A mother's lessons: Reflections from Teresa Pasquini

Presented by Teresa Pasquini
Mother, Advocate, Partner
When invited by Anna Roth, CEO of Contra Costa Regional Medical Center to participate in a Lessons Learned reflective writing activity with a group of local, national and international leaders of healthcare improvement I hesitated. How could my experience with the healthcare system compare to the important work of these great leaders? I had earned a BA in Liberal Studies back in 1977, but I never really used my education in a formal capacity. I had no letters like RN, MA, MD, or PHD behind my name. I was just a mom. But, I forced myself to reject the feelings of insecurity caused by my inexperience, lack of higher education, and professional degrees. I remembered that I was in fact an expert on navigating the chaos of the mental health system and my life experience earned me a PHD in system survival. That lived experience brought me to a Kaizen Event at Contra Costa Regional Medical Center in July of 2009. Before I share my life changing experiences at CCRMC, I need to go back to the beginning of this story.

I became a mom on August 22, 1982. I had a beautiful boy with ten fingers, ten toes, and all of the indications of a healthy baby. My son had 15 visitors on his first day of life. Grandma and Grandpa, Nonie and Papa, Aunts, Uncles, Cousins, and good friends welcomed his birth. A family joined together by the hopes and dreams of new life. It was my first time in the hospital as an adult. The care I received was amazing. The labor and delivery nurses were unbelievable. My husband brought them flowers as a token of gratitude for the care of his wife and newborn. I received a diamond pendant from my husband that I wear to this day commemorating our son’s birth, the day before our 2nd Wedding Anniversary. We were so proud and hopeful for our new family.

After a five month maternity leave, I returned to work briefly, but soon became a stay at home mom. I had secretly always wanted to be a stay at home mom even though this was the new era of the working woman. I had a promising career in business but left it eagerly and I was privileged to stay at home and care for our new son while managing our newly formed construction business.

From the beginning of my pregnancy I received excellent healthcare. Throughout our son’s first couple of year’s life was good. Then little things started happening that now I realize were clearly red flags. A serious speech dysfluency at age 3, too immature to start kindergarten, and failure to read in first grade. All of these warning signs brought special education supports and therapies through 3rd grade. Our request for testing of the school district failed to indicate a severe learning disability which was a relief. Behavior and defiance issues in 5th grade prompted immediate family counseling. Sleep problems began in 6th grade and by 7th grade there were serious emotional issues at play combined with the beginning signs of drug use. We sought immediate help from the pediatrician who had treated our son from birth. We began to navigate a maze of services in one of the most integrated healthcare systems. It was a nightmare. Balancing a business, a marriage, a family, and a serious mental illness was overwhelming at times. The memories are traumatic to recall these many years later.

The reality of our son’s symptoms wreaked havoc on our family which also now included a daughter. I had to take control and become my son’s case manager, a mental health system expert and special education advocate to save his life. I had the resources and ability to do this although not all families are so lucky. Although we were told when our son was diagnosed at 16 with Bipolar Disorder that we would be lucky if he lived past the age of 25, he is still alive today. After multiple involuntary holds, numerous hospitalizations, conservatorships, and several suicide attempts, my son’s mental illness and the mental health system have changed who I am and taught me that I needed support and partnerships to survive.

I joined the National Alliance on Mental Illness, NAMI, a non profit advocacy and education organization of family members of seriously mentally ill consumers. For a couple of years I went to monthly meetings and shared my grief with other families experiencing the same nightmare. We were on the same team that nobody wanted to be picked for and we helped each other and our children survive.

I remember one point in time when I was taken to my knees in pain. It was following one of numerous hospitalizations where I was ignored, my son was ignored and I felt defeated and broken. I knew that I could not control the current system and all of its injustice, but I realized that I could control how I spoke out and fought against the ignorance and discrimination toward families who have loved ones with serious mental illness. I had a Scarlet O’Hara moment from one of my favorite movies, Gone with the Wind. Just like Scarlet cursing the ravages of the War and her pledge to save Tara, “As God was my witness…” I was going to change the mental health system.

