Finally Wrong-site Surgeon Speaks Out

    

Everyday there is news about medical errors, with the most recent being the OIG report on Medicare Adverse Events published this week that stated that Medicare beneficiaries experienced adverse events that contributed to at least 15,000 deaths in a single month.  As I was reading this report I sat back and wanted to cry for our patients and for our care givers, and am saddened each and every time I read about these events that occur so often.  I then ask myself, “What do we need to do to fix this problem”?

Tuesday, I was doing a marketing video/photo shoot for my business school, Loyola University Chicago.  For this video shoot, I had to sit down with the staff and engage in a spontaneous meeting of some kind.   I took this opportunity to tell them what I do in my profession, Lean Healthcare, and discussed with them the reality, facts and figures of the errors that occur in our hospitals. I expressed my passion around patient safety and how hospitals can improve patient care. 

As part of the photo shoot, I had to speak to a small group about any topic of choice.  They were interested in the discussion started earlier. So I began talking about the blog that I was going to write about Dr. Ring who performed a wrong-site wrong procedure surgery, and published this case study in latest issue of The New England Journal of Medicine.

I applaud and commend Dr. Ring for his courage to put forth the detailed account of the events surrounding this error.  I have deep compassion for anyone in this scenario knowing that this error is a result of a broken system which allows this to happen, not the person. Dr Ring published this with the intent of helping others not to make the same mistake.  

This is what I hope is the beginning of physicians coming forward without fear to reveal the circumstances surrounding any adverse events. This is a monumental step moving forward to help improve our situation in healthcare.  It is significant that this event was disclosed by a physician whose support is critical in creating a culture of safety.   There is absolutely no way we can begin to correct any flaw in the system without the detailed knowledge on how this occurred.  

With his account of the event, it became evident that there were several system failures that existed to allow this type of error to happen. The circumstances around this mistake highlight the confusion, lack of and/or the practice of standards, miscommunication and general chaos that surrounds the environment in which care is being provided on a daily basis. I believe that Dr. Ring began the culture change to make patient safety a top priority in his organization.  Dr Ring wants this to be a learning experience for others so they do not have to go through something like this. 

As part of the lessons learned from this event there was a renewed emphasis and belief in the importance of the Patient Safety Standards set forth by the Joint Commission. The sharing of information and experiences is something we can all learn from. In light of the continued number of surgical errors, I would recommend that other organizations perform FEMA’s around this process. This ultimately should prevent other patients from harm.  

Before I spoke with the groups, they did not have an understanding of where our country is with healthcare care mistakes. After I told them the story about Dr. Ring and the publication of his mistake, they told me how thankful they were that he was brave enough to put the safety of patients first to help prevent errors and not let possible litigation stand in his way.

New England Journal of Medicine
Report from msmbc on Dr. Ring

OIG Report Medicare Adverse Events

AHRQ article Medicare Adverse Events

A New Approach to Healthcare Problem Solving

It is funny how things change our perception. I had a concept in my mind on how we should make changes to improve our healthcare system. My previous blogs ask the question, “We know what works so why can’t we just make it mandatory"?  We also know that mandatory standards fail, but why”?

As I was thinking about this question, I started listening to a WIHI audio conference that day, “The Leaders Needed for the Changes Healthcare Need.” The guests were: 

Marshall Ganz, MPA, PhD, Lecturer in Public Policy, Harvard University

Kate B. Hilton, MTS, JD, Principal in Practice, Leading Change; Leadership Coach, NHS England; Director, Organizing for Health

After this program, I started to think about how to make change in a different light. It is hard to understand the complexity that we have in our healthcare environment to be able to make successful change for improvement. Our current leadership style and culture do not support the “team” method of problem solving.  

This program was about theories of change modeled after community organizing principles that engages citizens to collaboratively work together and move to action. They talked about heuristic problem solving which is based on the things we do not know and must be learned. This is the type of problem solving that needs to occur in healthcare, we do not know the problem. How do we solve these problems as a “community” and not from the top? 

Each of us is problem solving continuously. This is what we do as a significant part of our daily jobs, but in that effort many times we each problem solve independent of one another. When this happens, there is no sharing of information or ideas, which leads to big communication gaps. Poor communication is one of the major problems in healthcare that leads to errors. 

