Alarm Fatigue Revisited

Here is a little throw back from one of our most popular posts! I know it can be searched but thought you all might enjoy seeing something from 2010....

 

Wednesday, September 15, 2010

Alarm Fatigue

I was cooking a BIG meal – one with several burners going, the oven on, and even the microwave.  It was one of those “Martha Stewart has nothing on me moments.” (Ok, I was really more like a I'm a tall version of Rachel Ray) There were 4 boys running in and out asking questions and trying to “help” - other kitchen noises like the garbage disposal, can opener, food processor plus of course the TV was on in the other room. It was loud - like the Chiefs Stadium when we beat the Chargers on Monday night – LOUD! The point is I had a lot going on and neglected to set the egg timer for one of my pans and ignored the beeping on the oven……all of this to say we ended up eating at Culvers that night.

My kitchen scenario is much LESS intense than a nursing floor. No one was critically ill, there were no emotionally distraught family members, there was no Code Blue – it was a kitchen. (Well, the food was critically ill by the end of it – I digress) The point is think about your most intense - loud - busy moments and then think of how much more intense - loud - and busy the nurse is and you will begin to understand  “Alarm Fatigue”.

On a floor with 30 patients with IV pumps, nurse call, telemetry, other physiological alarms, etc there is bound to be some noise. The current methodology of listening for an alarm can really hinder productivity – but leave productivity out of it – it is a major safety concern.

Let’s take an easy one - Do you know the most common way we document a response to an IV pump alarm? The patient has pressed their call button and the nurse is notified that the IV Pump was dinging in their room. Think about how scary that is for a patient and their family – who has no idea what the dining means. Do you know the most inexpensive way to fix that problem? Automate an IV pump alarm to the caregivers wireless and explain to the patient and their family what will happen if the alarm goes off. (BTW – repeat that information every time you enter the room for rounding.)

Here’s a freebie - Depending on your nurse call system there is generally a quarter inch jack that can take a contact closure alarm – old school – this is the way my Dad did it when he sold nurse call in the early 1980’s. Order the cord you can use it tomorrow in your hospital. IF you have a question (hospital) – call or email me I will walk you through it. There are much more expensive ways to automate these as well.

The challenge is at some point in alarm automation and “management” you simply begin to displace the problem. If a clinical alarm device is trigger happy then your wireless device will be as well. Too many alarms is still TOO MANY ALARMS – just because it’s quieter on the unit does not mean its better. At some point it’s time to really review the technology that is making the alarm happen, AND review the process of who is getting what alarm when and why. The event in Boston was not due to the alarm noise, really it wasn’t even due to accountability because no one “heard” the alarm. The Critical alarm was turned off and the Warning alarms were ignored. Some automation would’ve helped the issue but it may not have solved.

Patient safety officials across the country have said the heart patient’s death at Mass. General shines a spotlight on a national problem with heart sensors and other ubiquitous patient monitoring devices. Numerous deaths have been reported because of alarm fatigue, as beeps are ignored or go unheard, or because monitors are accidentally turned off or purposely disabled by staff who find the noise aggravating.  ()http://www.boston.com/news/local/massachusetts/articles/2010/04/03/alarm_fatigue_linked_to_heart_patients_death_at_mass_general/?page=1

It’s tragic that a death occurred due to an alarm issue, and no family should have to go through that.  That death should be a rally point for all of us in the device industry.  

Margin

I grew up in a family where the expectation was clearly set that you would advance in knowledge beyond what the teacher was teaching at school, the preacher taught on Sunday’s, or any coach could provide.  It was your responsibility to grow in wisdom.   I have carried that thru into my adult life by maintaining a daily “quiet time” to read, study, and grow - setting aside 45 min to an hour each morning. (which happens to be the quietest time available in a house with 4 young boys.)  

A few weeks ago I started a study called “Balancing Life’s Demands” which discusses mental, physical, emotional, relational and spiritual balance.   The study uses the word “Margin” and defines it as the difference between what needs to be done and the time you have to do it.  I will have yet another birthday soon….not real thrilled about it…..so the identification of what one would call balance or margin is becoming a more focused effort.    

The ironic part of this life assessment is over the past 14 years, I have consulted with dozens of hospitals on defining margin for their organization. I analyze the obscure data generated by specific variable workflow activities and give recommendation on utilizing technology to enhance it.  The software we developed automates much of that process and enables continuous improvement.   Aperum uses data visualization to identify the often misunderstood work load driven form theinconsistent demands on their care teams generated by patients.  

