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Insights from the Armstrong Institute

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Patient-Centered Care

The Ripple Effect

The doughnut shop I pass on my drive to the hospital isn't the kind of place where you might expect to see outpourings of random kindness. It sits in the shadow of a raised highway, a few doors down from a bail bond business and a block away from a prison complex that resembles a medieval castle. One Sunday before Valentine’s Day, the line to get served there was long, checkered with homeless people—some of whom sleep under the highway to stay dry and protected from the wind—and more well-off people getting breakfast or bringing bagels or doughnuts to work or church.

A homeless couple stood ahead of me. Their clothes and hair were dirty, and the undersides of their fingernails were caked in dirt, as if they had just come in from gardening without gloves. They appeared very much in love—standing close, gently touching and smiling. She wanted a heart-shaped doughnut, and he wanted the same. They reached deep into every pocket counting their change, hoping to find enough.

They were a nickel short. Sheepishly, they turned to me and asked for help. I had a feeling of injustice: Here I was bringing doughnuts to doctors, nurses and staff who did not need them, yet this couple would not have breakfast without help. Not wanting to shame them, I softly told them that they could order whatever they wanted and that I would be happy to buy them breakfast.

When they ordered, the cashier looked at them judgmentally. Perhaps she had been stiffed before, or maybe she knew they did not have the money. The woman spoke up, stating that I had offered to pay. The cashier looked at me and I nodded.

That is when the cascade started. “What a great idea,” said a woman behind me, who was picking up doughnuts for Sunday school. She offered to buy breakfast for the homeless person next to her. The nurse behind her did the same, as did the police officer further back. The nurse and Sunday school teacher discussed how they were going to come back the following Sunday to do this again.

I was also moved by their generosity and handed the homeless couple more money to cover lunch and dinner and perhaps pay for a stay at a shelter. They wept, and I sat down at the table with them. They spoke excellent English, as if they had graduated college or higher. The man explained how they never intended to be that way. They hit some “rough patches” and made a couple bad decisions, he said. “We are something,” the woman told me. I told them that I believed them. My only request, I said, is that when they got back on their feet, they “pay it forward” to someone in need.

For weeks, I reflected on that day not quite understanding what exactly had happened. Then I read a New York Times article on the science of paying it forward. Cornell University sociologists Milena Tsvetkova and Michael Macy explained how we are much more likely to perform a kind act when we experience or witness one. Experiencing a small kindness is more potent than observing one, though in the case of the doughnut shop, observing proved a potent pill. They describe how chains like I observed are not rare at all. At a drive-through coffee shop in Manitoba, Canada, one customer paid for the person behind them, and the chain progressed to 226 people. At a Chick-Fil-A drive-through, there was a 67-customer cascade after one generous customer paid for the person next in line.Read More »The Ripple Effect

Doctor Who?

One of the most exciting things about working in patient safety and health care quality is that it’s not solely about advancing science or applying performance improvement methods. It is also about the excitement of being part of a social movement that is changing the culture of medicine—putting patients at the center of everything, sharing errors in the hopes of preventing future ones, and confronting hierarchies that stifle communication and innovation.

Kate Granger, a physician in the United Kingdom who is living with terminal cancer, has tapped into that sort of enthusiasm in a big way. Last summer, reflecting on a recent hospital admission, Granger remarked in her insightful blog that some members of her care team never introduced themselves when approaching her. She wrote:

As a healthcare professional you know so much about your patient. You know their name, their personal details, their health conditions, who they live with and much more. What do we as patients know about our healthcare professionals? The answer is often absolutely nothing, sometimes it seems not even their names. The balance of power is very one-sided in favour of the healthcare professional.

She asked that health care professionals make a pledge to introduce themselves to every patient that they meet, and share the challenge with others across the National Health Service. Thus was born a movement that went viral, aided by the Twitter hashtag #hellomynameis. More than five months since her post, there is a steady stream of tweets every day. Some clinicians wear lanyards with the hashtag, a show of support and a reminder to introduce themselves. Last week, NHS Employers released a video celebrating the #hellomynameis campaign.

More than anything, introducing yourself to patients is an issue of providing compassionate care. But it is also a patient safety issue. We know that faulty communication so often lies at the root of medical errors. How many adverse events might be prevented if all clinicians introduced themselves, making them more inviting to questions and concerns?Read More »Doctor Who?

Patient Safety Summit: Four Years of Advancing the Science

At Johns Hopkins Medicine, we recently held our fourth annual Patient Safety Summit, a daylong gathering in which faculty and staff from across our health system share their work to reduce patient harm and foster a culture of safety. The event has quickly become a tradition, with more than 425 participants flocking annually to our East Baltimore campus to sample from a wide range of presentations and network with colleagues.

As I attended the summit, I was struck by how much our own internal patient safety movement has matured, and it gave me hope for the future of the larger patient safety effort.

When we held the first summit in 2010, the enthusiasm for patient safety was high, but the science was not always at the same level. While many of the poster presenters were excellent clinicians and staff who offered thoughtful suggestions on how to improve patient safety, their work was frequently weak on data, used simple methods and lacked theory.

This year’s summit featured 75 posters and 43 presentations, but the scope and quality of the science was breathtaking. Watch this video to hear highlights from this year’s poster presenters.

