one another. This formula holds true throughout the range of human activities, whether building cars or caring for the sick … or golfing.

I’m not sure that I can yet be counted amongst the kaizen faithful. I will retain a certain measure of what I consider prudent skepticism regarding management models imported from the business world. And as a colleague cautioned, “We shouldn’t be too quick to drink the Kool-Aid.” But I also don’t want my concerns to make me too timid about stepping up to that first tee. For some time now, we who work in hospitals and clinics have been too disconnected from the ideal of service that called us to our profession. We have been too disconnected from each other. I don’t know if kaizen and similar recent performance improvement initiatives are the answer. What I do know is that on that morning last week there was something positive going on in the hospital conference room. It was new, and different, and a little threatening. But actually – and now I’m speaking from my expertise as an organizational ethics consultant – in some ways it was a lot like golfing with friends.

AFSP Out of the Darkness Overnight Walk is June 26-27, 2010 in Boston, MA

The 2010 the Out of the Darkness Overnight will take place on June 26-27 in Boston, Massachusetts.

The goal of this journey, which will begin at dusk and finish at dawn, is to raise funds for suicide prevention. I would like to help end the silence and erase the stigma surrounding suicide and its causes, encourage those suffering from mental illness to seek treatment, and show support for the families and friends of the 30,000 Americans who die by suicide each year. Suicide is the third leading cause of death among teens and young adults and the second leading cause of death for college students.

I will post more very soon about what I am doing and how you can join me.

Please consider helping to save lives, reach out to those families who are devastated from losing a loved one to suicide and help create an outlet to help end the silence.

Registration opens in December here.

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.

•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. To learn more you can visit the AFSP website here.

Why 'to settle' can lead to harm

If something seems impossible, is it really? Or is it just hard to imagine?

Ten years ago the Institute of Medicine released To Err Is Human: Building a Safer Health System, the influential report that shared with the world that in the United States each year there are up to 98,000 deaths due to medical error. For example, 7% of patients suffer an error in medication – many of these life-threatening. In addition to causing unacceptable human suffering and loss of life, these errors may result in upwards of $50 billion in total costs. Other important reports followed, including Crossing the Quality Chasm: A New Health System for the 21st Century. The reports seemed to successfully end a period of denial, bringing a variety of stakeholders together. It was an awakening, not only validating those who had been speaking out for so long about quality and patient safety, but also spawning a movement that called upon and motivated improvers from all over the world seeking to change the status quo.

Where do we stand today?

In May of this year, the Agency for Healthcare Research and Quality (AHRQ) published the National Healthcare Quality Report (National Healthcare Quality Report 2008">NHQR) and the National Healthcare Disparities Report (National Healthcare Disparities Report 2008 ">NHDR). These reports measure trends in effectiveness of care, patient safety, timeliness of care, patient centeredness, and efficiency of care. The reports present, in chart form, the latest available findings on quality of and access to health care.

In short:

• Healthcare is suboptimal and continues to improve at a slow pace.
• Reporting of hospital quality is leading to improvement, but safety is lagging.
• Health care quality measurement is evolving, but much work remains.
• Disparities persist in health care quality and access.
• Magnitude and patterns are different within sub populations.
• Some disparities exist across multiple priority populations.

Although we are seeing some gains in improvement, we are challenged to sustain our gains and accelerate our efforts. The reports draw on lessons learned from other sectors about improvement.

Some common themes presented in the reports:

•Constancy of purpose is essential
There is no quick fix, we must remain disciplined in our approach with continued vigilance
• We must form Partnerships
Simultaneous efforts are required by multiple stakeholders
• Measurement is vital to improvement
Focus on quality, focus on results

Change begins with each of us

Earlier this year I noted that I sometimes feel like a radical or perhaps even outlandish in my thinking at times. It was only a few years ago, there were no red lines on the wall behind the beds – how could anyone providing patient care ever guess at what 30 degrees looked like? What was a Bundle? There were no months without a Ventilator Associated Pneumonia (VAP). When I reflect on it now, it feels like in some cases, we almost seemed to plan care knowing that assisted breathing was inevitably, or at least understandably, going to be accompanied by pneumonia. It was hardly imaginable that we could go months without a VAP. Now VAPs are a rare occurrence. When I was initially trained as a nurse- not my formal school-based training, but the ward/unit training which was something different altogether -I was taught that our 'rapid response' was commonly known as a Code Blue, a team of highly skilled clinicians that rushed to a patient in need of respiratory or cardiac rescue/resuscitation. Now we have rapid response teams (Medical Emergency Teams, RRTs, etc..) that rapidly bring extra needed assessment and care to patients when they first exhibit signs that may precede a dangerous decline in health.

