Sunday, December 26, 2010

Workforce Safety and Vitality: Request for your input

Greetings,

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

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

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

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

With respect,

Anna
Center for Workforce Safety Proposal for Employee Review

Friday, December 24, 2010

Reflections

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

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

Although in very early stages, we are in conversation about how to design a safer workspace for all staff. The Sheriff’s Office and Contra Costa Health Services have forged a stronger and more united bond not only to ensure there is safety and respect, but to reestablish where the two departments have common goals. We have begun discussions with the labor representatives and Risk Management to provide feedback in our process as we move along. In the next year, we will be developing a Center for Workforce Safety and Vitality. Still in the design and feedback stage, this is an essential step to new and redesigned patient care while ensuring that our system is a safe and rewarding place to work.
“I now know Cynthia through your stories.”Jim Conway
Jim Conway joined us for some of those conversations. He came to assist us in problem-solving and to provide his expertise on ways we could continue to provide safe and excellent service without compromising quality of care. As the detention staff and others met with him over the course of two days, he was struck by the deep respect they had for each other and their work. Evident was a committment to move forward in a meaningful way creating an enduring legacy to honor Cynthia and all who are committed to our mission. Before he left he thanked the detention nurses commenting “I now know Cynthia through your stories.”

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

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

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

Anna

Wednesday, December 22, 2010

System Redesign

I have been asked several times to post this again and have been waiting for today to do so. Remembering my Dad on his birthday…

On June 9, 2005 the first annual Hospital Redesign Summit was held in San Diego. How much more perfect could this get, since I was charged with helping lead System Redesign? Like everyone else, I wasn't quite sure what that meant. I arrived late that night to San Diego after a very full week of long hours in the hospital dealing with what seemed to be an expanding list of issues. My week was not consumed by the halls of Contra Costa but spent in other hospitals sitting at the bedside of my father who had fallen quite ill. After what seemed to be weeks of sleepless nights, my father was transferred to a large tertiary medical center. It was a welcome reprieve as the drips and lines seemed to be increasing with each day. With him safely tucked in at one of the finest centers in the world, I could now get on a plane to learn more about “Redesign.” To be honest, I was tired and needed a break.

My day started off with a video from Sorrel King, mother of Josie. To this day I will never forget her words, the words of a mother who lost her child to a chain of errors and system failures.
~Josie King Story~
She challenged hospitals to think about having a team that was available to bring care quickly to people who were deteriorating before they went into a cardiac or respiratory arrest. She called it a medical emergency team or rapid response team.

I went from session to session and could not escape the realization that our system was broken. It wasn’t about the hospital, but rather the whole system of health. I also found others who were trying to learn ways to improve their systems through ‘redesign.’ I came home energized and full of ideas about improvement methods and reliability, and concepts like ‘spread.’ I also came home to find my father sicker than when I had left.

The days following the Summit were filled with ideas scribbled on paper while sitting at my father’s bedside. I tried to keep up as the teams rounded on him. It seemed so odd that after all the time I had spent in a hospital, I hadn't a clue how it all worked. I couldn't figure out who was in charge of which part of his body. I couldn't keep up with his deteriorating health and growing amount of health care intervention. It was truly a mess but in just a few more days he was discharged to my home for what would surely be a very long but full recovery. It was four days later I had come back to work for a meeting about the digital diagnostic imaging system (PACS) when the call came in about my Dad. It wasn't good news…

As I drove home that night from the mortuary I wondered. Did he experience any harm due to error? He took high-risk medication, what if it was the insulin? Was it a postoperative complication or infection? Was it sepsis? I wondered what might have happened if there were some mechanism like the rapid response team that Sorrell King had described. I wondered about the people we serve.

When I returned to work, the System Redesign Team approached the most senior leadership and the Performance Improvement Committee with a request to endorse and actively participate in the IHI 100k Lives Campaign. In the months to follow, leaders all over the system stepped forward. Tools and how-to-guides were brought to life by teams that had already been working in many aspects of the 100k Lives Campaign interventions. We heard stories of steady improvements that began to take the form of breakthrough improvement. The energy was palpable.

As I read through the email responses to my ‘small test’ in communication and was stopped in the halls this last week, I realized that many people are wondering, "What ever happened to System Redesign?" It's a reasonable question, and it points to how redesign elements have been integrated into the current system. System Redesign was never occurring in a conference room but rather in improvement teams on your unit. 'System Redesign' wasn't a committee making sweeping changes and impersonal decisions that shaped the experience of the individuals we serve: you were, one decision at a time, one experience at a time, one patient at a time. The team located tools from experts to share with you. Tools that others across the nation had found, if used reliably, made it easier to do the right thing for your patients.

