Not Going to Vegas: What Healthcare Can Learn from US Air

I had an 11:20am flight to Las Vegas on Monday to attend the American Society of Health Systems Pharmacists (ASHP) Midyear conference. During the three hours that we sat on the plane, the airline had to fix three different technical failures. After the third failure, the pilot came on the loudspeaker and told us that “this plane does not want to go to Las Vegas”.

He had us get off the plane and head to another plane at an alternate gate, only to call us back to the same plane (they fixed the final problem – an oil leak).

I didn’t get back on the plane. I didn’t go to Vegas.

The plane got to Vegas. But, I just couldn’t take the chance. It was just too risky for me. I was uncomfortable.

Since I’m well educated on the processes and system checks and balances that airlines go through, I was thankful that they uncovered the problems with the plane, but I was equally as thankful that I got to make the choice NOT to get back on the plane.

It made me think of personalized healthcare. I would really like to be able to make my own educated decisions when it comes to my care. I’d like to know what hospitals are investing in assessments to uncover patient care risk that their processes may cause, perpetuate or prevent. I’d like to have access to quality information from the organizations that I choose to put my life in the hands of. But, as it stands, I don’t get that information from most places.

I know what questions to ask because I work in the industry. But, most people have no idea if the hospital they are going to have a C-section in has no hand hygiene program. Or if the place they choose to bring their children almost gave a toddler the wrong medication two weeks ago.

So, this is not a blog that will slam the airline for having technical failures. This is actually a blog that will commend the airline for being transparent with me, so that I can make my own decisions. I was refunded and they got me my luggage back to boot. Thank you US Air.

I believe in my work.

Claire

Oct-Nov Activities

I am a bad blogger these days. I bought a book about blogging and it said to update the blog three times a week. I think its been over a month since my last blog post. So, according to the blog book (and probably any social media marketer), I am a bad blogger.

Seriously though, I don’t have time to blog three times a week, so I do what I can.

This is what I did over the last 2 months:

1.) AmerisourceBergen (my employer) was an ambassador sponsor of the Lucean Leape Institute Gala. It was amazing to be part of this event and to be a council member for National Patient Safety Foundation. They are amazing organizations.

Here is a picture of me (far right), Diane Pinakiewicz, President of NPSF and Lucian Leape Institute, David Coletta, V.P., NPSF and Lucian Leape, MD,Chair, Lucian Leape Institute and Adjunct Professor of Health Policy, Harvard School of Public Health.



The event was incredible. I feel honored to have been there. I should have blogged about that. But @SusanCarr, editor of Patient Safety & Quality Healthcare Magazine was there, so I leave the journalistic coverage to the experts.

2). I helped manage a photo shoot for some our pharmacy technology. This was super fun.

3.) Lots of time in Washington, DC talking with health reform experts to help understand the different challenges and opportunities that our hospital customers will experience with some of the proposed legislation.

4.) Attended the e-Patient Connection conference (#epatcon). Since I have a twitter account and work in the healthcare space, I thought it would be valuable to understand the conversations that are taking place around communications and patient care. Plus I got to see @ePatientDave again, so that was great.

5.) Preparing for American Society for Health Systems Pharmacists (ASHP). We are sponsoring the ISMP ADC Symposia and the ISMP Cheers Awards. Plus AmerisourceBergen has a huge tradeshow booth presence.

That’s it…. just keep plugging along - trying to get AmerisourceBergen’s patient safety message out there (in person this month – not on social media) so, sorry if I’ve neglected my blogger responsibilities.

I’ll try to do better this month.

I believe in my work.

Claire

Top 25 Patient Safety Tweople

Barbara Olsen, aka @SafetyNurse listed her "top 25 tweeps for patient safety" and I feel honored to be included with such an honorable group of patient safety leaders. Since I am not a clinician, I often don't "get" what my counterparts mean when they use scientific lingo. I often feel intimidated because I don't speak the language of medicine.

Being included in this group, I feel validated - it proves that those of us who don't practice medicine still have a voice in patient safety issues.

Thank you @SafetyNurse for recognizing the importance of multiple perspectives. Hopefully, the information I find and share continues to be valuable to you and my fellow tweople!

I believe in my work.
Claire

I Am Not an Octopus

On Saturday, I was invited to my friend Eileen’s house for dinner. Since my husband would be out for a friend's bachelor party, and Eileen’s children similar ages to my own (1 and 3), I decided to venture out for the evening.

It was organized to be a small get together among friends; just one more couple was to join us. Upon my arrival, the house was quiet, the food was being prepared and the children playing nicely in the toy room. Ahh…what a nice Saturday evening it was turning out to be.

Just as I began to relax, the doorbell rang and like a tsunami, neighbors, family and more friends flooded into the house.