Thankfully, things are changing here and everywhere. I find strength in the stories from the bedside of others who are committed to improving health care. I'm not sure I would have ever identified myself as a skeptic, but I can say without reservation, that when it comes to improving health care through the use of improvement science, I do believe.

Refusing to settle

So having disclosed my bias toward improvement science as the way forward, why is it that improvement continues to feel as though it is regarded as a "soft" or support activity? It continues to be an after thought as if it's not the real work of saving lives. I refuse to accept that notion. To improve is to save lives. I am proud to be labeled naïve, outlandish, emotional, passionate, an extremist, or a purist when it comes to driving defects and non-value added activity out of what we do. Standing with you all of you, who are dedicated to serving our community, I will continue to focus on and realize 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.

B=ƒ(P,E), is not actually a mathematical equation representing quantifiable relationships but rather a heuristic designed by psychologist Kurt Lewin. It attempts to illustrate that behavior is a function of the person and his or her environment. George Halvorson in his book Health Care Will Not Reform Itself, states "the alternative to courage and focused action is a continuation and probably a worsening of the status quo."

Many will agree that it takes acceptance, willingness, courage, caring and honesty to engage in a change effort. I believe that it also takes constancy of purpose and discipline. There are many distractions along the way and the force of the status quo and pervasive nature of the health care industry's hierarchical culture can seem impossibly strong. Many have mastered the current state and their power or position and self-image may be derived from that mastery. I believe that to seek a new order, to resist the urge to 'settle' and to stand up and lead a transformation effort, is indeed the work of the courageous. However, the first step is to change ourselves, which may be the most frightening of all. Many will retreat to the status quo. Many will settle.

I will not.

What will you do?

Public Hospitals and Health Systems: More on Contra Costa Health Services

In an attempt to share information with others about our publicly owned and operated health system- Contra Costa Health Services-, I thought I would pass along a message I received over the weekend. The following a message to our board and to all is a response from Dr. Walker about the article by Drew Voros about ours and other public systems in California. More facts about California's Public Hospitals can be found at CAPH.org.

His response is as follows:

Dear Mr. Voros,

I want to thank you for your timely column today on the role of county hospitals in health reform. I am a practicing Family Physician for Contra Costa County Health Services since 1974, County Health Officer since 1983 and Health Director as well since 1995. I have also served as the Chair of the California Association of Public Hospitals, representing the 19 county hospitals in 15 of California's largest counties where 81% of Californians reside.

Although these hospitals comprise only 6% of California's hospitals, they provide half of all hospital care for the State's 6.6 million uninsured, 30% of inpatient care for patients insured by MediCal, and over 10 million outpatient visits.

Contra Costa Regional Medical Center and its 8 Health Centers throughout the county (reaching from Richmond to Brentwood) provide over 22% of the prenatal care and births in our county and over 430,000 outpatient visits. As you acknowledge in your column, we are daily seeing more and more patients who have lost their jobs, their health insurance and, often, their houses. Many have never been to a public hospital or clinic before and are grateful to find a source of health care in these turbulent times. The county owned Contra Costa Health Plan provides care to over 70,000 members, including those who voluntarily enroll covered by MediCal, MediCare, Contra Costa County Employee Insurance, private individuals and others. We are proud that over 9000 county employees and their dependents (like me and my family) trust their health care to our highly qualified physicians, nurses and other staff
The Health Plan also manages the care of nearly 10,000 low income uninsured individuals who receive care in our system through our Basic Health Care plan. An
important asset for the entire County is our UC Davis-affiliated Family Practice
Residency program, now training 39 Family Practice Residents from the nation's best
medical schools. Many stay on to practice in our community after finishing their training.