I keep telling myself this life assessment should be a no brainer - life margin should not be elusive or nebulous.  I have built an entire business on designing “at a glance visuals” – where the metric quickly and effectively means something to an organization. However, it’s easy to say “I prioritize my family and church first” but if you look at the quantifiable data of hours spent per week – it’s not really a balanced metric.  (Same is true in nursing if you analyze where they spend the most time – you will find it’s not at the bedside so the perception is the main priority is not “direct” patient care….but that’s another blog.)

Strangely enough, I was a week or so in to this new study when Ed Marx posted his blog Bank Life, Not Vacation Days.  I loved that he had thought of a metric for evaluating whether or not he was in check for his commitment to balance – PTO hours accumulated vs PTO hours used.   A simple and easy to define number that encompasses a lot of information.  That’s the key – everyone knows that you have fewer PTO hours than you do total work hours – so it’s not a 1 for 1 equivalent.   It’s a predefined measurement of additional time away from work. Our payroll company generates that automatically and posts it to our online account – I honestly have never looked at it.  Not because I am pretentious and think the walls would fall down without me (I travel enough to know that my team has the operations side handled).  Mainly, I love work and I don’t really think about it unless prompted by my husband that a vacation would be nice.  I took a look after reading his blog…..let’s just say I booked a vacation next month. 

Thanks Ed.

If you are in Health IT and are not familiar with Ed’s blog  –CIO Unplugged –  he is a consistent blogger that has a way of communicating things that present more than just HIT initiatives – he gets “real”.

HIMSS Day 2 & Histalkapalooza

My goal with HIMSS is generally to have meetings, see the vendors, and get inspired and rejuvenated for the next 11 months – being with 33K other geeks really helps me get refocused on what is really “innovative”.    However, as John Moore (@John_Chilmark) tweeted there are a lot of “Me toos” and at HIMSS.  It’s true you can see the wide  red ocean of nothing new being under the sun.  Or people thinking they are disrupters but really they are noise makers in an already disrupted space.

The booth that I was able to spend the most time in (ironically since I live less than 15 minutes from their Innovation Campus and pass it on my way to work every day – I hoped on two airplanes and a taxi to see them here) was Cerner.    Their Care Connect area was very impressive.  I am still a huge fan of  Mystation (even though it’s still not on an IPad where is should be).  I like the concept of driving more patient understanding and engagement throughout their care process.  This is something that could follow them home and be part of the home health model....not sure if she said that but that’s where my mind went.   Ashleigh showed me the Care Connect mobile device area.  It’s not easy to give a concise presentation that shows how really powerful a tool is and she did a great job.  If you have time stop by and ask for her.   The tool lets you see not only your patients but their status it’s a really nice blend of EMR with alarm notification information.  

I popped into the Hil-Rom booth – and got the standard – “who are you and why are you here”  after saying who I was I told them about the blog and one replied “yes only if you write nice things about us….”  (that should be the number one thing not to say to a blogger – it just makes it tempting to write less than flattering things….) I will do my best.  The challenge with nurse call is since it’s hardware and we live in a software world – it looks the same for a number of years before a new system comes out….same is true for Hil-Rom – it looks the same as it did the last couple of HIMSS.   However, they did make a statement which perked my interest – that “we don’t need middleware” – I think I am going to work on a post called “the death of middleware”.    It’s true – most nurse call light systems don’t need middleware but the implication from Hil-Rom is that they were middleware with the ability to automate information from their bed, their fetal link alert system, and their nurse call…..so that’s where you get the ding…..it’s not about “your” anything in middleware it’s about “their” everything.  So long as you have a single vendor ecosystem you can achieve what they described – kind of like how EMR sells their interoperability.  

I stopped briefly by Rauland - same as Hil-Rom the hardware just is what it has been for the last few years.  However, their newest software addition is Responder SYNC.  I have heard people call this single sign on...which I say kind of.  Sync claims to deliver on the promise that the alarm notification world has been talking about for years – Single Assignment.  Middleware claims this service by allowing a single point of assignment for multiple devices but as everyone knows that doesn’t really “sign you in” to nurse call – the lights and the tones do not follow the middleware assignment.   From what I saw - the greatest benefit to SYNC is the ability to sign on using EMR.  You are still limited in who can do this (Connexall and Cerner have made the interface) but evidently it's "open".     Stop by and ask about it - it's worth the converstation.

