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Voices for Safer Care

Insights from the Armstrong Institute

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

Is this health care’s “man on the moon” moment?

For the past four years, Johns Hopkins patient safety researchers and our partners across the country have been working on an ambitious effort to reduce central line-associated bloodstream infections. The project spanned 44 states and included 1,100 intensive care units. On Monday, the Agency for Healthcare Research and Quality, who funded this project, released the preliminary results of this project. They report that our collective efforts have reduced infections by 40 percent, prevented 2,000 infections, saved 500 lives, and avoided $34 million in health care costs. Stunning!

Below are my prepared comments from a press conference hosted yesterday by AHRQ to share this news:

On a snowy night in February 2001, Josie King, an adorable 18-month-old girl who looked hauntingly like my daughter, was taken off of life support and died in her mother’s arms at Johns Hopkins. Josie died from a cascade of errors that started with a central line-associated bloodstream infection, a type of infection that kills nearly as many people as breast cancer or prostate cancer.

Shortly after her death, her mother, Sorrel, asked if Josie would be less likely to die now. She wanted to know whether care was safer. We would not give her an answer; she deserves one. At the time, our rates of infections, like most of the country’s, were sky high. I was one of the doctors putting in these catheters and harming patients. No clinician wants to harm patients, but we were.Read More »Is this health care’s “man on the moon” moment?

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

What health care can learn from corn milling

Some of the best ideas for improving health care come from outside our field. For example, we’ve adapted cockpit-style checklists from aviation to improve teamwork and communication on our clinical teams. We’ve turned to performance improvement methods from manufacturing to reduce waste and defects in care delivery.

A recent experience reminded of the value of seeking ideas and inspiration from elsewhere. As I wrote in an earlier post, I was among 15 executives from various fields who toured Cargill through a fellowship run by the Malcolm Baldrige National Quality Award Program. On a visit to Cargill Corn Milling, among the largest of the gigantic company’s 75 business units, I heard a story with unexpected parallels to health care. Cargill officials told us that their nine plants used to compete against each other. Often, two or more of their plants would submit bids to the same customer, usually with different prices. This self-competition was inefficient, didn’t meet customer needs, and cost them market share and revenue. Something needed to be done.

The Cargill leaders recognized that they needed to organize themselves around what they provide to customers (i.e. their product lines) rather than their geographically based plants. And that’s what they did. The three main product lines were human food products (largely sugar), animal feed, and fermentation such as ethanol. Rather than having each plant compete against each other, they worked together to meet customer needs.

To support this new structure, they set cascading goals in which everyone—from the employee to the plant to the product line—knew what they had to accomplish to meet corporate goals. They changed the incentive structure so that plant managers had greater motivation to ensure the company’s success, customer satisfaction, product line success and their plant’s efficiency. With this reorganization, they weren’t pitted against others at their own company.

As I listened to the presentation, my pulse quickened. I leaned forward anxiously feeling as if I took a double espresso to pull an all-night study session. The parallels between corn milling and health care were haunting.

Read More »What health care can learn from corn milling

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

See one, do one, harm one?

Pronovost with groupI recently cared for Ms. K, an elderly black woman who had been sitting in the intensive care unit for more than a month. She was, frail, weak and intermittently delirious, with a hopeful smile. She had a big problem: She had undergone an esophagectomy at an outside hospital and suffered a horrible complication, leading her to be transferred to The Johns Hopkins Hospital. Ms. K had a large hole in her posterior trachea, far too large to directly fix, extending from her vocal cords to where her trachea splits into right and left bronchus. She had a trachea tube so she can breathe, and her esophagus was tied off high in her throat so oral secretions containing bacteria did not fall through the hole and infect her heart and lungs. It is unclear if she will survive, and the costs of her medical care will be in the millions.