 Marshall Ganz stated that, “Leadership is taking responsibility for enabling others to achieve purpose under uncertain conditions.” This type of leadership is not from the top down and is not defined by position. 

Both Ganz, and Hilton want to know how these principles for leadership problem solving can be applied to healthcare. 

These are the five practices in this framework:

1)    Values – Relationship building that links common values to action that is done with narratives. These narratives ask the questions of team members, what calls them to their profession and why do they care. 

2)      Relationship Values Commitment- Motivation around a shared work.  

3)      Structure- A common purpose, values, and responsibility.

4)   Strategy – How to translate the power to change. Working with teams to achieve     outcomes. 

5)      Move to Action- Measurable and visible. What gets measured gets done.

Teams are the supportive structure needed to make changes within ourselves. Ganz and Hilton suggest one way to bond teams is through stories and emotions. When teams collaborate and share stories, they connect their values and commitments are made together for quality patient care. Cognition does not move how we “ACT”; it is the emotional side and our values that are used for problem solving and decision-making. 

A collaborative team approach is not how we have been taught to interact in our healthcare environment. Training of teams is crucial and leadership is the support needed to change how we approach problems. Leaders take a new role and become learners who then teach and coach other teams. 

This is not about implementing mandates that do not work, or simply standardization or checklists. It is about creative problem solving that incorporates such things as the checklist within a new framework for change.   

To hear the complete audio program go to 

http://www.ihi.org/IHI/Programs/AudioAndWebPrograms/WIHI.htm?TabId=14

©2010 carol lepper Solutions for Lean Healthcare Inc.

The Culture of Lean Healthcare

We are all dedicated professionals with the safety of our patients at the forefront of our minds and yet failures continue to occur.

In my presentation, “The Human Side of Lean” the theme is about the “people,” our human side. I discuss how quality and the design of healthcare systems impact the culture and the way we do our work. It is all about the people.  Anyone who is involved in a serious adverse event is changed for the rest of their life. It alters the way they provide care and the trust they have in the system. Lean is an important part of the formula because the focus of Lean is on the people and the culture. Lean is an effective method to help people make improvements.

In a Lean culture organizations become learning environments and one of continuous improvement steered by the people

I know we are all on the same page in our efforts and devotion to provide excellence in patient care, but there are huge barriers to overcome to make that happen. Culture is the one thing that must change to make sustaining improvements. In June 2009, American Society of Quality’s (ASQ) White Paper on Health Reform supports this need for culture change. It states, “ASQ believes the most critical need of all in health reform is for meaningful, lasting changes in the deeply embedded cultures related to health and healthcare in the country.”

There are many who believe that the physicians are to blame for the culture of healthcare today, but remember they are also working in a severely flawed system. We have failed to give them a system they can trust. I believe some of the way physicians interact is due to these failed systems. Yes, they want it their way because some of the other ways do not make sense or offer the guarantee that things will happen as planned, on time with zero defects.   

It is our responsibility to make the systems work and to provide the structure and the tools to prevent the possibility of errors.  With the complexity of our systems, and the overload of information, it becomes impossible to give error free care without these changes.

Lean Healthcare strives for zero percent defects and provides the structure needed to improve patient care and support our team

We do not intentionally do harm to our patients, but it is an expected outcome. Hospital Acquired Infections (HAI)  are among the top ten leading causes death in the United States, and drive up the cost of health care by up to $20 billion per year. Research indicates that these infections strike hundreds of thousands of surgical patients and the percentage of patients acquiring these infections has steadily increased over the past six years.

In a speech by  Secretary of Health and Human Services (HSS) Kathleen Sebelius,  she discussed the 2008 National Healthcare Quality Report (NHRQ) reports on the quality of health care in America and challenged hospitals to work to reduce health care associated infections. Sebelius also called on hospitals across America to commit to reduce Central Line Associated Blood Stream Infections (CABSI) in Intensive Care Units by 75 percent over the next three years.

In the 2009 NHRQ report, they found that health care quality in America is suboptimal. The gap between best possible care and that which is routinely delivered remains substantial across the Nation. HAI’s are one of the most serious patient safety concerns. The HAI rates are not declining. Of all the measures in the NHQR measure set, the one worsening at the fastest rate is postoperative sepsis.