I agree a good place to start in considering ways to provide care to the many uninsured in our country is to bolster the Public Hospital and Community Clinic resources throughout the nation. The National Association of Public Hospitals and Health Systems (I am on the Executive Committee)is working with Congress and the Administration on just such a proposal. We are especially seeking support to be able to continue to provide care to more uninsured during the next 3years prior to any implementation of Health Reform in 2013. We anticipate increased demand for our services as more people lose their jobs and health insurance. It make a lot of sense for our country to build on its existing public assets to create expanded organized systems of
health care for the many who need it.

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

Public Hospitals and the Public Option

Does Contra Costa Health Services represent a "microcosm of a national single-payer health system?"

The following article was posted by the Oakland Tribune and ran in the San Jose Mercury News this week. With the permission of Drew Voros, I am posting the article it in it's entirety.

█ Voros: County hospitals already offer public option
Drew Voros, Oakland Tribune Business Editor
Posted: 11/10/2009 02:53:06 PM PST
Updated: 11/12/2009 09:00:30 AM PST

MARTINEZ — At the county hospital Thursday, they're having a talk titled, "Is it Rest in Peace for a Single Payer National Health Program?''

Considering the Contra Costa Regional Medical Center's growing popularity as a health-care option for residents, reports of the single-payer system's death on the local level are certainly premature. Taxpayer-funded medical services offered here represent a microcosm of a national single-payer system, including its being underfunded and set up to fail.

However, by making county hospitals the centerpiece of universal coverage in this country, we would prevent the need to reinvent the wheel. These facilities have become the de facto public option, so why not treat and fund them as such?

Like at county hospitals throughout the country, Contra Costa Regional Medical Center in Martinez is changing from the place of last resort for health care to the primary choice of many. Demand for its services is outstripping resources as unemployment and underemployment rise.

But even the fully employed come through the doors of county hospitals. Of the some 50 million uninsured in this country, as many as one-third of those choose to go the county-hospital route rather than pay hundreds of dollars a month in employer-subsidized health insurance such as Kaiser.

The "benefit'' of health insurance through employment really means you will get a subsidy, paid by the employer, that more and more workers shun because of the rising costs. We need to make premiums and/or co-pays cheaper for the populace if we want a successful health care system.

While Congress debates creating a public option for the health care industry to compete alongside the Kaisers and Blue Shields of the world, our elected leaders would be well served to examine how county hospitals could expand their role in achieving that goal. Clearly the facilities and personnel are in place. Missing is a system that provides adequate funding, and that's where congressional reform comes in.

Last week a majority in the House of Representatives approved a nearly $1 trillion health-care reform package. Before we waste billions of dollars establishing something new, we should utilize what we have.

Making county hospitals the headquarters for the public option in health care will not make it more or less attractive than private insurance, which of course will always be offered. What it will do is keep the most knowledgeable public health officials in charge of the public health dollars.

Standing outside the Martinez medical facility and ignoring the posted no-smoking rule, one Concord man said he didn't understand what was going on with health care in this country. While he did not disclose the reason he was there, "Bryan'' summed up the problem we face with health care in this country.

"It doesn't matter what they (Congress) do. This is where I will come for my health care because I can't afford insurance,'' he told me.

Sometimes you have to take the water to the horse.

Drew Voros is the business editor. His column runs on Wednesdays. He can be reached at avoros@bayareanewsgroup.com.
Follow him at www.twitter.com/bizeditor. █

In a previous post, I explored how systems like ours -Contra Costa Health Services (CCHS)- may already form part of the foundation of America's "Public Option."

You can find the original post here.

The new climate of change offers us the opportunity to rethink what our (government owned and operated health systems) "value" is in the nation. Are we a place where primary care plays a prominent role? Are we a perfect place to grow the primary care workforce? Are we an example of a publicly owned and operated health system that operates and co-exists in an environment with the private sector? Do we have something to offer when we move beyond the debate of "what" the national health policy will look like, to "how" we will actually reform our health systems at the local level? Questions to think about as we move into the era of reform.