I applied for a Family Member position on our local Mental Health Commission. I had no clue what I was getting into or that my life would change profoundly as the result of this volunteer position. After a couple of meetings, I recognized that there was very little public recognition of the harm being perpetuated on families and their loved ones in a very broken system of care. There was mostly talk of the “positive” things being done. I began speaking of the negative things that my family had experienced by the mental health system. The negative versus positive dynamic created a tension that challenged my advocacy work early on as a Commissioner. In order to encourage the benefit of direct action, I wrote an open letter to the Commission in 2008 on the differences of positive and negative tension. That letter read in part as follows:

Dear Commissioners,

…As a mother who has also fought to save my son's life in the mental illness war, I do know the heartache and grief of which our Chairwoman speaks. We have shared our pain and struggles. We share a desire to serve our community and improve the lives of those who suffer, as our son's have suffered. We share a desire to "...influence the system toward positive change even in this tough economic situation."

As human beings, we often share substance, but not always style. It is that distinction that creates the beauty of a group who comes together to solve such an enormous task. It is that distinction that creates the challenge of a group who comes together to solve such an enormous task.

I recently re-read Martin Luther King Jr’s, famous April 16th, 1963, "Letter from a Birmingham Jail," about the importance of confrontation. It is a brilliant piece. The theme is the difference between positive and negative confrontation and their purpose in solving crisis. The letter discusses King's disappointment in the response from the white moderates to his direct-action program. He stated that the "...white moderate, who is more devoted to order than to justice; who prefers a negative peace, which is the absence of tension, to a positive peace, which is the presence of justice..." King wrote, "Actually, we who engage in nonviolent direct action are not the creators of tension. We merely bring to the surface the hidden tension that is already alive. We bring it out in the open, where it can be seen and dealt with. Like a boil that can never be cured so long as it is covered up but must be opened with all its ugliness to the natural medicines of air and light, injustice must be exposed, with all the tension its exposure creates, to the light of human conscience and the air of national opinion before it can be cured.”

Like King, I am not afraid of tension. My deep moral concerns, for the mentally ill and their families, cause me to challenge the power structure and systems that prevent their rightful justice. I don’t believe that tension prevents people from working together productively. I don’t believe that tension prevents progress and change.

As a Commissioner, I seek hope and change. I believe the tension that may arise, from seeking answers from those in power, and expecting accountability, can be constructive. I can not operate as a rubber stamp for those systems that continue to defend minor improvements, for a few, when so many others suffer deeply. Balancing negative peace and positive peace is the challenge before our commission. These are drastic times. Tough questions must be asked. The people we represent deserve the answers. It is the responsibility of our community service to accept that challenge.

Sincerely,
Teresa Pasquini

This letter created drama and further division on our Commission. The pull of the status quo was mighty and I was encouraged to be more collaborative and not use my personal story so much. I took that advice to heart and rejected it in part. This was personal. I would not be silenced about the harm caused to my family, but I sought to find a more respectful way to challenge the status quo and consider the bigger picture. That led me to the July 2009 Kaizen event at CCRMC.

In July of 2009, I was one of two family members asked to participate in a one week rapid improvement event for congestive heart failure. The team wanted to explore the risk factors of CHF for behavioral health/psychiatric patients. As a family member and mental health advocate, I was asked to participate. There was concern about me whispered around the tables and behind closed doors. Cautious warnings were shared about my outspoken, even radical, direct action approach. Fortunately, the Administration of CCRMC took a risk and opened their doors and minds and even encouraged me to push them forward. The first Kaizen was the beginning of a partnership that ignited our shared vision of hope.

We started off strong, excited, with the creation of a mission statement to “transform healthcare to be accessible and welcoming for all” We ventured into discussions that were previously reserved for internal staff meetings. We were now speaking freely of access, safety, errors, and improvement. We were teaching and learning together and laying down the tools that had been failing. We were challenging the status quo and embracing the tension that comes from change. And there was tension.

The tension was often whispered offline or subtly felt in meetings. The staff was not trained to be open with “outsiders” in the room. The patients and families were not familiar with “medical speak.” But, through determination, courage, and leadership, the comfort level increased and lessons were learned. The main lesson learned is to respect each others lived experience and assume good intentions. Remove blame and shame and establish a just culture mentality based on equity of ideas balanced with regulatory demands. If there are tensions, embrace them and fight through them in order to find the benefits for the patients, the families, and the staff who serve them both.

