“Jaded Julie, please list some words that you feel are essential in a Lean transformation.”
“Hey, Curmudge, it’s not fair to start a friendly conversation with a snap quiz. Besides, your classroom days were over long ago. But here are my answers: kaizen, muda, and gemba.”
“Good Japanese, Julie, but what about a good old English word, ‘trust’? We talked a little about trust back on February 25, 2008 in our discussion of nemawashi. People in gemba have to trust the organization or they won’t try to make their work more efficient. Wouldn’t life be more difficult if we couldn’t trust the people around us?”
“That’s for sure. It would be like being in prison or working inside the D.C. Beltway. It’s a jungle in there, and the rules of survival—raw physical or political power—are vastly different from those in the real world. I suppose in your long career you have seen a few trust violations.”
“Some were more critical than others. One of the less serious cases involved an entry-level technician in our lab who asked me what books he should study to become a better analytical chemist. When he left to accept a new job elsewhere, he took with him everything from my bookshelf that I had recommended.”
“Curmudge, your trust in that guy was certainly misplaced, but at least it was a one-of-a-kind event. Lack of trust in the workplace tends to go on and on, and it’s apparently getting worse (1).”
“The word for ‘on and on,’ Julie, is ‘insidious,’ but you have the right idea. Not trusting one’s boss is like living with your head in a guillotine; one must either go elsewhere or have a spouse with a stable career. It was once said of one of my bosses, ‘He’s out of town? Good! That means that no one will be fired today.’ And a boss who can’t trust his employees tends to feel like a jailer or a zookeeper.”
“I guess there’s more to trust than just saying, ‘to get it, you have to give it.’ I see that you have recently been reading a book on the subject, The Speed of Trust (2), which is probably the reason we began this conversation.”
“I acquired the book because I am convinced of the importance of trust in a Lean transformation. Furthermore, to quote the author, ‘The ability to establish trust with all stakeholders is the leadership competency of the new global economy.’ The author is Stephen M. R. Covey; he is Covey the Younger, not his dad of ‘7 Habits’ fame. It’s an excellent book, and it appears to be the definitive work on the topic. Covey parses and dissects ‘trust’ into more pieces than I thought imaginable.”
“To me, Curmudge, trust is just…trust. If I were writing a book on the subject, it would be extremely short. Can you tell me more?”
“I knew you would ask. There are two main dimensions of trust, character and competence. Character may be defined as one’s integrity, humility, and personal values. Competence is one’s intelligence, expertise, and ability to deliver results. Both dimensions are essential for credibility and for successful leadership in the world of business. ‘Leadership is about credibility…walking the talk.’”
“Curmudge, I know that you can’t squeeze a 354-page book into a blog posting. Can you share just a few points for me to think about while I’m washing the dishes this evening?”
“Covey suggests 13 behaviors that, if practiced, will help us to interact with others in ways that increase trust. These are the titles, and it shouldn’t take much imagination for you to fill in the details: talk straight, demonstrate respect, create transparency, right wrongs, show loyalty, deliver results, get better, confront reality, clarify expectations, practice accountability, listen first, keep commitments, and extend trust.”
“I’ve got a question about the book’s title, Curmudge. What does Speed have to do with Trust?”
“Think about going through Security in an airport, Julie. All of that inconvenience is because we can’t trust passengers not to be terrorists. If we could trust everyone and did not have to take off our shoes, we’d be speedier in getting to our flight.”
Affinity’s Kaizen Curmudgeon
(1) Luftig, J. T. and Ouellette, S. The decline of ethical behavior in business. Quality Digest, p. 36-38 (May 2009) http://www.qualitydigest.com/magazine/2009/may/article/decline-ethical-behavior-business.html
(2) Covey, Stephen M. R. The Speed of Trust. (Free Press, 2006.)
Friday, May 29, 2009
Thursday, May 21, 2009
Happy Second Birthday
“Tanti auguri a te, tanti auguri a te, tanti auguri Jaded Julie, tanti auguri a te!”
“Curmudge, it sounded as if you were singing, ’Happy birthday,’ but I couldn’t understand the words. What gives?”
“It’s the second birthday of the Kaizen Curmudgeon blog, so I was singing, ‘Happy birthday’ in Italian. Everything sounds better sung in Italian. It is translated, ‘Best wishes to you.’ Happy birthday, Julie; you are two years old.”
“And I thought I was 39 and that you are at least 95. The first of our 80+ postings was on May 23, 2007. How long are we going to keep this up?”
“I guess until there is something more important for me to do, or perhaps until my face goes ‘plop’ onto the keyboard.”
“If you did that, Curmudge, your nose would land on the ‘u’ key, and the computer would keep cranking out uuuuuu’s until someone found you.”
“It wouldn’t be a bad way to go, but meanwhile, there’s a lot more to be said about Lean and health care.”
“Topics, Curmudge, that you have no credentials to write about.”
“Hey, you’re supposed to be my source of expertise. Besides, I read good books and articles and talk to good people. Since I have forgotten most of the chemistry, physics, engineering, and math that I once knew, I’d better learn something else. We need to stand in front of a mirror when we tell our readers to, ‘Be all you can be.’ That’s what I’m trying to do.”
“Well, Curmudge, is that all we are going to do today? Just blow out the candles on the birthday cake and go home? Usually there is a lesson in each of our Kaizen Curmudgeon postings.”