In general the floor seemed very steady but not busy – not the shoulder to shoulder crowd we sometime experience at HIMSS – but it was steady.  I did hear several vendors say there were fewer people….

My evening ended at the HISTalkapalooza event – I was not fashionably late.  I saw some amazing shoes (especially @TIMURDC which were my favorites) and was able to chat with lots of interesting people including the folks from Dr. First – I am going to see their booth today because it sounds amazing.   I chatted with Jonathan Bush about his lack of ability to score soccer tickets while sitting next to Neal Patterson….  I ended up on the front row of the prizes and was able to snap some fun photos....  the one of @Farzad_ONC has been retweeted a lot.  As I left, once again ran I into Judy from Epic.  Thanks for the invite Mr. H.

 If you have time today - I am speaking at the Burwood Booth 5019 @ 3:15p  come check it out.

 

 

Nurse Call Selection Process

 I thought I would share some tips to anyone looking to upgrade their nurse call system or drive any change within their current platform (upgrade is a variable term which encompasses hardware and software)  Sphere3 has walked a number of hospitals through this process and are glad to be of service to any hospital looking to update.

Hospital Tips:

1)      Define the REASON for change first – it’s generally three things – new construction, remodel, or existing system is "old". Your hospital will have some SOPs attached to each one. If you are looking for definition around "old" we have tools you can use to define and structure your business case for update.
 
2)      Define the INITIATIVES you want to improve which will be enabled by the change. Strip away everything that does not align with those initiatives, and compare the systems.

3)       Define the WORKFLOW associated with improvement of these initiatives.  Don't think about the technologies - define what would be the best process to improve your initiatives.  I know this can be very chicken and the egg for some folks.   There are groups like Sphere3, Burwood and others that can provide you with a vendor agnostic view of what current technology CAN do which allows you to define HOW you want the system to work.    
 
4)      Pick Three Systems and review for alignment with your core workflow, and meet with representatives.  Provide them all with the same workflow and initiative information and allow them to present how their system will meet your needs.  Their presentation MUST show you how their product will perform the workflows you have described.

They will all have “Whiz Bang” features and will highlight them as something that you should use to make your decision.  The truth is  if “Whiz Bang features”(which can only be supplied by “one” vendor) become decision points then it really detracts from your ability to make a workflow decision.  Please note – talk paths, voice over IP, single sign on for multiple applications, SQL databases, etc these are not Whiz Bang – these are essential functionality statements.  Understanding each systems IT structure and potential limitations is really important.  We should never make a decision in a bubble – multiple parties use the system and multiple parties maintain the system.   Make a clear delineation between Whiz Bang and Functionality.  
 
5)      Reduce to 2 systems and set up site visits of ACTUAL working client sites – their factory tours are all cool and the experience is meant to be incredible. Whether you go to the “farm” or an “experience center” you will be wowed…..that’s the point. Though I will agree with the vendors – having the opportunity to see all of the flexibilities of the systems can be valuable.   Go visit at least one real client site….proof is in the live pudding. 
 
6)      Review the database for ease of reporting AND structure.  If they claim have ability to interface with other products such as middleware, RTLS, phones,  Aperum® etc ask for them to provide a site where the data has been validated. Then ask for a sample DE-identified file for review. I need to emphasize here – there are holes in the way certain systems record data – it’s important to understand what those are and how it will impact your ability to use their data to make decisions in the future.
 
7)      Get your prices and take time to understand what is in them (or hire someone to review them for you who will understand the gotchas.) I have found on several projects now that pricing can be challenging to review (even for me and I started working with nurse call in 1986….if you do the math that’s a funny statement.) I have seen simple parts lists with a price to a 300+ page document.  If they send you a 300+ page document – read it – wow is it revealing about what they will and will not guarantee. (Check the contract if they will not “guarantee the operation of their IT system” runaway)

When you strip away everything that is “fluff” in these proposals and get down to the brass tacks of will this do what you want, will the vendor be available to service you when you need (not when they can make time to get to your area), and is the hardware AND software high quality and reliable  --- then you know you are making a good decision based on your specific needs not on their competitive advantages.

I could write pages on this process – if you are making a change this is a major capital and operational investment that affects a hospitals HCAHPS scores (which leads to reimbursement etc) it's important to really do your homework.  The industry changes are really interesting right now so don’t get caught with a system that won’t be here in a year or a company that can’t support your needs. 