There is no urgency in fixing this problem. The culture of patient safety is a culture of the nation, not just the healthcare organizations. With $50 million in grants given to states in 2008 to help fight healthcare-associated infections (HAI), the CABSI goal should be 100% this year.

There are JCAHO standards on the Culture of Safety, and yet organizations have changed very little on how they deal with people who are involved in adverse event. They still look at the person who made the error rather than the system. After doing many root cause analysis, it became evident to me that this person is just the last person in a totally failed process. Disciplinary action will not fix the problem and will only further prohibit the reporting of events. Even with standards in place, there continues to be errors, they do not fix these issues or change the culture.

A culture of safety is an founding principal of Lean  

Sadly, in the March/April 2010 issue of Patient Safety, there is an article providing guidelines on what to do after an adverse event. Not only are we making errors, but we do a poor job supporting our clinicians to cope with this type of event.   

Every time there is harm to a patient, it has a life changing effect on the patients, families, providers, and leadership within these organizations. I know that eventually we will improve and figure out some of the answers, but I am committed to find ways in which we can do so rapidly and effectively.

Insanity is doing the same thing over and over again and expecting different results.
Albert Einstein

“There has to be a Better Way”

Lean Healthcare is an Answer

©2010 Carol Lepper Solutions for Lean Healthcare Inc.

Patient Safety and Lean Healthcare

When I was reading the Patient Safety and Quality Healthcare magazine, March/April 2010, I was struck by how the foundation and Lean concepts are related to patient safety.  While Lean Healthcare boasts of increased efficiency, decreased costs, I have not seen the same zest or specifics about how Lean improves Quality and Patient Safety.

As a healthcare leader in patient care and safety, my experience with Lean confirms that implementation of Lean concepts will improve patient safety. The founding principles of Lean methodology are being brought forward in the literature as a venue to improve patient safety.

Lean Concepts

Continuous Improvement and Implementation of Best Practice through Standardization

Current research has proven that evidence based practice makes a difference in the quality of care. The Michigan Keystone project that focused on central line-associated blood stream infections (CLABSI) is one example. By standardizing best practice interventions, this project resulted in an estimated 1,800 lives, $281 million saved and 140,700 fewer hospital stays.

Today this program is known as CUSP, a comprehensive unit-based safety program. CUSP a collection of key changes to improve care practices related to CLABSI’s, and is implemented at the unit level.  By moving the implementation to the unit level it supports the Lean theory that establishing best practice begins with the clinicians who are performing the work. Continuous improvement strategies are performed throughout the different facilities in Michigan as each facility implements this program the results are shared and evaluated.

Lean Healthcare

Visual Workplace and Human Factor Engineering (HFE)

HFE is a science that studies how we interact with our environment and with each other and strives to optimize those interactions. It looks at ways to help us do the right thing. The writings of Donald A. Norman professor at the University of San Diego and Northwestern University, and Kim Vicente professor at University of Toronto state that there are two types of knowledge.

1)      Head knowledge, is what we contain in our human memory and is the type of knowledge that healthcare has focused on. The depth of knowledge needed and volume of information processed daily makes relying on our memory a flaw in the assumptions about our ability to provide error free care.  

2)      Knowledge of the world is the knowledge that is part of our environment. This knowledge creates mental models based on our past experiences and is used as part of our decision making process.

As healthcare becomes more complex delivering safe patient care relying solely on these types of knowledge becomes impossible. One important rule of HFE is to make things visible, which is part of the visual workplace used in Lean Healthcare. The visual use of tools gives us clues on what is the right thing to do.

Color coding is one method of using visuals. Color coding can be used in many different applications; marking different types of gas cylinders and lines, storage and labeling of lookalike sound alike medications, emergency carts supply locations and job aides on how to use the equipment, matching up IV lines to the correct medication bag. To decrease interruptions for nurses when preparing medications and performing critical tasks that could lead to errors, no interruption zones have been marked on the floors, signs are placed in the physical space, and a visual “Do not Disturb” vest has been worn by nurses. Visuals can also be used as a trigger for the next step in a process. To eliminate delays, a visual in the lab signals the staff when a specimen has been delivered and is ready for processing. All of these visuals improve patient safety.