Read More »Patient Safety Summit: Four Years of Advancing the Science

A method to the mystique

A few months ago, I posted about the pleasure of meeting Horst Schulze, a former Ritz-Carlton executive who created his own ultra-luxury hotel chain based on many of the principles he employed while working for the Ritz-Carlton. It was clear to me that the hospitality industry has something to teach health care about what it takes to create a culture of service excellence, and what it truly means to treat employees and staff with the utmost respect.

For that post, I only heard about Ritz-Carlton; I now got to experience it. As part of the Baldrige Executive Fellowship Program, I spent two days in January with the Ritz-Carlton in Pentagon City. Aside from hearing from senior leaders how they maintain excellence, I lived the Ritz-Carlton experience as a hotel guest.

Read More »A method to the mystique

Tuck someone in today

One of my colleagues, Nancy, recently shared a surprising experience that she had with her son—one of four children—as she was getting ready to send him off to college. The night before he left, this strapping, six-foot-tall man, who plays football and lacrosse, made an unusual request: He asked his mom to tuck him in to bed. When he returned home for a long weekend, he again wanted to be tucked in.

Nancy and I talked about what it felt like to be tucked in: You felt safe and protected, warm and loved. It is a great feeling and we all need it.

“Tucking others in” is a beautiful image of the care that is often lacking in health care. I remember a discussion with a family about limiting care of one of their loved ones. The patient, Paul, was 50 years old with metastatic cancer. He was now septic, on a ventilator and unable to communicate. We were meeting with his wife, brother and sister in-law. It was difficult for them to accept that he was dying.

We sat down in a messy conference room crowded with notebooks, the walls covered in reminders to staff. I opened the conversation by asking if they could tell me what Paul was like. I hadn't had the chance to get to know him. All of their eyes lit up, and they told me how he loved to drive around the country to see Bruce Springsteen concerts. He was a ‘60s hippie who never changed. They described his hearty laugh and how he loved to play jokes on people.

I thanked them, and they thanked me for trying to understand Paul as a person. I then asked what they understood about Paul’s prognosis. We talked about what Paul would want done in this situation. The wife and brother looked at each other. Their answer: Paul would want to withdraw life support with Bruce Springsteen playing loudly and the rest of us tailgating in his hospital room.Read More »Tuck someone in today

Putting a little Ritz in health care

Recently, I had an enlightening encounter with Horst Schulze, who led Ritz-Carlton Hotels to national awards and has since opened his own hotel chain, Capella. Hortz gave an informal presentation to members of a program that I’m taking part in, the Baldrige Executive Fellowship, and we continued to talk afterwards. Capella has five ultraluxury hotels from New York to Singapore, and all have been recognized as tops in their region. Horst spoke to us of a culture of excellence. He knows—he has built such a culture time and time again. Excellence does not occur by chance. It requires clear goals and a system.

Horst explained that to be great, everyone in the organization needs to know the goals, in order of importance. For Capella, the goals are 1) keep existing customers, 2) add new customers, and 3) optimize the spend of each customer. Every employee not only needs to know the goals, but they need to know the behaviors to achieve them. The Capella employees ensure a warm welcome, compliance with and anticipation of guests’ needs, and a fond farewell.

All employees are required to know service standards. Twenty-five of them. One of them states that you are responsible to identify and immediately correct defects before they affect a guest—for example, getting customers food when the restaurant is closed. Defect prevention is key to service excellence, just as it is to delivering safe health care. Another service standard states that when a guest encounters any difficulty, you are responsible to own it and resolve the problem to the guest’s complete satisfaction.

Capella has standard processes for everything—how to submit defects, how to resolve them. And they trained staff in the goals, the behaviors and the processes. Each hotel, every morning is required to have a huddle at which all staff attend. They review the goals for the company and read one of the behaviors, called service standards. Every day they read a different one. They cycle repeats every 25 days.

If a manager did not do this, Horst said, they would be fired.

Read More »Putting a little Ritz in health care

Company churns out burritos, French toast — and inspiration for health care

This year I am participating in an executive fellowship that is designed to expose leaders in various industries to the Baldrige Framework, a model for organizational excellence. As part of the program, the fellows visit companies that received the coveted Malcolm Baldrige National Quality Award, administered by the U.S. Department of Commerce. Recently, we toured Cargill, a large, Minnesota-based company that has about 75 business units, and spent time with two of them: Cargill Kitchen Solutions, which largely makes egg products for McDonald’s, schools and many other customers; and Cargill Corn Milling, a maker of corn syrup, animal food and ethanol.

We not only talked to leaders and reviewed their strategic plans, but visited the plant. We spoke to employees on the floor, as food was prepared on a massive scale: eggs being cooked by the thousands, breakfast burritos being assembled and placed on conveyor belts, French toast cooked, stacked and placed into boxes.

As we talked to leaders, toured the plant and reviewed their strategic plans, I was struck by three things.

First, everything and everybody was focused on the customer. The customer was at the center of every discussion, every decision and every strategy. From the CEO to the managers to people on the shop floor, they talked about meeting customers’ needs. Usually it was the first thing out of their mouths, and they used the impact on customers as a scale for weighing every decision. Indeed, many staff, from senior leaders to line operators making an hourly wage, said, We know who pays our paycheck; it’s the customer. If we want a paycheck, we better meet their needs.Read More »Company churns out burritos, French toast — and inspiration for health care