“There is in this one too, Julie. I just said it, ‘Be all you can be.’ It sounds trite and like the U.S. Army, but those are five powerful words. If one has read and keeps reading this blog and the books we reference—and practices what we preach, she’ll be well on her way to being healthy and wise (these days one can’t say much about being wealthy). Otherwise, you’ll do what I did—become ‘so soon old and so late smart.’ Who wants to end up as an old has-been who wasn’t much?”
“That’s a good trick, Curmudge. You were just assertive and humble in the same paragraph. So do you know some examples of people close at hand who are becoming all they can be?”
“You bet I do. The people we work with in the Kaizen Promotion Office are excellent examples. They read all our blog drafts for accuracy, they devote several weeks each year to training, and they work their heads off. These people are the best folks in the world to work with, and they would be winners in any environment.”
“Curmudge, if you’d like to take my hand as you step down from your soapbox, you won’t fall and end up critiquing our Emergency Department. But first, do you have any final words on ‘being all you can be’?”
“Sure. Just do it!”
Affinity’s Kaizen Curmudgeon
“Curmudge, it sounded as if you were singing, ’Happy birthday,’ but I couldn’t understand the words. What gives?”
“It’s the second birthday of the Kaizen Curmudgeon blog, so I was singing, ‘Happy birthday’ in Italian. Everything sounds better sung in Italian. It is translated, ‘Best wishes to you.’ Happy birthday, Julie; you are two years old.”
“And I thought I was 39 and that you are at least 95. The first of our 80+ postings was on May 23, 2007. How long are we going to keep this up?”
“I guess until there is something more important for me to do, or perhaps until my face goes ‘plop’ onto the keyboard.”
“If you did that, Curmudge, your nose would land on the ‘u’ key, and the computer would keep cranking out uuuuuu’s until someone found you.”
“It wouldn’t be a bad way to go, but meanwhile, there’s a lot more to be said about Lean and health care.”
“Topics, Curmudge, that you have no credentials to write about.”
“Hey, you’re supposed to be my source of expertise. Besides, I read good books and articles and talk to good people. Since I have forgotten most of the chemistry, physics, engineering, and math that I once knew, I’d better learn something else. We need to stand in front of a mirror when we tell our readers to, ‘Be all you can be.’ That’s what I’m trying to do.”
“Well, Curmudge, is that all we are going to do today? Just blow out the candles on the birthday cake and go home? Usually there is a lesson in each of our Kaizen Curmudgeon postings.”
“There is in this one too, Julie. I just said it, ‘Be all you can be.’ It sounds trite and like the U.S. Army, but those are five powerful words. If one has read and keeps reading this blog and the books we reference—and practices what we preach, she’ll be well on her way to being healthy and wise (these days one can’t say much about being wealthy). Otherwise, you’ll do what I did—become ‘so soon old and so late smart.’ Who wants to end up as an old has-been who wasn’t much?”
“That’s a good trick, Curmudge. You were just assertive and humble in the same paragraph. So do you know some examples of people close at hand who are becoming all they can be?”
“You bet I do. The people we work with in the Kaizen Promotion Office are excellent examples. They read all our blog drafts for accuracy, they devote several weeks each year to training, and they work their heads off. These people are the best folks in the world to work with, and they would be winners in any environment.”
“Curmudge, if you’d like to take my hand as you step down from your soapbox, you won’t fall and end up critiquing our Emergency Department. But first, do you have any final words on ‘being all you can be’?”
“Sure. Just do it!”
Affinity’s Kaizen Curmudgeon
Thursday, May 14, 2009
Prescription Drugs--Brand and Generic Names
“Say Curmudge, a few weeks ago we talked about your wife’s fall in Prague that dislocated her shoulder. How is she doing?”
“When we got back to the U.S. we learned that she had injured her rotator cuff, so it was repaired in our outpatient surgery unit. Her take-home instructions for controlling pain were to take one MS Contin tablet every 12 hours starting at 8:00 p.m. and one or two Percocet tablets as needed every four hours. Our experience with these meds was instructive, so I put our dialog into a script. You, Jaded Julie, can play the part of Mrs. Curmudgeon.”
“Okay, as long as I don’t have to fall down and break something.”
“You’re settled into your recliner, MK, so I’ll go to the drugstore and get these two prescriptions filled.”
“Don’t take too long, Mudge, the anesthetic is wearing off and my shoulder is beginning to hurt.”
So I took the two scripts, one for Percocet and the other for MS Contin, and had them filled. When I returned home and took the bottles out of the bag, one was labeled OXYCODONE/APAP and the other MORPHINE SULFATE ER. Apparently we had received generic substitutes for the prescribed meds. But which was which? I read the fine print on the page of cautions that accompanied each bottle, but Percocet was not mentioned anywhere.
“Mudge, CODONE sounds a bit like Contin, so maybe I should be taking the other stuff, the MORPHINE SULFATE, as needed.”
“Nope MK. Until I learn more, we’d better trust the pharmacist and take the pills in the bottle that says ‘every four hours as needed’ even though the bottle isn’t labeled Percocet. Meanwhile, there’s something I want to track down.”
“Track! Curmudge, you couldn’t track an elephant in four feet of snow.”
