Nov 4, 2011

IHI Announces Winner of David Calkins Memorial Scholarship

Chi Chu, a second year medical student at UMass Medical School, won this year's David Calkins Memorial Scholarship, good for a free seat at the National Forum and up to $1,000 for travel, lodging, and expenses.

Here is his winning esssay:

For years, St. Anne’s free clinic has opened every Tuesday evening to provide free medical care to communities in and around Worcester, Massachusetts. St. Anne’s is the busiest free clinic in the area, often seeing over 80 patients in one night. Frequently, searching for medications is the most time consuming step in patient care. Because medications are almost all donations, they are notoriously difficult to track, and there is little in the way of record keeping for what comes in. Thus, searching for medications that may not be in stock takes up a significant amount of time per patient, forcing them to wait and occupying a volunteer who could be caring for others.

I am working on a process improvement project to eliminate waste in the medication management process using Lean methodologies. The goal is to decrease the total time spent managing drugs by 50% in 3 months. This includes time spent logging the incoming donated medications, searching for medications, and counting medications to dispense to patients.

Currently, I am collaborating with the clinic coordinators and volunteer “regulars.” These are the people who are most familiar with the clinic’s processes, and who show other volunteers what to do when they come for the first time. Therefore, they are in a prime position to help map out current state processes and implement tests of change.

The primary outcome measures include average time spent logging donations, searching for medications, and dispensing medications. We also plan to track volunteer ratings of the ease of finding and dispensing drugs. These balancing measures will check that changes are not making the process too complicated, which is particularly important given the week-to-week turnover of most volunteers.

So far, the medications have been sorted into bins according to the class of each medication. We have also nearly finished entering the in-stock medication quantities into an electronic spreadsheet. Because the medications are shared with other local free clinics, we are collaborating with coordinators of the other clinics to keep the spreadsheet updated. This real-time inventory will help drive decisions going forward.

Our focus is on designing an efficient, robust, and sustainable process for determining if we have a certain medication, finding it, and then dispensing the correct amount. Change ideas we are considering include prepackaging commonly dispensed quantities of certain drugs (which would reduce patient waiting time and avoid recounting) and using visual management principles (to allow easier identification of drugs that need restocking). In short, we have many ideas – we now need to put them to trial. We plan to pilot small tests of change, targeting the most frequently dispensed medications according to our data. In this manner, we hope to get actionable feedback each week regarding what worked and what did not, such that we can determine how to proceed in the next week. Ultimately, we hope to instill a culture of continuous quality improvement that persists through changes in leadership, allowing St. Anne’s to provide ever better care for all future patients.

Editor's note: Click here for more on the David Calkins Memorial Scholarship.

Nov 3, 2011

Lessons from the Dana Farber Cancer Institute

I consider myself lucky. My experiences as a patient are limited and predictable. My sister, on the other hand, suffers from a combination of chronic conditions. Midnight trips to the ED due to extreme pain occur regularly – often times accompanied by needless harm.

About a week ago, my sister was admitted to the ED, doubled-over in excruciating pain. The medical staff called for a CT scan. As a nurse was administering an IV for contrast solution, my sister explained that the needle was not in a vein. Unfortunately, the nurse did not heed this plea. After administering the scan, two things happened:
1) The scan showed nothing
2) Ashlee’s arm ballooned to three-times its normal size, stiff with contrast that never made it into her veins

Despite the success stories and leaders of patient-centered care I learn about IHI, my sister’s experiences leave me in limbo – somewhere between skeptical and cynical – regarding the state of care.

This limbo changed last week.

I joined 20 IHI team members on October 27 on a site visit to the Dana Farber Cancer Institute. We had the unique opportunity to dive into the patient experience without bearing the burden of being a patient.

Aside from the familiar name, I was completely unfamiliar with what Dana Farber offers to patients. But it quickly became apparent that Dana Farber did something special. Our destination, the Yawkey Building, stood out as the new building on the block. Instead of the cold, industrial design of its neighbors, the Yawkey building welcomes with a glass facade, cut with naturally-colored, wood trim. The design feels like it could hold an art institute, and in a way, it does (more on this later).

Patients and visitors can self park or valet (for the same fee!) in the underground garage. We made our way seven stories underground – the first few stories were full and when we found open spaces, they were reserved for patients and families. Nearly 100 feet underground, it became clear what sets Dana Farber apart. Patients are afforded the luxury of valet parking to avoid the garage – a nice touch when they clearly have more important things on their minds.

