HCPro.com - Patient Safety Quality Monthly

Measuring Your Hand Hygiene Culture?

Mon, 28 Feb 2011 13:43:00 GMT

Measuring Your Hand Hygiene Culture?
Hand hygiene or sanitizing is one of those areas that continue to be with us, but it is not an easy one to measure to see if we are making progress. Sure we can do direct observation to try and see what people do and some organizations are using dyes in soap etc so they can scan hands. While these direct data collection measures are useful (and a great way to encourage accountability), they don't really give us an easy to manage indicator of our overall Hand Hygiene culture – including staff, physicians and visitors.

So let's consider another approach. What if we attempted to estimate our hand hygiene culture through an indirect measure? When we design data systems we look for the easiest way to get us as close to a useful answer as possible. So for hand hygiene culture let's consider the indirect measure of "Volume of Hand Sanitizer Used". Every time an employee, physician, patient or visitor squirts a little of that foam or gel into their hands, they are indicating support of your hand hygiene culture.

We can probably feel quite comfortable drawing the correlation between volume of sanitizer used and the strength of our culture. Keep it simple, we are not trying to correlate volume of sanitizer to infections – just to our culture of hand hygiene awareness and willingness to take some action.

Let's take it another step and expand that to add volume of hand soap used in the facility. Now if we combine these two volumes we will start to have a pretty good indication of the number of times that people do an effective job of hand hygiene. Sure, some people will wash their hands without soap, and yes some of the sanitizer spills on the floor or gets left in the container – but that will probably remain constant over time. So looking at the trend is a pretty solid indicator.

So how can you do this? Call up your supply management people and ask for the monthly numbers. They have to resupply and purchase new containers so they will probably have a pretty easy time of giving you a ball park number of containers used. Next we need to convert the containers used into "Uses" or "doses". This will vary depending on your product but the conversion is in the sales literature or just a quick web search.

Now we have a combination of doses of soap and sanitizer. How do we analyze this? Start with the whole facility and see if it is increasing. Use your standard data methods (Trends, crossing averages, control charts etc.) to monitor the long term trends – remember to smooth them out. Look for a continuous increase in the use of the products which would imply that more instances of hand hygiene are occurring which would imply that we have developed a stronger culture. I would suggest monthly usage data, but remember that there may be quite a lag.

After you have looked at the overall facility trend – with a 3–4 month rolling average, consider calculating the number of hand hygiene instances per person. Just estimate the employee hours, including physicians as well as visitor and patients and that will give you a rough indication of hand hygiene instances per person. Again, not perfect, but does it really have to be? Are you pleased with the number? If you doubled or tripled the number would you be pleased? Are you seeing a trend that is reassuring?

As always, our data is supposed to help us make good decisions, even rough estimates can be very useful.

If you have been doing this we would love to hear how it is working for you. Drop us a note and we will report back on what we are hearing. (KROHDE@greeley.com Sr. Consultant for Patient Safety and Process or TSWARTZ@HCPRO.com Editor of Briefings on Patient Safety)

Are you rolling?

Tue, 23 Nov 2010 12:30:00 GMT

In our world of patient safety and quality, we are inevitably dealing with analyzing and presenting data that we collect. Sometimes we just present last month's values. Unfortunately, that doesn't put the data in any form of context. It makes it hard to answer the questions "So are we getting better or worse?" and "So is our process smooth and under control?"

One good way to help answer these questions is to provide a historical trend. We often try to do that with our data. But if there are a small number of data points or samples, we can often end up with a bad case of the "jaggies." You know those graphs—the high peaks followed by the grand canyons! These jagged graphs can often led the viewer to jump to conclusions and say, "Oh no! That looks terrible!" when there is just one occurrence compared to our normal zero occurrences.

The answer to this is to smooth the data. A smoothed graph can reduce the knee-jerk reactions and help ensure that we are effectively communicating the real underlying trend. A powerful method to smooth our data is to use a rolling or moving average. A rolling average takes a series of prior points, adds them together, and then divides by the number of points. That resulting average is then plotted. We then move over one point and do it again. We just roll across the rest of the graph in this same way. The more points we put into the average, the smoother the trend is. This gives us a nice directional trend for the magnitude of the data.

It is likely that you all have done rolling averages at some point in your analysis, so this isn't really a new concept. Let's take it to the next level. If rolling the averages is a good thing, what else can we roll?

How about rolling standard deviations? The standard deviation tells us how big the spread of the data is. That's useful because it helps us understand if the process that is producing the data is tightly controlled (small spread—highly consistent) or if the process is loosely controlled and producing a larger spread and distribution of the data.

We often take a data stream and calculate the standard deviation based on all the points. But if this is driven by a process, isn't it likely that the process may be getting better or worse? We should assume that the standard deviation might change over time. So, back to rolling. How about if we roll our standard deviation?

Perhaps we have daily data that we collect. Consider calculating a standard deviation based on the daily samples for the past month. Plot that, then move over a month and calculate the standard deviation, and then keep on rolling. This gives us a smoothed curve of the changes in standard deviation over time. Look for major changes. Hopefully you will see a smaller standard deviation after you have implemented a process improvement. Likely you will begin to see an increase in the rolling standard deviation when your process is declining.

One more example for extra credit! Consider two data streams that we all collect—these might be mortality and complications. It is a nice touch to see if they correlate, so we might do an analysis and calculate a correlation value for the entire data set. Consider a rolling correlation. Calculate your correlation on a part of the data, then move over one and do it again. Keep on rolling across your data. Now you will see any changes in correlation between your indicators over time. This can be a great diagnostic tool.

Remember, when you do rolling, you change the magnitude and insert a shift in the data. You have to watch out for that. But expanding your rolling to other areas may open a whole different window on your data. Keep on rolling!

Ken Rohde, Senior Consultant

Push and Pull in the ED

Tue, 26 Oct 2010 12:30:00 GMT

If your organization is working on improving patient flow—and who isn't?—it is likely you have run into a problem where the ED is pushing people from the emergency room to the nursing floor, and the nursing floor or ICU is complaining that they were "not ready" or the patient was just "sent up". Sometimes you hear similar things when a patient is "pushed" out to the discharge team or to any other unit.

Our goal in any situation where we are moving patients is to have a smooth and well-managed flow. Anytime there is poor synchronization, we know we will have process problems, staff frustration, and potentially safety issues.

Managing flow is a classic problem and is a great place for us to apply one of the powerful LEAN concepts. That's the concept of PUSH and PULL.

In a simplified fashion, PUSH says that when we are done with our tasks we push the patient (or product) on to the next step in the process based on our needs—not the patient's. The opposite of this is to PULL. As soon as we are ready in our process, we reach out and get the next patient or product and PULL them into our process. Obviously, we would all prefer to be able to PULL things into our process when we are good and ready, and we may get a little upset if people are constantly pushing. Generally, processes that PULL are more easily synchronized.

So let's go back to the issue of coordination of flow between the ED and the floors. Why does the ED have a tendency to PUSH to get people moved out of their area? Typically it's because they are trying to balance their flow—as more people come in, the folks who are already there have to go somewhere. So they get pushed out to the floor or back to "the street."