Ms K’s complication is tragic—and largely preventable. For the type of surgery she had, there is a strong volume-outcome relationship: Those hospitals that perform more than 12 cases a year have significantly lower mortality. This finding, based on significant research, is made transparent by the Leapfrog Group and several insurers, who use a performance measure that combines the number of cases performed with the mortality rate. Hopkins Hospital performs more than 100 of these procedures a year, and across town, the University of Maryland tallies about 60. The hospital where Ms. K had her surgery did one last year. One. While the exact relationship between volume and outcome is imprecise, it is no wonder she had a complication.

Ms. K is not alone. Of the 45 Maryland hospitals that perform this surgery, 56 percent had fewer than 12 cases last year and 38 percent had fewer than six.

One day, after the ICU team—nurses, medical students, residents, critical care fellows and the attending—made rounds on Ms. K, we stepped outside of her room. We talked about what we could do to help get her well and to a lower level of care. But we also discussed the evidence for the volume-outcome relationship, highlighting that the hospital that performed Ms. K’s operation performed one in the previous year. Upon hearing this, the medical students cringed, quizzically looking at each other as if observing a violent act. The residents and fellows, the more experienced clinicians, stood expressionless; they commonly see this type of tragedy.Read More »See one, do one, harm one?

Coming home

Last week, my family returned from a vacation in Jamaica. The kids had spring break and it was great to get away with them. Upon returning to the U.S. and after clearing passport control, the customs agent said “welcome home.” No doubt they are trained to say this; I hear it every time I travel internationally. Nevertheless, those words always warm my heart and make me smile. They reflect for me a national culture, a set of values and beliefs about how we will behave. Welcome home to the U.S. reminds me that we live under the rule of law, that we are all afforded due process, that we have freedoms to voice our concerns, to practice our religions, to vote.

As we drove home, we rounded the corner and our house came into view. Again warm feelings flooded me. Seeing my home, I reflected on the deeply held beliefs of love, of support and nurturing, of forgiveness, of warmth and comfort—the culture of our home.

Two days later, on Monday, I returned to work, starting as the attending physician in the ICU. As I walked into the ICU, I thought about the culture we have created there, the sets of norms and beliefs that govern behaviors, my largely hidden assumptions about the organization and my colleagues.

Clinicians, when you walk into your clinical or hospital, what kind of culture are you part of? Is this a place where patients are the “North Star,” their needs guiding all of your work? Is it a place where clinicians’ egos are put aside and they focus on what is right rather than who is right, where we commit to practice evidence-based medicine, to work as a team, to continually learn and improve? Is it where staff seek to identify and mitigate patient safety hazards, respect the wisdom of frontline workers and empower them to improve? Is it a place where we see our differences as strengths rather than weaknesses, where we support each other, hold each other’s hands when we are down, laugh and cry together?

Read More »Coming home

Dreaming the dream

Susan BoyleThe video of Susan Boyle’s debut on Britain’s Got Talent is well worth watching. She walked on stage, wearing a frumpy dress, overweight and awkward. Members of the audience snickered and rolled their eyes as this 47-year-old told the judges that she wanted to be a singing star. I suspect she had her own doubts. Yet she had the courage to try. She believed in herself and stunned the audience with her voice.

Susan’s story is typical of so many personal journeys. We face skepticism from others, and we are filled with self-doubt. Sometimes we listen to those little voices whispering: You cannot do this. Yet when we overcome the doubts, we are often successful. If we give into those voices, we will surely fail.

This same self-doubt exists in patient safety. I know because I had plenty of uncertainty about my ability to reduce patient harm. More than a decade ago, we decided to reduce central line-associated bloodstream infections on one intensive care unit. We doubted it was possible and whether we could have a role in reducing harm. Most of the physicians thought it couldn’t be done. Sick people get infected, they said. These infections just happen. In our own way, we felt frumpy and awkward.

Initially, we did not debate whether we could stop these infections. We focused on consistently following those practices shown by evidence to reduce them. We had been complying with those practices just 30 percent of the time. Our clinicians agreed that we would follow a checklist to help ensure 100 percent compliance and then see what happened to our infections. As compliance rose, the rates went to nearly zero, and the doubts disappeared.

Read More »Dreaming the dream