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,

Anna

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.

Anna

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:
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.

Patient:
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


PT/OT:
Feedback on arrangement of furniture/equipment

RT:
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

Do:
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.

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,
Anna


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.
http://ChasingTheRabbitBook.com
for preface, forward, intro, and blog.

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

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

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



from www.engagewithgrace.org
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.


1 http://www.publicagenda.org/citizen/issueguides/right-to-die/publicview/people-concerns
2 http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1282180
3 California Healthcare Foundation, “Attitudes Toward End-of-Life Care in California,” 3. (Lake Research Partners, November 2006).
4 Ibid.
5http://www.nytimes.com/2008/04/07/health/policy/07care.html
6 “When Compassion is the Cure: The Case for Hospital-Based Palliative Care.” California Healthcare Foundation, 2008, p 31.