So why don't we have the same problems in other areas like endoscopy or outpatient surgery? The primary difference is the amount of control that those processes have on the incoming stream of patients. We use that time-honored approach of "the appointment" to control the incoming flow. If we don't have a slot in the schedule, we move the patient to next week. This really is just reaching out to our patient population and PULLING them in when we are ready.

The ED doesn't have that luxury. We can't schedule motor vehicle accidents and strokes to fit the convenience of our processes. And because the ED can't schedule when people arrive, it starts a whole chain of events that ripples through the organization. A surge in the ED causes a surge in ICU and med-surg, and everyone gets out of synchronization.

Does that mean that this will never change? Not really. There are some great process flow activities being done to improve the flow in the ED—and they are really helping. But perhaps one of the most interesting changes on the horizon isn't even coming from process improvement projects in the ED; it is coming from marketing!

A key satisfaction differentiator for people who use the ED—and have a choice—is the wait time. When the marketing folks recognized this, it became a key advertising focus: "We guarantee we will see you in the ED within 30 minutes." Now, by itself, that didn't really change our flow, it just put a lot more pressure on the ED staff!

The real change came when the marketing people took it to the next level—displaying the actual wait time on billboards or on the Internet. "The present wait time at our ED is 12 minutes." This results in a fascinating change in the whole process dynamic. In the past there was no control over the incoming flow to the ED (except for diversion). Now the incoming flow is being balanced by market forces. If the wait time is long at one ED, people will check the Internet and go to another ED with a shorter wait time. Without a lot of prior process thinking, we are now doing what might be called "load leveling" out in the community.

This will change the whole PUSH-PULL dynamic. Now when an ED is ready for more patients from the community, it reduces its wait time on the Internet, and in the larger markets, this will result in PULLING patients from the community to the ED—something that in the past we could never control as directly.

Of course, this is not happening everywhere or that quickly, but it is an interesting example of how we can use tools like PUSH-PULL to better understand and communicate the process world we deal with every day.

Ken Rohde, Senior Consultant, October 2010

What’s that barrier protecting?

Wed, 25 Aug 2010 12:30:00 GMT

In patient safety and quality, we regularly talk about barriers. Sometimes they are the bad barriers such as a barrier to acceptance of a safer way to work, and sometimes they are positive barriers that are there to protect us, such as a double-check or an equipment guard or a locked door. We often think the more positive barriers the better. But is that really so? We need to carefully think about what harm the barriers are protecting us from and ensure that there are no unintended consequences.

Let's consider a couple of simple examples.

One of the risk areas in the nursery is the potential for abduction of a newborn, so it is natural that we think about adding barriers to protect them, such as lockdowns based on a protection band on the baby that causes the doors to automatically lock. Seems like a good barrier. Maybe we have even recommended it for our facilities.

Ideally that barrier will keep the abductor and the newborn on the nursery side of the door and prevent them from running off so the nursing staff or security can deal with the situation. But are there potential unexpected consequences of this? Absolutely. The classic example, which isn't that unusual, is for the abductor to slip out the door just as the lockdown is triggered, thereby locking in the responders instead of the culprit. Then there is much running back and forth to the override switch to open the doors so the situation can be resolved. The barrier could end up working backwards, keeping the good guys locked in giving the bad guys a head start. In this case, the unexpected consequences of our barrier might outweigh the benefits.

Another example involves the scrubs that so many nurses, surgeons, physicians, and technicians wear. These are designed as barriers to keep contamination away from the wearer and also to keep from spreading contamination around the hospital. But has your organization clearly stated what they are barriers for? Are they a barrier to protect the care provider or the facility or patient or maybe all three. Can we really be sure that this barrier is effective if we haven't clearly defined why we have it?

Shoe covers can protect the surgeon's shoes from spills in the OR, but when they are worn down the street to the fast food joint, they pick up all kinds of dirt that is then tracked back into the hospital. Gown and gloves worn for a bedside procedure help protect the physician, but also help preserve the cleanliness of the procedural area. Typically, protective clothing is worn to protect the wearer from harm AND to prevent the spread of contamination. Are your barriers causing unexpected consequences and maybe spreading contamination rather than doing their job?

This certainly doesn't mean that we shouldn't have barriers—they are a necessity in our world. However, we need to be smarter than the barrier and make sure it is keeping the bad stuff on the right side!

Ken Rohde, Senior Consultant, August 2010

Are We Getting It Right?

Tue, 27 Apr 2010 12:30:00 GMT

When we talk about our culture of safety and high reliability, one mantra that is often quoted is, "Get it right the first time and every time." As we strive to improve patient safety and quality, this really makes an excellent goal at all levels, from the individual, through the department, to the organization or system, and then even nationally.

Within our own organizations, we track our measures and indicators to see how well we are doing. Last month, the Agency for Healthcare Research and Quality (AHRQ) gave us its latest report card on how well we are all doing collectively. The National Healthcare Quality Report has been published every year since 2003, and while we hope that all our facilities are above average, it is useful and interesting to look at our industry as a whole.

The report is more than 150 pages long, so I have pulled a few key points that I found interesting. The entire report is available online from AHRQ.

Let's start with the overall AHRQ summary, especially those areas related to patient safety and quality. The report stressed that:

Some areas merit urgent attention, including patient safety and health care–associated infections (HAIs). … Some of our findings are disturbing. For example, last year we reported that approximately one out of seven adult hospitalized Medicare patients experienced one or more adverse events. This year, we see problems specifically in the area of HAIs. (pp. 8,11)

What was the data showing?

Of the 33 hospital measures related to safety, 12 (36%) improved at a rate greater than 5% per year. In contrast, of the 19 hospital measures not related to safety, 16 (84%) improved at a rate greater than 5% per year. Still, more than half of safety measures showed some improvement. (p. 12)

The key message I take away from this is either it is harder to improve measures related to safety or we focus more on those things that are performance-related or are seen to have a more direct connection to the market. Probably both.

In addition, the other area requiring urgent attention was HAIs. The report stated:

It is unfortunate that HAI rates are not declining. Of all the measures in the NHQR measure set, the one worsening at the fastest rate is postoperative sepsis. The two process measures related to HAIs tracked in the NHQR, both covering timely receipt of prophylactic antibiotics for surgery, are improving steadily. However, HAI outcome measures are lagging; only one shows improvement over time while three are worsening and one shows no change. This may, in part, reflect improving detection of HAIs. (p. 6)

Better reporting always causes an increasing peak before we can pull it down. So what do I take from this? We still have a long way to go. Anytime we see an increase related to better reporting, it is concerning, because that means there are still things we have not yet seen. But always remember that in reporting, we want to see an increase in the number of reports and a decrease in the burden caused by the reported problem (severity).

Bottom line: Although we are making some important forward strides, the report clearly indicates that our patient safety and quality, when measured on a national level, still needs to urgently focus on "Getting it right the first time and every time."

Ken Rohde, Senior Consultant, April 2010

Olympian Culture of Safety

Tue, 23 Mar 2010 12:30:00 GMT

Building a culture of safety is an ongoing commitment. We need to keep people interested and aware of the implications of all the things we do daily for our culture of safety. To keep this conversation fresh, it often helps to have good talking points to bring the culture of safety to life.