“What is going on?” I asked Eileen. “Where are all these people coming from?”

Eileen told me how a few small phone calls turned the evening into a full-blown house party and not to worry, she was used to this, everything will be fine.

I thought to myself, “I am not prepared for this.”

To my shock, Eileen began pulling extra food from the freezer, wine glasses from the shelves, and juice cups for the six more children that now played in the toy room. She and her husband communicated like a well oiled machine, preparing the food and actually being able to talk to their guests while keeping an eye on their children.

I, on the other hand, was a complete mess; chasing my 15-month-old around the house, petrified that she would knock someone’s wine over or escape out of the house as people meandered in and out.

At one point my 3 year old was begging me to push her on the swings while my 15-month-old was wiggling out of my grip as I tried to change her diaper.

Sweating and completely exhausted, I looked at my children and said, “I AM NOT AN OCTOPUS!”

Like any sane mother would, I packed up and left the party. I was simply unprepared for the evening and called it a night.

After I put the girls to bed, I sat with my coffee on the couch and thought about how smooth a transition it was for Eileen to go from a house of 4 people to a house filled with 20. I was flabbergasted at her ability to transition, her ability to pull from the cabinets what she needed, how she communicated with her husband, all while keeping her children safe and happy. What did she have, that I didn’t have?

My conclusion? Eight Arms...

Is this what its like for clinicians in emergency rooms, and hospital units when they get an unexpected increase in patients? What must occur for hospitals to be prepared and what are the criteria for success? What supplies? What are their means of communication? What is the process? Where, on earth, do you start?

Most would say, “start with the patient”. Anchor everything you do with the patient, and be prepared. Grow your arms: set up your supplies efficiently, automate when you can. It’s the system that supports the outcome.

Hospitals are clearly more complex than a home, but both function for the same purposes; a place to keep us safe, to foster health, and to support the varied challenges of the day. It’s the people that make a place a home. It’s the patients that make a hospital a hospital.

Patient centered care is a powerful model - a model that the industry is pushing for especially in this time of healthcare reform.

The patients, the clinicians, the automation, can not be successful if they function in silos. They all must be connected to something…an anchor…like an octopus. Shouldn’t that anchor be a patient?

I believe in my work.

Claire

With Sadness

It is with tremendous sadness that Mike Guckenberger, V.P. Pharmacy Healthcare Solutions, lost his battle with cancer yesterday and passed away. Mike was the consummate professional and was always committed to his customers and his AmerisourceBergen colleagues. He will be greatly missed.

ISMP ADC Self Assessment Tool

Through my organization’s relationship with the Institute for Safe Medication Practices (ISMP), we recently contributed to the development of their new Automated Dispensing Cabinet (ADC) Self-Assessment. The tool can be downloaded at www.ismp.org.

It’s important to look at the role of the ADC in the hospital’s medication distribution system. I encourage everyone to use the tool and assess the use of this technology in everyday workflow.

Great work ISMP!

Claire

Diagnosis: Unknown; My Own Patient Experience

Two weeks ago, while setting up a Webinar around some pharmacy solutions that my company implemented at a hospital on Long Island, NY, I started calling people by the wrong name. Whats worse, is that I had NO idea I was doing it until people started correcting me with looks of concern on their face.

My boss asked, "Are you okay?"

"Yes, yes, I'm fine," I say.

Later that afternoon I stood up at my desk and felt a surge of blood to my brain that left me dizzy and confused. Scared of what was happening to me, my heart started to pound and the world around me became fluid and unsteady. I sat back down and decided that once I felt better, I would call it a day and go home.

That evening, after I put my one-year-old to bed, I called my mother to continue a conversation that we had begun earlier that morning.

"Where did we leave off after I talked to you this morning?" I asked her.

"Claire, I don't know what you are talking about, we didn't speak today," she replied.

"Yes, we did mom," I said annoyed, "you told me that Grandpa lost the remote control to the television."

"No Claire, I'm quit certain that we did not have a conversation today," she continued, "Are you feeling okay?" She sounded concerned.

I began telling my mother all the other things that occurred that day and we chalked it up to stress. I took a hot shower and went to bed early hoping that a good night's sleep would cure my confusion.

The next morning, while in a meeting, the same dizziness and confusion started happening along with a dull headache, and I asked my boss to take me to the emergency room. After a myriad of tests, everything looked clear and I was told to go home and follow up with my primary care physician.

My PCP sent me for more blood tests and an MRI. When I returned home from my doctor visit, I was pummeled by a migraine. With my eyes closed and fighting back the nausea, I grabbed my cell phone and crawled to the couch. Since my husband was 3 hours away on business, I frantically called my mother to come sit with my children as I was clearly unable to take care of them.