“C’mon, Julie, stick with the script. No improvisation allowed.” “I found it, MK. A book on prescription drugs that I bought for 50 cents at the used book sale. It says that oxycodone with acetaminophen is sold under the brand name Percocet and morphine is sold under the brand name MS Contin. We’ve got the right stuff.”
“Please Curmudge, can I go back to being Jaded Julie? If I stay Mrs. Curmudgeon much longer I’ll have to get color put in my hair.”
“Okay, Julie, you can be you again. I think you see the problem; generic drugs are great because they cost less, but the names are often unfamiliar. As we have experienced, even health care providers most often prescribe drugs by brand name (1). So our systems need to be designed to prevent the patient’s becoming confused as to what is in a given bottle. That could easily happen if the patient is still woozy following outpatient surgery.”
“The uncertainty that you and Mrs. C experienced would have been avoided if the bottles had been labeled ‘OXYCODONE substitute for Percocet’ and ‘MORPHINE SULFATE substitute for MS Contin.’”
“I have seen that on labels for other meds; perhaps it should be on all bottles where a generic has been substituted for the prescribed brand name drug. Of course, a puzzled patient could always call the pharmacist or the physician or find a table of brand and generic drug names on the computer (2). But senior citizens and lots of other folks may be reluctant or unable to do any of these things.”
“Curmudge, it’s a good thing your wife didn’t take the extended-release morphine sulfate every four hours; she would have accumulated a real snoot full of morphine.”
“And possibly a worse case of constipation.”
Affinity’s Kaizen Curmudgeon
(1) Steinman, M. A., et al. What’s in a name? Use of brand versus generic drug names in United States outpatient practice. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1852907
(2) http://www.rxlist.com/drugs/alpha_a.htm
“When we got back to the U.S. we learned that she had injured her rotator cuff, so it was repaired in our outpatient surgery unit. Her take-home instructions for controlling pain were to take one MS Contin tablet every 12 hours starting at 8:00 p.m. and one or two Percocet tablets as needed every four hours. Our experience with these meds was instructive, so I put our dialog into a script. You, Jaded Julie, can play the part of Mrs. Curmudgeon.”
“Okay, as long as I don’t have to fall down and break something.”
“You’re settled into your recliner, MK, so I’ll go to the drugstore and get these two prescriptions filled.”
“Don’t take too long, Mudge, the anesthetic is wearing off and my shoulder is beginning to hurt.”
So I took the two scripts, one for Percocet and the other for MS Contin, and had them filled. When I returned home and took the bottles out of the bag, one was labeled OXYCODONE/APAP and the other MORPHINE SULFATE ER. Apparently we had received generic substitutes for the prescribed meds. But which was which? I read the fine print on the page of cautions that accompanied each bottle, but Percocet was not mentioned anywhere.
“Mudge, CODONE sounds a bit like Contin, so maybe I should be taking the other stuff, the MORPHINE SULFATE, as needed.”
“Nope MK. Until I learn more, we’d better trust the pharmacist and take the pills in the bottle that says ‘every four hours as needed’ even though the bottle isn’t labeled Percocet. Meanwhile, there’s something I want to track down.”
“Track! Curmudge, you couldn’t track an elephant in four feet of snow.”
“C’mon, Julie, stick with the script. No improvisation allowed.” “I found it, MK. A book on prescription drugs that I bought for 50 cents at the used book sale. It says that oxycodone with acetaminophen is sold under the brand name Percocet and morphine is sold under the brand name MS Contin. We’ve got the right stuff.”
“Please Curmudge, can I go back to being Jaded Julie? If I stay Mrs. Curmudgeon much longer I’ll have to get color put in my hair.”
“Okay, Julie, you can be you again. I think you see the problem; generic drugs are great because they cost less, but the names are often unfamiliar. As we have experienced, even health care providers most often prescribe drugs by brand name (1). So our systems need to be designed to prevent the patient’s becoming confused as to what is in a given bottle. That could easily happen if the patient is still woozy following outpatient surgery.”
“The uncertainty that you and Mrs. C experienced would have been avoided if the bottles had been labeled ‘OXYCODONE substitute for Percocet’ and ‘MORPHINE SULFATE substitute for MS Contin.’”
“I have seen that on labels for other meds; perhaps it should be on all bottles where a generic has been substituted for the prescribed brand name drug. Of course, a puzzled patient could always call the pharmacist or the physician or find a table of brand and generic drug names on the computer (2). But senior citizens and lots of other folks may be reluctant or unable to do any of these things.”
“Curmudge, it’s a good thing your wife didn’t take the extended-release morphine sulfate every four hours; she would have accumulated a real snoot full of morphine.”
“And possibly a worse case of constipation.”
Affinity’s Kaizen Curmudgeon
(1) Steinman, M. A., et al. What’s in a name? Use of brand versus generic drug names in United States outpatient practice. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1852907
(2) http://www.rxlist.com/drugs/alpha_a.htm
Thursday, May 7, 2009
Patients, you too can make a difference.
“Jaded Julie, after spending last week talking about how health care workers can make a difference, let’s consider how patients can make a difference in the care that they receive. The link between Lean and this topic is rather tenuous, but this is too important to neglect.”
“Curmudge, you have been reading again.”
“Right, and in addition I have also been talking with my favorite physician.”
“But why write about it here? Most of our readers work in health care. It will be like preaching to the choir.”
