Dear Edie--
Welcome to the list!
My suggestion is that when demands overtax resources in a health-care
environment, your best hope is always putting the patient explicitly
first. If our esteemed host Rick Karash raises no bandwidth issues, I
would like to share two columns I wrote on this very topic, below.
cheers,
tom
[Host's Note: I think it's a good use of bandwidth to distribute Tom
Petzinger's articles. Hope you enjoy! In general, quoting a famous
physicist, msgs here should be "as short as possible... but no shorter!"
... Rick]
THE FRONT LINES
Nurses Discover
The Healing Power
Of Customer Service
By Thomas Petzinger Jr.
02/27/98
The Wall Street Journal
Page B1
(Copyright (c) 1998, Dow Jones & Company, Inc.)
SALT LAKE CITY -- HAD ANY OUTPATIENT surgery recently? Did you have to
strip naked and put on one of those ridiculous, wide-open hospital gowns,
even though it was a minor procedure? If so, you weren't being treated at
LDS Hospital. At LDS, outpatients wear their underwear into surgery.
What's more, they walk into the operating room instead of being rolled in.
Nothing is quite the same here since a group of nurses pushed through a
major re-engineering effort a while back. Their official purpose was
making outpatient surgery more competitive in the local market. But the
initiative came to radical results because it proceeded from a starting
point unusual in medicine: putting the customer first.
The principal facilitator was Diane Kelly , who spent 15 years as a
neonatal intensive-care nurse. Early in her career she was perplexed by
the priorities of some families. For instance, "I'm working like crazy to
save a child, but the parents get upset because the grandparents can't see
the baby." Clinical competence, she eventually saw, was only part of
medicine. "We hold people's lives in our hands at a very vulnerable
time," she realized. "Health care is about a personal encounter." (In
quainter times, people called this "bedside manner.")
Ms. Kelly became convinced that medical and business people knew too
little of each other's worlds to fix the problems in health care. So she
studied for an M.B.A. and became a "whole systems" planner at LDS and its
regional affiliates. "Innovation will come from people who have crossed
boundaries," she says.
In helping to re-engineer outpatient surgery Ms. Kelly had a powerful ally
in Joan Lelis, who had just become chief of surgical services. A nurse
herself, Ms. Lelis had a combative streak and wasn't cowed by surgeons.
Ms. Lelis and Ms. Kelly, working with front-line nurses at LDS and its
affiliates, moved to create a more efficient operation that looked at the
whole patient -- not just the procedure -- as the customer.
A FEW REFORMS had more marketing than medical benefit, such as valet
parking, hot blankets and a kitchen stocked with free refreshments for
family members. Ms. Lelis was incredulous that relatives had to roam the
hospital to break a bill for a vending machine: "You're spending $3,000 on
a loved one, but you better bring correct change."
The real problem was delay. A few surgeons missing the 7:30 a.m. start
time sometimes wrecked an entire day's worth of schedules. "It was
absolute chaos," recalls Cathy Hughes, a top nursing manager. So the
nurses began tracking chronically late surgeons, pointing out how their
tardiness actually shrunk the surgical capacity of the clinic. Staff
nurses also adopted a rallying cry: "7:30 means 7:30."
Nobody likes getting stuck with needles, so the nurses made it a routine
to draw blood during the insertion of IVs; this eliminated the need for a
lab technician to draw a second sample, further reducing delay. The
committee also championed cutting back on rote X-rays and other orders
that weren't specifically indicated, a process they called "minimum labs."
Their action cost the hospital revenue, but the increase in outpatient
capacity vastly made up for the loss.
In talking to patients, the nurses discovered a subtext in the complaints
about delays: resentment over the loss of personal control. So instead of
requiring patients to fill their post-op prescriptions here, which held up
their departure, the nurses asked doctors to write prescriptions that
could be filled anywhere. This also eased congestion.
SOME PATIENTS were especially bothered to spend half the day without
underwear -- for shoulder surgery, say. Ms. Lelis was convinced this
longstanding practice was meaningless as a guard against infection,
persisting only as the legacy of a culture that deprived patients of
control. "If you're practically naked on a stretcher on your back," she
says, "you're pretty subservient." The nurses persuaded an
infection-control committee to scrap the no-underwear policy unless the
data exposed a problem; they have not.
They also turned to a design problem. Pre-op procedures and surgeries were
conducted at opposite ends of the hospital, forcing patients to wait as
long as 40 minutes for a wheelchair or gurney. To save time, the committee
decided healthy patients could walk the distance instead of staring at
ceiling tiles like characters in an episode of "Dr. Kildare."
As these changes took effect the nurses witnessed something amazing:
Recovery times grew demonstrably shorter! People went under feeling better
and woke up feeling better. They left for home sooner, freeing up still
more capacity. Ms. Lelis says these snowballing effects proved "if you're
guided by only one phrase -- do what is best for the patient -- you will
always come up with the right answer."
Today, peak capacity is up more than 50%, with zero increase in staff or
square footage. Patient satisfaction is way up. "Leaders like Joan and
Diane have instigated controversial notions and caught the eyes of
physicians," says Gary Hunter, a plastic surgeon here. "We've learned from
them. And the result has trickled down to our patients."
Though it may be clearest with human health at stake, the lesson applies
universally. When scarce resources create conflicting demands, the
interests of the customer provide the largest space on which to seek common
ground.
