Saturday, February 27, 2010

Common Things

Why do we do common things uncommonly well?

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

“We do common things uncommonly well”

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Thanks for sharing Jeremy.

Tuesday, February 23, 2010

We need to talk...again


As promised at last weeks CCRMC Improvement Academy, I am reposting the communication entry. You can also find this on the CCRMC iSite welcome page.

Be well,

Below is my original post-

I've been thinking about how important it is that we talk and listen to each other. This blog was designed in an attempt to open an alternative line of communication. It was my hope that not only two way conversation may occur, but perhaps an open forum of dialogue from a diverse set of perspectives might follow.

The importance of communication cannot be underestimated. In the United States the root cause of sentinel events that has been most frequently identified since 1995 (66% of reported sentinel events), is communication*. Could that mean that the majority of serious preventable harm in US hospitals is caused by communication failures within the system?

In reviewing the Institute of Medicine’s six “Aims for Improvement” what could this framework be communicating to us on behalf of the patients we serve?

Safe: Please don’t hurt me. Provide care for me with a health system that is safe.
Effective: Give me what I need based on the best known science.
Patient-Centered: Please respect me and all the things that make me uniquely who I am. Let me choose to be involved in my health care decisions in a way that I am comfortable.
Timely: Please don’t make me wait unnecessarily. Provide care to me at the right time.
Efficient: Please don’t waste my time or my care provider's time.
Equitable: Please give me an equal chance to be healthy. Please don’t leave me out.

The importance of communication probably isn't a new concept to you. Communication is at the root of so much of what goes right and wrong for us in all aspects of our lives. We communicate for reasons beyond mere information exchange. We communicate for survival and companionship.

Last week, while at a meeting for the Integrated Nurse Leadership Program I learned about tap code , a method of communication that is commonly used by prisoners. In this case it was used by prisoners of war (POW) to communicate with each other. Letters are placed on a grid and by assigning a number to each letter; prisoners could communicate with one another by tapping on things such as a wall or pipes. It is simple in design yet very effective.

Newcomers can easily and quickly catch on. Information such as what questions interrogators were asking, to who needed help or extra food or supplies could be shared among the prisoners. POW Vice Admiral James Stockdale describes the code ,"Our tapping ceased to be just an exchange of letters and words; it became conversation. Elation, sadness, humor, sarcasm, excitement, depression -- all came through." Here is a link to a video of Stockdale speaking about the importance of the ability to communicate. In listening to him it's clear to me that this tool not only allowed for the exchange of information, but also the exchange of human spirit. He recalls that the men would communicate at any cost, "if you get caught and tortured for a while, that's just the do it anyway."

Failed communication isolates us from each other and all too often leads to misunderstanding; misunderstanding to misinformation; misinformation to complete chaos.

In the coming weeks, operations leaders will begin to seek input from you about how we can better communicate, how we can better listen. Our aim is to build an enduring system that promotes open and transparent communication. It’s not to say that we haven't done many things to promote better communication, because we have, but we can improve and we need to do more. Your participation will be essential. We are seeking the input of others from within our system that specialize in communication. Please join us as we seek your help to explore strategies that will strengthen our ability to connect with each other and those we here to serve.

More very soon...

Sunday, February 21, 2010

This is wellness? I froze!
The CCRMC Improvement Academy will meet in the hospital lobby this coming Thursday February 25 at 9:00 AM.

I could not be more delighted as we will be joined by Danielle Ofri, MD, PhD, DLitt (Hon), Assistant Professor of Medicine at New York University, practicing physician at Bellevue Hospital and Author of multiple publications, including her most recent book, "Medicine in Translation: Journeys with my Patients". Dr Ofri is also the Editor-in-Chief and co-founder of the Bellevue Literary Review (BLR), the first literary journal to arise from the halls of a hospital. The BLR publishes poetry and prose that touch upon relationships to the human body, illness, health and healing.

We're in for wonderful a treat. This is a morning you will not want to miss!

I look forward to seeing you there.