If you have questions feel free to email me or call us.

kgovro@sphere3consulting.com

Sphere3® announces partnership with Stryker

Sphere3®, the industry leader in medical device alarm and alert analytics, has partnered with Stryker to provide a next generation bed-related compliance and safety alarm management tool.  Stryker’s new iBed Wireless system uses state-of-the-art sensory and communication technology to provide real-time smart bed data about patient position and bed configuration to enable determination of bed compliance with hospital safety standards and safety risk conditions.  The iBed Wireless system also produces and alarms wirelessly for notification of potential patient falls.  Additionally, data about siderail position, bed exit, brake, bed height, and more will be visually displayed and combined with other medical alarm and alert data to provide better insight into the patient's safety and other aspects of their stay.

“We are excited to partner with Stryker beds.  It's powerful for our clients as they build a non-filtered view of the patients stay through their movement, request patterns, and physiological alarms.  Stryker beds produce data and combined with our analytics tool it's amazing to see the picture of the patient stay.”  CEO, Kourtney Govro.

Intego Acquired by CAS

Recently, I had the chance to chat with Charles Bell, Founder of Intego Nurse Call.  I always enjoy meeting fellow entrepreneurs - for those of you who don't know entrepreneurship is an incurable disease as much as it is a passion.

Listening to Charles, I am reminded of the raw creativity and passion that drives innovation and ultimately new jobs into our struggling economy.  Charles started his company in the early 1980s but has been in the industry since the early 1970s.  He regaled me with stories of old Zettler systems that he was able to wire and do innovative things with, but finally settled on the fact that he needed to build something all his own that would challenge the status quo.

The Intego mindset is simplicity - how can we provide a system let the RNs be with patients more?  How can we leverage what has to be there in the wall In a communication model that compliments ease of use? 

Charles speaks highly of what he calls the ROC - this model takes all the patients calls from nurse call and routes them directly to the centralized operator core.  Thus, removing the direct interaction from the caregiver and allowing her to prioritize her response using her skill set as a nurse to determine who/ what needs attention first.   The strategy is to utilize a low cost device - such as a pager - that can compile the messages the caregiver receives.

This model is one that I have been promoting for a while as well.  The data models that I have run support the idea that providing greater context to the alarm and alert message can be extremely valuable to the caregiver.  The challenge is the design model - the clinical aspects of the design must be setup by a RN with a technology background.   Someone who understands the information being recievded in the command center and how it can be distributed in a meaningful way. 

The theory is this - patient presses the big red button on their pillow speaker (aka the "paddle") the call goes to a centralized point in the hospital, such as the operator area (where external calls are received) then the operator triages them back to the floor.  (Look back to the blog I did on Chris Heim from AmCom) 

Since you are using a lay person to triage - its important to design a really simple decision tree process.  (Similar thought if you have your IT Help Desk triaging Nurse Call issues)  

What I have found looking at this model is often laziness kills it's effectiveness.  The operators may not use the available messages and only distribute a blank - assigned message - ie "PCT Needed".  If the team answering the calls are not driven to follow the process it becomes garbage in garbage out.  It is critical to manage the data associated with their effectiveness and following the process. 

The other side of this data is to identify if the caregivers are using a task list approach or varying their response based on type of need - you cannot run the data model or report on this model any more effectively than decentralized to phones if you are not following the process correctly.   

I also HIGHLY recommend coupling this with strategic automatic distribution of specific Emergency level call types AND allowing the caregiver to call back into the patients room via a call back feature on their wireless phone (or smart phone if available).

This strategy is complimented by Intego recently being acquitred by Critical Alert Systems. CAS is a relative new comer to the industry, as its a purpose built organization to compile specific technologies to drive full throttle into the industry. Charles will remain with Intego focused on driving new business and strategic relationships. 

Great conversation - thanks to Charles for taking the time to chat with me.

If you have a health IT business in the medical device space and want to be featured in the blog email me - our next feature is with Strykers Rich Mayoras - talking about their new wireless bed.

HIMSS 2012

I am really looking forward to HIMSS this year - it's always a lot of fun to see everyone and catch up on the year.  For the first time Sphere3 will be not simply attending HIMSS - we will be displaying in two of our partners booths. 

This is our new video that has had over 100 views in the past 2 days.

The Burwood Group is a consulting firm out of Chicago that really has an incredible practice around healthcare technology.  I have had the pleasure to work with them on several projects in the past year and would highly recommend their services to any hospital.  Their clinicians are really well spoken people with a great depth of knowledge in technology and transition planning.   