A great recent example was the 2010 Winter Olympics in Vancouver. We may not initially connect the Olympic Games with our hospital culture of safety, but there certainly are some interesting areas for discussion.

With the games starting with a tragic death, followed by two weeks of athletes spinning 30 ft. overhead in freestyle skiing or snowboarding, rocketing down slopes or slides at close to 100 miles per hour, or even skiing with guns, we may be tempted to conclude that there is no culture of safety there.

But is that really the case? In some ways, the Olympics are not only a world-class athletic event, but also a tremendous case study in safety and reliability.

What can we learn or use in discussions from the Olympics?

Following the death on the luge track, there was a rapid analysis (root cause analysis) and the track was changed (corrective actions). Can we respond rapidly within our facility and actually make changes in a matter of days, or does it take us months?
The organizers were willing to make significant changes in a matter of days even in the face of significant public opinion—they didn't worry too much about outside opinions. Hopefully, we are willing to make significant changes when required, including temporarily closing units or stopping admissions.
There may have been early indications of excessive risk that were not heeded prior to the event. Think about our FMEAs and occurrence reporting. Do we pay attention to our early warnings?
Athletes practice and hone their skills. Those who made it to the competition had spent years in continuous practice. Do we recognize the value and requirement of practice when we are trying to perfect skills in our hospitals? Do we practice Olympic-quality "code blue" or rapid response drills? We may worry that we don't have the time to put that level of practice into our activities. But isn't preventing harm or death really a gold medal in our world? Isn't it worth practicing?
What about the opening ceremonies? There were performers spinning and repelling down from the ceiling of the stadium. They all had fall protection (PPE). They didn't sacrifice their personal protection because it would "look bad" on worldwide television. What about the simple use of gloves, gowns, and splash shields in our world?

As you build your own culture of safety and reliability, it probably is good to step back and evaluate whether you are approaching this with Olympic seriousness. If not, maybe it's time for a culture adjustment.

Ken Rohde, March 2010

Improving Our Forecasting: Smooth It and Scale It!

Sat, 20 Feb 2010 12:30:00 GMT

Boy did it snow! Big storms all up and down the East Coast caused organizations and even the whole government to move into reaction mode. The weather reports gave enough early warning so that airlines could cancel flights and reposition planes, but it still was a mess—especially if you were traveling that week. Although this was a big event that ultimately had a lot of impact, there was enough warning to do a lot of risk mitigation.

The next week another storm headed for New England, and the weather reporters were forecasting 10–12 inches of snow in some areas. Schools closed, activities were canceled, and work let out early. But the storm didn't materialize. In this case, there was a lot of action, but did it really mitigate risk? Could it have actually caused more risk?

Forecasting the risk of snowstorms is a tough job—typically one that we put a lot of faith in even though it is "just a forecast." We may not recognize it, but we are also in the forecasting business. Although we aren't forecasting the weather, aren't we forecasting falls, medication errors, harm events, mortality, quality of care, potentially compensable events, as well as future satisfaction? In our world of patient safety and quality, people are putting a lot of faith in our forecasts.

What can we learn from the recent snowstorms that can help use do better forecasting?

Think about the difference between a discrete event and a trend

Chicago and Buffalo were slightly amused at the impact the snow had on Washington, DC. Why? Because for these two cities, this kind of storm was a known part of the trend that they were used to. In Washington, DC it was an unusual, emergent event. When we are alerted to a potential emergent event that is outside of our trend, we move into reaction mode. Depending on how big the alert is and how well managed our organization is, this response may range from prepared to knee jerk.

Now think about your event or complication data that you present to your leadership team. Does it show an impressive spike? That communicates an "emergent problem" or "storm on the horizon" and can move your organization into reaction mode, which may not be completely appropriate and may divert resources from other more important areas.

Typically this happens for two reasons:

First, we probably didn't smooth our data and provide a longer term trend for comparison. If, rather than seeing an apparent spike in the forecast (actually the "hindcast") we see a longer term direction of movement and the rate of change, this can help us focus on the more realistic longer term trend and make better decisions.
Second, we may have been careless in the selection of our scale. I am sure you have seen the graphs with the "jaggies" and perhaps even a Mt. Everest. Often they are purely artifacts of the automatic scaling function of our software. If you make the scale small, more snowstorms look like "the big one." Big visual spikes can cause big actions, even when the data is not big.

Smooth It and Scale It

So what can we do to help make our forecasts more effective? Consider making these two techniques important tools in your Patient Safety & Quality toolkit.

Always smooth your data. Consider using a rolling average that is based on the number of periods of data that you are sharing. Set the expectation that people will start saying, "Can we drop a smoothed line on that?" This is easy to do in Excel or other packages. Remember that a smoothed average may shift your curve, so do a quick adjustment for that if necessary.
Base your scale on your acceptable limits, not the magnitude of your data sample. Consider always putting your acceptable limit on the graph and basing your scale on it. If your data is unacceptably outside of the limit, go ahead and expand the scale, but if your data is just a faint vibration and there is a lot of range between the data and the acceptable limit, avoid the temptation to expand the scale "just so we can see it better." That turns those little bumps into big snowstorms and can elicit the wrong reaction from the end user of your data. If you continue to have too much room between your actual data and your limit, you may need to move the limit by raising the bar.

Just like we watch the snow forecast to decide how we will plan our day, people in our organizations look at our Patient Safety and Quality data and try to make good decisions from it. Help them out: SMOOTH IT and SCALE IT!

Building Your List of Data

Fri, 22 Jan 2010 12:30:00 GMT

Last month's article discussed the need for the following three lists to help manage your quality and safety program:

Processes
Active projects
Most important data

This month we will look at an approach to building your list of data.

The data list is vital as you begin the process of making sure you have the right data and the right amount of data, are effectively communicating the data, and that it is causing change. One of the main reasons for making this list is that we are often overwhelmed by the amount of data that is available. With many thousands of pieces of data, which we can plot against any other piece of data, we end up with millions of combinations of data—no wonder we get overwhelmed. Unfortunately, the magnitude of data often stops us from even making the list.

Don't Get Overwhelmed—A Partial List Is Better than No List

Don't fret that your list of data will not be complete—it will likely never be. Just get started and gather the most important data on the list first. One good approach is to start with reports instead of the data. If there is already a report, it is likely that the data are being used, and that moves it up a notch. Reports are also easier to collect.

Start with the organizational dashboards and then move to the department and service line dashboards. This should get most of your core measure data and important performance data.

After you have collected the data from the dashboards, add on the required reports to the board or your state. This will likely include all the CMS or Joint Commission data.

Now start rounding up all those other reports. For each of your data systems, print the list of reports and add them to the list. Remember that there are reports in compliance, risk, pharmacy, lab, nursing, medical equipment, etc.

Now you should have a list of several hundred data reports that are likely being used in the organization.