My best,


Tuesday, February 16, 2010

The Model for Improvement, Lean and CCRMC: Much more than rubbish

A couple of weeks ago I was speaking at the Improvement Academy and there was a comment from one of our nurses, Grace, who said "While you all talk about all this statistics, I want to tell you about my week with the garbage." After the laughter subsided Grace went on to tell us about the PDSA she and others had conducted in the prior week. The group wanted to identify and standardize optimal placement of common items (in this example it was the waste bins) in a patient room to decrease clutter. The project was part of efforts to eliminate falls on the unit.
I'm sharing the PDSA below because it involves the use of The Model for Improvement and Lean(5S). My aim is to illustrate that these approaches (Model for Improvement and Lean) are not competing science, but in fact complimentary. We can and are using both the MFI and Lean together to facilitate changes that lead to improvements.

You can imagine the fun we all had talking about a PDSA that focused on the ideal placement of rubbish! In all seriousness, the staff tested their way into standard work. Does this sound familiar? This is an application of The Model for Improvement and Lean Methods, set in the context of our unique culture.

Much more than rubbish, this is a wonderful example of how we are using science, action and us to transform our system.


Here is the PDSA.

What is this PDSA aligned with? Why do this?:
Reducing harm - this test is connected to the aim to eliminate falls at CCRMC by June 2010.

This cycle is being used to, test a change?

What question(s) do we want to answer on this PDSA cycle?

AIM of this PDSA: Can we accomplish the following(?):

1. Decrease clutter in a patient room
2. Eliminate / remove cables when not in use
3. Make it easy for everyone to place items in the correct location

Plan to answer questions: Who, What, When, Where

Who's involved in this testing cycle?
Patient, Nurse, Charge Nurse, Housekeeper, PT/OT, RT and Dietary

What are they going to try and do?
Standardize placement of key items in patient room to minimize clutter and facilitate safe mobility in room.

Provide feedback on ease of furniture arrangement

Primary nurse:
Detach cables when not in use/ untether them from potential clutter
Monitor of furniture / equipment arrangement

Night shift nurse:
to clear overhead table before breakfast

Charge Nurse:
Label where equipment/furniture to be arranged in room

Environmental Services:
Keep / return equipment and furniture to designated area
Feedback on ease/feasibility of furniture and equipment arrangement

Feedback on arrangement of furniture/equipment

Feedback on location of their equipment.

Nutrition Services:
Will not place meal tray in room if overhead table is cluttered. This will need alternative.

When will this happen?:
• Will begin on 1/20/2010 for one week
• Assessment at end of every shift (except Sat and Sun)
• Make appropriate changes based on feedback.

Where is this going to happen?

3E -02 [IMCU]

Plan for collection of data: Who, What, When, Where (Yes we have to collect data)

Charge Nurse and Relief Charge Nurse to survey patient and staff with regards to new room arrangement.

What do we think is going to happen? Predictions (for questions above based on plan):

1. Easier to locate / predict where furniture/equipment are
2. Open space for patient to get in and out of bed
3. Room appears organized

Carry out the test this week; Collect data and begin analysis.
1. One unit, one room with multiple staff.
2. Survey questionnaire.
3. Label and place garbage can in one spot (red, blue and plain)
4. Stepping stool placed at designated area out of patient way, at bedside cabinet below monitor.

Study/what happened?
Complete analysis of data.

YES, the predictions were accurate.
-Everyone liked knowing where things go
-New lesson learned with regards to configuration of patient’s bed.

Act- so now what?

Are we ready to make a change...plan for the next cycle?

We think we are ready to try this on a bigger scale.

Nurse Program Manager to send an email to dietary manager to not place meal tray over the sink if overhead table is cluttered.

Charge nurse to present findings at next CCRMC Improvement Academy.

Friday, February 12, 2010

Excellence vs. Perfection

Some thoughts...

I've been asked several times this week, "What do you think of Toyota now?"

I would like to emphasize that I do not, nor have I ever, claimed to be an expert on Toyota Motor Company or the Toyota Production System (TPS). I am, however, extremely interested in change across a variety of scales; The Model for Improvement, Lean methodology, statistical process control (SPC) and the pursuit of excellence through continuous learning and improvement.