“That’s better than not preaching at all. Maybe Mrs. Curmudgeon and my contemporaries will read what we write. Much of my generation’s health care knowledge is out of date except for what we have learned the hard way—by experiencing illness and injuries. And younger people tend not to think about health at all until they are blind-sided by a crisis in mid-life.”
“On January 29 we suggested ways by which patients might avoid nosocomial infections, and on February 19 we mentioned how the patient can help achieve a correct diagnosis. Is there more to the story, Curmudge?”
“There certainly is, Julie. Let’s start with a bad example. Some people seem to be oblivious to how they are mistreating their body and to what their body is trying to tell them. They don’t seek help until the problem is serious, and then they show up in the ED expecting a magic wand. If the ED doc arranges an appointment with a specialist and the patient feels a bit better in the meantime, she becomes a no-show. Then if she takes a turn for the worse, she’s back in the ED again. Some people just don’t understand.”
“You’re right, Curmudge. I’ve seen patients who are not only clueless about health care; they seem to be clueless about everything except possibly procreation.”
“The plight of the uninformed, totally passive patient will be even worse in the future, Julie. Health care delivery is changing fast, and many of the changes will be beyond our control. The one thing a patient can control is his or her involvement. The savvy patient knows that her health is best served by forming a partnership with her primary care physician and when necessary, an appropriate specialist.”
“As you recommended, Curmudge, I read Marie Savard’s book (1). She spells out in eight steps what a patient should do to manage and control his/her health care, including collecting and studying copies of one’s medical records. Here is her summary: ‘Nothing will ever replace trusting your intuition, keeping providers abreast of all your health information, being well informed yourself, establishing an interactive rapport with your doctor instead of cowering in his presence, taking part in decisions about your treatment, teaming up with a health buddy especially when you go to the hospital, and safeguarding your health by living right.’”
“Here’s one to add to your list, Julie. ‘Patients should acquire a general knowledge of the symptoms of afflictions common to their age group. Then they can respond appropriately to observing or experiencing the initial stages of a stroke or heart attack.’”
“I presume, Curmudge, that you know the initial symptoms of ‘dying of old age.’”
“Of course I do, Julie. It’s just like your needing to learn the symptoms of insidious impertinence and pernicious chutzpah.”
“(I have no idea what he said; but I’d better learn, because I think it was directed at me.) By the way, Curmudge, you have said that you talk occasionally with your favorite physician. Do you call him (or her) Doctor?”
“Normally I address physicians as ‘Doctor’; I figure that they have worked hard to earn that level of respect. But I always call my very favorite physician by his first name.”
“That’s interesting. Why do you do that?”
“Because he calls me ‘Dad.’”
Affinity’s Kaizen Curmudgeon
(1) Savard, Marie. How to Save Your Own Life. (Warner Books, 2000)
“Curmudge, you have been reading again.”
“Right, and in addition I have also been talking with my favorite physician.”
“But why write about it here? Most of our readers work in health care. It will be like preaching to the choir.”
“That’s better than not preaching at all. Maybe Mrs. Curmudgeon and my contemporaries will read what we write. Much of my generation’s health care knowledge is out of date except for what we have learned the hard way—by experiencing illness and injuries. And younger people tend not to think about health at all until they are blind-sided by a crisis in mid-life.”
“On January 29 we suggested ways by which patients might avoid nosocomial infections, and on February 19 we mentioned how the patient can help achieve a correct diagnosis. Is there more to the story, Curmudge?”
“There certainly is, Julie. Let’s start with a bad example. Some people seem to be oblivious to how they are mistreating their body and to what their body is trying to tell them. They don’t seek help until the problem is serious, and then they show up in the ED expecting a magic wand. If the ED doc arranges an appointment with a specialist and the patient feels a bit better in the meantime, she becomes a no-show. Then if she takes a turn for the worse, she’s back in the ED again. Some people just don’t understand.”
“You’re right, Curmudge. I’ve seen patients who are not only clueless about health care; they seem to be clueless about everything except possibly procreation.”
“The plight of the uninformed, totally passive patient will be even worse in the future, Julie. Health care delivery is changing fast, and many of the changes will be beyond our control. The one thing a patient can control is his or her involvement. The savvy patient knows that her health is best served by forming a partnership with her primary care physician and when necessary, an appropriate specialist.”
“As you recommended, Curmudge, I read Marie Savard’s book (1). She spells out in eight steps what a patient should do to manage and control his/her health care, including collecting and studying copies of one’s medical records. Here is her summary: ‘Nothing will ever replace trusting your intuition, keeping providers abreast of all your health information, being well informed yourself, establishing an interactive rapport with your doctor instead of cowering in his presence, taking part in decisions about your treatment, teaming up with a health buddy especially when you go to the hospital, and safeguarding your health by living right.’”
“Here’s one to add to your list, Julie. ‘Patients should acquire a general knowledge of the symptoms of afflictions common to their age group. Then they can respond appropriately to observing or experiencing the initial stages of a stroke or heart attack.’”
“I presume, Curmudge, that you know the initial symptoms of ‘dying of old age.’”
“Of course I do, Julie. It’s just like your needing to learn the symptoms of insidious impertinence and pernicious chutzpah.”
“(I have no idea what he said; but I’d better learn, because I think it was directed at me.) By the way, Curmudge, you have said that you talk occasionally with your favorite physician. Do you call him (or her) Doctor?”
“Normally I address physicians as ‘Doctor’; I figure that they have worked hard to earn that level of respect. But I always call my very favorite physician by his first name.”
