Real Life Experience with Real Time Problem Solving

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Real Life Experience with Real Time Problem
Solving

• Kenneth Sands, MD, MPHBeth Israel Deaconess
  Medical Center
• Mass Coalition for Prevention of Medical Errors
• HAI Working GroupFebruary 4, 2009

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Goals

• After this presentation you will be able to
•  Understand the concept of real time problem
  solving, as applied to the health care setting
• Determine key design considerations for
  implementing real time problem solving within an
  organization
• Understand specific applications to infection
  control
• Understand elements that might lead to
  programmatic success or failure, based on
  specific case examples from BIDMC.  

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Disclosures

• Ken Sands has no business or industry
  relationships with relevance to this
  presentation.

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BIDMC Putting a Major Stake in Quality and
Safety
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The Beginning of this Journey for BIDMC

• In October 2007, the BIDMC Board attended a 1.5
  day retreat devoted to clinical quality and
  safety.
• Sponsored by Blue Cross Blue Shield MA as part of
  their innovative Lead program
• Activities
• Employee shadowing
• Panel Discussion with Three patients with a range
  of experiences.
• Didactic session on role of governance in quality
  and Safety
• Breakout sessions on institutional goal setting

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Follow-up to Board Retreat

• Employee shadowing, patient voice both extremely
  powerful
• Need to move from project work to more
  consistent, reliable execution across the
  enterprise.

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Target Condition endorsed 12/07

• Develop a system by which everyone in the
  organization consistently identifies barriers to
  work and care and implements solutions as close
  to real time as possible.

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12/07 View of Current Condition
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Diagnostic Why were we like this?

• Problems are not called out and just worked
  around.
• no clear expectation
• sense that calling out problems as blaming people
  and creating confrontation
• dont have time
• Problems that are reported get stale
• System not designed drive immediate
  investigations solutions
• Few people involved in investigating problems /
  developing solutions.
• Leaders assumed to be responsible, and feel the
  limitation of their time.
• System not designed / managed to involve everyone
  everyday in problem solving
• Learning yield from problems is low across the
  entire staff.
• Learning design remains centralized or in silos,
  not transparent and decentralized.
• Too much dependence on those quality experts to
  do the work of improvement vs. ownership by the
  broader population.
• Improvement proceeds by projects that are on top
  of the work instead of an integral part of the
  work.

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12/07 View of Target Condition
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Characteristics of the Framework for Problem
Solving

• Engages front line staff, not only in the
  identification of problems, but in the design of
  solutions
• Is multidisciplinary and collaborative
• Analyzes to root cause before solving problem
• Embraces standardization and specificity of work
  flow
• Borrows from well established methodologies
  perfected in other settings (LEAN, Toyota, six
  sigma, etc).

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Plan For Reaching Target Condition

• Educate the workforce regarding the importance of
  calling out problems, and in their participation
  in developing solutions
• Develop the system that allows all employees to
  call out problems quickly and easily.
• Develop a help chain that supports employees in
  solving problems

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Plan For Reaching Target Condition (cont.)

• Orient managers/directors to real time problem
  solving
• Develop systems that allow analysis and
  identification of larger opportunities for
  improvement from RTPS
• Define measures of success, and track those
  measures

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Specific Action Steps in Each Arena

• Training
• Reporting, Sharing Analysis System
• Help Chain System Development
• Communications
• Measures of Progress

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We held a naming contest to replace RTPS
Winner SPIRIT

• Multiple communications from CEO
• Discussion thread posted on the blog
• Hundreds of submissions for names

• Solutions
• Promoting
• Improvement
• Respect
• Integrity
• Teamwork

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Key Elements of the Rollout Approach

• Decision to go whole house vs. limiting to
  specific unit or service line

• Rationale
• No way to know where the root cause will take
  you
• How to say one persons problems are more
  important than anothers?
• Fear of stalling

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Key Elements of the Rollout Approach

• Evolution of Hunting/Fetching Theme Gave the
  program tangible, direct relevance to employees
• Quick Timeline March 3 start date

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Training/Orientation

• Target group managers and above, physician
  leaders, other key individuals (example HCQ
  staff) n gt 600
• Full day, experience based (in the field picking
  up real problems and trying to solve)
• Train the Trainer model, with initial
  consultant support (Value Capture) transitioning
  to BIDMC leaders