Four hours later, the headache subsided and I emerged from the dark cave that was my bedroom.

My mother and husband were sitting on the couch and I said to them simply,
"Something is wrong with me."

The next morning my mental state had changed. I was having a hard time speaking - I had to concentrate on every word. I thought I was having a stroke.

Again, I was taken to the emergency room and this time was given a spinal tap because the physician was afraid that I may have had a brain aneurysm or some kind of bleeding in the brain.

While I waited for the procedure, I couldn't help but think about all the other scared patients in the hospital. Patients with cancer, or a heart attack, or respiratory issues, or patients like me who had no idea what was happening to them.

I wondered if the doctors realized how vulnerable we all were and how we count on them to take care of us and to keep us safe. I wondered if they realized how much our loved ones count on them too. Because they too become vulnerable and feel unable to help.

It was SO ironic that my thoughts were interrupted by a physician who began to argue with someone on her phone outside of my room.

"It CLEARLY STATED on the chart that she is ALLERGIC to that medication! How could you be so irresponsible! Now she is back in the emergency room!" she shouted.

After spending countless days at my job, reading, talking, and writing about medication errors, I was witnessing the aftermath of one right outside of my hospital room. "This is unbelievable", I thought to myself.

After the spinal tap showed a clear result, I was partially diagnosed with a complicated migraine. Apparently, these migraines show similar symptoms to stroke and/or aneurysm. I just needed to get my MRI to rule out any tumors.

The next day I received my MRI (it was clear) and my PCP called a neurologist who saw me a few days later. For the following week, I had two migraines a day. One in the morning and one in late afternoon. Some were tolerable, others unbearable.

And throughout all, I had to manage getting test results from two different hospitals, my PCP, the lab, and the MRI facility. Some organizations were wired with HIT, others not, and once I finally sat down with the neurologist, some report pages were missing from the fax machine and the neurologist had to take my word for it when I told him that all results seemed clear. Some reports had my name spelled wrong. Some even had my maiden name to add to the confusion.

In the end, I've been prescribed some preventative medications and some medications to take if I feel a migraine attack may be coming. It almost feels silly that after fear of a catastrophic condition, I'm left with a bunch of headaches (not to downplay migraines, they are indeed, debilitating). Through this experience, I feel like I've witnessed all the things that I study, analyze and write about. Medication errors, health information technology, the role of the primary care physician, the role of the pharmacist, and the most important role - the role of the patient.

I realized that I shouldn't and couldn't put my care in the hands of any ONE doctor, or nurse, or pharmacist. The person ultimately responsibility for my care was me. I am even more committed to the work that my organization does now that I've had this experience.

I'm excited to get back to business and to continue this important conversation. But, hopefully this time, I'll use the right words.

I believe in my work.

Claire

MJ and Healthcare Reform?

I’m just finishing up a presentation outlining the basics of healthcare reform and I feel like my head might explode.

Lesson? There is no such thing as healthcare reform basics.

On July 4th, I was at my parent’s house for a barbecue with my husband and two girls. When we sat down for dinner, my mother asked me how work was going and I told her that I was working on this healthcare reform presentation.

Naturally, this peaked curiosity for others at the table, including my mother’s childhood friend who is a nurse practitioner.

“Oh! And what have you learned, Claire?” she asks.

Why is it that even as a thirty-one-year-old professional with a career, a husband and two children, my parent’s friends can still make me feel like a sixteen-year-old who is doing a book report?

“Ummm…well, I learned that its…complicated?” I search for her approval.

“That’s right. Anything you would like to share?” she adds while passing the corn-on the-cob.

Just then, my inner sixteen-year-old decided to spew as much info at her that she couldn’t possibly make sense of it, or argue, or try and tell me that I don’t know what I’m talking about because I am an adult and I DESERVE TO BE TREATED LIKE I KNOW WHAT I’M DOING!

Phew! Sorry about that.

By the end of my rant, there were opinions being thrown out all over the place, from what it means to be American, to physician accountability, to responsible medicine, to owning surgery centers, to Canada, to medical errors, President Obama, the AHRQ and finally…

wait for it…

Michael Jackson.

Now, how the heck did we land on Michael Jackson?

I couldn’t tell you for the life of me. But, I share this story with you, because for a good 45 minutes, we all shared our opinions about the health of Americans, of human beings and the fact that we all have a stake in the humanity of others…like …Michael Jackson.

May he rest in peas (as my 3-year-old says).

To me, there was no better to way to celebrate our independence than to share in healthy debate with everyone and some good ole’ corn-on-the-cob.

I believe in my work.
Claire

Top 5 Inefficiencies We See in Hospitals - "Last 100 Feet"

You wouldn’t know it by looking at headlines that read “Nurse Incarcerated for Administering Wrong Dose Medication” or “Pharmacist on Trial for Manslaughter” but, 90% of medication errors are due to a failed system, not the proactive negligence of clinicians.