Mistake proofing or Poke Yoke is used for system designs that prevent errors.  Some examples include the gas ratio protection in anesthesia machines, medical equipment devices that do not allow the user to assemble or use incorrectly with the design of the connections and computer fail safe software.  Another example is Broselow Pediatric Emergency Tape System which uses a visual color code that matches up the size of a child to the correct supplies needed in an emergency. When the colors are matched, only the correct supplies are available for use.

Lean Healthcare utilizes these concepts and methods that are referenced throughout this issue of Patient Safety and Quality Healthcare.  They continue to be highlighted as a practice to provide safety in our system and improve patient care quality outcomes.

 © 2010 Solutions for Lean Healthcare

 

 

Lean Thinking and Evidence Based Hospital Design

Rady Children’s Hospital to use Evidence Based Hospital Design

On October 10, 2010 Rady opened a new 4-story building which makes Rady Children’s the largest pediatric hospital in the state of California expanding its capacity from 288 to 442 licensed beds. As part of this new building Rady used a new trend called “evidence-based design.” The research results of using this design links the environment/atmosphere to better patient outcomes.  The elements of evidence-based design include such things as natural lighting, air flow, and room design – private rooms with space for family members to stay with loved ones, soothing atmosphere, and use of sound with waterfalls, aesthetics like artwork and the use of color.

Many hospitals are beginning to expand, and they are using evidence-based design.  As I thought about these new methods of construction, I had concerns about the use of space and what it does from an efficiency perspective. Does evidence-based design address the physical work flow inefficiencies in our current system? These designs include input from patients and families, but how much are users consulted? Historically new plans fail to consult the users of the system, resulting in an increased waste of time with movement in the new design.

As I was doing Lean consulting at other hospitals, I found some examples of new construction that did not include input from users.  In the entrance of a new building there was a long beautiful atrium, with patient care services housed along all sides of this atrium. When I first observed this space, I thought this is going to be a long walk for nursing to deliver care, it was about a quarter of a mile one way. There were Pod designs where the nurse could only see only a small section of patients and had to walk around the whole pod to get to the nursing station. Another nursing station had only one way in and out creating congestion, confusion and increased walk.  Ancillary departments were not moved along with the new space increasing the walk and turnaround time for service. 

A hallmark of Lean Thinking in healthcare is to remove waste which will increase efficiency, improve quality and decrease cost. Lean includes the front line workers in all process improvements, including new construction. The implementation of Lean Healthcare prior to new building improves the physical design and efficiency.

The costs of these new buildings is increasing, so can we consider smaller square footage for new buildings?   In the past, implementation of Lean has lead to cost avoidance by decreasing the size of new projects. This is due to the fact that as Lean improves the turnaround times for care, it increases capacity without adding beds.    

After the Rady hospital opens it will be interesting to see how the design impacts patient flow and the movement of staff.  As research continues to evaluate the use of evidence- based design, efficiency must be one of the measures included.

http://www.signonsandiego.com/news/2010/sep/23/rady-childrens-hospital-opening-new-tower/

Lean is the Way of the Future in Healthcare

Donald Berwick MD, the newly appointed head of the Centers for Medicare and Medicaid Services (CMS) gave his first public speech September 13, 2010, to attendees of America’s Health Insurance Plans (AHIP) conference on Medicaid and Medicare. He called on leaders to join in the pursuit of “Triple Aim” to improve healthcare in the US.

Triple Aim has three goals:

1)     Improve quality of care with one of his priorities patient safety.

2)     Better health for populations.

3)     Reduce per capita cost by eliminating waste.

Lean Thinking in healthcare will address safety, the quality of care and will decrease costs.  

Our system is so fragmented that it is difficult to see the “whole” patient process. The quality of care suffers as a result. Each unit of care functions independently creating poor communication with critical patient information being lost. Healthcare waste such as duplication, rework, and movement further dilute the clarity of the care process.

The implementation of Lean Thinking will streamline patient care, and remove waste. Lean identifies the patient experience as a “whole” system rather than separate functions. This becomes a team method of providing care. This way of seeing care from a new perspective, makes the process clear to all the caregivers.

Communication breakdown is a major contributor to patient errors. To reduce these failures, communication standards are developed as part of the new streamlined process. This helps eliminate much of the guesswork and assumptions that often drive how decisions are made regarding care.  

