Monday, April 27, 2009


As you know, there is a national health emergency in place. The outbreak of swine flu in Mexico has been deadly and has caused a shut down of normal operations in that country.
There have also been 5 states in the United States so far that have confirmed cases.
We are in preparation mode for further information and/or action plans.
At this point, at CCRMC and Health Centers, we are doing the following:

1) Respiratory precautions,
2) Appropriate testing and cultures
3) Capacity planning with regional partners
4) Frequent informational updates.

There will be twice daily open huddles--9AM and 4PM, in Conference Room One, Building 1 starting today at 4PM.

Any questions, call Anna Roth 370-5101.

Jeffrey V. Smith, MD, JD
Executive Director
Contra Costa Regional Medical CenterAnd Health Centers

Sunday, April 19, 2009

Sing Out Loud

As we begin week two of our Value Stream Mapping, we continue our journey toward the reliable delivery of care that is always safe, timely, patient-centered, effective, efficient and equitable. I want to thank everyone for your genuine interest and tireless efforts as we move forward. I know it isn't always easy.

I offer two very brief examples of those who, when faced with criticism and resistance, stood their ground. I have added links to both examples if you want to learn more.

"To fly, we have to have resistance" -Maya Ying Lin

Maya Yin Lin, was a 20-year-old student from Yale University who faced significant criticism of her design for what has become the most-visited memorial in Washington DC, The Vietnam Veterans Memorial. In the midst of tremendous challenge, Lin remained focused in her vision and after extensive review from several government agencies, her design was chosen… yet Lin wasn't even mentioned at the dedication ceremony.

Lin has since gone on to design all over the world. A few examples of her work includes the Civil Rights Memorial in Montgomery, Alabama and an Academy Award-winning documentary Maya Lin: A Strong Clear Vision. In 2003, Lin served on the selection committee for the World Trade Center Site Memorial Competition.

"I want to be like Elaine Paige"- Susan Boyle

This one seems a bit light-hearted, but I found it wonderful and inspirational to watch Susan Boyle – as people sat laughing at her and making fun of her – stand tall and sing out loud.
Here is the link to her video.

Contra Costa Regional Health Foundation's "Jazz at the Craneway"

With a fog kissed bay and spectacular view of San Francisco, a fantastic evening at the Contra Costa Health Foundation's annual fundraising event "Jazz at the Craneway" was had by all.

Friday, April 17, 2009

Update from James Mountford

I wanted to draw attention to the latest comments from James Mountford. I included the original post and all of the discussion to lend context to his comments.

Check out Dr. James Mountford's latest work

When clinicians lead
, published in The McKinsey Quarterly. A brilliant piece, well worth reading by Mountford and Webb.

Jeff Smith said...
I could not agree more with Dr. Mountford!! It is critical to get clinicians into the policy making process.

However, the impediments to this change are very significant--as discussed in the article (i.e., clinician skepticism, negative career incentives, and a paucity of mentors).

An additional impediment is more subtle, and much more problematic in my opinion. That additional impediment is the coldly calculated self interest of "organized medicine" (i.e., physician interest groups on the national and local level). These groups are not interested, as a whole, in changes to the health care system that do not result in more revenue for their members--whether or not the changes are better for patients.

In the US, we should always remember that Medicare was originally proposed by President Truman in 1945 as a universal coverage initiative. "Organized medicine" killed that initiative to guarantee coverage and turned the system into a "guaranteed payment" program. At a time when other countries (like the UK) were creating health care systems that recognized the need to treat health care as a human right, the US was more interested in the reimbursement of physicians.

So, a very intense cultural impediment to clinician leadership is the risk of being "thrown out of the club" for advocating for systems that work for patients but not for doctors.....