Let’s face it; you never read headlines like “System Failure at Madeup Hospital Causes Wrongful Death”. Why? Because the general public and mainstream media have no idea the nuances that make up a system within the units of a hospital. Most people have no idea that one hospital unit may be run completely different than a neighboring unit.

I only understand it because my job requires me to, and if I didn’t have hospitals for clients, I would have no idea what the system is referring to.

Since I am not a clinician, I will attempt to outline the top hospital inefficiencies that we see in the hospitals we work with in order to educate my hospital friends and the public:

1.) Medication Receipt– this is when an order is sent to pharmacy and is not received on time. In order to administer a medication at the right time, the nurse will re-order the medication. Most often, nursing ends up receiving two orders and now has to send one of them back causing pharmacy to process a credit for the double processed medication order. Some organizations have a full-time employee just to process medication credits.

2.) Documentation - on a typical assessment, we find that nursing spends up to an hour organizing and documenting patient data before her shift even begins. She then spends another hour documenting medications and administration data. This is taking her away from her time at the bedside taking care of the patient. More shockingly though, a lot of nurses have their own document. A "cheat sheet" if you will, which lacks standardization and consistency.

3.) Hunting - hunting down a medication or supply because it is either not in the patient’s drawer or has not been received from pharmacy is one of the biggest things we see. The nurse will go searching in her own unit or neighboring unit to find the supplies, thus leaving another patient or unit with a missing medications and/or supplies only to cause the hunting process all over again through the perpetuation of the missing meds and/or supplies.

4.) Extended Length of Stay – ever see a patient wake up in a hospital bed and be willing to chew through the walls to get out of there? Well, greater than needed length of stay is the fourth major inefficiency that we see all over the country. Greater length of stay means increased cost, risk of hospital infections and exposure to medication errors. One of the most efficient changes we have seen in addressing this is the implementation of multi-disciplinary rounds (but that’s a whole other story).

5.) Technology Readiness – It is absolutely necessary for the medication process to be standardized in order to optimize technology investment. The wasted time caused my nurses waiting for access to the automated dispensing cabinet (ADC) alone is good enough argument to address this process. In fact, in a survey conducted by ISMP, 48% of nurses state that “ADCs are not located in areas free from distraction”. This compilation of inefficiencies lends itself to a high risk process that needs serious redesign in our hospitals.

There is a common model in the industry that visually illustrates what happens in a major medical error. It’s called the “swiss cheese model”. It mainly illustrates that when multiple system inefficiencies line up properly, this is when a medication error occurs.

Think of the system as multiple processes that seem so simple (like having the right supply in the drawer, or getting the medication on time) and when multiple inefficiencies happen together, someone gets hurt.

I think its important to understand this in simple terms, especially for those of us who are not practicing clinicians and don't work within the four walls of a hospital. However, I am constantly surprised by how many hospitals we go into who have no clue the kind of system variation that goes on between and within the various units.

We must educate ourselves and our hospital partners so that we, as a teammates (doctors, nurses, pharmacy, patients, cleaning crew, c-suite executives, professional services consultants), can look at this system and never have to read "System Failure in Your Hospital Causes Wrongful Death".

I believe in my work.

Claire

I Do It Myself!

My three-year-old is the funniest little girl on the planet. She keeps me on my feet and cracks me up all the time. Although she has her tantrums, her giggles are much more effective in getting my attention – and she knows it. Its because of this that she has learned the art of comedic timing. After a job well done, we do a high five, a finger touch and a fist bump. She is awesome.

I think we all learn how to get what we want very early in our lives. While one approach may work for one, it may not work for another. And I always say, “know your audience”.

I wonder how many healthcare providers know their audience. Some will say that it is different everyday. So, how do we make sure that everyone in healthcare, while wanting to please many stakeholders, remembers that it’s a team approach?

I’ve been to many collaborative conferences, and summits, and advisory boards, etc. And I’ve seen first-hand how many hospitals pull waste and unnecessary cost out of their processes with the help of outside partners. It can be done. But it takes guts to look at yourself and accept that you may need some help. My three-year-old demands, “I DO IT MYSELF”! Sometimes she does do it herself. But, sometimes she simply can’t, and I’ll step in to help.

We all want to think we can do it ourselves. But in the wise words of Dr. Seuss,

“I’m afraid that some times
you’ll play lonely games too.
Games you can’t win
’cause you’ll play against you.”

Sometimes it’s hard to see what we need. Sometimes we need someone to step in and help. I’m going to take my own advice and “know my audience”.

Audience – I say to you – have fresh eyes look at your organization. It’s never a bad idea to partner with a vendor that has your best interest in mind. Teamwork is much more effective than playing the game alone.

