SaferPatients

In the just-released 2013 Industry Survey: Strategic Imperatives for an Evolving Industry, a survey of health executives reveals that the 3 biggest priorities for hospitals are 1) patient experience, 2) clinical quality 3) cost reduction.

Chief Financial Officers for surveyed hospitals estimated the percentage reduction of operating costs for the next 3-5 years.

The average was set at 11%.

How are hospitals going to do this? Lean + TeamSTEPPS. Lean for process improvement to drive out the waste. TeamSTEPPS (or CRM) to create a culture of accountability to make sure the waste stays driven out.

We typically see an average ROI on Lean process improvement work of 4 to 1. One dollar spent on improving processes return $4 on waste reduction and volume increases.

Unfortunately, you only keep that $4 improvement every year if you have an operational culture where peers hold one another accountable to adhere to the new waste-free, efficient process. Otherwise, your organizational culture will eat your process improvement efforts for lunch. This is one of the true values of an effective TeamSTEPPS program. Tt creates a culture of cross-check, accountability, stop-the-line when standardized work is ignored.

Everyone has processes. Everyone is doing Lean. Everyone has bundles (CLABSI, CAUTI, VAP, SCIP, etc..). Everyone has protocols. Everyone has checklists. Everyone has medical expertise and training. What everyone doesn’t have is “culture.”

Culture is what separates the profitable and on-going, from the broke and going-out-of-business. What are you doing today to change your culture? If the answer is nothing, be prepared to be looking for new employment by 2015.

Children’s Healthcare of Atlanta saved $23 million on hospital costs by slashing central-line infections by nearly 80 percent.

Altogether, the hospital avoided 550 bloodstream infections since it launched the initiative in 2006, an overall reduction of 77 percent, according to the article. Two of the hospital’s units have had more than 1,000 days and more than 800 days, respectively, without a central-line infection.

Hospital officials embraced a variety of infection-avoidance tools, including checklists for inserting and maintaining central lines, and teamwork training for the improvement of communication between physicians and hospital staff.

The tools used by the Children’s were first introduced to health care by LifeWings in 2001. The methodology was refined, studied, published, and made poplar by work done at Johns Hopkins. “Real change rarely occurs overnight. It requires sustained effort and unwavering focus, day after day, month after month, year after year,” Michael Rinke, lead author of the Johns Hopkins study, said in a statement. “It’s a slow, arduous process, but the payoff can be dramatic.”

The $23 million in savings are further proof that patient safety and quality initiatives, when executed successfully, have a significant Return on Investment. it is projected that up to 15% of hospitals will go out of business by 2019. Results like Children’s was able to realize are critical to economic survival.

By now almost everyone involved in health care quality improvement has heard of the checklist used to insert central lines that was developed Peter Pronovost, MD, professor of anesthesiology and critical care medicine at Johns Hopkins University School of Medicine. The checklist has made Dr. Pronovost famous.

That checklist has long been known to reduce bloodstream infections when used correctly. It has now been proven to reduce patient deaths in Michigan hospitals by 10%.

The British Medical Journal (BMJ) studied the use of the checklist and discovered  a drop in patient mortality in Michigan hospitals. Though previous studies found a reduction in infections, this is the first to link the checklist program with reduced mortality.

“It’s breathtaking,” Pronovost told The Baltimore Sun. “With our program, patients are alive who wouldn’t be if they were outside Michigan.”

The results are so dramatic that the average ICU in Michigan now has better infection numbers than 95% of the ICUs in the remainder of the country.

While checklists must be well-designed, and getting staff to use them correctly can be tricky, with results like these, why isn’t every hospital using the same checklist program?

Watch a three-minute movie about LifeWings

Here is an interesting blog post from Seth Godin, author of Linchpin and Poke the Box (two of my favorite books). Seth says…

“Thousands of doctors have signed up for a service that, among other things, they can use to try to prohibit patients from posting reviews. You can read a bit about it here.

In Iowa, in a surprisingly similar move, the state government is moving ahead with a law that will make it a crime to take or possess videotapes of factory farming that might harm the commercial interests of the farmer.

In both cases, an organization is trying to maintain power by hiding information from the public. Can you imagine being arrested for possession of a photo of a pig?

It’s easy to argue that from the public’s point of view, laws like this are a bad idea. The public certainly benefits from the outing of bad doctors and from the improved hygiene of factory farms. In that sense, it’s unethical for doctors and legislators to subvert their responsibilities by ordering the un-empowered to shut up.

I think it’s interesting to think about from the doc’s point of view (and the chicken farmer), as well. The temptation is for those in charge to defend the status quo by fighting transparency. This ignores a simple truth:

When book reviews are posted, book sales go up.

Yes, the argument of fairness matters.