As steps and waste are removed, the quality of care improves. Each step that is removed decreases the potential for errors. As this occurs the cost per capita of care goes down.

The Lean healthcare culture and philosophy provide the environment in which these results can be achieved. I believe

 “Lean is the Way of the Future in Healthcare”

©2010 Solutions for Lean Healthcare Inc.

Checklists Continue to Improve Patient Safety

Surgical Checklist Reduce Deaths Washington Post, January 15, 2009

A study prompted by the World Health Organization (WHO) and Harvard School of Public Health showed that the implementation of a surgical checklist throughout eight countries improved the death rate by more than a third. Atul Gawande, a Boston physician who led the study said, “A checklist seems like a no-brainer, but the size of the benefit is dramatic.” If every OR in the US implemented this checklist, we could save between $15 billion and $25 billion a year on the costs associated with surgical complications. Surgeons are discovering the use of a checklist similar to an airline check is a simple tool that can prevent errors in the operating room.

Donald Berwick, currently the head of the Centers for Medicare and Medicaid Services (CMS), and past President of the Institute of Healthcare Improvement (IHI) supports the use of a checklist in the OR. He said, “I cannot recall a clinical care innovation in the past 30 years that has shown the results of the magnitude demonstrated by the surgical checklist. This is a change that is ready right now for adoption by every hospital that performs surgery.” Very few U.S. hospitals were using the checklist and Berwick planned to introduce it to 4,000 hospitals.

This WHO study confirms that the use of a checklist improves patient outcomes. This is another example of a proven best practice standard that is easy to implement, but there is no mandate for US hospitals to use such a list. JCAHO is considering including more of the steps, but as of the July 1, 2010, the Joint Commission National Patient Safety Goals did not include a complete safety checklist. The current goals that are in place regarding wrong site surgery, (WSS), are non-prescriptive allowing hospitals to implement their own policy and method to meet the standards. It is obvious that these Joint Commission standards are not providing safety to our patients as evidenced by the fact that we continue to have critical surgical errors. California is one example.

Avoidable mistakes rise in California despite hospital efforts San Francisco Chronicle June 2, 2010

In the latest fiscal year, California hospitals reported 197 cases of "retained foreign objects" for a total of 350 incidents over the past two years. Three years ago, a new law gave state public health officials the authority to issue administrative penalties for violations that put patients at risk of death or injury. California intends to use $800,000 of the almost $3 million in such hospital fines that have been collected since 2007 to research how to help hospitals reduce their chances of leaving objects behind after a surgery or procedure. I ask why we are spending this money to do more research, where there is a proven method available.

It is difficult to measure the current state of errors since there is limited published information. The state of California is an exception. They publish fines that are levied to their hospitals regarding surgical errors on their website California Healthline. As bad as these reports may seem, I applaud California for even making this data available. I believe that transparency is a key factor to improving our healthcare system. This is one of the best sites that provides detailed information daily on all healthcare issues occurring in California and nationally. It would be nice for other states to have a site like this.

The fact remains that we are rich with technical advances and exceptionally talented healthcare professionals. It is beyond imagination that we can let the state of our system continue. The use of a checklist is standard work made easy and reliable every time. It has proven to save lives.

Is anyone really listening to what is happening in our healthcare system? Surgical errors continue to plague our nation’s healthcare organizations, and it seems as if even trying to make improvements is in constant chaos.

On April 2010, Ontario, Canada made the use of the checklist mandatory.

©2010 Solutions for Lean Healthcare Inc.

Sullenberger Urges Hospitals to Adopt Aviation Culture of Safety HealthLeaders Media, July 23, 2010

The aviation industry uses a checklist to maintain the safety of airline passengers. The use of a checklist has also been proven as a way to decrease hospital acquired central line-associated bloodstream infections. Yet the culture of our healthcare system does not allow this to become a unified standard of practice.

Captain Chesley “Sully” Sullenberger gave a stern lecture at the American Hospital Association’s Leadership Summit in which he urged those leaders to adopt the safety culture of the aviation industry. He said, “They must stop thinking of accidents as inevitable and start thinking about them as unimaginable.” Sullenberger is the man acclaimed for the Jan. 15, 2009 “Miracle on the Hudson.”