Besides, giving yourself a high five, a finger touch, a fist bump is just…well…weird.

I believe in my work.

Claire

NPSF Perspectives

I’ll admit I was a little nervous about the National Patient Safety Foundation meeting and the live twitter. The entire social media – twitter/blog thing is very new to me and I’m still learning. It’s a strange world, cyberspace, and I’m feeling a little vulnerable. After all, these are my thoughts and my experiences and I can and will only speak for myself.

So, here is my impression of the NPSF conference. I think it went well. I think that having an industry organization that is dedicated to “subject matter” rather than to a particular clinical role is special. It invites people from every role in a caregiver setting to work in partnership around one thing – keeping patients safe. With that said, I believe that some of the most important points from the conference are as follows:

1.) The Role of Technology – Since the advent of the Stimulus Package, there has been much buzz around the importance of HIT and its impact on patient safety and hospital efficiency. There is no arguing the power of technology and the need for hospitals to enter the 21st century and get moving on IT adoption. However, if the implementation of large IT investments are not managed properly and thoughtfully (with the buy-in from all clinical areas) this could actually increase the amount of medical errors. The Joint Commission issued a Sentinel Event Alert (link) on the dangers of poorly designed or implemented healthcare information technology.

2.) Physician Collaboration – My colleagues and I attended an NPSF luncheon that included Lucian Leape Institute members David M. Lawrence, MD, CEO (retired), Kaiser Foundation Health Plan and Kaiser Foundation Hospitals, and Paul O'Neill, former Chairman and CEO, Alcoa, 72nd Secretary of the US Treasury, and Founding Co-Chair, Pittsburgh Regional Healthcare Initiative. It was an open forum to ask questions about anything. And one of the questions was around physician participation while executing quality initiatives and the “attitude barrier”. I was interested to hear the panelists explain the role of physician training and how physicians are trained to take ownership of the care and do anything to retain it. Even if it means kicking quality improvement teams out of the operating room.

Following the luncheon, I had a great conversation with Donna Woods, EdM, PhD who is currently Research Assistant Professor at the Institute for Healthcare Studies in the Feinberg School of Medicine at Northwestern University. She was telling me that one of her research projects revealed that only 10% of medical schools offer even one text book that is dedicated to patient safety. Only 10%. - in the entire country (eyebrows up everyone).

3.) Looking at the Process – I’ll be honest, this is my favorite. Of course I am biased, but I still think this is not well understood and I’m psyched to hear any attention given to process improvement. Anywhooo, I sent a live twitter during our Thursday morning presentation and all it said was, “standardize, standardize, standardize” and a colleague back at our headquarters text messaged me, “standardize what?” (I told you I was new at this). What I meant was standardize your processes. Look at how nurses are using the automated dispensing cabinets (or not using them), find out the barriers to proper use and waiting times, find a better way, and standardize it. Even if it means figuring out a better place to put the automated dispensing cabinet. Addressing processes is the step before large HIT investments. Want barcodes? Get your process standardized to use them properly. Want less nurse interruptions? Improve your process and standardize them. Want the budget to execute process improvement project? See number 4.

4.) Role of Executive Leadership – I ran into Dr. John Combes, M.D. President and Chief Operating Officer for the Center for Healthcare Governance while I was running up the escalator. I’ve only had a few conversations with him and attended a presentation that he gave at the American College of Healthcare Executives around the role of executive leadership and hospital boards. His main message – executive leadership and hospital board members must play a significant role in patient safety and quality initiatives. They must invest in system improvements and they must involve patients in the process. I heard these same messages echoed at this years NPSF conference.


Our individual presentation Creating Rapid & Innovative Improvements Outside of the Capital Budget went really well.

Michelle Mandrack from the Institute for Safe Medication Practices gave a really great presentation around the impact of medication distribution on nursing workflow in “the last 100 feet”. Kathy Rapala from Aurora Health Care talked about the “One Aurora” model and how it drives high reliability. Mary C-D from Aurora talked about a particular process improvement project that looked at setting up the workflow to better support barcode readiness.

They all did an incredible job.

I would love for anyone else who attended this year to comment on other messages they feel resonated this year. I’d also love any feedback you have on the live twitter – things that worked and made sense, things I can do better. I’ll be sending out live twitter feeds at other presentation throughout the rest of the year and obviously want to make these worth while to my twitter followers. So, please, let me know what I can do better.

I want to give a quick thank you to Kathy Rapala, Director of Clinical Risk Management, Aurora Health Care, Mary Cieslak-Ducheck (aka Mary C-D), Director System Nursing Integration, Aurora Health Care and Michelle Mandrack, Director Consulting Services, Institute for Safe Medication Practices. Your passion and dedication to your work is inspiring. I know I can speak for everyone at AmerisourceBergen and say that it is a pleasure to work with you and your organizations. We look forward to future collaborations.