In considering the question about Toyota, I reflected on my time at the IHI and the many hours spent with Jim Conway. During his tenure as the COO of Dana-Farber Cancer Institute, it was his job to respond to the tragic events that resulted in the death of Boston Globe health reporter Betsy Lehman. The institution had always prided itself on being a center of excellence. The event devastated all involved. The error involved breakdowns in standard processes and raised issues of trainee supervision, nursing competence, and order execution. Like only a handful of organizations at that time, the leadership team at Dana-Farber led their organization, and the nation, into a new era of introspection and transparency inviting patients and families into the planning and design of Dana-Farber's systems.

That said, it should come as no surprise to you that when our organization faced a tragic event that resulted in the death of a patient in our Emergency Department this summer, I immediately turned to my mentor Jim and asked, "How does an organization best face, own, respond to and recover from such an event?" This was only after I asked myself the following:
How could something this devastating happen here at a place where we don't just try and get by, but we aim to be the best?

What do I tell the staff who work so hard and so well every day?

How do we shed the shame, the embarrassment and how do we learn so this never happens again?
He said, "Never forget that excellence is not the same as perfection and within the gap between them sometimes lies tragedy. That is why learning and improvement must be an enduring attribute of your system."

Returning to the original question I've been asked so many times this past week, "What do I think about Toyota now?"

I think they're not perfect.

Be well,

I did post on Toyota in the fall. You can find that post Grasping for Salvation: Is the Mighty Toyota Falling here.

Some suggested readings from Steve Spear:
"3 Questions: Steven Spear on Toyota’s Troubles,” conducted by the MIT News Office.
"Toyota: Too Big, Too Fast," by Gordon Pitts
in The Globe and Mail (February 5, 2010)
"Learning from Toyota's Stumble,"
e-article at HarvardBusiness.Org.
for preface, forward, intro, and blog.

Thursday, February 11, 2010

Dr Atul Gawande speaks about the use of checklists to improve care. You can find the PBS Newshour segment here.

Saturday, February 6, 2010

From the Community Clinics of California:
adding a bit of levity to a very serious message.

Friday, February 5, 2010

Engage with Grace: One Slide

The problem with communication is the illusion that it has occurred.
~ Shaw

Can you answer five questions?
Please consider taking two minutes at the end of your next presentation, blog post, tweet, or facebook update to share this slide. ~Anna

Why It Matters:
Many of us do not die in the way we would have chosen

•73% of Americans would prefer to die at home[1], but anywhere between 20-50% of Americans die in hospital settings.[2]

•More than 80% of Californians say their loved ones “know exactly” or have a “good idea” of what their wishes would be if they were in a persistent coma, but only 50% say they've talked to them about their preferences.[3]

•Eight out of ten people say it is “very” or “somewhat” important to write down EOL wishes, but only 36% actually have written instructions.[4]

•According a NY Times article,Dr. John E. Wennberg of Dartmouth Medical School, the chief author of the study, said doctors and hospitals that provided more care, or more intensive care, did not necessarily achieve better results for patients. He stated, “Some chronically ill and dying Americans are receiving too much care — more than they and their families actually want or benefit from[5]

Engage with Grace from Health 2.0 on Vimeo.

And it comes at a great cost
•A study by the California Healthcare Foundation compared patients who received palliative care services (i.e. reducing the severity of symptoms, not trying to cure the disease) versus those who did not over the last three days of life. The cost for patients who received palliative care services was $492 versus $2,671 for those who did not, creating a savings of $2,179 in the last three days of life.[6]

People don't talk about death, which means that often times, people aren't able to die in the way that they lived — with intent. Some people die in a hospital when they would have preferred to be at home. Others are kept on life sustaining treatments way beyond the point they would have wanted. This comes at a high cost to us, our families and the healthcare system. Communicate your wishes. Engage with Grace.

3 California Healthcare Foundation, “Attitudes Toward End-of-Life Care in California,” 3. (Lake Research Partners, November 2006).
4 Ibid.
6 “When Compassion is the Cure: The Case for Hospital-Based Palliative Care.” California Healthcare Foundation, 2008, p 31.