(Yet) it turns out that transparency increases profitability.

Here’s the thing: when consumers get used to transparency, they’re also more interested in the quality of what you sell, and are more likely to willingly pay extra. They’ll certainly cross the street to buy from an ethical provider. And once people start moving in that direction, the cost of being an unethical provider gets so high that you either change your ways or fade away.

Inundate us with images of cleanliness and quality instead of blacking us out. Don’t race to the bottom (you might win). Instead, force your competition to race you to the top instead.

[Aside: the same objection happened when we started regulating hygeine in restaurant kitchens. Yes, it got more expensive to clean the pots and kill the rodents, but it was okay, because post-Duncan Hines, demand for quality went up enough to more than pay for it.]

The same argument holds true for doctors. Once information about good doctors becomes widespread, patients will be more willing to seek out those doctors, rewarding the ones who consistently take better care of their patients. The entire profession doesn’t suffer (we’ll still go to a doctor) merely the careless doctors will.

One more: A leading politician in India is arguing that bribery (in certain transactions) ought to be legalized. Why? Because if the briber feels free to rat out the bureaucrat, bribery goes down.

In all three cases, sunlight is an antiseptic and the marketplace rewards those that behave–and the entire market grows when the standards increase.

Consumers and those that want their admiration ought to reward those in favor of transparency.“

This week’s post comes from the monthly CRM Newletter produced by Memorial Healthcare System in Hollywood, FL. Memorial is ranked as the 6th best place to work in health care by Modern Healthcare magazine. The article, reproduced here in it entirety was written by Dr. William Perryman, Chief of Cardiac Surgical Services at MHS. Dr. Perryman’s article will give you a sense of why Memorial is such a great place to work.

“Performing pediatric cardiac surgery in a foreign country with a support team from a variety of centers can sometimes be challenging to get everyone on the same page. This is a similar situation to that often faced by airline crews and was the genesis for the development of Crew Resource Management (CRM).

On a recent trip to the University of the West Indies (UWI) Hospital in Jamaica, we had the opportunity to use CRM during surgery for 7 children having complex cardiac surgery. The OR team had surgeons, anesthesiologists, perfusionists, OR nurses, residents and students from Joe DiMaggio Children’s Hospital, Jackson Memorial Hospital, University of Florida Shands Hospital and host UWI Hospital.

The equipment that we used was, at times, different from case to case and different from MRH (Memorial Regional Hospital). The perfusionists were using whatever cannulae they could find and anesthesia was using drugs, sometimes, with different names than they were used to in US. I was operating with a different faculty member each day or a resident.

As you can imagine, this is a very similar scenario to airline crews who arrive for a flight on equipment that may vary, with a flight crew who have never flown together before and a cabin crew who face the same challenge.

CRM allowed all present to understand each component of the operation, what adaptation might be needed and what specific “stuff” would be required for that particular child. CRM proved to be an excellent solution to an ever-changing operating room scenario and allowed us to leave with all children safely managed through their operations and returned to delighted and grateful parents. CRM also provided a template that could be continued after our departure.”

Dr. Perryman is correct. Airline pilots frequently fly with other pilots and flight attendants whom they have never met before, and with aircraft mechanics, dispatchers, and air traffic controllers whom they have never worked with before.

The Captain of the flight has just a few moments to create an effective team that utilizes expert communication and collaboration skills to detect, catch, and correct the inevitable small mistakes and errors humans make before those mistakes become serious or fatal. The blueprint for creating this expert team from a group of aviation experts is crew resource management (CRM).

As Dr. Perryman’s experience clearly shows, CRM is the blueprint for even widely disparate, international medical experts to creat an expert medical team. If CRM can work in that environment, it can work anywhere.

Here’s the account of a surgeon falling asleep in the OR during two successive surgeries. The story appeared in the Boston Globe.

“When Dr. Loren J. Borud began his first case at about 8 a.m., an operating room nurse noticed he looked tired and wobbly. She was so concerned, according to one account of the Friday last June, that she suggested Borud postpone his next patient.

Borud said he had been up all night working on a book, but he kept operating, starting a second case, during which he briefly fell asleep, according to a report from state investigators. The nurse again called him aside and suggested “maybe he should take a break,” according to her interviews with investigators, but he continued the surgery.

The operating room nurse called the plastic surgery department twice to report Borud’s behavior that morning and early afternoon, the report said, and the office nurse told her to “keep an eye on him.” But no senior surgeon or administrator ordered Borud to stop operating - even though there was widespread awareness of his history of drug and alcohol abuse, according to investigators. Read more »

In a recent survey of nurses, physicians, and administrators 96% of respondents say they had witnessed or experienced disruptive behavior from a physician.

In my first post, I wrote about becoming a “Topgun” or being the best of the best. Read more »