With the creation of our mission statement came the realization that a previous hospital policy was considered to be non accessible and non welcoming for approximately 600 psychiatric patients each month. The consumer and family voice was strong and challenged the administration to consider re-opening the door to the Psychiatric Emergency Service that had been closed five years earlier in order to re-direct psychiatric patients through the regular ER. By working as a team of change agents, the Heatlthcare Partnership helped push this idea forward by electing two of its members to attend the weekly Executive Operational team.

One of our community partners and I, representing consumer and family voices, joined the inner circle of the hospital leadership to further the opportunities to unite in innovative, strategic, operational change. The first outcome of this effort was the decision to convene a Value Stream Mapping Event for Behavioral Health. The Executive Team supported and teamed with its community partners to explore this idea through science. This effort resulted in the re opening of the Psychiatric Emergency entrance in May of 2010 for direct access to medical and psychiatric care. This has recently been acknowledged by the Joint Commission as an example of excellent patient care.

Opening doors and opening minds to the possibility of systemic improvement through the use of patient and family member advisors has been a primary aim of the Contra Costa County Healthcare Partnership. Since July of 2009, a small group of patient, family and staff have met weekly to develop a shared vision that would transform the delivery of healthcare in our local public system and beyond. We have learned that it is not possible to transform, improve, or integrate our system if we continue with hospital/clinic centric, hierarcachael or territorial thinking. We discovered that we must look behind the doors of our homes, homeless shelters, hospital floors, clinics, ERs, Board rooms, other health divisions, and the CEO’s office in order to prepare ourselves for the cultural shift. We have been doing that in Contra Costa these past months.

It is my honor to share my story and reflections of my journey. I thought back on our family experience during a recent visit to our son while my husband and I drove a total of 5 hours round trip. Psychiatric patients are not often treated near their community, but in far away placements. When we arrived, our 28 year old son came running with such happiness at the sight of our car and stopped at a high wire fence, waving to us. It reminded me of when he was in kindergarten and he used to run to the school yard fence to greet me. The fence reminded my husband of a prison and it took him a while to get out of the car and head into visit with our son in this locked psychiatric facility. My husband still struggles with his inability to rescue his son from his symptoms and the system. They have stolen his son’s freedom, dignity, and often the will to live. How do we hold on to hope when our son continues to suffer by a broken, fragmented, under funded mental health system? I choose to seek partnerships with other change agents who believe that all deserve the right care at the right time. Contra Costa Regional Medical Center and Clinics have offered our patients and families a trusting, authentic, shared learning experience and partnership.

I have exposed my life and story, to the community, in order to help make positive systemic changes. I have interfaced with all layers of the system to teach and learn. I have committed to the Healthcare Partnership with Contra Costa Health Services because of its focus on the whole person and the whole system. I believe in a systemic view when considering transformation. We must unify and empower all who intersect in the care of our most vulnerable patients.

My family has had the misfortune of being exposed to every level of care provided on the continuum of mental health services. I have been to the dark corners of the system. Some were in my own home. Some services were private based care, others were public. I have challenged the hierarchical cultures of both systems, not to be rude or disrespectful, or radical, but to shine a light. I have seen too much and know too much to ignore the realities that cause consumers and families to destruct and die. As JFK said, “We are not here to curse the darkness, but to light a candle that can guide us through that darkness to a safe and sane future. For the world is changing. The old era is ending. The old ways will not do.”

We need to speak the truth, hear the truth and go and see the truth. Constancy of purpose and focused direct action will create a system where the consumers, the families and the providers work in a true partnership. No politics, no discrimination, no special interests, no egos, just pure ethical healthcare based on the needs of the patient. I have seen it happen. It is possible.

Paul Batalden's idea, "virtually" speaking: A tapestry of lessons and reflections

I am responding to a suggestion presented by Paul Batalden in the recently published Lessons Learned in changing healthcare... and how we learned them. He notes that we are surrounded by leaders who have lessons to share. He states that we too could engage in a process much like they did and learn together. Below you will find a slightly modified version of an email invitation I sent to some colleagues. It's self-explanatory so I will move to my point. I hope you will reach out to those in your network. Please feel free to take my invitation and modify it for your own use or write your own. Additionally, I hope you will engage in this virtual test. Please feel free to join in and comment or send something you would be willing to share.