More very soon
~Anna

Here is the video that I included in my original post offering a friendly hello from some of us at Contra Costa Regional Medical Center.

National Survivors of Suicide Day is Saturday, Nov. 21, 2009

Saturday November 21 2009 is the 11th annual National Survivors of Suicide Day.

A day of healing for those who have lost someone to suicide.

It was created by U.S. Senate resolution in 1999 through the efforts of Sen. Harry Reid of Nevada, who lost his father to suicide. Every year, American Foundation for Suicide Prevention (AFSP) sponsors an event to provide an opportunity for the survivor community to come together for support, healing, information and empowerment.

On National Survivors of Suicide Day, simultaneous conferences for survivors of suicide loss will take place in the cities around the world. Please visit the AFSP website to find an event near you. There are several sites in the bay area listed. Here is a link to the conference that is being held at University of California San Francisco (UCSF), Parnassus Campus.

I will bring this event up to the Healthcare Partnership and let you know of any local activities planned on our campus.

For those who don't live near a conference site or who find it difficult to attend in person, the 90-minute broadcast will also be available from your own computer on the AFSP website from 1-2:30 p.m. EST, with a live online chat immediately following the program.

So many lost, so many left behind and all preventable.

~Anna

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.

•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. To learn more you can visit the AFSP website here.

On Possibility: Why 'to settle' can lead to harm

Ten years ago the Institute of Medicine released To Err Is Human: Building a Safer Health System the seminal report that shared with the world that in the United States each year there are up to 98,000 deaths due to medical error, 7% of patients suffer a medication error and in addition to unacceptable human suffering and loss of life these errors may be up $50 billion in total costs.

The report was supported by several leaders such as Don Berwick and Lucian Leape had been talking about the defect prone system of production we call US Health Care.

Several reports followed including CROSSING THE QUALITY CHASM: A New Health System for the 21st Century.

So where are we today? Have we improved?

Earlier this year I noted...
I often feel like a radical and even outlandish at times. I look back just a few years ago. I remember when there were no red lines on the wall behind the beds. How did we know what 30 degrees looked like? What was a bundle? I remember when we didn't believe it possible to go months (even years in some cases) without a Ventilator-Associated Pneumonia. I remember when I believed the only rapid response was known as a "code blue." Why would I think otherwise? It's how I was trained.

Thankfully, things are changing here and everywhere. I find strength in the stories from the bedside of others who are committed to improving health care one test at a time.

I'm not sure I would have ever identified myself as a skeptic, but I can say without reservation that when it comes to improving health care through the use of the science of improvement and reliable design, I do believe.

So having disclosed my bias toward improvement as science and as the way forward, why is it that improvement still feels like it's regarded as a "soft" or support activity? Why does it still feel as if it's perhaps not the real work of saving lives? Why is it I still wonder if I am naive, outlandish, emotional, passionate, an extremist, or a purist when it comes to driving defects and non-value added activity out of what we do and focusing on our mission which is "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."

B=ƒ(P,E), is not actually a mathematical equation representing quantifiable relationships but rather a heuristic designed by psychologist Kurt Lewin. It states that Behavior is a function of the Person and his or her Environment .[1]

George Halvorson describes in his book Health Care Will Not Reform Itself, The alternative to courage and focused action is a continuation and probably a worsening of the status quo.
It takes acceptance, willingness, courage, caring and honesty to engage in a change effort [2]. I would add it also 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 power or position is derived from that mastery. To seek a new order, to resist the urge to settle, to lead a transformation effort, is indeed the work of the courageous and the first step is to change ourselves which may be the most frightening of all. Many will retreat to the status quo. Many will settle.

Bravo! I love it. I love it.

Please take the time to read the article Prescription for Success: Don't bother the nurses that ran in the San Francisco Chronicle and see for yourself what some bay area hospitals are doing to reduce medication errors.

One highlight..."Between September 2006 and September 2009, medication errors at the hospitals dropped by an average of 87.7 percent."

You make us proud and you teach us all that there is another way!

