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Real Life Experience with Real Time Problem Solving

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Real Life Experience with Real Time Problem Solving Kenneth Sands, MD, MPH Beth Israel Deaconess Medical Center Mass Coalition for Prevention of Medical Errors – PowerPoint PPT presentation

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Title: Real Life Experience with Real Time Problem Solving


1
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

2
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.  

3
Disclosures
  • Ken Sands has no business or industry
    relationships with relevance to this
    presentation.

4
BIDMC Putting a Major Stake in Quality and
Safety
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8
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

9
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.

10
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.

11
12/07 View of Current Condition
12
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.

13
12/07 View of Target Condition
14
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).

15
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

16
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

17
Specific Action Steps in Each Arena
  • Training
  • Reporting, Sharing Analysis System
  • Help Chain System Development
  • Communications
  • Measures of Progress

18
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

19
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

20
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

21
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

22
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

23
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.

24
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?)

25
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.

26
Key ElementTransparent Reporting Structure
27
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28
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.

29
GO TO VIDEO The warfarin medication callout
30
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.

31
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32
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

33
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.

34
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

35
GO TO VIDEO on pumps
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