“That’s interesting. Why do you do that?”
“Because he calls me ‘Dad.’”
Affinity’s Kaizen Curmudgeon
(1) Savard, Marie. How to Save Your Own Life. (Warner Books, 2000)
Friday, May 1, 2009
Making a Difference
“Curmudge, I’ve seen you reading a lot of books on Lean and management. They don’t seem to be the type of book that old geezers read between shuffleboard games. Who buys these books, anyway?”
“The books are written for top management, Jaded Julie. I suspect they are purchased by managers on the way up, MBA students, and one—as you irreverently said—old geezer. The contents of these books should be valuable for middle managers and even for the folks in gemba. It’s too bad that their exposure to the authors’ ideas is so limited.”
“Maybe we can help, Curmudge. If we discuss some of the books’ more important concepts, it might inspire the middle managers who read this blog—all five of them—to implement the authors’ teachings. Let’s start with Quint Studer’s Hardwiring Excellence (1).”
“Good idea, Julie. Studer felt that three things were so important that he put them on his book’s front cover. ‘Employees want three things: (a) They want to believe the organization has the right purpose. (b) They want to know that their job is worthwhile. (c) They want to make a difference.’”
“Having the right purpose shouldn’t be too difficult for a hospital, especially if its mission statement is clearly articulated by top management. (Articulated! Curmudge is putting words in my mouth.) And it should be easy for those of us performing direct patient care to recognize that our job is worthwhile. However, we all must help people such as housekeepers and cafeteria workers to appreciate their own importance. The housekeeper is ‘protecting the patient from a nosocomial infection.’ It’s like the janitor at the Johnson Space Center who said his job was to ‘help put a man on the moon.’”
“Convincing a person that she is ‘making a difference’ may fall more on the individual than on management. One might ask, ‘making a difference between what and what?’ As seen by an inpatient, the difference might be between you, Jaded Julie, and a nurse in another hospital or the nurse on the preceding shift.”
“That, Curmudge, sounds like the personal brand that we were talking about a few weeks ago.”
“It’s that and more, Julie. A nurse can make a big difference to the patient by fully and effectively implementing the Nursing Process, as you described to me back on December 3, 2007. Of course, a nurse’s workload must allow her to spend the necessary time with the patient. Hopefully that will result from Lean initiatives conducted in his or her unit.”
“Curmudge, I remember reading an article by Sandra Nettina on ways that a nurse can make a difference (2). Because the nurse is the member of the care team who is closest to the patient, she should become the patient’s advocate. The nurse’s assessment should be holistic and include understanding the patient’s mood, support system, and concerns. That will allow her to better represent the patient’s interests. In addition, she should listen to the patients, help solve their problems, and teach patients to be their own advocates.”
“That certainly sounds like the Nursing Process as it should be practiced. I hope our nurses have time to do it.”
“Here is a quotation from Nettina’s paper that needs to be shared. ‘I provide hands-on care for all of these patients, none of which I had ever met before. They bared their souls to me, shared the most intimate details of their lives, and admitted their fears and failures to me, a nurse. I listened to them and gave them my understanding and compassion. They touched my soul and I hope I touched theirs.’”
“Julie, if that isn’t ‘making a difference,’ I don’t know what is.”
Affinity’s Kaizen Curmudgeon
(1) Studer, Quint. Hardwiring Excellence. (Firestarter Publishing, 2003)
(2) Nettina, Sandra M. Nurses: The Perfect Patient Advocates. http://www.medscape.com/viewarticle/503902
“The books are written for top management, Jaded Julie. I suspect they are purchased by managers on the way up, MBA students, and one—as you irreverently said—old geezer. The contents of these books should be valuable for middle managers and even for the folks in gemba. It’s too bad that their exposure to the authors’ ideas is so limited.”
“Maybe we can help, Curmudge. If we discuss some of the books’ more important concepts, it might inspire the middle managers who read this blog—all five of them—to implement the authors’ teachings. Let’s start with Quint Studer’s Hardwiring Excellence (1).”
“Good idea, Julie. Studer felt that three things were so important that he put them on his book’s front cover. ‘Employees want three things: (a) They want to believe the organization has the right purpose. (b) They want to know that their job is worthwhile. (c) They want to make a difference.’”
“Having the right purpose shouldn’t be too difficult for a hospital, especially if its mission statement is clearly articulated by top management. (Articulated! Curmudge is putting words in my mouth.) And it should be easy for those of us performing direct patient care to recognize that our job is worthwhile. However, we all must help people such as housekeepers and cafeteria workers to appreciate their own importance. The housekeeper is ‘protecting the patient from a nosocomial infection.’ It’s like the janitor at the Johnson Space Center who said his job was to ‘help put a man on the moon.’”
“Convincing a person that she is ‘making a difference’ may fall more on the individual than on management. One might ask, ‘making a difference between what and what?’ As seen by an inpatient, the difference might be between you, Jaded Julie, and a nurse in another hospital or the nurse on the preceding shift.”
“That, Curmudge, sounds like the personal brand that we were talking about a few weeks ago.”
“It’s that and more, Julie. A nurse can make a big difference to the patient by fully and effectively implementing the Nursing Process, as you described to me back on December 3, 2007. Of course, a nurse’s workload must allow her to spend the necessary time with the patient. Hopefully that will result from Lean initiatives conducted in his or her unit.”