March 2, 2009 12:19 PM
Mary List said...
You are right on in your assessment, Dr. Smith, about self-intrest as the primary thwart to "righteous" health care. May I take this a step further into the specific and suggest that it is high time that physicians everywhere lose the man-made idea of "The Week-end?" The day of the week has no relevance in health care. You know the list of job titles in which there exists a committment to work weekends. Physicians, specialists, all surgeons, etc. ought not be able to cite a particular day of the week as a reason for not working. And yet, this is exactly what happens on 52 Fridays a year to those who are unfortunate enough to be admitted to any hospital that day of the week. Or, in an alternative vignette, if that's the day of the week it was determined that you needed such-and-such a procedure that "can't be done until Monday." Am I wrong to believe that this organization around the week-end accounts for, at the least, two days of stasis re: length of hospital stay? Can we afford this whimsical arrangement, created as the Industrial Revolution progressed, to be maintained nowadays in the realm of health care, which we agree is a right for all? Do Doctors Without Borders personnel out there in the world "take off" every weekend?
I think we have, for those who can afford it, a good health care system, and just the existence of this blog site lets me know that there are those who seek to improve on all the good things we've got. I propose that nationally you physicians that work in clinics and for nursing homes and for public health and in the acute care setting look forward to adding committment to working weekends as part of your chosen profession. And do not hand out a "weekends off" benefit for any reason. This is not patient centered health care. I wonder what the change in medical school applications would be if school children grew up knowing that to be a doctor would mean committing to weekend work the whole of your career. Full surgery schedules on both Saturday and Sunday, as well as clinic hours at the same availabilty as weekdays... what a concept! Would it improve outcomes? Would it reduce ER visits due to timely intervention at a clinic visit? Whom would it inconvenience except a physician (maybe a technician's? Really and truly, Dr. Smith, if you'd like to pay it forward, hatch this idea to the medical profession as a whole. We nurses "pilot" programs on our acute care units rather often. Can a county entity pilot such a program eliminating the weekend days of the week as static days and begin a "putting your money where your mouth is" posture of full availability of services seven days a week? Would the medical profession defend such a thing? Would physicians come to respect even the idea that weekend days off may belong to other professions, but not theirs? As do nurses, caregivers, housekeepers, firefighters, police, etc. (the list I mentioned above, which you already know).
Please consider this idea as relevant to the mission statement of CCCRMC.
Mary List, RN, MSN

March 16, 2009 11:22 AM
Jeff Smith said...
Mary, I believe that you are very correct. Our national system of health care is really not "patient centered." Although I am certain that many individuals would debate that assessment, the final outcome makes the reality quite clear. Spending more on health care, we have poor public health outcome measures--that is all that it boils down to.

As for your argument about weekends, I also agree. There is no good patient care reason for weekends to be treated differently than weekdays.

March 17, 2009 12:49 PM

James Mountford said...

Anna: thank you for highlighting the article on your blog. It's prompted me to have a good look at the blog -- you write beautifully (and often movingly) about fascinating and important topics. I will return often!

To Jeff and Mary's interesting comments: I agree aligning the incentives for physicians (and, I'd add, of organizations) with those which will best serve patients' and the public interests is critical. If this is to be the year for healthcare reform in US, doing this will need to be front and center if it's to be successful. A striking example of misalignment is a payment system under which the 'reward' for keeping someone with a longterm condition as healthy as possible is reduced provider income.

I think that creating this alignment, and then ensuring that those who perform best (in terms of delivering high quality, efficient care) prosper will be one of the most important pillars in building clinically-led services. Because healthcare's too complex to get high quality and efficiency without having the key technical experts --the clinicians-- at the heart of the decision-making about how to design and run services.

April 17, 2009 10:50 PM

Thursday, April 16, 2009

Stephen Ruffa on Going Lean

I wanted to highlight comments I received from Stephen Ruffa, an aerospace engineer, a business researcher, and a Shingo Prize winning author. His comments can be found below, or here in the blog. I thought you may find his insights helpful and didn't want you to miss them. To learn more about Stephen Ruffa and his latest work you can visit his site here.