Begin Managing the Data List

Once you have the initial data list based on the reports, you want to begin using this list as a tool. Now is a great time to get the list in Excel or Access and begin to add some fields to help you manage the data list. Remember, you are not managing the actual data here, you are simply managing the names of the reports. Consider adding fields to your spreadsheet to capture some of the following:

Who uses the data reports? The more departments or service lines that use the report, the more likely it is that the data are useful.
What is the report used for? How is the report connected to action? How does it trigger action?
Are the reports required by regulation?
Are they seen as credible, or are the underlying data questionable or is the report dismissed by parts of the organization?
What system does the report come from?
Give the report a grade. Is the report easy to use and understand? Does it provide good management decision support or just numbers?
What is the lag? Are the data in the report up to date or does the report reflect historical data that are several months old?
Now sort through the various categories and roll up the list of reports into different areas. Look for the most important reports and what data are on them. Often you will see that there are some widely used reports that do not show up on the dashboard, and some of the dashboard data may not tie directly into actions.

From this initial list you can begin to grow your report management, which then can lead you to better management of your data, which is vital if you want to effectively improve your safety and quality.

Making a List, and Checking It Twice

Tue, 22 Dec 2009 12:30:00 GMT

There is a popular lyric that is often heard this time of year: "Making a list, and checking it twice." In its original context, the list was made to determine whether someone was "naughty or nice." In our world of patient safety and quality, we don't need a list to determine naughty or nice; we need a list to help us keep our patients safe and ensure the success of the organization. Actually, one list isn't enough—we need three. In addition to all the checklists and tables that we use, consider where your organization stands on the following:

Do you have a list of all your processes?
Do you have a list of all your performance improvement activities?
Do you have a list of all your data?

We all work to manage and improve all of these activities, but often we forget the simplest of tools—the list. Maybe it is time to set a goal for 2010 to work on developing all of these lists.

Your Process List

The process list is the cornerstone of your process management program. It should list all the key processes in your organization and will likely be broken down into sub processes. Then what do you do with this list? Use it to prioritize your process management activities. Rank your processes by risk, complexity, impact on economics, and impact on regulatory compliance. Then start linking your process list with your occurrence reporting system and your data. Remember that the IHI is putting out some good material to help support your process list.

List of Performance Improvement Activities

The next list includes all those process, safety, and quality improvement activities that are being done. Where does this list come from? Start with all the corrective actions from your cause analyses, and then add the improvements from your FMEAs, performance improvement teams, accreditation audits, commitments to Leapfrog, and others. Before you know it, your list will include several hundred performance improvement activities—maybe many more than you realized. Next, group them together and prioritize the list. The top priorities you must get done; the items at the bottom of the list … well, maybe they just don't make the cut this year. Help your staff members know where to put their time.

List of Data

Consider committing to make a data inventory list in 2010. Think of this as your master list of all the data that you collect in your organization. Your supply management department knows all the supplies and equipment in its inventory—do you know what data you have in inventory? Remember, all that data is not free. In one way or another, you are paying with resources for every number and bit of that data. We can't afford to waste it or collect it and not use it. Once you make this list, connect it back to your process list; determine what data is still valuable and what data should be discontinued. Look for imbalances—for example, are you collecting a disproportionate amount of data in any one area?

All three of these lists are key management tools to help make sure that you are being effective in improving your safety, performance, and risk management. Feeling that you have control over these areas really does end up being pretty "nice."

Have a great holiday season, no matter how you spend it, and hopefully it won't all be spent at work!

Ken Rohde 12/22/09

Building Your Culture of Safety by Breaking Down Barriers

Wed, 25 Nov 2009 12:30:00 GMT

Are you busting barriers? No, not those good barriers that prevent harm, but those nasty barriers that separate silos and departments. Have you involved your facilities, engineering and maintenance folks in your culture of safety? How about your relationship between quality and risk management? What about the IT department? These areas are ripe for some "barrier busting" if you want to increase the speed of improvement of your culture of safety and reliability.

The more I work with organizations to build their culture of safety, the more striking to me the number of missed opportunities of not getting your facilities and engineering folks more actively involved. Sometimes we just don't think about the non-clinical expertise within these areas. On the clinical side, we are thinking about performing FMEAs to reduce risk. Do you know that the facilities/engineering and maintenance folks are likely performing maintenance risk and prioritization analysis? That's how they decide whether they need to spend the resources to replace something or fix it or whether they should just wait. In addition, they are doing HAZWOP analysis to evaluate hazardous waste operations, yet another risk assessment activity.

In addition, you may find that your engineering team has some real skills in planning and tracking tasks as part of project management. Often, the clinical side is a little weak in managing projects and activities, whereas this is likely a real strength on the engineering side. Consider getting internal assistance from our teammates in the other departments. Ask them whether they can help with setting up some action tracking systems or project scheduling approaches, as they may have the software and people who are good at such tasks.

Another area to take advantage of is change management. With all the process changes we are putting into play, how do we make sure the changes will deliver the benefits we expect without any unexpected consequences? Consider talking with your IT folks about how they manage changes to the software systems. You may get some great ideas from their methods—and if you don't, maybe you just uncovered an area of concern!

Another key silo closer to home is the working relationship between the risk management and quality departments. All those occurrence reports are some of the most valuable quality data we have—make sure they are getting shared. If your occurrence reports are not being effectively used, you are letting an organizational barrier put your culture of safety efforts at risk. Break down that barrier quickly!

So if you want to develop a more integrated approach to improving your culture of safety and reliability, consider the following:

Combine forces with facilities/engineering on your FMEA program
Make sure your expectations for safe behaviors are shared between both the clinical and non-clinical areas
Learn from the project management and action-item tracking systems that are in place in engineering, maintenance, and bio med
Work with members of IT to learn how they manage change
Get your risk managers and quality people to share data

Building our culture of safety is a continuously ongoing effort; we have to keep pushing and adjusting and working on all aspects of building an effective culture of safety and reliability. Some parts are easy to address, some seem almost impossible, and then there are some important things that we can do but they take some effort—busting some barriers is a good place to start.

Ken Rohde 11/25/2009

Zero-Tolerance Rules: Can they work?

Fri, 16 Oct 2009 12:30:00 GMT

This month there was an interesting article in The New York Times about a 6-year-old boy who was suspended from first grade because he took his Cub Scout combination knife, fork, and spoon to school. I personally remember those days well and can see myself wanting to show off this cool thing to my classmates. Unfortunately, the student ran afoul of the school's "zero-tolerance" rule about bringing a weapon to school. He is now subject to 45 days' suspension at the district's reform school. In my day, the threat of reform school was about as dire a consequence as I could imagine.

Completely independent of the rights or wrongs of this specific case, it provides a great conversation starter in your organization about zero-tolerance rules. When we work to build a culture of safety, we often need to focus on improving compliance, and a valuable tool to do this is to establish a limited number of "critical rules" or "red rules", of which we have zero-tolerance for violation. But if we use critical rules or red rules, how do we keep from falling into the same trap as the school district did with the 6-year-old?

Although actual zero-tolerance may not be ideal, if we want to use rules that approach this, we should consider the following:

There should be a limited number, and they should reflect our highest risks or most important values.
Everyone should know them. They should be clearly communicated, even to the point of being over-communicated.
We should make them as easy as possible to comply with.
They should be drilled into our behaviors.
They should be uniformly enforced.