Yawkey’s main lobby and information center feels open and welcoming. Art hangs on the walls and from the ceiling. Dick Tonachel, a DFCI volunteer and one of our hosts, warmly greeted us and took us to our luncheon. Dr. Benz, the President of Dana Farber, welcomed us to Dana Farber. Then, in true patient-centered fashion, the leaders of the Dana Farber Patient and Family Advisor Council took over the meeting.

PFAC consults DFCI management to improve operations. As former patients, they provide a valuable end-user perspective. We learned that their input was sought out from the beginning. Initial blueprints were changed as the PFAC explained that certain plans could be improved for the patient experience. Including this perspective is so natural, but is not the industry norm.

Our group of 20 IHIers split into small groups of 5-6 members for the tour. Anne Tonachel – our tour guide, Dick’s wife, a DFCI volunteer, and a cancer survivor – led us through the institute.

A piece of art hung just outside the luncheon room. Anne explained that the building committee placed a high value on displaying art throughout the facility. This particular piece was titled The Souper Dress – a 60’s mod-style dress printed with a series of Campbell’s soup cans – an Andy Warhol original. The piece was donated to DFCI and is proudly displayed. We saw more art throughout our tour, some which was created by patients. It is all approved by a patient-filled committee.

(Starting with a Warhol was incredibly fitting. His fascination with Campbell’s Soup revolved around how egalitarian the soup was. The President of the United States and a minimum wage worker have the same Campbell’s experience. I think this sends a great message for the aspirations of our healthcare system.)

We continued on to the patient examination rooms. Anne pointed out that there were no cracks or seams in the room. The counter tops were one, continuous material. The examination table had no sections held together with seams. Places for germs to hide were minimized. Anne then pointed out the floor. No one noticed it at first. Instead of the standard, monochromatic tile, this tile included two perpendicular columns of color. Studies show that nauseous patients have an easier time when a simple floor pattern gives their eyes something to focus on.

This is when it hit me. DFCI pays incredible attention to detail. If there is something that can make the patient experience slightly easier, it is implemented. These small details add up to an experience that may be unmatched in health care. To drive this point home, Anne showed how every examination table in the building is stocked with the exact same items, in the exact same places, so a medic can handle an emergency on any floor.

The building team sought the eco-friendly Silver LEED certification. Aside from using as many renewable materials as possible, outdoor gardens collect rain water which helps minimize the energy consumption of the air conditioning system. DFCI thought of everything – and received Gold LEED certification.

Our final stop was a two story, indoor healing garden. Fresh plants are rotated monthly. Soft music plays. No food, drinks, or electronics are allowed. The calm of the room is soothing, giving patients a great place to reflect and mentally heal.

Going into this site visit, my mind was preoccupied with the upsetting patient story of my sister. But knowing how bad things can get and then seeing how incredible things can be had a profound impact on my spirit. It was a delight to see the Dana Farber Cancer Institute at work. We can all hope that this level of intentional quality will spread throughout our entire system.

- Alex Anderson, Executive Assistant at IHI

Oct 31, 2011

New Course Provides Refreshing Perspective on Care Delivery

Health care consumes one dollar out of every seven in the US economy, but it remains disappointing in terms of availability and quality of care. It is no surprise that it is central in media coverage and political debate.

Despite all the attention, little headway is made because of a powerful but false assumption: That whatever good is gained must be traded off for something else in return. The reasoning goes that more or better care must be more expensive, so we must chose between getting more or saving money. In other words, we cannot get more, but pay less.

This premise – and the resulting conclusions – is mistaken. In fact, it is possible to provide better care to more people at less per unit and total cost. Accomplishing this requires applying a more sophisticated approach to managing the delivery of care.

The newest course in the IHI Open School, “Achieving Breakthrough Quality, Access, and Affordability,” demonstrates how this more dependable, reliable approach works. By the completion of the course, students will come to understand that:

· The delivery of care is a far more complex undertaking than in years past because the contributions of many more people – spanning many more specialties and disciplines –have to be coordinated and integrated.

· The complexity of systems creates vulnerabilities that weren’t significant in simpler systems. Given the number of contributors involved and the strong interdependencies among their work, small aberrations – that might have had minimal effect – can gel to cause major harm.

· Certain behaviors, if avoided, and other behaviors, if embraced, both protect against these failures and also contribute to success.

As a result of these lessons, the best of both worlds is enjoyed: The full benefit of complexity is appreciated, diagnoses and treatments incorporate what is best known across multiple disciplines, AND the systems that harness all these contributions are reliable and responsive.

- The course is authored by Steven Spear, DBA, MS, MS, Senior Lecturer at the MIT Sloan School of Management, Senior Fellow at the Institute for Healthcare Improvement, and author of a number of influential articles on operational excellence in general and healthcare excellence, and author of the award winning book, The High Velocity Edge.