Copyright ) 1998 Dow Jones & Company, Inc. All Rights Reserved.
THE FRONT LINES
A Hospital Applies
Teamwork to Thwart
An Insidious Enemy
By Thomas Petzinger Jr.
05/08/98
The Wall Street Journal
Page B1
(Copyright (c) 1998, Dow Jones & Company, Inc.)
CHICAGO -- YOU ARE surrounded by an invisible enemy. It strikes without
notice at the worst moments. Your weapons only make it more powerful.
This is life in a big-city hospital, and the enemy is infection. Patients
check in for routine procedures and get sicker, instead of better.
Hospital-borne infections afflict nearly two million patients a year, of
whom nearly 100,000 die. In a never-ending arms race, greater antibiotic
use only causes the worst germs to spread further. Some bacteria have
evolved resistance to every known antibiotic.
But as this epidemic worsens world-wide, a medical team here has reversed
the trend. How? By conquering traditional communication boundaries within
the workplace. Any organization besieged by outside forces can profit from
the lesson.
Lance Peterson, a microbiologist and infectious-disease physician, moved
to Chicago in 1992 and sensed a collegiality he'd never seen in big
cities. That attitude was also evident at his new professional home of
Northwestern Memorial Hospital, where he encountered another infection
specialist named Gary Noskin. They had every reason to become rivals. But
a shared passion for investigating infection instead threw them into a
close research partnership.
Their collaboration was propitious. In 1992, a cancer patient became
Northwestern's first victim of an insidious new strain of bacterium
enterococcus, which causes a variety of infections, including the deadly
septicemia. The new strain was immune even to the powerful antibiotic
vancomycin, earning it the name VRE, as in vancomycin-resistant
enterococci. Investigators found light switches, blood-pressure cuffs and
stethoscopes colonized with VRE.
AS INFECTION spread inside the hospital, the two doctors launched a
regular Monday morning meeting to plot countermoves. With all drugs
powerless, their best hope was cutting off the germs' path between
patients. "It's all about breaking the links of transmission," says Sandra
Reiner, a nurse who participated.
To focus the attack, the team engaged an outside lab to analyze the DNA of
infectious bacteria cultured from patients. Samples with identical genes
share a common source, signaling a mini-epidemic instead of random
outbreaks. By studying patients infected with the identical strain, the
task force could close in on a piece of contaminated equipment or a staff
group lacking the most aggressive infection-control measures. Some
staffers initially were offended to have their practices questioned, but
learning about the virulence of VRE invariably persuaded them of the need
for elevated safeguards.
Candor was key. Hospital-borne infection, also called nosocomial
infection, is a touchy subject in many institutions. Yet the Northwestern
task force launched a wide-open dialogue, opening the Monday meeting even
to equipment technicians, residents and visiting staffers from other
institutions. "For complex, changing problems, you need a lot of diverse
input," Dr. Peterson says.
As resistant pathogens spread -- to hematology, transplant and dialysis
patients, for instance -- representatives of those units also joined the
committee, not out of bureaucratic obligation but medical urgency. "There
were patients dying," Dr. Noskin says. It's doubtful anyone could have
planned such eager cooperation. "We didn't set out to do anything
special," says Ms. Reiner. "We set out to do our jobs."
A critical addition was hospital pharmacist Mike Postelnick, who
recognized that antibiotics effectively act as fertilizer for many
bacteria. Physicians often resist meddling by pharmacists, but not this
time. Antibiotic use has since plunged in favor of alternate treatments.
INTERNAL communications accelerated when the physicians won approval for
an in-house genetics lab, cutting the time spent waiting for DNA analysis
from days to hours. "Now we're attacking in real time," Dr. Noskin says.
The task force also began searching out infection before symptoms
appeared, culturing rectal swabs from at-risk patients (such as those with
compromised immune systems) and isolating any who tested positive.
The team also found that outpatients, such as cancer patients returning
for chemotherapy, were bringing infection in. So computer technicians and
admitting people joined the task force, creating software that identified
which returning patients might pose a threat.
Eventually the team absorbed even maintenance officials. Studies suggested
that a sink shortage was inhibiting hand-washing, so top management ripped
out drinking fountains to fill hallways with washbasins. Infection experts
also joined the design team for Northwestern's new $580 million building,
now nearing completion. Touring the site in his hard hat, Dr. Peterson
points proudly to the staff-only sinks being installed inside the entries
to 500 private rooms. "You have to walk by the sink to get to the
patient," he notes.
In the latest fiscal year, nosocomial infections at Northwestern totaled
5.1 per 1,000 patient days, roughly half the last-known national rate.
Over three years Northwestern's rate has plunged 22%, saving $4.2 million
in annual medical costs, and at least a few lives.
Infection respects no political or bureaucratic barrier. Neither do
competitors, customers or destabilizing new technologies. When threats
mount, healthy organizations communicate across all boundaries. "Other
places are more protective of turf," says Dr. Peterson. "There's very
little territoriality here."
Copyright ) 1998 Dow Jones & Company, Inc. All Rights Reserved.
Thomas Petzinger Jr.
http://www.petzinger.com
Please read The Front Lines,
every Friday in the
Wall Street Journal
--"Thomas Petzinger, Jr." <tom@petzinger.com>
Learning-org -- Hosted by Rick Karash <rkarash@karash.com> Public Dialog on Learning Organizations -- <http://www.learning-org.com>