Let's step through these criteria for zero-tolerance rules and look at how two organizations apply basically the same rule. We will compare this school district to the TSA airport screening process.

A knife in either world is not acceptable; however, the risk in grades one through five, although not marginal, is probably not the largest risk or most important value in those situations.
You can't get close to the TSA checkpoint without seeing posters or videos or even hearing the TSA officers explaining the dos and don'ts. I doubt if that level of communication was done at the school door.
At the TSA checkpoint, compliance with the zero-tolerance rule is supported by an inspection process, scanners, and a team of people who are 'helping' us comply. I have forgotten to remove things from my luggage, and the process has helped me comply. I doubt if there were metal scanners, inspectors, etc., at the school door. (Although by the time you get to junior high, metal scanners are not that uncommon!)
I travel every week and get lots of practice in TSA compliance. I wonder whether there was ever a knife drill or simulation for the first graders?

Independent of the value of the zero-tolerance rule, as patient safety or human performance folks, we probably could have predicted that there would be more problems with the zero-tolerance rule at the first-grade level than at airport security. But in this case, well-meaning people set up a potentially faulty rule system and have had to deal with a huge public outcry. When you think about the outcry, it probably isn't focused on fighting the rule—which isn't a bad rule. I doubt if anyone is encouraging first graders to take knives to school. I would contend that the outcry is because people recognize there is a failure in the rule process, rather than a problem with the rule itself.

Think about your red rules, critical rules, or zero-tolerance rules—have you made these most important rules the easiest to comply with, understand, and defend? If not, you may be setting your organization up for a similar failure in the rule process.

Ken Rohde 10/15/09

Leadership Sentinel Event Advisory

Thu, 24 Sep 2009 12:30:00 GMT

Last month, The Joint Commission issued a Sentinel Event Alert titled "Leadership Commitment to Safety." You all know how important the commitment of your leadership team is, and you've probably been fighting to develop it for as long as you have been in the safety and quality area. Some of you may be winning the battle—we are starting to see some strong dedication in some facilities—but the need for all the leadership teams to get committed is strongly stressed in this advisory. So how should you use this advisory to help move your organization?

First, make sure people know about it. This is a more general advisory. It is focusing on a deep underlying cause, not a specific set of events. This makes it a little more difficult to get it into play, but if no one reads it, it is not going to help your organization!

Second, plan a strategy. The advisory lists 14 suggested actions. Although these 14 items are a great place to start building your strategy, they are still a bit general.

Below are some specific suggestions for how you can try to get the broader suggestions into play. Each of these suggestions is coded to the 14 suggested actions.

Make sure you have a clear safety goal that is endorsed by the board and leadership. Test this by asking, "Would I like that on the banner over the front entrance?"
Make sure all key leaders know how many significant events happen in your facility. If you ask the board, senior leadership, directors, managers, and frontline staff members, "How many significant events have happened here in the past two years?" and you get radically different answers, you know you may not have good transparency.
Develop your performance algorithm. Make sure it includes both reporting and harm. Strive for an increase in number of reports with a decreasing severity.
Refocus your cause analysis and prevention from regulatory response tools to business tools. Cause analysis should be just a normal part of the business.
Set simple expectations for safe behaviors. Everyone should know them by heart. Yes—everyone, clinical, nonclinical, leadership, and physicians.
Set some simple expectations for your data and trends. Make sure you can answer the four simple questions: magnitude, direction, variability, and rate of change. Aggregate, aggregate, aggregate!
Get your risk and event data out to the trenches. Let the front lines and the management ask questions about the events and trends—don't just push the graphs and data out to them.
Prioritize through a master list. If you don't have all your quality and performance improvement projects on a master list, leadership can't and won't get involved. One master list means projects will get looked at and prioritized—even those we don't want looked at. But if we want leadership commitment, they have to know where we are spending our efforts.
Get physicians involved. Make sure they see the benefits to their patients and practice. Don"t assume they will unless you work with them to identify the benefits to THEM.
Encourage the voice of the patient. I was at a hospital as a patient last week, and there was plenty to see and talk about with the staff members who were helping me. Make sure you have a process to really listen.
Quality management stresses the front lines—get them involved in mapping your processes so you see the real "as is" way you are doing things.
Use the results of your culture of safety survey. It can tell you a lot about your culture. Set some goals for change. Compare the leadership responses to the front lines—bet they don't look the same.
Notice and comment! If no one notices, nothing will change!
Notice and comment! If no one notices, nothing will change!

Ken Rohde 09/24/09

Policies, Procedures & Competencies - Oh My!

Wed, 26 Aug 2009 12:30:00 GMT

"In our organization, we use policies and procedures as interchangeable words; they are just paragraph headings in the same document."

"We are trying to balance the amount of formal guidance we provide. On one side, we want lots of good guidance, but on the other, if we write all that down, it is a burden and a risk if we can't do it."

"A lot of the stuff is just good skills and competencies; they should know how to do that before we hired them. If they can't do it, procedures won't help—we need new people."

If our goal is to get it right the first time and every time, we need to make sure people know what to do. We can't just assume everyone knows all the steps in our processes, so we write it down in our guidance documents (i.e., policies and procedures). We need to train people on certain skills and competencies that they use repeatedly and have them demonstrate back to us that they can perform them.

We talk about policies, procedures, competencies, and skills all the time, but in many organizations, we haven't taken the time to step back and really look at the framework that makes it all fit together. This month, we will provide some thoughts on building your guidance framework and how all these parts fit together.

To ensure that our guidance helps us fulfill our goal of safe, effective, and satisfying care the first time and every time, we needs to do two things:

Capture and share our collective knowledge
Provide a standard with which to compare our performance

Our written guidance and training programs are key methods to share knowledge with those who use our processes. So how can we define these concepts so we can more effectively manage them? Lets try the following:

Policies: Our policies are our commitments to the outside world, our communities, and our accreditations and regulators. These are the binding corporate promises we make that define what they can count on. For example, when we commit to an EMTALA Policy or equal opportunity employment policy, we are committing that we will live up to the laws and requirements that have been defined outside our facility. Our policies should be short, carefully worded, inclusive of the regulations we will meet, relatively long-lasting, and difficult to change.

Tip: Consider pulling all the policy paragraphs together into one list. Does it accurately reflect what is important to your organization? Does it fit with your strategy? Your strategy and policies should fit together like a hand and a glove.

The outside world should judge us by our commitment and success in delivering on our policies.

Procedures: Procedures are our internal documents that provide the step-by-step sequence for how we should perform a procedurally controlled task. The level of detail of this guidance is dependent on the complexity of the task, the level of experience of the person performing the task, and the safety, risk, economic, or regulatory implications of not getting it perfect. We should be able to change our procedures as our process, people, and equipment change. This means that we probably need to change our procedures more frequently and more rapidly than we change our policies.

Tip: Be careful of combining your policies and procedures in the same document with the same change and approval cycle. This mixes two different levels of approvals together and can often cause long delays in changing your procedures, which results in poor guidance or even increased noncompliance.