Stephen A. Ruffa said...
The goals of your organization appear to be well suited to a lean transformation. And lower waste is certainly the most visible outcome of lean. Still, I hope that you’ve been cautioned that directly targeting this outcome without first understanding the organization’s dynamic conditions--those uncertain demands and shifting needs that often drives these wastes to accumulate in the first place--can affect what your efforts are able to achieve.

This dynamic focus, which has been demonstrated by some of the world’s most successful firms, seems particularly important for dealing with the types of challenges faced by healthcare.

April 15, 2009 5:23 AM
Anna Roth said...
Dear Mr. Ruffa,

Your comments are greatly appreciated. I agree that the shifting demands and the root cause of those are critical for us to understand. It will be a great challenge.

We have been told how important it is to avoid oversimplifying the journey of a Lean transformation and that although many organizations employ Lean techniques, far less experience total transformation.

I do believe that we (the system) create not all, but a significant amount of the variation in demand, and that our fully integrated health system is well positioned to significantly level or smooth our flow using Lean principles.

I would like to learn more. I have read your book "Going Lean" and am waiting the arrival of "Breaking the Cost Barrier". Can you direct me to any other resources?

April 16, 2009 6:28 AM
Stephen A. Ruffa said...
I'm glad my comments were helpful. In response to your question, I just wrote an article to help explain the importance of applying a "lean dynamics" methodology to challenging circumstances (like those seen in healthcare)--how this produces stronger, much more sustainable results that lead to greater innovation.

The article titled, "Going Lean as a Solution to Navigating Uncertainty and Crisis", and you can link to it through my book's website at

Also, more is on the way--including training and other publications. If anyone has specific questions, they can reach me through the same website.

April 16, 2009 7:42 AM

Tuesday, April 14, 2009

Meet Goat 1 and Goat 2

As if I could resist posting this!

Press Release can be found on the CCHS website.

Hospital Receives Goats to Help Maintain Weeds, Vegetation

The county's Regional Medical Center got a new pair of four-legged friends this weekend to gobble up highly flammable brush on the center's 13.5-acre campus in Martinez.

The goats, on indefinite loan from Byron Boys Ranch, are tasked with controlling weeds and other vegetation growth at the hospital, which is operated by Contra Costa Health Services (CCHS). The animals are a part of the latest move by CCHS to become more eco-friendly.

"They're going to help protect the hospital against wildfires," said Larry Carlson, Facilities Manager at Contra Costa Regional Medical Center. "This is a real novel idea. It's green, it's proactive and it'll save money. Every weed they eat is a weed our gardeners won't have to pull."

According to Carlson, the medical center is the first hospital in the area to employ goats for vegetation control. The idea for the goats stemmed from a move two years ago by the Board of Supervisors that limited the use of pesticides in county operations.

Tanya Drlik, who coordinates the county's Integrated Pest Management program for CCHS, said, "Goats can be a great alternative to pesticides, which we want to avoid around sensitive areas like hospitals."

Integrated Pest Management uses environmentally friendly strategies that focus on long-term prevention of pests and their damage.

Carlson said the goats would also chew up most of the allergens that come with weeds and overgrown vegetation, reducing symptoms for people with allergies at the hospital.

The pair is currently living in a pen in which they have free roam. When at work, they will be tethered and supervised for their safety. The goats will circulate various areas of the medical center, including the parking lots, the hillside and the redwood grove.

Carlson, who is the primary caretaker of the goats, is seeking volunteers to help care for the goats when they are not roaming the campus.

To learn more about Goat 1 and Goat 2 and our Integrated Pest Management efforts please click here.

Friday, April 10, 2009

Increased Demand on Public Hospital and Health Systems in California

It likely comes as no surprise to you because you are delivering the service, but I thought you may like to see the numbers from the California Association of Public Hospital and Health Systems (CAPH) February 2009 Report. The report is based on data from October 2008 compared to October 2007. The report also notes that the number of unemployed and uninsured in California has been growing at an even faster pace in late 2008.