Here is the email invitation I sent:

I am writing you today because each one of you has inspired me. Your support and the lessons you have shared with me have made a difference to me and in my life’s work, to serve those most vulnerable and to stand up for what I believe in - to never settle. I have turned to you when I needed guidance and I have tried to offer the same in return. It is in this spirit that I reach to you now. While reading Lessons Learned in changing healthcare... and how we learned them 2010: 9-12 edited by Paul Batalden I was moved to action. In his Introduction: Moving Forward Together through Reflection and Sharing, Batalden addresses the pressures we all face in the ever changing environments in which we work. I don’t need to list them out to you as I know you are all too familiar. He notes that there are people all around us leading change and learning lessons. It’s a relatively quick and highly relevant read which I have linked here.

I loved reading the lessons from the amazing leaders that Paul brings together so brilliantly. Presented are succinct stories that present practical lessons that we can all apply in our work environments.

Here is an excerpt from his Introduction:

"When all the authors had submitted their chapters, we collated the learnings across the speakers and recognized that, together, they form a "tapestry" of lessons. We kept probing for the underlying threads that seem to weave themselves through the presentations, and we explore some of the most prominent in the last chapter.

.... step back from these presenters and their lessons and realize that in your own community, in your own network, a process similar to this one could be undertaken, allowing you and your colleagues to inquire of each other about the lessons that have been helpful to you. Explore how your particular setting contributes to the way change is learned and how it happens.

… Through introspection, we can recognize that each change leader has had to create a personal frame of understanding to make sense of what he or she faces as the processes of building knowledge, taking action and reviewing and reflecting become real. Naming the lessons and reflecting on how they were learned is an exercise in contemplation and self-discovery. Sharing these thoughts in conversation with others allows them to be examined, refined and further developed. The opportunity for learning about leading change in today's healthcare is all around us.

The collected lessons and how they were realized offer significant counsel for these times of change. But of potentially equal value is insight into the process of eliciting them. What we did in our local setting, you can do in yours. Everywhere that leader are at work, there is the potential for a "learning laboratory" to help others develop their own leadership knowledge and skills. This is a book about leading from within the frames of personal experience and, through conversation and interaction, across them.

Whom should you invite? We asked physicians who are active as leaders; you could ask nurses, administrators, laboratorians, therapists, social workers, nutritionists, pharmacists – any healthcare professionals working as leaders. The key is the process of reflecting on the experiences: naming the lessons and exploring the means by which they were learned. Sharing them publicly enables others to see the real journeys involved in becoming a leader and, through conversation and interaction, to form communities of individuals engaged in that practice. Watching the process allows us to see that we are all immersed in the phenomenon of leadership development."

As I read the insights presented I thought of you. I recall your stories and your words of wisdom. Some of you used theory to teach me, while others offered a story about your experience. In every case you offered a genuine and thoughtful lesson in the spirit of sharing what you have learned along your journey in the hopes it would be of help to me. I know I may not have always gotten back to you, but I want you to know you did help me and you made a difference.

Here is the real purpose of my email:

I would like to extend an invitation to you to share a lesson with me and others about something you have learned while leading change in your setting. I would also like to do as Paul Batalden suggests and share it publicly. In the past, I have had guest authors on my blog “Doing Common Things Uncommonly Well” and I received positive feedback from both the guest authors and readers.

My specific ask: Please consider writing a one (preferable) or two pages (shorter seems to go over better in the blog world and I know how busy you all are) about a reflection or something you have learned on your journey. It could be something you have already written or something new. I will then post your entry on my blog, with you as the author (or, for those who wish, I can open the blog and you can self-post). Of course I hope you would consider placing the shared lessons and reflections on your blog, Facebook page, Linkedin site, Ning, etc… as well. The aim is to allow others to share in the privilege that I have had, to learn from you. Most importantly, we can learn together!

I end my invitation with a one final quote from Batalden, “There is no claim of a magic five realizations – only the recognition of the truth that emerges from reflecting, listening, having conversations and connecting to the experiences of others within our own lives.”

Please join me. I will start by sharing a reflection I once wrote. You can find it below.

With my deepest respect and gratitude for your support, friendship and all you have taught me.

Anna

Shifting from “having more” to “being more.”
Presented by Anna Roth
CEO, Contra Costa Regional Medical Center and Health Centers

In a call to action, Tim Brown, CEO of the Global Design and Innovation Consultancy IDEO, asks if we could shift our thinking from having more to being more*. A curious question don't you think? He further asks if this question only has relevance to those who "already have lots?"