I will be presenting at their booth on Thursday at 11am  you can register here http://www.burwood.com/himss12

We will also have the pleasure of being a part of the Connexall Booth.  Connexall is an industry leader that has more than doubled their market size in the past year.  Their team is lead by John Elms and Mary Baum.  They are aligning the brand of Connexall US with transformational care by spending a great amount of time listening to hospitals across the United States.
http://www.connexall.com/listening/

As I did last year - I will be updating the blog throughout the conference sharing thoughts and learning.  Send me an email if you would like to see Aperum in person and we can coordinate a time to meet.

The Immersion Principle

In college we were required to take a foreign language to graduate, and if you read through the information you figured out that with one additional class and a study aboard you could get a minor.  This was a no brainer for me – I got to go to Spain all in the name of education.    The purpose of the study abroad was to immerse student into the language and the culture.  Unlike a class which trickled information into your glass slowly with finite precision allowing you to drink at reasonable pace – a study abroad throws you into the lake with a small life vest and expects you to learn quickly how to tread water.   

Have you been immersed in the culture and the environments of the people you are developing products for?  Technologist, if you are in the business of creating a “business” is it really worth it?  Can you truly attach passion to it?  As for me and my house – we don’t think it’s a long term answer.   Passion comes from creating tools that really help people. 

I met some really great folks at the Connexall User conference in Toronto.   One was Craig Martin an “IT Guy” from University of Michigan Health System.  Craig and his IT team have immersed themselves into the different units to gain clear knowledge of clinical needs.    Craig described his goal of disintegrating silos and creating more effectiveness in development and decision making ideals around purchasing and creating healthcare products.   The formula is really quite simple from a high level view -  it’s to become the foreign exchange student on the clinical unit – to immerse yourself in the culture and life of the people who will be most affected by the choices on technology - the end user.  On a hospital level Craig’s “Immersion Principle” takes a person from IT and attaches them to the hip of a nurse to experience a day or week in the life of someone who is directly engaged in patient care.  Craig said  “We in healthcare IT cannot hide from the sometimes overwhelming things that go on in our hospitals.” 

I am impressed by this team they were focused on creating environments for better care by utilizing technology as an enabling tool.  I can’t say that of every hospital.   

Technologist – when was the last time you stepped foot in a hospital for something other than a sales call?  Where does your passion for product come from? Is it in a paycheck or is it in the realization that what you are doing is making a difference in the lives of the sick and helpless.  This which we do for the least of our brothers…….

After being in the hospital with #4 for a week – I will never look at a call light system the same again.  My passion is in the eyes of that sick baby.

When you immerse yourself into a culture – your perspective is forever changed.   Do you need an inspiration?  Spend a day on the floor of a hospital with a nurse doing nothing but observing – not selling, not creating, just observe.  Let their reality become your reality.  

The 3rd Annual Medical Device Conference

I am really excited about the workshop S3 is presenting at the Medical Device Conference.  The presentation will take a look at how different types of industries measure effectiveness.  We are in process of touring, interviewing, observing, and documenting several interesting places to bring value to the MDC attendees. We will be looking at Shatto Milk Company, US Toy's 750,000 sq foot Distribution Center, a Call Center, a manufacturing facility, and more.  During the workshop we will use the case studies to determine how efficiency and effectiveness metrics were used to improve productivity, customer satisfaction, and more.   We will be applying the learning to developing useful metrics (IndicaresTM) for your hospital's patient communication platform.

I will be blogging about some of the experiences prior to the class so stay tuned to learn more.

Sign Up - this will be a lot of fun!

http://www.tcbi.org/files/agendas/MDC3_Agenda.pdf

The ER Visit Blog

As some of you saw in a recent tweet, I had to journey to the Emergency Room for a brief visit.  While it wasn’t intended to give me material for a blog post – it has provided me with some thoughts that are worth sharing to my fellow technologists.

During the visit one of the questions I was asked by my fabulous nurse was "Who is your primary care physician?" This should be an easy one, right?  Well, it’s easy if you have been to a PCP more recently than your last year of college.  Yes, a little known fact about me is I have a terrible phobia of Doctors (ironic right?) As part of my discharge process both the Nurse and the Doctor said I needed to followup with a PCP.   I told them I understood and thanked them for their help – fully knowing in my mind that I had no intention of going to see a PCP….that’s where sick people go and I am not sick…I am healthy, OCD about eating right, I don’t need a doctor.   My husband had other thoughts and soon I was scheduled to see a PCP.