“Curmudge, I remember reading an article by Sandra Nettina on ways that a nurse can make a difference (2). Because the nurse is the member of the care team who is closest to the patient, she should become the patient’s advocate. The nurse’s assessment should be holistic and include understanding the patient’s mood, support system, and concerns. That will allow her to better represent the patient’s interests. In addition, she should listen to the patients, help solve their problems, and teach patients to be their own advocates.”
“That certainly sounds like the Nursing Process as it should be practiced. I hope our nurses have time to do it.”
“Here is a quotation from Nettina’s paper that needs to be shared. ‘I provide hands-on care for all of these patients, none of which I had ever met before. They bared their souls to me, shared the most intimate details of their lives, and admitted their fears and failures to me, a nurse. I listened to them and gave them my understanding and compassion. They touched my soul and I hope I touched theirs.’”
“Julie, if that isn’t ‘making a difference,’ I don’t know what is.”
Affinity’s Kaizen Curmudgeon
(1) Studer, Quint. Hardwiring Excellence. (Firestarter Publishing, 2003)
(2) Nettina, Sandra M. Nurses: The Perfect Patient Advocates. http://www.medscape.com/viewarticle/503902
Thursday, April 23, 2009
A Day in a Hospital in Prague
“Hey Jaded Julie, remember when we talked about falls back on February 12?”
“Of course I do. You said your wife was vertically challenged; I figured that meant she falls a lot.”
“Well, she did it again.”
“Was she hurt?”
“This fall was worse than usual. She tripped on a marble step, fell on the hard surface, and dislocated her right shoulder.”
“Oo, sounds bad. Where did it happen?”
“In a hotel in Prague, Czech Republic. We spent the rest of the day in the local hospital getting her shoulder relocated. Being the connoisseur of health care that you are, I thought you’d want to learn what a Czech hospital is like.”
“Are you sure you didn’t push your wife just so we’d have something to talk about?”
“I’m sure. Now I have to wait on her hand and foot. With her right shoulder, arm, and hand immobilized, she can’t even unscrew the top of a tube of toothpaste.”
“So the hotel called an ambulance, and they rushed your wife to the hospital, right?”
“Right. The ambulance ride was unremarkable except that I had to pay the equivalent of $100 in Czech money before they unloaded her. Then they rolled the gurney down the middle of the hallway that served as the ED waiting room. Only a few waiting patients looked up. They put her on an unpadded stainless steel table for a perfunctory triage.”
“Per…what? Well, a dislocated shoulder is pretty obvious.”
“After that, they plopped my wife into an ancient wheelchair, and we joined the line of sick and injured in the hallway. My wife’s requests for pain medication were ignored. After about an hour, a doctor came by and said that we would have to wait a couple more hours (four hours after her last meal) before he could work on her shoulder. They moved her to an inpatient room to wait. Her wheelchair was pushed by a silent, absolutely expressionless male.”
“Was the room what you’d expect in the United States?”
“Not at all. The whole hospital was 1940’s vintage. Perhaps that’s understandable, because only 20 years have passed since the ‘velvet revolution’ when the Czechs threw out their communist rulers.”
“You were telling me about the room.”
“Cast iron beds, four per room. Gas lines were on, not in, the walls. My wife had one roommate, an older woman who had had surgery on her foot. The hospital was not crowded.”
“I think I can understand why.”
“After awhile, they took my wife out for x-rays. They used what appeared to be old-fashioned plates, and the x-ray technician also read the x-rays. I had to pay cash on the barrelhead, the equivalent of about $30, for each x-ray. Finally, they took my wife to reduce (relocate) her shoulder. After some sort of IV anesthesia but before it could take effect, the doc put her shoulder back into place. It required three attempts. Three people held her down; I could hear her screams where I waited in the hallway. After another follow-up x-ray (another $30 worth of Czech currency), she was taken back to her room. We had to wait another four hours before being released. Fortunately, the hospital accepted my credit card.”
“I presume your fluency in Czech made the hospital stay easier.”
“My fluency is limited to ‘hello,’ ‘goodbye,’ ‘please,’ ‘thank you,’ and how to order a beer (pivo). In our rush to the hospital, I left my Czech phrasebook back at the hotel.”
“But don’t most Czechs speak English?”
“Children and doctors do, but the nurses didn’t. Our communication was almost comparable to that of a Czech couple in a U.S. hospital.”
“If you had been able to communicate, you could have taught the Czechs about Personalized Care.”
“I’m sure they never heard of Lean or Quint Studer. A little AIDET or C.A.R.E. would have been nice. I fear that what might be viewed as standard work was a bunch of rigid rules left over from communist days. I’m surely glad my wife didn’t have to have any sort of incision; one would be very fearful of nosocomial infections in that place.”
“How well did the hospital staff do with hand hygiene?”
“The nurse who cared for my wife put on rubber gloves when she emptied the roommate’s urine bag. But I don’t recall her washing her hands or using hand sanitizer. Nevertheless, she was the one cheerful, friendly person that we encountered.”
“So how would you sum up your experience in the hospital?”
“They probably practice acceptable medicine. I’ll know that better if my wife makes a full recovery. However, their reduction of her shoulder without effective anesthesia is not typical practice in the U.S. In my view, the hospital (which we later learned was a state hospital) was drab, dreary, depressing, unfriendly, rigid, and totally devoid of a healing environment.”