Surgical Care Improvement Kaizen One Report Out Today at CCRMC, Building One, Conference Room One at 10:00 AM

Greetings-

I'd like to remind everyone that the work from the Surgical Care Improvement Kaizen Team will be presented this morning at CCRMC Building One Conference Room One at 10:00 am. Teams went to Gemba(現場), and many were in your areas this week. Thank you for your cooperation and participation.

It is imperative that we learn together to fulfill our promise to provide the highest quality and highest value service to our community, making possible, health for all.

Finally, I have been asked by some of our colleagues from other organizations if they could "come and see" what we are doing. This is not a closed session. Our doors are open to all. We welcome you and know you have much to contribute.

All teach, all learn.

Please join us at CCRMC Building One Conference Room One at 10:00 am.


I look forward to seeing you there.
Anna

Designing tomorrow's health system: Don Berwick and Tom Nolan are looking for your input

Help the Institute for Healthcare Improvement design a low-cost, high-quality health system for the future

Don Berwick and Tom Nolan are asking for your input on how to design a low-cost, high-quality health care system for the future. To learn more, submit your ideas and stories, and engage in a conversation about health system transformation, click here.

Contra Costa Regional Medical Center Successfully Completes its First Ever MERP Survey With Zero Deficiencies

Congratulations to All!

CCRMC Passes First Ever Medication Error Reduction Plan Survey With High Praise

Medication errors are among the most common medical errors, harming at least 1.5 million people annually. In the United States in hospital settings alone, medication errors account for more than 7,000 deaths and an estimated $3.5 billion in extra medical costs to treat drug-related injuries each year.

To address this problem, the California State Assembly passed legislation in 2001 requiring that all general acute care hospitals and certain other facilities adopt a formal plan to eliminate or substantially reduce medication-related errors, known as a Medication Error Reduction Plan (MERP). The triennial survey is unannounced. The MERP survey is a comprehensive, organization-wide look at medication error reduction policies, practices, plans and processes. The surveyors look closely at hospital processes, including how medication safety for patients is assured through use of technology such as electronic order entry procedures.

This week Contra Costa Regional Medical Center successfully completed its MERP survey with zero deficiencies.

MERP surveyors were impressed by our staff’s knowledge of medication error reduction practices. The surveyors commended our highly visible level of multidisciplinary teamwork and collaboration stating "your strong multidisciplinary involvement of all staff shows through." Highlighted as a "unique strength" was the placement of pharmacy service on the units bringing services closer to the patient and their experience.

The results of the survey are a testament to your commitment and dedication to providing safe, high-quality care to our patients. I am confident that we are moving toward the promise of delivering safe, effective, efficient, timely, patient-centered and equitable care to every patient, every time.

You have stepped forward and challenged the status quo. You have learned together one test at a time, demonstrating that big change begins with a bold aim and a small test.

Enjoy this moment. We should be proud.

Sincerely,
Anna

A Greater Force

A little time for fun...

Although I really wanted to catch the inaugural performance of LA Phil's new conductor Gustavo Dudamel this weekend (thanks to Pedro for the heads up), I had to yield to a greater force.
It was well worth the sacrifice.

"Grasping for Salvation" Is the Mighty Toyota Falling?- Toyoda speaks about Toyota

Drawing from Collin's latest book "How the Mighty Fall" Akio Toyoda speaks candidly about the state of Toyota and publicly "apologized for the death of a California family in a crash that led the company to recall 3.8 million cars in the US to take out floor mats."*

If you've had the opportunity to read one of the many books written about Toyota then you know that this type of what I see as accountable and transparent leadership seems to be an enduring attribute of the Toyoda family legacy. Because of the bleak economic situation in Japan after the World War II, the company was forced to go back on its no-dismissal policy and lay off 1600 employees. At that time Kiichiro Toyoda took full responsibility for the organization's problems and resigned.*

I read the comments about Toyoda's state of the organization update and was wondering what do others think? So many of the comments seem angry. I'm not sure why? I wonder what people think the leader should do? Should he not have come public to tell others what his assessment is?

Any thoughts? I'm not asking about Toyota (the company), however those are welcome, but any thoughts on Toyoda (the leader)?