Our procedures form the backbone of measuring compliance. If we don't write down a specific set of steps or a specific sequence we want things done in, we can't really complain if people do it differently. We compare how people perform a procedurally controlled task to the procedure to see if they met the standard.

Competency: Not every activity requires a formal written procedure. In fact, too many unnecessary procedures leads to excessive burden, regulatory/accreditation issues, and compliance problems. Your competency programs are designed to ensure that everyone has the skills and knowledge to perform all the tasks that are procedurally controlled and especially that they know what to do, and can do, all those tasks that are not covered by specific written guidance.

Tip: As you are developing your guidance solutions, carefully balance the procedurally controlled tasks with the portions of the process that should be controlled by a competency or by skills training. Consider annotating your process maps so it is clear if each action is guided by more formal written procedures or if it is fully covered by training and a demonstrated competency. If you see any activity that you can't trace the guidance back either to a procedure or trained competency (including all those job aids), you should give it another look and perhaps worry a little.

We evaluate competencies by both demonstration in a training setting and then by observation in a real-world environment. If we start to see problems in performance in our non-procedurally controlled tasks, we may decide to take a look at how effectively we are managing our competencies.

Building an effective approach to provide guidance to all those we are counting on to get it right the first time and every time requires that we understand and incorporate clear understandings of how we make sure they know what to do. If we can assist you in your policies, procedures, or guidance solutions, please give us a call.

Ken Rohde 08/25/09

Getting Improvement Projects Done!

Thu, 16 Jul 2009 12:30:00 GMT

"It's been five years since the event happened. I thought for sure we had it all fixed—and now this happens, and I find out we didn't do half the things we were supposed to do!"

"We finish a root cause analysis and have another eight corrective actions that we promised to do. Then we have the improvement teams, the responses to the state and The Joint Commission, as well as all the things the board wants. I bet we have at least 100 performance improvement/patient safety projects that we have started—I have no idea how many we have finished."

If you are like most organizations, a key weak point in your performance improvement/patient safety loop may be getting things done. Perhaps you are becoming confident at doing your problem analysis and designing good improvements based on best practices. But the real test is whether all that effort actually makes changes in the way your processes work, and those changes ultimately change your outcomes, satisfaction, or efficiency. If the project doesn't get done, there is no partial credit, but more importantly, there is no improvement.

So what are the typical things that stand in the way of getting our improvements done? Let's look at a couple of classical failure modes:

We didn't really get full buy-in from our leadership, so it has been an ongoing battle to get resources and funding. Perhaps we get the nods and "nice job," but there is always something standing in the way of the capital or the approval to expend the time.
Although the proposed improvement looked like a great idea to the team, we failed to get buy-in from the impacted departments or functions that would have to make some changes to make the improvement work.
Maybe everyone is on board, and we really got the CFO to approve the funds, but it still slides along because no one person is in charge of the project.
We have a strong project leader or manager, but the number of activities that need to be coordinated is getting beyond his or her grasp and things are falling through the cracks. What was at first a "darling" project is now a can of worms and about to be canceled.

If you have been involved in quality projects for any length of time, I am sure you have seen all of these scenarios and probably many more. Typically, we can divide the reasons that our projects don't get done into two major reasons.

First, sometimes we don't clearly sell the benefits to all stakeholders involved. We often think of our jobs in quality/performance improvement and patient safety as analytical or technical jobs—we look at problems and then design solutions. Often, we need to add a sales hat to all the others that we wear. Although we think the benefits are self-evident, don't count on it. If we don't sell the benefits, leadership attention and resources will go elsewhere.

Key point: Your leadership buys in to the benefits, not the description of the features, of your improvement. If you can't clearly explain and sell the benefits, it is less likely you will get the support you need. Think benefits—always!

Second, we often forget that each of these improvements is really a project. We need to take full advantage of our project management skills. We need to assign a project manager, set a schedule and due date, assign resources, and track actions that build up to completion of the project.

Key point: Activities that are not on the master list—all in one place, with an owner, due date, and approved resources—don't get done. Keep a master list of all performance improvement projects, and track their status regularly with your committees, department leadership, and senior leadership team. Out of sight is out of mind, which means the project won't get done. Don't rely on meeting minutes. Make a list!

In future articles, we will look at some simple ways to get your improvements done. If we can be of any assistance in helping you plan for or 'get your improvements done' please give us a call and we would be pleased to chat.

Ken Rohde 7-16-09

Adding Effective Change Management to your Quality & Patient Safety Toolbox

Fri, 12 Jun 2009 12:31:00 GMT

"We thought the move of the pediatric service to the new location was going to be great—unfortunately, we didn't consider all the aspects and we were overcome with unintended consequences."

The old adage "Out of the frying pan and into the fire" is really discussing change management and our ability to make changes and only experience the good rather than the bad, unintended consequences. We can't leave this to chance if we want our changes in process, equipment, location, methods, etc., to go well. If we do not effectively make changes, there is the possibility of a large impact on patient safety and quality.

The science of making sure a change goes well is called change management, not to be confused with managing change, which is usually used to describe the methods of getting people to emotionally accept and support change. When we use the term "change management," we are talking about a structured approach to make sure that all possible implications are considered when we make a change.

As with cause analysis, change analysis needs to use a graded approach. Some changes need to be very carefully managed—such as moving an ICU to a new location with a full patient population. Other changes can be done within the normal business methods. It all depends on the risk and complexity of the change. Highly complex changes with a high potential risk need to be carefully managed.

Following are some key parts of change management:

Step 1: Make sure you know about changes. Set up a formal process to make sure major changes do not get made without the ability to manage them. People have to tell you about change.

Step 2: Determine what level of change management you need to apply. Evaluate the risk and complexity of the change.

Step 3: Use the appropriate Change Management Tools. Some typical change management tools might include:

High-risk/high-complexity changes:

FMEA of new process, equipment, service, etc.
Checklist of key potential effects
Management risk review meetings

Low-risk/high-complexity changes:

FMEA
Checklist of potential impacts

High-risk/low-complexity changes:

Checklist of potential effects
Management risk review meetings

Low-risk/low-complexity changes:

Normal business practices

Step 4: Plan for and manage off ramps. Make sure you know how you will respond if you find that there is a major problem halfway through a change. Some changes are irreversible; make sure you know what you will do.

Don't leave change management to chance! If we can be of assistance to you in developing a realistic and workable change management process for your facility, please contact us at 888/749-3054 ext. 3506 or email mnicosia@greeley.com.

Ken Rohde 6-10-09

Become best friends with your CFO to improve quality & patient safety

Thu, 14 May 2009 12:30:00 GMT

Last month we talked about the first of the three key areas that are vital to consider adding to your plan for improving quality and patient safety. These three areas are:

Rapidly get your process management activities under way and under control
Become best friends with your chief financial officer (CFO)
Make safety, quality, and performance improvement a profit stream by reducing COPQ

This month we will look at the vital importance of building a strong relationship with your CFO as part of your quality and patient safety plan and how you can get their attention by reducing COPQ.