“And do you have any final words for the Czech hospital?”
“I sure do. ‘Na shledanou.’ It means ‘goodbye.’”
Affinity’s Kaizen Curmudgeon
“Of course I do. You said your wife was vertically challenged; I figured that meant she falls a lot.”
“Well, she did it again.”
“Was she hurt?”
“This fall was worse than usual. She tripped on a marble step, fell on the hard surface, and dislocated her right shoulder.”
“Oo, sounds bad. Where did it happen?”
“In a hotel in Prague, Czech Republic. We spent the rest of the day in the local hospital getting her shoulder relocated. Being the connoisseur of health care that you are, I thought you’d want to learn what a Czech hospital is like.”
“Are you sure you didn’t push your wife just so we’d have something to talk about?”
“I’m sure. Now I have to wait on her hand and foot. With her right shoulder, arm, and hand immobilized, she can’t even unscrew the top of a tube of toothpaste.”
“So the hotel called an ambulance, and they rushed your wife to the hospital, right?”
“Right. The ambulance ride was unremarkable except that I had to pay the equivalent of $100 in Czech money before they unloaded her. Then they rolled the gurney down the middle of the hallway that served as the ED waiting room. Only a few waiting patients looked up. They put her on an unpadded stainless steel table for a perfunctory triage.”
“Per…what? Well, a dislocated shoulder is pretty obvious.”
“After that, they plopped my wife into an ancient wheelchair, and we joined the line of sick and injured in the hallway. My wife’s requests for pain medication were ignored. After about an hour, a doctor came by and said that we would have to wait a couple more hours (four hours after her last meal) before he could work on her shoulder. They moved her to an inpatient room to wait. Her wheelchair was pushed by a silent, absolutely expressionless male.”
“Was the room what you’d expect in the United States?”
“Not at all. The whole hospital was 1940’s vintage. Perhaps that’s understandable, because only 20 years have passed since the ‘velvet revolution’ when the Czechs threw out their communist rulers.”
“You were telling me about the room.”
“Cast iron beds, four per room. Gas lines were on, not in, the walls. My wife had one roommate, an older woman who had had surgery on her foot. The hospital was not crowded.”
“I think I can understand why.”
“After awhile, they took my wife out for x-rays. They used what appeared to be old-fashioned plates, and the x-ray technician also read the x-rays. I had to pay cash on the barrelhead, the equivalent of about $30, for each x-ray. Finally, they took my wife to reduce (relocate) her shoulder. After some sort of IV anesthesia but before it could take effect, the doc put her shoulder back into place. It required three attempts. Three people held her down; I could hear her screams where I waited in the hallway. After another follow-up x-ray (another $30 worth of Czech currency), she was taken back to her room. We had to wait another four hours before being released. Fortunately, the hospital accepted my credit card.”
“I presume your fluency in Czech made the hospital stay easier.”
“My fluency is limited to ‘hello,’ ‘goodbye,’ ‘please,’ ‘thank you,’ and how to order a beer (pivo). In our rush to the hospital, I left my Czech phrasebook back at the hotel.”
“But don’t most Czechs speak English?”
“Children and doctors do, but the nurses didn’t. Our communication was almost comparable to that of a Czech couple in a U.S. hospital.”
“If you had been able to communicate, you could have taught the Czechs about Personalized Care.”
“I’m sure they never heard of Lean or Quint Studer. A little AIDET or C.A.R.E. would have been nice. I fear that what might be viewed as standard work was a bunch of rigid rules left over from communist days. I’m surely glad my wife didn’t have to have any sort of incision; one would be very fearful of nosocomial infections in that place.”
“How well did the hospital staff do with hand hygiene?”
“The nurse who cared for my wife put on rubber gloves when she emptied the roommate’s urine bag. But I don’t recall her washing her hands or using hand sanitizer. Nevertheless, she was the one cheerful, friendly person that we encountered.”
“So how would you sum up your experience in the hospital?”
“They probably practice acceptable medicine. I’ll know that better if my wife makes a full recovery. However, their reduction of her shoulder without effective anesthesia is not typical practice in the U.S. In my view, the hospital (which we later learned was a state hospital) was drab, dreary, depressing, unfriendly, rigid, and totally devoid of a healing environment.”
“And do you have any final words for the Czech hospital?”
“I sure do. ‘Na shledanou.’ It means ‘goodbye.’”
Affinity’s Kaizen Curmudgeon
Thursday, April 16, 2009
The 5P Pyramid--Up to Levels 4 and 5
“Here we are on Level 3, Curmudge, where we stopped last week. The climb up here wasn’t nearly as difficult as it was the first time.”
“Practice makes perfect, Jaded Julie. Soon we’ll have it hardwired.”
“I see a sign over there. Can we talk about that before we go higher?”
“Of course. It’s a Communication Board, sometimes called a Performance Indicator Board. Among other department goals, it displays the brand goals and metrics that the team has chosen to indicate their progress toward achieving the Affinity promise of personalized care.”
“Metrics? That’s like meters and kilograms, right?”
“In ‘Leanspeak,’ a metric is something that is measured, such as patient satisfaction scores.”
“I remember, Curmudge. Something that is not measured tends not to get done. The communication board needs to be kept up to date so that a problem becomes immediately evident and can be tackled ASAP.”