Is this transparent leadership or do you agree with the comments?

Surgical Care Improvement Value Stream Report Out Today! CCRMC, Building One, Conference Room One at 10:00 AM

To All Staff-

Greetings,

I'd like to remind everyone that the findings from the Surgical Care Improvement Value Stream will be presented this morning. Teams went to Gemba(現場), and many were in your areas this week. I thank you for your cooperation and participation.

In a stand up report using an A3 format the current state will be presented. Teams will show us what they found and present a vision for the ideal future state. Taking the time to learn about our system and ways to deliver the highest quality and highest value service to individuals and their families is essential. Reflecting on our improvement work in the Congestive Heart Failure (CHF) Value Stream, much of the ideal future state presented in their stand up report has now become standard work delivered to every patient every time.

It is imperative that we learn together. Our aim is to provide the highest quality and highest value service to our community, making possible, health for all.

Please join us at CCRMC Building One Conference Room One at 10:00 am.

I slept and dreamt that life was joy.
I awoke and saw that life was service.
I acted and behold, service was joy.
- Tagore

This is ours to do. If not us, then who?

I look forward to seeing you there.
Anna

As we look back on the events of September 11, 2001, we remember the bravery, courage, and humanity shown that day and the many to follow. We remember those lost, and those whose lives have been forever changed.

Being Still

Be still and know...

I’m often asked what my plans for our organization are. For many of us, and I know for myself, not knowing what is going on, where we are going, what will happen tomorrow or other sorts of "blanks" or "voids" can lead to an uneasy feeling. Sometimes when faced with a “blank” we create stories, and sometimes, we even convince ourselves that our stories are in fact the truth. This behavior of filling in the blanks is not that unique. It turns out we do this quite often. Our stories not only help us make sense of/or tolerate the unknown, they move us to action when we are faced with the facts - even facts that feel too difficult to bear. Our stories add texture and context to what information we do have.

This is all sounding vague. Let me draw from the IHI website about the value of storytelling:

Anyone involved in quality improvement efforts knows that scientific principles are at the center of this work. But even the most evangelical quality engineer will caution that this only part of the solution. Improvement strategies and measurement tools are most effective when embedded in an organizational cultural that ensures that changes are embraced and sustained. And there is no better means of inspiring cultural change than through the simple craft of telling stories. As Donald Berwick, MD, MPP, puts it, "Measurement is important, but it’s the stories behind the numbers that are the most enduring wellspring for change."

So what does this have to do with where we are going? How is this connected to what is happening today at Contra Costa Regional Medical Center? It is a time of change for CCRMC, and with that, a time for new opportunity. We have an opportunity to find a new way forward together.

As Edgar Schein notes in his new book Helping, “ Many people in senior management or leadership positions have the ability to be effective change agents.” He says we must do this "by not only learning how to help, but also to learn to accept help." This is what makes leadership so complex. By accepting help he says, we become “genuinely involved in the culture of the group, and how to give help to the group and to individual subordinates as individual areas of improvement are identified." (Helping: How to Offer, Give, and Receive Help, 2009, p 132)

Elias A. Zerhouni echoes this perspective noting that leaders who want to fix things or make change, will be most successful "if they initially adopt a helping role which, in turn requires their willingness to be helped. Once they create a climate of trust, they will elicit crucial information about what is going on and learn the local cultural rules and norms." Discovery and creativity, he argues, are eminently social processes. (Letters from Leaders, 2009, p 61).

So does this mean that part of leadership may include becoming vulnerable, and available? Maybe to rush to find the answer or fill in the blanks is not always helpful? Although it sounds quite simple, this isn't easy stuff. Maybe this is why Hoshin Kanri directs us to "go and see" (Genchi Genbutsu / 現地現物) in order to understand?

I have no answers today. I too am filled with questions, but I do believe that to lead is also to learn.

...and maybe, at least for me, sometimes I just have to be still.

What does a Public Option look like?

"The work goes on, the cause endures, the hope still lives and the dreams shall never die." -Edward M. Kennedy

Remembering Senator Edward M. Kennedy for his tireless efforts and dedication to guarantee the basic right to health care for all Americans.