I believe in my work.

Claire

Creating Rapid and Innovative Improvements Outside of the Capital Budget

We are off to the National Patient Safety Foundation meeting tomorrow! My colleague, Susan Stinson will be presenting with Aurora Health Care and ISMP on Thursday morning at 10am. The session title is Creating Rapid and Innovative Improvements Outside of the Capital Budget. For anyone interested in signing up last minute, bellow is a little bit about the presentation:

Identifying the impact of the medication distribution systems in the last 100 feet to the patient bedside can be daunting. Hospitals are being asked to make changes in their processes to help drive results and trying to implement improvements at low or no cost is crucial, particularly in these economic times.

Representatives from Aurora Health Care of Wisconsin, the Institute of Safe Medication Practices (ISMP) and AmerisourceBergen are presenting at the National Patient Safety Foundation’s 2009 Patient Safety Congress on May 21^st on “Creating Rapid & Innovative Improvements Outside of the Capital Budget.” The focus will be on making those process improvements in order to optimize technology investments especially in the “last 100 feet” when medications are administered and documented.

A representative from the Institute for Safe Medication Practices (ISMP) will discuss how the most harmful medication errors occur mainly in the administration of the drug – after dispensing. ISMP is a leader in educating the healthcare community in safe medication processes.

Hope to see you there! If not, I will be twittering live at the event to share the key learnings with my tweeple!

Claire

You Wreck Me

I jam out on my way to work in the morning. It wakes me up and gets my feet tapping for the day. Today’s jam out song was “You Wreck Me” by Tom Petty. My husband has seen Petty in concert a few times and he tells me about people flying out of their seats and dancing in aisles as soon as they hear the first few chords. I don’t blame them. I have to all but tie my hands to the steering wheel to keep from playing air guitar as I drive.

After I hit rewind and listened to it a few hundred times, I came up with the bright idea that this should be the Obama administrations theme song. I mean, its perfect…the world is saying:

Rescue me should I go down
If I stay too long in trouble town

If the healthcare industry had an address, I think it wouldn’t be too far from trouble town. There is always hope of moving into a better place, but one can’t just decide they don’t like where they are and move on to greener pastures. We must have a clear idea of where we want to be, how much it costs and if it fits the budget, and if we can all live peacefully there. And then there is the sifting through the junk, throwing out the things that are outdated and useless and finally packing up what works and carrying it with you.

I commend the administration’s effort to get moving on health reform. Trisha Torrey wrote a great piece on understanding healthcare reform. Read more about that at http://patients.about.com/od/patientempowermentissues/a/hcreform-hub.htm.

I can picture the President in his “corduroy pants” with the First Lady saying,

Now and again I get the feeling
Well if I don’t win, I’m gonna break even
Rescue me, should I go wrong
If I dig too deep, if I stay too long

I’d like to take this opportunity and thank the President for his effort and motivation. I’m hoping it doesn’t wreck him because it moves us. It moves us all onto our feet and gets our toes tapping and ready to roll up our sleeves and get to work.

I believe in my work.

Claire

Tunnel Vision

One of my favorite television shows is Sunday Morning on CBS. Yesterday, they did a story about text messaging and related this societal obsession to the Laputians in “Gullivers Travels”, the classic novel by Jonathan Swift. According to Gulliver, the Laputians are

“always in such deep thought that they have to employ special servants to alert them when there is something worth seeing or hearing or when a response is needed”- http://tiny.cc/PoI9s

I thought about my own “deep thoughts” around medication process and realized that I too can get tunnel vision sometimes. There are so many other ways that organizations can address medication safety. Things like driving greater consistency in medication decisions for one.

Aligning the drug formulary and medication policies with industry best practices can standardize products and processes that result in safer, more cost-effective care. Also, you can provide ways for medications to be monitored and managed with greater accuracy.

Most importantly, we can all step out of our heads for a minute and look at the environment around us. The Lean Blog posted some great thoughts around this subject last week http://www.leanblog.org/2009/05/you-learn-lot-just-by-watching-then.html.

Maybe we shouldn’t think too “laputiously” about this – it is after all, simple observations that can bring significant ideas. Hopefully, we all won’t need special servants to remind us to pay attention to our environment. Say, like “Microsoft outlook meeting reminder”.

OOPS!!! Gotta go!

I believe in my work.