So where is System Redesign now? System Redesign has been diffused into structures such as Safety and Performance Improvement and the teams you are on in your local work areas. Some of you call it the IHI work. Some of you may know it as the work we have done on Lean. Others still may not call it anything specific, but it is the output of the team efforts you are all engaged in across our great health system. Redesign can be found everywhere. I found a number of people who said you didn't need more resources but you need to find different ways to do the right thing, a viewpoint supported by Steve Spear in the New York Times (More for more? Spear, S.), where he notes that in health care, more is not necessarily better. Not necessarily more, but better, that is redesign.

Recently, I was on the fourth floor and a rapid response was called. I watched as the team delivered what appeared to be a seamless response that resulted in a rapid transition to critical care. I thought of his family. A few days later, I learned that the man had been discharged home. I thought of my Dad.

Friday, December 17, 2010

Perinatal Kaizen 1 Report Out

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

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

Monday, December 13, 2010

WIHI on The Patient Activist


The Patient Activist
Thursday, December 16, 2010, 2:00 PM – 3:00 PM Eastern Time

Guests:
Bill Thatcher, Executive Director, Cautious Patient Foundation

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

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

Charles Maclean, PhD, Founder, PhilanthropyNow

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

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

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

To enroll, please click here.

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

Saturday, December 11, 2010

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

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


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

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

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

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

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

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

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

Friday, December 3, 2010

Joint Commission Survey

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


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

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

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

Today we celebrate, tomorrow we accelerate.

Anna

Sunday, November 28, 2010

Perinatal Rapid Improvement Event # 1 begins Monday November 29

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

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

What's happening here at CCRMC?

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

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

What is Lean?

Basically, lean is centered on creating more value with less work. Lean Management is a generic process management philosophy derived mostly from the Toyota Production System (TPS). It focuses on reduction of the original Toyota seven wastes in order to improve overall customer value.

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

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

Why Lean and why now?

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

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

What's Next?

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

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

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

More very soon...
Anna

Saturday, November 27, 2010

Eliminating harm: The science of delivery

What would Deming say about this?

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

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

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

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

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

Anna


Here are the studies below:

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


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

Engage with Grace: Do you know the answers?



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

From Alexandra Drane:

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

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

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

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

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

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

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

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

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

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

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

Monday, November 15, 2010

CCRMC Improvement Academy: Opportunities and Challenges in Health Care Reform

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

Thursday, October 28, 2010

Sad News

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

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

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

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

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

With deepest sympathy,
Anna

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

Friday, October 22, 2010

A call to action in the perfect storm

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

The following is an excerpt from my post:

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

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

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

Friday, October 15, 2010

Have you had your flu vaccine yet?

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

Flu Vaccination information is available at cchs.org

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

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

Where to Get Vaccinated

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

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

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


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

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

Links of interest:

flucliniclocator.org (check clinic for details)

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

Wednesday, October 6, 2010

CCRMC Improvement Academy: 5s Reports Thursday, October 7


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

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

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

More very soon…

Here’s a review of what 5S is.

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

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

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

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

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

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

Friday, September 24, 2010

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

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

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

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

Anna

Thursday, September 23, 2010

A new day in American Health Care

“We will go through the gate. If the gate is closed, we will go over the fence. If the fence is too high, we will pole vault in. If that doesn’t work, we will parachute in. But we are going to get health care reform passed.”
-House Speaker Nancy Pelosi, March 23, 2010
Many of the provisions of The Patient Protection and Affordable Care Act take effect today. The provisions contain protections for consumers and for many of the nation's most vulnerable and in need of health care. I realize there are mixed feelings about the reform legislation. Many may feel this is too little, while others may disagree with health reform altogether.

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

More very soon,
Anna

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

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

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

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

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

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

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

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


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

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

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

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

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

Wednesday, September 22, 2010

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


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

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

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

Anna

Tuesday, September 21, 2010

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


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

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

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

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

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

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

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

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

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


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

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

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

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

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

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

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

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

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

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

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

Tuesday, September 14, 2010

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

Greetings,

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

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

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

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

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

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

Sincerely,
Anna


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

Wednesday, September 8, 2010

Pround Knowledge: Appreciation for a System


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

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

Session II: Appreciation for a System

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

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

Hope to see you there.

Tuesday, September 7, 2010

Exploring Ethics at "Food For Thought"

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

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

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

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

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

So, mark your calendar, send in your RSVP, and enjoy as much of the reading as feasible.
Hope to see you there.

Friday, September 3, 2010

Remembering Sergeant Paul Starzyk

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

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

Tentative Schedule for September 6, 2010
7:00 AM- Uniformed personnel form up in front of the fountain near the flag pole.

