Kenneth Sands, MD, MPH
Beth Israel Deaconess Medical Center
Mass Coalition for Prevention of Medical Errors
HAI Working Group
February 4, 2009

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.

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

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

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

“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.

<Process Name>
Call Out Analyze Get to Root Implement Solution Celebrate
P S
P
P
P
P
P
P
P
P
D el ay
P
P
P
P
S
S

• Problems are not called out and just worked around.
– no clear expectation
– sense that calling out problems as blaming people and creating confrontation
– don’t 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.

<Process Name>
12/07 View of Target Condition
Call Out Analyze Get to Root Implement Solution
P
P
P
P
P
P
P
P
P
Celebrate
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P

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).

• 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

• 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

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

We held a naming contest to replace “RTPS”
• Multiple communications from
CEO
• Discussion thread posted on the blog
• Hundreds of submissions for names
Winner: SPIRIT
S olutions
P romoting
I mprovement
R espect
I ntegrity
T eamwork

• 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 person’s problems are more important than another’s?
– Fear of stalling

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

• Target group: managers and above, physician leaders, other key individuals (example HCQ staff): n > 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

8:00 Gather, greetings
8:30 Orientation to real time problem solving
9:30 Help chain concept
10:30 Techniques for solving to root
12:00 Fan out to work areas; observe work
1:00 Discussion of problems witnessed, attempt to solve to root with employee; activate help chain.
3:00 Regather, discuss experience

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.

• Employees LOVE getting out on the floor and seeing other people’s 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?”)

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.
SOLUTION: 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.
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.

Reporting Log: Challenges
• The tension between structured/searchable vs. unstructured/easy to use.
 Tension between controlled access vs. open access
 Tension between directive to enter problem vs. contact your help chain resource
• Our decision: highly unstructured.
 Our decision: entirely open
 Our decision: reach out to the help chain resource; interaction with the computer is secondary.

T

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

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

• 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.”

• 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