You probably see your CFO when you attend executive meetings or when you have to defend your budget, but do you really consider the CFO as a key part of the patient safety and quality team? If you don't, you may be missing a key player who can really help you move your patient safety and quality program forward.

If you want to make the CFO a full member of your patient safety and quality team, you need to focus on speaking the language of the CFO and understanding how to benefit them.

Speaking the language of the CFO

The CFO is responsible for managing the financial aspects of the organization and typically does not come from a clinical background. It is unlikely that they are going to become "clinical", so we need to become "financial". To do this, we need to be able to speak at least a few phrases of "finance". You don't have to be a financial wizard—that's their job—you just need to be able to get their attention.

Make sure you understand the following key financial concepts and can talk about the impact of the quality and patient safety plan on them.

The difference between sales and profit. These often get confused. If our organization performs a complex orthopedic surgery and is paid $50,000, we can consider that a sale of $50,000. But the organization does not get to keep all that. It goes to pay for staffing, supplies, electricity, repayment on loans, and contribution to charity care etc. Many healthcare organizations consider themselves fortunate if they get to keep 2% of that as profit (or reinvestment, if you are a nonprofit). This means that there is only about $1,000 left after that surgery. If you don't know the exact ratio of profit for your organization, you won't be far off if you think -5% to +5%.

Cost of poor quality. If we did everything right, we didn't have any rework, we never wasted any surgical packs or food, we never had any claims or lawsuits or no-pay events, then we get to keep the profit for our stakeholders or reinvest it in new services, equipment, and staff members—and we make the CFO very happy. But if we make quality or patient safety mistakes, we are using up money the CFO had already planned to use to pay a supplier or to make a payment to the bank or to send us in our paychecks! The CFO now ends up with new unplanned expenses and has to scramble to find the money to deal with our quality and patient safety mistakes. All those avoidable costs are our cost of poor quality, sometimes called COPQ. This is your link directly with the CFO—we both can speak this language. We need to prevent COPQ, and the CFO needs to deal with any COPQ that we can't prevent.

Let's go back to that $50,000 surgery that generated $1,000 of profit. Did you imagine that your present COPQ could waste $1,000? Were there unused surgical packs that were opened? Did the surgery take an extra 20 minutes causing you to cancel another patient? Was there a postsurgical infection? Was an object retained after surgery, creating a potential legal claim? If you are not absolutely on the ball, you can easily eat up all the profit and more with just a few quality or patient safety issues. And you wonder why CFOs are always frazzled!

Consider a $30,000 no-pay event. That's all COPQ. If we do not get reimbursed for $30,000 that we spent on a patient, that eats up all the profit for $1,500,000 of other surgeries. If each surgery costs about $45,000, that means that the one no-pay event used up all the profit from the next 33 cases. From the CFO's perspective, that's a pretty good reason to avoid ever having a no-pay event.

Thinking of COPQ reduction as a profit stream. Now the good part. Did you know that quality and performance improvement can turn a profit? Of course, we have that in the back of our mind, but let's look at how powerful that can be.

For example, if we implement a quality improvement activity that saves $100,000 in COPQ, that's the same as if we just saved the organization $100,000 in profit. If we are making a 2% profit, that savings is equivalent to $5,000,000 of new surgeries! Think of the effort it would take to get those patients and then do all the surgeries.

Make sure you are thinking about the leverage of your quality improvement activities and the COPQ that they reduce. Convert that into "new sales it would have taken to benefit the organization as much as we did with our quality improvement activity." If you show some interest in thinking this way, you will warm your CFO's heart.

Return on investment (ROI). But there is no free lunch. If you want to do quality improvement activities, you need the staff resources and equipment to do them. The CFO is really looking for an ROI. If the CFO gives you the budget to pay for two additional quality people, the CFO wants to know how much COPQ reduction you will give them back. If that ROI is better than putting the money in the bank or in a different project, your quality plan looks like a good investment—probably a much better investment than Wall Street.

Make sure you talk with your CFO about the value of the COPQ reductions you can contribute to the organization. If you don't, they only see the cost side of the investment—and to a financial person, that's not very attractive.

Don't worry about being a financial wizard, but especially in today's economy, you need to make sure you are working closely with your CFO—and that means thinking (and talking) in a way that connects with them.

Ken Rohde 5/14/09

Rapidly get your process management activities underway and under control

Tue, 21 Apr 2009 12:30:00 GMT

Last month, we talked about three key areas to consider adding to your plan for improving quality and patient safety. These areas included:

Rapidly get your process management activities underway and under control
Become best friends with your CFO
Make safety, quality and performance improvement a profit stream through reducing COPQ.

So, how can we rapidly get our process management activities underway and under control? Virtually all our facilities have a quality and/or performance improvement function, and we are all doing improvement projects to improve outcomes and meet specific measures that have been proposed (or mandated) by the outside world. The real question is, "Do we have a well-structured approach to process management?" Remember, that's management – not just improvement. A key test I like to use is summed up in the question, "Do you manage your processes as robustly as you manage your people?" We have a complete and comprehensive list of all employees that includes their performance and details of what they do, as well as a clear understanding about how they fit into the overall success of the organization. Can you say the same for your processes? Often, we can't even list them, let alone know how well they are performing. If you want to implement a comprehensive process management approach, you may be interested in the Greeley 7-Step process management framework. This framework includes the following steps:

Understand and map your process. If we don't know all our processes by name and don't have them documented, we will have a hard time managing them. (Process mapping)
Evaluate and manage the process risks. It doesn't make sense to try and improve the efficiency of a process that is inherently flawed and unsafe, so our next step is to evaluate the process for safety and risk. (FMEA, HAZWOP, probabilistic risk assessment, etc.)
Evaluate and manage the process efficiency. If the process has acceptable risks, then we move on to improve the efficiency and cost-effectiveness of the process. (Lean, 6 Sigma, visual process analysis, value analysis, etc.)
Perform formal change management. One of the riskiest places in the process management cycle is when we decide to change a process. It is essential that a formal change management process is used to ensure that we do not introduce unintended consequences. (Change management checklist, management risk assessment reviews, off ramps, FMEA, etc.)
Develop safe and effective policies and procedures. Once the redesigned process is approved, it is essential that the interfaces with the end user are clearly and safely defined. Typically, this is done through our policies, procedures and job aides. If we do not do this step well, we can negate all the good efforts to change our process, because the new process is not performed correctly and reliably. (Policy and procedure content review, policy and procedure writing guidelines, etc.)
Integrate your process with the workplace. The process and the physical workplace need to work well together. A comprehensive process management approach will help ensure that they do. (Visual Factory, 5S, etc.)
Manage process exceptions and breakdowns. Process management is an ongoing task. Just as we monitor the performance of our employees on a daily basis, we need to monitor our processes on a continuous basis. This allows us to identify breakdowns or trends that need to be addressed and collect the information that is needed to support all the other steps. (Problem identification and resolution, reporting, screening, cause analysis, etc.)

If you want to make significant improvements in your organization's safety and performance, make sure that your process management approach addresses these key areas in an integrated fashion. We work on a daily basis with our healthcare clients to assist them in improving their process management approaches. Please feel free to contact us if you are interested in the Greeley 7-Step approach.