We don’t have to look far to see possible applications of this thinking all around us. Rather than look for more resources, what if we could get more productivity out of the resources we already have? This is very much aligned with Lean thinking and supports engagement in process redesign. The principle of accomplishing more with the same amount of resources or inputs (simpler still, be of more value with less), or thinking leaner, has been well accepted. Yet if it's such an easy concept, why is change so slow and so difficult? Why do we have experts - whole departments in some cases - dedicated to leading change? The answer may be a bit more personal than we like. What if we are part of the problem? Could this be why W. Edwards Deming and Taiichi Ohno (大野 耐) stressed that in order to make real change we must first change ourselves? They said - and they are well supported by many others - that all change begins with the individual. More explicitly, all change starts with me/you.

I once gave a talk with my esteemed colleagues Dr. Jason Leitch and Dr. Peter Lachman on transformation. We presented a common theory, The Model for Improvement. We then provided three distinct examples of the application of our theory in transformation efforts taking place on very different scales: a hospital, a county, and a country. The take-home message was that all change, no matter how big or small, occurs at the point of the individual experience. In short, no matter how many policies or change events you engage in, if it doesn't result in a change at the point of the actual experience you are trying to alter (in this case at the point of care), it isn't change, it's simply activity. In order to determine if the change you are making is in fact an improvement, you must have a measurement method (measurement is a topic for another post altogether.) My point is that the examples we presented support the idea that all change, whether on a single unit or spanning a nation, begins with changing ourselves.

Let's think about the idea that we as individuals are the target of change. In your setting, who is it that is most likely to NOT let go of what they have? Looking at it another way, who is deriving power or authority in your environment/context from institutional inertia - commonly known as the status quo? Whose identity is coupled with mastery of the current state? Are they likely to give it up? I'm not targeting any particular person or group. I'm simply asking. Who do you think is open to change and who is least likely to really change (the haves or have-nots)? This can get particularly tricky if one can siphon off the new and exciting parts of an innovation/new thing AND keep what they already have. It's a tough question, but I do try and ask myself, where do I fall? Perhaps it's easier to draw on someone else to think this through?

Marshall Ganz...
I saw him speak at the IHI National Forum year before last (my favorite event of the year) and he was downright moving. I found his plenary address so much more than a speech. Were you there? Did you hear it? He speaks not of having more, but of being more.

On the uncertainty of change and the pull of the status quo - the safety and comfort of what we know - he writes the following:
"When we face uncertainty, we often feel conflicting emotions. On the one hand, we may be fearful - things will go wrong, we will fail, others will see. We then retract, metaphorically at least, to protect ourselves from danger. On the other hand, we may be curious - the unexpected can be exciting, bring new opportunities and new growth. So faced with the challenge of learning to act in new ways, we may retreat into the security what we know, or, at least, what will reduce our anxiety; or we may risk leaning into the uncertain. We may learn best when we can do both: secure ourselves in enough certainty that we have the courage to risk exploration. Learning to balance security and risk is not only key to our own learning, but to the learning of those with whom we work, for whom security may be more elusive and the risks greater."

I understand and believe that change is scary. Many will retreat. Our perception of ourselves, whom we believe others approve of and depend on, is often that which we spend most of our time being. But what about our dreams? I know this sounds like a bit of starry-eyed-babble, but what if we try and see ourselves as what or who we really want to be? Better yet, what if we could be that which we are capable of? Do we even know what that is? What if everything we think we are supposed to be were washed away? Dr. Robert Schuller asks, "What would you attempt to do if you knew you would not fail?" What would I do? I'll admit I don't have the answer. I have many questions. Is what I do based on being something or having something? Do I seek knowledge or mastery of the current state in order to understand how to change it fundamentally for the better? Or do I seek understanding of the current state in order to better know how I can achieve rewards from it? Aren't these awful questions? Is it possible I choose superficial success, such as having more because it's too scary to try and be more? Is it possible that the barriers I impose on myself serve a very important purpose: protection from the risk of failing or experiencing pain?

For today that's enough of what Tim Brown describes as "head-hurting thinking." If the answer is to come, it will only be through synthesis of all those divergent ideas and belief systems surrounding what it means to move beyond "having more" to actually "being more." Who knows, maybe having a little fun is part of it? I already confessed I had no answers. I only have starry eyes filled with hope.-

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

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

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.

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.

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.