I've been following the social media coverage from other parts of the world covering the debate here in the Unites States regarding the pros and cons of a "public option" as part of health care reform. Some people in other countries have found it amusing and some have expressed feeling that their system has been misunderstood. Social media campaigns such as the WeLovetheNHS campaign have sprung up on twitter. Even Gordon Brown has found his way to Twitter to make a 140 character (or less) public proclamation of pride in Britain's National Health Service.

It prompted me to think about our system (CCHS). We too are a fully integrated health system based on primary care and prevention. I'll admit, I was feeling a little misunderstood as well. When I asked, I found others shared my feelings. I realized that like those who "lovetheNHS", I love our public system, CCHS. I am proud to be a public servant and proud to be a part of what has been since 1880, our community's public option.

So today I decided to take to heart Paul Levy's recent comments in his blog ecouraging us to "stand on a soapbox" and be "seen." He reminds us that "people have given their lives to allow us to have freedom of speech."

I realize and accept the debate about the public option appears to be dominated at the present time by debate about insurance/coverage/money, which is a critical discussion. I would, however, like to offer a moment of pause to remind those of you in our system (and others who may find it worthwhile) that the public option as we realize it through fulfillment of our mission is so much more. It's about safe, efficient, effective, timely, patient-centered and equitable care for everyone. It goes beyond coverage (but yes, it does include it). It's about health.

One of the things I have learned through my exposure to Lean Methodology is how important it is to go and see for yourself (Genchi Genbutsu / 現地現物) to thoroughly understand the situation. I would ask that we all take the time to understand and to "Go and see" , for ourselves what a public option is.

Earlier this month in his Directors Report Dr. William Walker said that "Above all, we should encourage people to get information from objective sources and not rush to judgment."

You can find Dr. Walker's podcast (available at http://cchealth.org/topics/podcast/) about this topic with others and let them know they can get more information at these sites:


http://aarp.convio.net/site/PageNavigator/Myths_vs_Facts
http://www.whitehouse.gov/realitycheck/
http://www.politifact.com/truth-o-meter/

Although you won't find any speeches or soap boxes, in the spirit of being "seen" and participation, I thought I would offer a friendly hello from a publicly owned and operated, fully integrated health system here in America.

Sincerely,
Anna

Into a new world

"and we shall learn" -W. Edwards Deming

In response to our session on variation I thought you may like the video below. W. Edwards Deming uses powerful descriptions such as being in prison. Sound familiar to what some of those who played the game said?

What Deming says is needed is "transformation, which will come from movement into a new world."
Movement into a new world? What does that mean? Does it feel like we are, or should sustain our system as is? If we were to change, how should we change? Where is the new world? Are there any signs leading us?

For those of you who attended the session this week I'm curious to hear what you think of this video and if you have any thoughts about this concept of movement into a new world?

Thanks to everyone for coming and learning together. We'll try and post the video from our session here and on iSite in the next few days.

~Anna

Please join us for our next session:
Variation Happens
Thursday September 27th at 9:00am at CCRMC Building One Conference Room One.

Here is a very brief clip of Deming- Enjoy!

Uninsured in California: Interactive Map from the Sac Bee

http://www.sacbee.com/1098/story/2114278.html
Here is an interactive map of those under 65 without health insurance in each county in California. When you compare, bear in mind the actual numbers and the size of our system (whole system capacity) including the number of medical center beds compared to other counties.

What you all do every day is truly spectacular.

Anna

"The Good, the Bad and the Ugly?" I'll agree with two of those!

See the PBS Online NewsHour feature of Contra Costa County and the California Budget Process. Bravo Supervisor Gioia and Dr. Walker! I share your frustration.

I'm sure this was a difficult process for all. I do agree with Governor Schwarzenegger that this budget is bad and it is ugly, but I'm having a hard time finding the good.

"It's about people, not products"

There is no question, and I make no attempt to hide the fact that I am heavily influenced by the teachings of W. Edwards Deming and The Deming System of Profound Knowledge.

Here is Part 1 of a short series that can be found on YouTube about W. Edwards Deming. Enjoy!