“Are you ready to go up to the higher levels, Julie? It’s windy up there today, but we won’t stay long.”
“You’re right about the wind, but the view of downtown is pretty good. The most distinctive features are the 222 Building, Appleton Center, the old Zuelke Building, and the County Jail. But here on the pyramid things look pretty much as Liker depicted them in The Toyota Way. (1)”
“That must mean that the Toyota concepts of People and Partners (Level 4) and Problem Solving (Level 5) are enduring. We discussed those back in January of 2008. Fortunately, the application of these Toyota concepts to hospitals has been addressed by Studer (2) and Stubblefield (3) (the People concept, Level 4), and by Graban (4) (Problem Solving, Level 5). We may devote a whole discussion to these people in the future.”
“I recall your mentioning that all these books are must reading for health care leaders. Is there anything in them that bears upon our Affinity promise of personalized care?”
“Almost everything, Julie. Both Studer and Stubblefield agree that satisfaction of patients is directly related to satisfaction of employees. We achieve that by providing employees a place to work where they feel they have a purpose, are doing worthwhile work, and can make a difference. The authors emphasize that continuous leadership development is absolutely essential. Graban’s discussion of problem solving reinforces what we already know about going to gemba and getting to the root cause of errors, which can be serious patient dissatisfiers and the most critical problems in a hospital.”
“Thanks for bringing me up here, Curmudge. Maybe the image of a pyramid will help me retain what I have learned for a few thousand years.”
“Lots of luck, Julie. Let’s hike down the back trail. It’s not nearly as steep as the way we came up.”
“So what are we going to talk about next week, Curmudge?”
“It’s a secret.”
“A secret! I bet that just means you haven’t thought of anything yet.”
“Not true, Julie. I planned next week’s conversation a couple of weeks ago. When I can’t think of anything for us to talk about, that will mean that the synapses in my brain are getting lost and senility is setting in.”
“Oh? You mean that isn’t already happening?”
Affinity’s Kaizen Curmudgeon
(1) Liker, Jeffrey K. The Toyota Way. (McGraw-Hill, 2004)
(2) Studer, Quint. Hardwiring Excellence. (Fire Starter Publishing, 2003)
(3) Stubblefield, Al. The Baptist Health Care Journey to Excellence. (John Wiley, 2005)
(4) Graban, Mark. Lean Hospitals. (Productivity Press, 2008)
“Practice makes perfect, Jaded Julie. Soon we’ll have it hardwired.”
“I see a sign over there. Can we talk about that before we go higher?”
“Of course. It’s a Communication Board, sometimes called a Performance Indicator Board. Among other department goals, it displays the brand goals and metrics that the team has chosen to indicate their progress toward achieving the Affinity promise of personalized care.”
“Metrics? That’s like meters and kilograms, right?”
“In ‘Leanspeak,’ a metric is something that is measured, such as patient satisfaction scores.”
“I remember, Curmudge. Something that is not measured tends not to get done. The communication board needs to be kept up to date so that a problem becomes immediately evident and can be tackled ASAP.”
“Are you ready to go up to the higher levels, Julie? It’s windy up there today, but we won’t stay long.”
“You’re right about the wind, but the view of downtown is pretty good. The most distinctive features are the 222 Building, Appleton Center, the old Zuelke Building, and the County Jail. But here on the pyramid things look pretty much as Liker depicted them in The Toyota Way. (1)”
“That must mean that the Toyota concepts of People and Partners (Level 4) and Problem Solving (Level 5) are enduring. We discussed those back in January of 2008. Fortunately, the application of these Toyota concepts to hospitals has been addressed by Studer (2) and Stubblefield (3) (the People concept, Level 4), and by Graban (4) (Problem Solving, Level 5). We may devote a whole discussion to these people in the future.”
“I recall your mentioning that all these books are must reading for health care leaders. Is there anything in them that bears upon our Affinity promise of personalized care?”
“Almost everything, Julie. Both Studer and Stubblefield agree that satisfaction of patients is directly related to satisfaction of employees. We achieve that by providing employees a place to work where they feel they have a purpose, are doing worthwhile work, and can make a difference. The authors emphasize that continuous leadership development is absolutely essential. Graban’s discussion of problem solving reinforces what we already know about going to gemba and getting to the root cause of errors, which can be serious patient dissatisfiers and the most critical problems in a hospital.”
“Thanks for bringing me up here, Curmudge. Maybe the image of a pyramid will help me retain what I have learned for a few thousand years.”
“Lots of luck, Julie. Let’s hike down the back trail. It’s not nearly as steep as the way we came up.”
“So what are we going to talk about next week, Curmudge?”
“It’s a secret.”
“A secret! I bet that just means you haven’t thought of anything yet.”
“Not true, Julie. I planned next week’s conversation a couple of weeks ago. When I can’t think of anything for us to talk about, that will mean that the synapses in my brain are getting lost and senility is setting in.”
“Oh? You mean that isn’t already happening?”
Affinity’s Kaizen Curmudgeon
(1) Liker, Jeffrey K. The Toyota Way. (McGraw-Hill, 2004)
(2) Studer, Quint. Hardwiring Excellence. (Fire Starter Publishing, 2003)
(3) Stubblefield, Al. The Baptist Health Care Journey to Excellence. (John Wiley, 2005)
(4) Graban, Mark. Lean Hospitals. (Productivity Press, 2008)
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