Here are some highlights:

Public hospital systems represent the core of the health care safety net in California. Though just six percent of all hospitals statewide, these 19
Public hospitals:

• Are located in counties where 81% of Californians live
• Provide nearly half of the hospital care to the state’s 6.6 million uninsured
• Operate 54% of all top-level trauma centers
• Operate 43% of all burn units
• Deliver 10 million outpatient visits a year
• Operate more than 100 outpatient clinics
Train nearly half of all new doctors in California

Adding to the challenge:

• The number of uninsured in public hospital emergency rooms increased by 19%.
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 12% increase in the number of patients in its ER
Los Angeles County also saw a 12% increase for its four hospitals’ ERs

You can find the report here.

So what can we do?

Our redesign efforts are being examined and shifting focus to support Lean thinking. We will develop increased capacity in innovative ways. We will work smarter, not harder. Our Lean efforts will help us to capture capacity that already exists in our system but is buried underneath complex layers of process. We believe that not only do many of these processes add no value to the patients experience; they have no value for those of us who work in the system as well.

How will we do that?

You may already be seeing teams forming around the medical center who are planning to 5S their work areas. Here’s what they’re doing.

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 is appropriate.

If you would like to get involved please let me know.

Teams plan to give a report on April 20th as we begin Value Stream Mapping at CCRMC and at the Pittsburg Health Center.

We will report out to the medical center and health centers when all the 5S reports are in.

More soon…

Thursday, April 9, 2009

Alto Desempeño en Salud: las reflejos de Pedro Delgado

Un improver asombroso bloguea acerca de su viaje para mejorar seguridad paciente en Irlanda del Norte.

Pedro Delgado, an amazing leader in quality improvement and patient safety, blogs about the journey in Northern Ireland and the UK to improve patient safety. In his recent post Inutil, he stresses that as professionals we have two roles; our work and to continuously improve.

He reminds us of Don Berwick's comments in his plenary speech at the 2009 International Forum on Quality and Safety in Health Care in Berlin. Don Berwick asserts that we would all be better off "if professionals (us) would behave with patients and families not as their hosts in our care system, but as guests in their lives."

This is a wonderful read and well worth the time. I also want to remind everyone that the blogs are accessible via the web to anyone. Please encourage those we serve to learn more about what we are doing in our system and around the world to improve health care. Pedro's blog is a great place for Spanish readers to learn more about quality improvement and patient safety in health care.

Click here to go to Pedro's blog.

Thank you for sharing your blog with us Pedro. I look forward to following your journey El cruce de la Sima de Calidad!

Friday, April 3, 2009

Going Lean

In November, the California Health Care Safety Net Institute (SNI)launched its Lean Core Measures Improvement Initiative. Funded by the California HealthCare Foundation, the program will introduce and spread the use of Lean as a management 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. CCRMC, along with three other public hospital systems was awarded a grant to bring 'Lean' thinking to our system.

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?

As part of our award 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?
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 defined by the external customer and in our case it's always the patient. Basically, lean is centered on creating more value with less work. Lean manufacturing 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.

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

Why Lean and why now?

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

For many of us it is difficult to hear our system described as "financially unsustainable," but that is how our system was described at last weeks board meeting. This shouldn't surprise any of us. As a government owned and operated system, we are in fact a reflection of the US Health Care system. I understand many would argue that industry is a better description than system. However you prefer to describe it, we do offer a glimpse of what the nation faces.

Currently health care makes up about 17% of the GDP and is climbing at a steady and very unsustainable rate.In America, we hear daily debates about bailouts, stimulus packages and health reform. Although the solutions are still in the development phase it is clear we must change course nationally and it is just as clear we must do the same here at the local level. Lean Management offers a systematic way of improving efficiency while improving not compromising quality.

What's Next?
Mike Rona and Patti Crome are on their way back to CCRMC. On April 20th we will work with teams of key stakeholders and perform an exercise called value stream mapping. This mapping will examine steps in our processes and weight them in value from a patients 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, but 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. Anyone from the Operations Team can answer your questions so please don't hesitate to ask.

More very soon...