To learn more, you can go to the The W. Edwards Deming Institute® website.

The Justin Micalizzi Memorial IHI Scholarship for 2009

Opportunity from MITSS-Medically Induced Trauma Support Services Clinicians and the IHI.

From the MITSS blog:

Justin’s Hope Project & IHI are pleased to announce the Justin Micalizzi Memorial IHI Scholarship for health caregivers who are committed to serving vulnerable, underprivileged and underserved pediatric populations. The Scholarship covers the cost of Forum General Conference fees and includes a stipend for travel, lodging, or other conference costs.

http://www.ihi.org/IHI/Programs/ConferencesAndSeminars/21stAnnualNationalForumonQualityImprovementinHealthCare.htm?TabId=10 for more information.

Reality Check on Health Care Reform: Message from the Director and Health Officer of Contra Costa Health Services

Below is an All Staff Message from Dr. Walker:

Over the last few years, I’ve devoted a number of my messages in the monthly Director’s Report to the issue of health reform. I’ve been alternately optimistic and pessimistic about the chances of success for a variety of state and federal proposals.

For those of us working in an organized health system like ours, it isn’t hard to see how the United States’ broken health care non-system affects us all - most recently people losing their jobs and their health coverage. As the Health Officer for Contra Costa County, I know how critical it is that Congress agrees on a solution to the health care crisis. What we have now is a non-system that leaves millions without adequate quality care,increases the stress on safety net providers like Contra Costa Health Services and impacts on the health of all residents.

The safety net that each of us supports is ripping more each day.

It is understandable that people are worried about what the solution will be. Health reform is a complicated issue with many moving parts. I spend a number of hours each week on phone conferences with my colleagues across the country discussing strategies and solutions and realize that rational and civil debate is critical to identifying the best strategy for the years ahead.

It worries me to see so much misinformation about options being considered. From my discussions with health leaders around the country, I know many of the “facts” being used to frighten people are false.

I think it is important for those of us who work in a public health system providing high quality service through a myriad of programs speak up and describe how our system works. It is also important that the voices of those benefiting from government-run health programs are heard so others can learn from their experiences. And those being harmed now, who have lost their jobs and their health coverage, should also be encouraged to tell their stories.

Above all, we should encourage people to get information from objective sources and not rush to judgment. Please share my podcast (available at http://cchealth.org/topics/podcast/) about this topic with others and let
them know they can get more information at these sites:

http://www.healthreform.gov
http://healthreform.kff.org/
http://aarp.convio.net/site/PageNavigator/Myths_vs_Facts
http://www.whitehouse.gov/realitycheck/
http://www.politifact.com/truth-o-meter/

I know this is a very complex and confusing discussion at the present time. Let’s all do our best to keep informed and help others to stay informed. And I will do my best to keep you up to speed with current information.


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

Contra Costa County "must shed more than $50 million, atop the $150 million cut from the county budget since December."

Read Dr. Walkers comments in The Contra Costa Times about the budget.

For those who think Health Care Reform isn't necessary, please think again.
The current state is unsustainable. The time for change is now.

Interrupting Harm

Here you can find The San Francisco Chronicle's "Dead by Mistake", a series dedicated to exploring the profound effects of harm caused by medical error. On the site they highlight the Institute for Healthcare Improvement's (IHI) Global Trigger Tool- a tool used for measuring adverse events. You can read more about the GTT here.

Remember, to count is only part of our work. We must find harm, understand where our defects are, make predictions, test our theories/changes, and ultimately interrupt the cycle of harm before it ever occurs. We must use design science to eliminate needless death, pain and human suffering, unwanted waiting, helplessness and waste, and we must do it in a way that no one is left behind (IHI.org).

Many of you have asked to learn more about measurement. As promised, I will begin a series of weekly learning sessions with an aim to demystify quality improvement.

Please join me for next week's session: Understanding Variation on Thursday August 20th at 9:00 AM at CCRMC in Building One, Conference Room One.

Be well,

Anna

Finding our way forward...

All staff message:

Greetings,

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

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

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

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

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

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

Sincerely,

Anna