Claire

What We Have Here is Failure to Communicate

My father-in-law is currently suffering from frontal lobe dementia – characterized under the Alzheimer’s umbrella of memory disorders. It’s a horrible disease that has robbed him of so many things. One of those things is the ability to communicate. In fact, since I’ve known my husband, I have never been able to have a conversation with his father. It’s strange to be physically around someone and not be able to develop a relationship with them. He was recently noted as being in stage 7 of this disease (the last stage) and is currently under hospice care - care that he could have qualified for long ago if the healthcare system was set up better for caregivers and families to communicate.

My father-in-law has a disease that robbed him of his ability to SPEAK. Can you imagine? But, because of the breakdown in communication among caregivers, he didn’t get the respectful care that he deserves. And because of our broken healthcare system, people DIE because of communication breakdowns.

The government has pumped millions of dollars into the healthcare industry to try and make it easier for hospitals to implement IT systems that help facilitate better communication. But, I have to ask, do we really need COMPUTERS to help us talk to each other?

Doesn’t that just seem a little, I don’t know, 1984ish? Brave New Worldish?

The airline industry has billions of dollars worth of technology, but at the end of the day, they needed to address the human culture of the industry in order to realize high reliability.

Organizations can implement world-class technology, but if your people can’t use it the right way, it’s a waste.

I don’t mean to sound like I don’t think technology makes an impact. I do. But it seems like everywhere I go and everything I read has something to do with technology being the “silver bullet” cure that the industry is looking for.

I’m going to go out on a limb here and argue that, no Regis, this ISN’T the final answer (ducking for cover). There are other things we need to do first.

I know there are some doctors and nurses out there that will share my enthusiasm. Because every unit, on every floor, of every hospital I have ever done work with, has created work arounds because the “technology” doesn’t always fit in their system of workflow.

Before we implement the technology, can we try and set up our hospitals to make it easier to communicate as HUMAN BEINGS? Because if you implement too soon, you can make things worse.

Unlike my father-in-law, some of us still have our faculties intact. It’s a shame that my mother-in-law could have gotten the help she desperately deserved a long time ago. It’s a shame that she turned to me last night and said, “I feel like the system failed him”. And frankly, I don’t think she cares if our hospitals are wired or not. She just wants to talk to someone who will help her take care of the person she’s loved for the past 40 years.

Talk to us. Talk to each other.

Is there anybody out there??

I believe in my work.

Claire

The Simple Truth about Complexity

I joke around with my family by telling them that I have “themed weeks”. A “themed week” is a week when a particular subject tends to come up all the time, no matter where you go. And since I did some serious traveling last week, I thought it particularly interesting that everywhere I went, the word simple kept coming up.

While in the security line at the airport, the man in front of me kicked off my themed week by asking, “remember when going to the airport used to be simple?” as he was attempting to balance on his right foot in order to take the shoe off his left.

I smiled and said, “sure, but better to be safe than sorry, right?”

He didn’t answer.

And when I arrived in San Antonio for the American Organization of Nurse Executives (AONE) conference, it was pouring rain and I couldn’t seem to find an umbrella in all the airport stores. I thought, “It’s such a simple thing, how can no one have an umbrella to sell?”

DISCLAIMER: I am not a nurse – only the daughter, niece, cousin, friend, and employee of nurses. Nurses are the greatest people on earth.

Anyway, while at the conference, I took a class that focused around the healthcare industry’s desire to simplify. And the speaker talked about how important it is that before we try and simplify, we must acknowledge the complexity of the environment in which we work. I couldn’t help but think about Malcolm Gladwell’s The Tipping Point, and how his main theory is that changes in simple things can make an enormous impact.

I leave San Antonio and I’m flying across the country to meet with a hospital client. It is a six-month milestone meeting and the team goes line-by-line through what we call the “action register”. The action register is a tool we use to organize all the activity that each team member is responsible for accomplishing. It’s absolutely grueling to have to walk through EVERY activity, but one simple activity that isn’t acknowledged can throw off the entire project - the project looses momentum and the rest is history. But here is the kicker - once we went through the activities, we spent the rest of the meeting focused on the incredible impact that ONE accomplishment had on the rest of the project. The one project was the implementation of multi-disciplinary rounds.

The facilitation of multi-disciplinary rounds had the most positive impact on the entire project. The rounds were able to streamline the workflow in ways that enabled the teams to work more efficiently and with a safer level of care. It is so exciting. They are doing incredible work.

I’m off to the airport and I realize that I haven’t talked to my mom (the nurse) in a while. I call to check in and she says, “Claire, I was trying to explain what you do for work to a friend and I need you to explain it to me in simple terms.”

