Into 2012

Welcoming a new year filled with possibility

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

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

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

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

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

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

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

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

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

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

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

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

I look ahead with confidence and optimism.

Something to smile about

If you can't see the slides below, click here to view the PowerPoint.

Fluoride Varnish at CCRMC and HC

I wanted to share some results from what began as a “small test of change” to improve dental health in children here in Contra Costa County. Fluoride application is one improvement in our health care system that stands out as having a positive and immediate impact.

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

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

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

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

More very soon.
Anna

The Morning Commute: Perintal Services at CCRMC

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

Remembering my Dad on his birthday -

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

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

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

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

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

Rapid Improvement/Kaizen Event Reports are TODAY

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

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

"connected"

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

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

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

Thank you, Elena.
....always
Mom

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

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

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

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

You can view his presentation here.

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

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

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

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

I would have loved to keep at that job longer. But, as you know, the politics of Washington, and especially the politics of the United States Senate, said, “No.” But, overall, I don’t feel an ounce of regret. What I feel is grateful for the chance I had to serve, and for the generous support I felt, including from so many of you.

I want this afternoon to share with you a little of what I learned on the expedition; and what I think it means for you – for all of us. It’s a sort of good-news-bad-news situation. The good news: the possibility of change has never been greater – not in my lifetime. The bad news: if it’s going to be the right change, the burden is yours.

. . . .
Cynicism grips Washington. It grips Washington far too much, far too much for a place that could instead remind us continually of the grandeur of democracy. . .

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

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

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

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

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

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

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

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

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

Go with your gut

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

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

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

Anna

Engage with Grace

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

Below is an excerpt Alaxenadra Drane's post:

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

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

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

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

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

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

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

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

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

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

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

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

Giving thanks

Dear Contra Costa Colleagues and Partners,

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

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

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

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

Anna

Near Poor

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

PCHH Rapid Improvement Event

Greetings,

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

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

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

Anna

CCRMC and HC's, Patient Centered Health Home

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

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

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

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

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

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

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

More, very soon.
Anna

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

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

7:45-8:15 AM Richmond Health Center

10-10:30 AM CCRMC Hospital Lobby

12:15-12:45 PM Pittsburg Health Center

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

Anna

Observance in Cynthia Palomata's memory - October 28th

Dear Contra Costa Health Services Community,

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

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

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

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

Sincerely,
Anna

"No one left out"

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



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



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

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

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

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

...No one.
Anna

Lean Forward

In November 2008, the California Health Care Safety Net Institute (SNI) launched its Lean Core Measures Improvement Initiative.The program introduced the use of Lean/ Toyota Management System (TMS) as a strategy to streamline processes and create a more patient-focused environment that supports timely delivery of treatment and other healthcare services with optimum quality at the least cost. Over the last two years we have been working with deliberate focus and speed to integrate Lean/TMS as our leadership system. Many of you have participated in improvement events (rapid/kaizen), and/or had the opportunity to learn of the ongoing efforts at one of our many monthly “report-outs.”

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



What's happening here?



Mike Rona and Patti Crome from Rona Consulting provided the first of a series of Lean Intensive workshops for partners (users and providers) across our county involved in the delivery of health care. You may have seen some of the teams out in the medical center and clinics participating in an exercise called a waste walk. This was an eye opening experience for those of us who went. We went out to CCRMC in search of waste. We wrote down our examples on sticky notes and placed them on a wheel based on what type of waste they were. At times it was almost laughable, until we began to see the waste literally falling off our waste wheel. Some of us did what is called a spaghetti diagram. We followed the path of workers to see where they go to get their work done. The movement was phenomenal to watch. In summary, although it was a fun and very easy exercise, it was also quite sobering.





What is Lean?


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




Why Lean/ TMS and why now? 


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



Currently health care makes up about 17% of the GDP and is climbing at a steady and very unsustainable rate. Although the solutions are still in the development phase it is clear we must change course nationally and it is just as clear we must do the same here at the local level. Lean/ TMS offer a systematic way of improving efficiency, while improving- not compromising- quality. 



What's Next?


On October 24, 2011, a team of key stakeholders will perform an exercise called value stream mapping focused on the Patient Centered Medical/Health Home (PCMH). The team will examine steps in our processes and assign value to them from a patient’s perspective. We will then follow this up with a series of rapid improvement events or kaizen events (also known as kaizen blitz).

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

It feels like so much to learn, but we will learn together. We will take one step at a time. If we fall down seven times, we will get up eight. Please ask questions and keep an eye out for updates. If you have questions so please don't hesitate to ask.



More very soon...

Anna

CCRMC and HCs Delivery System Reform Update

Dear Contra Costa Health Services employees and partners,

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

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

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

Sincerely,
AnnaIncentiveProgramfour-pagesummary

Go and See

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

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

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

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

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

We know you

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

Insights from the ER from Worrell Design on Vimeo.

Insights from the ER from Worrell Design on Vimeo.

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

Kaizen Report-Out This Friday

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

7:45-8:15 AM Richmond Health Center

10-10:30 AM CCRMC Hospital Lobby

12:15-12:45 PM Pittsburg Health Center

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

Anna

The Choice is Ours

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

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

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

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

The choice is ours.

Sustainability Study - Support for Our Course

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

All Staff Message: Sustainability Study - Support for Our Course

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

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

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

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

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

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

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

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

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

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

Message from Alaska

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

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

Keep an eye out. More very soon...

Below are the slides from Friday's Report Out

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

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

7:45-8:15 AM Richmond Health Center

10-10:30 AM CCRMC Hospital Lobby

12:15-12:45 PM Pittsburg Health Center

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

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


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


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


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

Anna

Sea Level

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

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

What is Lean anyway?
There are many different variations of Lean in practice so I offer a very limited and generic overview that is consistent with the overall philosophy and reflective of CCRMC's Lean efforts.

Generally, Lean is centered on creating more value with less work. Lean Management is a process management philosophy derived mostly from the Toyota Production System (TPS) and grounded in W. Edward Deming's System of Profound Knowledge. Lean focuses on reduction of the original Toyota seven wastes in order to improve overall customer value.

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

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

What are we doing at CCRMC and the Health Centers?

Teams of key stakeholders perform an exercise called value stream mapping (VSM). This mapping examines steps in our processes and determines how much value these steps add to the patients experience of care from their perspective. In partnership with users of our health system/community members, teams then imagine/dream the ideal future state and present that to the system.

To begin developing and testing changes that are aimed at realizing this ideal future state a series of rapid improvement events or kaizen events (also known as kaizen blitz) are conducted. In these improvement events several small tests and simulations are performed. Changes are developed and tested with front-line staff and users of our system. Teams in the site where the work actually occurs then implement changes and continue to refine them on an ongoing/continuous basis, pursuing the ideal future state.

The table below displays upcoming events dates


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

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

Anna

Got Tdap?

Get a free Tdap (whooping cough) vaccine

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

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

Learn more at Contra Costa Health Services

Visit from LAO, CHEAC and CAPH

Greetings,

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

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

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

Thank you for all that you do.
Anna

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

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

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

Anna Roth

Released today:

Police Sergeant Paul Starzyk Memorial Overcrossing” Approved by Legislature

Tuesday, August 16, 2011

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

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

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

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

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

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

                                                                                         

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

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

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