His quick decisions to avoid crashing came after more than 30 years of aviation improvements and safety training. The improvements involved standardization, adherence to checklists, and required a change in the culture to one that focused on safety. He said, “This culture change in aviation is much like the change that is needed in Medicine.” Lean Healthcare implementation includes all of these attributes and is becoming a way to address these issues.

So where has healthcare gone wrong?

The healthcare culture is a major barrier to quality improvement. Although Joint Commission has Patient Safety Standards which include a culture of safety, this culture is not being embraced by the healthcare community. Research studies and the stories I have heard from patients/families confirm this. We have not been able to get into the heart of our system to make the necessary changes in the culture for the safety of our patients.

Central line-associated bloodstream infections are costly and kill 31,000 patients a year in the United States. In May 2009, Secretary Sebelius of the Department of Health and Human Services (HHS), called on hospitals across America to reduce central line infections by 75% over the next three years.

As a way to make improvements in central line infections, a checklist was introduced to hospital ICU's at John Hopkins. The use of this checklist got the central line infections down to almost 0%, and was then implemented across the entire state of Michigan. As part of the success, the hospital had to undergo a culture change. This change allowed all members of the team to intervene when there was a concern over safety or the standard was not being met. This practice is not readily accepted in hospitals today.

What is wrong with our healthcare system and our government? It should not take 3 years to improve central line infections by only 75%, when we already have a standard of best practice that will prevent these infections? It is not OK to continue to put our patients at risk within the next 3 years while we try to meet this goal. After that, there will still be 25% or 7,750 patients that will get infections and die.

I do not understand the rational for HSS not striving for 0% infections when we know how to achieve that goal. I think the use of the checklist should mandatory and implemented as best practice in all hospitals.

As we continue the pursuit to improve our system, we are still faced with barriers that I believe need to be addressed. Lean Healthcare is a way to do this, but there also needs to be additional support and understanding of these barriers to make healthcare safe in America.

We would not get on a plane if the pilots were allowed to choose if they used a checklist.

Seattle Children's Hospital

http://www.nytimes.com/2010/07/11/business/11seattle.html

This article describes the process Seattle Children’s Hospital has used to incorporate Lean into their continuous improvement system, or C.P.I. It explains how a new supply system, and the implementation of checklists, standardizations, along with non-stop brainstorming with the front line staff has led to improvements that they believe provide the highest quality of care and is most cost effective. The results of Lean have saved $23 million in patient care costs and $180 million cost avoidance in capital projects. Other healthcare organizations have shared their Lean story as well.
A RN from another hospital has a negative view about Lean implementation, which she believes has lowered staffing levels. This negative opinion is common with other clinical professionals as well. A hospital spokesperson in her organization does not share that view. Here, there is a strong disconnect between these perceptions of Lean.
This is an example of how “Lean” in an effort to reduce waste has not fully engaged the front-line staff enough to embrace Lean and see the improvements that can be made. I know that nurses will strongly resist any change that they do not feel improves patient care. When there is a concern from any clinical provider about the safety of Lean changes, these concerns must be addressed. When they are not recognized, the belief about “Lean” becomes negative.
There are many reasons for these thoughts about Lean. Some of these I have experienced when either the nurses/providers do not understand and/or see the positive results that Lean can make and leadership is not aware of these perceptions.
It is critical in a Lean transformation to have these views heard and addressed. Lean will never be fully embraced until these issues are resolved. This is unfortunate because Lean Healthcare has countless opportunities that improve patient care, cut costs, and increase patient and employee satisfaction.
A Lean philosophy must be embedded into the culture of the organization to succeed in a Lean transformation.

Denver Saves with Lean Healthcare

Read an interesting article about savings when implementing a lean solution.

"What are the things that keep you from working efficiently?" And "Are there things you see happening to patients that shouldn't?"

Those questions are the essence of a multilayered efficiency system known as Lean that has swept through Denver Health over the past five years with the fervor of a religious conversion.

In an era marked by soaring health care costs and epidemic layoffs, even as it serves more and more uninsured patients while public funding dwindles, Denver Health has saved money and jobs — and improved patient care — using decades-old Toyota practices.

$54 million benefit Read More http://www.denverpost.com/news/ci_15627406