“Okay mom, lets say when you come into work in the morning, one of your responsibilities is to review patient Joe’s chart to find out what medications he is taking, and if he has any allergies, etc. After you talk to Joe, you learn that he can only take his medicine with apple sauce. So, you check the refrigerator and there is no applesauce. You try and call support services to restock the fridge and you can’t find the number. You waste 30 minutes of your morning trying to get more applesauce. Joe is waiting on his applesauce and won’t take his medication without it. Now his meds are not on time. And since you are 30 minutes behind schedule, you decide to wait until later to document when you gave him his meds. And since you are so exhausted by the end of the day, you forget to write in his chart that he needs applesauce with his meds. And the next nursing shift goes through the same thing.”

“Umm…okay…” she says.

“Well, we make sure that the applesauce is in the refrigerator. We uncover and help eliminate the system/process failures that waste your time,” I explain.

“But, that’s so simple!” she says.

“Very simple mom! But add hundreds of those types of simple things and you get a complex mix of inefficiencies! Imagine now that Joe is 2 years old. And he has Cystic Fibrosis.”

“Poor little guy,” she says.

“Yep, poor little guy with angry parents. He didn’t think he’d have to wait 30 minutes for his applesauce. And neither did his parents, and now they are irate. Get it now?” I ask.

“Yep. I get it,” She answers.

Something as simple as stocking the applesauce can make a huge difference in the patient experience and the caregiver’s availability to work efficiently.

This, of course, is a VERY simple way of talking about waste, inefficiency and the patient experience. But, these types of simple things make a huge difference in our healthcare systems all over the country. Sometimes these inefficiencies can result in complex medical errors. Sometimes fatal.

I’m happy to be back home with my kids. My ten-month-old still has that baby smell. And my two-year-old is playing air guitar now and it makes me laugh so hard. Those are the things I miss when I’m away. Because at the end of the day, it’s the simple things that make all the difference.

I believe in my work.

Claire

Crossing the Quality ...Gorge?

Hi All!

I’m embarrassed to say that I had to look up the word “chasm” in the dictionary this morning.

I’m writing a case study about a medication administration assessment that my company just completed and I’m tying it back to the Institute of Medicine’s Six Aims for improving American Healthcare. I know all about the 1999 release To Err Is Human: Building a Safer Health System, the IOM report that brought tons of public attention to the crisis of patient safety in the United States. But, admittedly, I don’t really know much about the 2001, IOM follow up: Crossing the Quality Chasm: A New Health System for the 21st Century.

My first question: “What is a chasm?”

So, I look up “chasm” in the dictionary and it says “GORGE”. And its in all capital letters – like the actual meaning of the word GORGE isn’t enough, they must capitalize it as if to REALLY emphasize how LARGE this word and its meaning is. I feel like its screaming at me.

I slam the book shut and I’m not sure I want to know any more about the quality GORGE in American health systems. I have two young children, one who has been hospitalized twice for respiratory infections, and sometimes ignorance is bliss.

My second question: “If I ignore it, will it go away?”

You know the saying, “if I can’t see it, it can’t see me”? Yeah, well, unfortunately it doesn’t apply here. Because if we close our eyes, and ignore this problem, it doesn’t go away - it gets bigger and it becomes, well, a GORGE.

I can’t help but feel somewhat like a proud parent as I write this case study. The hospital that I am writing about has the courage to open its eyes and say, “we need to find out what we don’t know” and they hired us to sift through their individual GORGE, like an archeological dig, and we were able to come to them with the truth and some very simple ways they can address their most pressing issues around patient safety.

Like many hospitals around the country, they could have “closed the proverbial book” in hopes that the issues would simply go away. But, this hospital didn’t. They made it a priority to uncover their realities so they can implement the changes needed to support a deeper level of safety.

In the spirit of being “in the motherhood”, I’d like to give them some positive feedback so they keep leading the way to high quality care. In the meantime, I’d like to encourage other institutions to look at their own “chasm”. And maybe the next IOM report can read, “Crossing the Quality Bridge: How American Health Systems Made the Safety Connection”.

I believe in my work.

Claire

Hi Everyone!

I hope it doesn't look too self serving that I blog about my job and what services my company offers. Believe me, it is more than trying to promote what we do. I am one of the few lucky people who actually believes in her work. If I am going to spend hours away from my children everyday, it better be doing something that I am passionate about.I really feel that everyone needs to be passionate about patient safety. Everyone, at some point, will be a patient. Even caregivers are patients. So, isn't it in everyone's best interest to support any effort to make the care they receive the safest it can be? It is SO important that we all remember that this issue touches all of us.

I travel around to country gathering information from third-party organizations about patient safety and I work closely with AmerisourceBergen medication administration consultants to help promote some of the things the Company does to help hospitals implement process improvement techniques. So, over the next few months I will be blogging about what I learn and some of the important work my company is doing.

So to start, here is the new Web site we created around our process improvement solution.

http://bestmedicineforhealthcare.com/carerx

I encourage everyone to share this experience with me so we might all learn from each other. I believe in this work.

Best,

Claire