Next month we will look at how we can better integrate our quality and safety activities with the CFO.

Ken Rohde 4-20-09

A Plan for Safety, Quality, and Performance Improvement in a Declining Economy

Thu, 12 Mar 2009 12:30:00 GMT

The financial news just keeps bearing down on us. Fortunately, healthcare is not getting buffeted as violently as the banks and car makers—at least not yet. So what do we, in the safety, quality, and risk areas, need to be doing to prepare ourselves and our organizations for a long, tough road ahead?

I suggest that we all need to step back and make sure that the quality, safety, and performance improvement activities are really the right ones for a tightening economy. If we are doing the wrong things, the economic pressure will pile up on us and our organizations—and, ultimately, some won't survive. We need a simple plan.

The following are key areas we need to be thinking about in a declining economy:

Rapidly get your process management activities under way and under control. We have been so focused on outcomes that the understanding and management of what "goes on under the hood" has fallen behind. The pressure is going to turn up on all of us to know our processes inside out and be able to make them hum like a good race car mechanic.
1. Make your list of processes now!
2. Do a quick assessment of which processes have the largest impact on the organization
3. Focus
4. Don't reinvent the wheel; get rid of "not invented here" and beg or borrow the best practices you can find and implement the most useful parts
Become best friends with your CFO. The decisions over the next five years will be driven by keeping organizations alive and providing the best possible care. If we in the quality, safety, and performance improvement world can't talk the language of the CFO, we will not be helping them succeed, and they will not be helping us in our areas. The CFO may not be your daily contact, but we need to be talking to them and their staff as frequently as we are talking to the folks on the floor. This will take some cultural realignment in some organizations — but you have to do it. Do you invite the financial analysts to your committee or PI meetings?
Make safety, quality, and performance improvement a profit stream through reducing cost of poor quality (COPQ). Always remember that there are two key profit streams in the organization:
1. One is generated by patients coming in the door. We get to keep a part of the amount we charge for their care as profit, either for the stakeholders or to reinvest in the organization. The more profitable patients coming for care the better off we are. That's why we advertise and market—to get patients to come to our facility.
2. The second stream is generated by reduction in our Cost Of Poor Quality (COPQ). COPQ is all the money and resources we spend that we really don't have to (waste). All those no-pay events, all those unused surgical packs, all those increased length of stay events, all the extra time we spend after a fall or medication event, even if no one was hurt. They are all COPQ. This is our world! Every dollar we can help the organization save is direct profit saved. If you reduce COPQ by $100,000 and your organization generally makes a 2% profit, your savings is the same as increasing the sales of patient care services by $5,000,000! Make sure you can demonstrate your profit contribution!

Next month we will continue with the next parts of the plan and some thoughts on how to start putting this plan into action at your facilities.

Ken Rohde

Using ’Big-Deal Events’ to Help Us Learn

Thu, 12 Feb 2009 12:30:00 GMT

Moving your organization from simply reacting to errors to proactively preventing errors is a key part of building a strong culture of safety. To prevent problems, we need to know about them and be able to openly discuss and learn from them. In healthcare, we are sometimes reluctant to make a big deal about events because we don't want to scare our patients or perhaps open the organization up to questions—this makes it difficult to be a learning organization. This is unfortunate because people learn from big-deal events because they reach us at our emotional core.

The water landing last month of US Airways Flight 1549, provides a great opportunity to use a big-deal event from another industry as a safety moment to discuss and learn within our own facilities. Have you taken advantage of Flight 1549 to open conversations within your senior leadership or department meetings? Don't miss this opportunity.

Think how powerful it could be to have your CEO compare Flight 1549 to your organization and use it to ask questions that can advance learning.

The following are some of the key learning points I took away, which might make great safety moments or discussion starters within your leadership and department meetings:

The vital importance of training: It certainly looks like the crew did just what we would have wanted if we were passengers on that flight. They all had the right competencies, were up to date in their skills, and did not hesitate to spring into action.
- Discussion point: When we think about our competencies, whether clinical or nonclinical, do we look at them as vitally important things that may save a life, or just a check-off box? Are there things that would keep us from springing into action?
The rapid response of the community. Within minutes, the ferries on the river had gone from their normal activities into rescue mode. The news media asked one of the ferry crew members, "What were you thinking about?" The individual responded, "We train for this all the time. I wasn't really thinking, we just did what we had practiced."
- Discussion point: Comparing the response of the river community to our facility emergency preparedness plan, have members of our community drilled with our organization enough so they could respond as quickly and effectively?
Clear division of labor in an emergency. The crew had only about three minutes to perform actions in a difficult and highly emotionally charged situation. The cockpit and cabin crews appear to have performed admirably—they all knew what to do and how to do it.
- Discussion point: What can we learn from this about the ways we manage our CODE responses or our rapid response teams?
Importance of learning from near misses. Although no one was killed, this was a real big-deal crash. Yes, there were a lot of well-trained people and right behaviors, but there was also some good luck as well. Does the fact that no one was killed make it any less important to the airlines or the National Transportation Safety Board or even to us—the flying public? It shouldn't.
- Discussion point: Do we honor near misses? When we have events where we are fortunate to have good luck, do we treat them as though we didn't have good luck? Even if the worst doesn't happen, we should learn from events as though the worst did happen. What is a recent example in our facility in which something could have gone very wrong but didn't because of luck? Did we analyze that event based on the worst case? Why not?

Talking about big-deal events is a great way to open up conversations that get to the shared values and beliefs that make up our culture of safety. It is a good habit to spend a couple of minutes at the beginning of your leadership or staff meetings on a safety moment. Maybe using Flight 1549 can help build that habit.

Ken Rohde
Consultant
The Greeley Company

Costs of Poor Quality

Thu, 15 Jan 2009 13:48:00 GMT

I was just going through some of the research I did a few years ago on the costs of poor quality and came across the following information, which is still true today.

In the 2002 BMJ medical publication of the year [BMJ 2002;324:1478 (June 22)] there is an article on the conclusions of a study led by the Juran Institute, which found that "$39 billion a year is being wasted on outmoded and inefficient procedures in the United States." The article also stated that "30% of all direct healthcare spending was the result of poor quality care including overuse, misuse and waste."

The main cause of waste was cited as unnecessary administrative activity. According to the article, authors of the study said "A number of experts believe that the potential to reduce cost by eliminating inefficiency is enormous."

In the article, CMS was quoted as saying that "US spending on healthcare will likely exceed $1 trillion by 2011, equivalent to over 6% of projected gross domestic product."

"A number of experts believe that the potential to reduce cost by eliminating inefficiency is enormous."

How can we begin to chip away at this inefficiency? Look at your clinical processes and:

Gather data on errors
Look for common causes
Map processes
Eliminate waste
Determine if the right person is doing the right thing at the right time
- Competencies (do we have the right staff?)
- Staff allocation (multidisciplinary integration at the bedside)

At Greeley, we call this Process-Driven Integrated Care (PDIC).

For more information on Process-Driven Integrated Care and reducing the costs of poor quality, contact Sharon Courage.