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Training Program Agenda

• 800 Gather, greetings
• 830 Orientation to real time problem solving
• 930 Help chain concept
• 1030 Techniques for solving to root
• 1200 Fan out to work areas observe work
• 100 Discussion of problems witnessed, attempt
  to solve to root with employee activate help
  chain.
• 300 Regather, discuss experience

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Stories from Training The Stamps
PROBLEM Employees of primary care unit have
internal process for personal purchase of stamps
and mailing envelopes because of impression that
internal mailroom processes US mail too slowly.

• ROOT CAUSE
• Why? Examples existed of slow arrival of
  prescriptions to patients
• Why? There are specific items that affect the
  efficiency of the internal mail room, such as
  hand-addressed envelopes and time of day that
  mail arrives.
• Why were these not known? Clinic had never
  called out the issues to the mail room director.

• SOLUTION
• The help chain was engaged and the Mail room
  director visited the clinic in real time, giving
  a quick orientation regarding ways to improve
  turnaround to internal mail. Many of these
  things were not known to the primary care team.

• ACTION
• These actions were completed before we left the
  floor.

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Training/Orientation Surprises, Challenges

• Employees LOVE getting out on the floor and
  seeing other peoples work. Builds mutual
  respect
• Seeing the problems is transformational (common
  participant statement)
• Need to reinforce respectful conversation about
  workarounds (can you believe what they were
  doing on floor x?)
• Need to address manager defensiveness (why do
  you want to go to my unit for this exercise
  have you heard something?)

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Stories from Training The Lighting

• PROBLEM
• The monitor techs in the nursing area cannot get
  proper contrast to monitor their screens with the
  overhead lighting on, but with it off other parts
  of the nursing station are unacceptably dark.

• ROOT CAUSE
• The lights are on one switch. Why? The problem
  had been called out before but not felt
  resolvable without a significant cost.Why were
  neither of these solutions put in place? The
  Nurse Manager didn't want to make another capital
  request, and the Engineering Technician didn't
  want to sign off on the change given the concern
  about the open outlet. Why? Neither engaged
  their bosses.

• SOLUTION
• The help chain was engaged and the Electiricity
  Manager signed off on removing the light bulbs
  from above the monitor techs and sealing off the
  sockets.

• ACTION
• These actions were completed before we left the
  floor.

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Key ElementTransparent Reporting Structure
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Reporting Log Challenges

• The tension between structured/searchable vs.
  unstructured/easy to use.

• Our decision highly unstructured.

• Tension between controlled access vs. open access

• Our decision entirely open

• Tension between directive to enter problem vs.
  contact your help chain resource

• Our decision reach out to the help chain
  resource interaction with the computer is
  secondary.

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GO TO VIDEO The warfarin medication callout
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RTPS Applied to Infection ControlCentral Line
Infections

• RTPS
• Observe a central line insertion
• Even if all is done correctly, look for barriers
  to standard, reliable practice (fetching,
  waiting, equipment problems)
• Dive into why these barriers were present (why,
  why why)

• Classic
• Calculate monthly CLABSI rate
• Analyze trended data using statistical process
  control
• Educate regarding central line bundle
• Audit and report percent compliance with bundle.

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Lessons Weve Learned So Far

• Value of employees getting out of their regular
  setting
• As trainees
• Seeing different floors
• Importance of Sharing problems
• Democratization of Decisionmaking

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Lessons Learned from the Challenge

• Managing manager anxiety
• Feeling in the spotlight
• Need for more and ongoing training.
• Challenge of Transparency
• Confidential or inappropriate posts
• Using the log as a weapon
• What to do about nonspecific complaints
• When it does come down to a resource issue
• Better defining institutional coaches.
• Linkage between small local projects and the need
  for the big project.

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Next Steps for BIDMC

• Deepen institutional knowledge of industrial
  approaches to process improvement
• Develop a more advanced, defined competency for
  managers for local real time problem solving
• Further develop the model for internal coaches
• Strengthen linkages between local problems and
  larger process improvement initiatives

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GO TO VIDEO on pumps