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

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

11:35 AM - Police Chief's comments

1139:17 AM - Moment of silence
"The wicked flee when no man pursueth: but the righteous are as bold as a lion."- Proverbs 28:1

Thursday, September 2, 2010

"You are not alone"

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

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


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

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

My best,
Anna

Wednesday, August 25, 2010

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

"We have learned to live in a world of mistakes and defective products as if they were necessary to life. It is time to adopt a new philosophy...." -W. Edwards Deming
REMINDER:
CCRMC's Improvement Academy meets Thursday August 26th at 9:00 AM in Building One, Conference Room One. I will present an overview of W. Edwards Deming's System of Profound Knowledge.

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

Please join us.
Anna

Tuesday, August 24, 2010

More on Forgiveness

Posted by Jon Stanger, MD

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

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

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

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

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

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

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

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

· Never ignore or trivialize the victim’s suffering.

· Causes must be uncovered and confronted.

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

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

· Forgiveness and reconciliation are processes that often take time.

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

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

· Sincere expression of regret or apology.

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

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

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

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

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

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

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

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

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

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

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

Final grade – “Incompetent.”

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

Sunday, August 22, 2010

A Culture of Safety: Forgiving

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

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

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

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

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

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

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

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

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

Now, we move forward.
Anna

Saturday, August 21, 2010

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

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

Something wonderful to look forward to!

Anna

Friday, August 20, 2010

Upcoming changes in our system

Posted by Tess O'Riva, CCRMC Communications Director

In last Monday's message to staff , Dr. William Walker, Health Services Director, described some of the ways he is preparing Health Services to best meet the challenges and opportunities within Health Care Reform.

His message is below.
"In recent Director’s Report messages, I described what health reform under the Patient Protection and Affordable Care Act and the California Medi-Cal waiver means to Health Services and the patients we serve. As provisions of the Act and new requirements of the waiver – a bridge to health reform’s complete roll-out – are unveiling, I continue to realize that in order to prepare ourselves to meet the challenges that are before us now and into 2014, significant changes in our system, particularly the service delivery side of our organization and our leadership structure, must begin.

The new legislation offers many opportunities for demonstration projects and pilot programs, which would be well suited to our system. There are also new requirements and incentives for integration across our various Divisions. With this in mind, I have asked Dianne Dunn-Bowie to move to a new role as Executive Director, Health Services Integration and Governmental Relations. Dianne, with her many years of experience in all aspects of health care, will help us to strengthen key political relationships, build new community partnerships and develop new models of service integration.

We must move quickly to seamless and safe handoffs of patient care between our inpatient and outpatient systems. We must improve access to primary care and specialty services and develop more effective interactions between inpatient and outpatient staff. We must develop improved case management and care coordination functions. I have concluded that this will not happen within the current structure of separate Divisions. I am therefore combining Ambulatory Care and the Medical Center into a single Division under CEO Anna Roth effective September 1, 2010.

This past year has been an unprecedented year of change at CCRMC. In the last twelve months all but one executive leadership position has turned over as leaders retired after a long and rewarding career at CCHS. Several months ago, CCRMC CEO Anna Roth began redesigning a number of her departments, including safety and performance improvement, professional development, detention health and emergency services, behavioral health, perioperative services, and inpatient medicine. In addition to the ongoing operational redesign efforts, Anna has introduced initiatives to build internal capacity to grow and continually improve.

Also on September 1, 2010, Dr. Chris Farnitano, Chair of our Family Medicine Department, will move into a management Medical Director position with primary responsibility for leading the development of new models of team-based care, patient-centered medical homes, improved patient flow and timely access to outpatient care. Our goal is to be a national model for improved chronic disease benchmarks. Dr. Farnitano will also be intimately involved in the system changes necessary for the installation of our Electronic Medical Record over the next couple of years. We are also currently recruiting to hire a Chief Operations Officer for the Hospital and Health Centers. Reporting relationships for this new structure are now being developed.

In the weeks, months and years ahead we have much work to do. As we continue to learn more about the specifics of health reform, I anticipate that there will be additional restructuring. Some of our efforts will be successful and others will need to be tweaked or rethought. This will be an exciting time for all of us.

The dedication we have to serving the community and to supporting each other makes us a model for the new American system of health care. We have made great strides over the past decades to develop a system that puts the patient/consumer/client first and provides the kind of services that care for the whole patient. I believe that with the dedication and commitment of all of you, we will successfully make the system changes necessary and meet the challenges that are before us."

Putting Contra Costa Health Services at the forefront of Health Care Reform is both exciting and inspiring. I share Dr. Walker's belief that our system is poised to change the way health care is delivered and be a model for the nation, not only because of our unique structure, but because of the people we work with. I can't wait!

Tess O'Riva

CCRMC Communications Director