As I bemoaned the coming doctors visit I had a call from my conscious the voice of reason since age 12  (her name is Carrie) and without belittling me she made mention that you can’t improve when you don’t know where you start.  Then, in a way only she can, she reminded me that I preach to dozens of clients and businesses.  "Kourtney, don't you tell people there is a need for “baseline” data before starting an improvement process.  Yet there is not one ounce of data pertaining to your medical care over the past 10 years."   (other than my calorie counting iphone ap)

Sometimes, even when we are healthy we need a doctor.  Technologist, do you make products that make sick hospitals better or do you create products that enable the on-going health management of hospitals?  At some point isn't the goal for the hospital to be well - doesn't that somehow work you out of a job if you are always focusing on sick?  

Even if you are focused on fixing a pain - How do you know that your technology or service has improved their facility?  Do you know specifically what processes you impact and what things within the processes you are measuring that link directly to patient satisfaction and improved care?  Can you measure them? Will you measure them?  Or are you satisfied with the status quo technology buying cycle where people by a feature and are not guaranteed a result.

Technology enables a process.  A process is NOT worth changing or implementing if the steps are not measurable and the data derived is not linked to a meaningful goal.

Technologist, if you are not providing a baseline that is documented with data directly from an existing technology prior to implementing a new technology then you are doing the hospital, it’s clinicians, and it’s patients a huge disservice. 

In case you were wondering - There is value in driving the wellness of organizations as well as fixing a pain.

In the end – I did go to see a Primary Care Physician. To all of you doctors out there, I chose him on a few factors - he was recommended by someone I trust, time spent with patient exceeded the norm, but my final decision point for choosing him..... what made the biggest portion of my decision?  He was part of the network of the hospital that I visited and he had automatic access to my electronic patient record from my Emergency Room experience.  No phone calls – no faxes just a few clicks and there I was in all of my single entry glory.  I drive 35 minutes to his office.

I know my Data is important in decisions and that on-going my data available to my care providers for logical diagnosis decisions is critical.

Reflections of a Former Fat Girl

A wise CEO I know said that “Trended Change is the only Change of Value.”  In terms that most of us can relate to – if you lose 10lbs and can’t keep it off then you have failed.  I have been on as many diets as Oprah Winfrey and failed as many times.  At my largest I was well over 215lbs, my smallest around 140lbs.  Now, I am somewhere in between.    Whether it was a pill or a plan I would move blindly towards the current fad diet searching for my magic bullet.   I call it experiential learning, after years of failure I have figured out that the magic bullet does not exist.  

The only way to succeed in consistent long term weight loss and management is by lifestyle change.   Which is a lot different than saying “I am going on another diet” A diet may provide a specific goal but it also implies a designated time frame, at some point we reach the goal.  How many of us look forward to reaching the goal so the diet is over and we can go back to “normal”?

A lifestyle change means that you not only have identified the functional causes, but you have established a starting point.   A lifestyle change involves education and understanding, which may require technology and data. Once you have identified the functional causes you can hone in on the decisions and behaviors that are creating the situation and begin to make a change.    I applaud my friends at Cerner for the KC Slimdown challenge and www.cernerhealth.com if you haven’t taken a look pop on and see.  If you are competing with Team S3 – good luck - I like to win and I really like Sporting KC. (It's one of the prizes)

At this point you may be asking – why is this CEO of a patient experience & safety analytics company writing a blog about diets?   Improvement whether its weight or patient experience is all about making a lifestyle change, and managing yourself after the change.     One of the reasons weight watchers works is because you are consistently watching your weight.  Hospitals need tools to consistently watch their weight.   I get on a scale nearly every day which some may find excessive but seeing the number motivates me towards doing the right things during the day.   

S3 Aperum is the like the scale I get on each morning.  It’s providing patient experience and safety data in a "weight management" format to allow leadership to make adjustments and alignments as needed.  I would love to tell you it is the magic bullet, but it’s only part of the puzzle.   Like any weight loss or management program technology is a tool that enables us to succeed it’s not the tool that makes us succeed.    We have developed 4 key areas called pickle points where hospitals have issues surrounding patient safety and satisfaction.  3 of the 4 are not technology based – they are identified using technology but the root is in people, policy, and behavior.

For fun – if you have a “Slimdown” story you would like to share – please post it as a comment.  We would like to hear of your success, your process, and on-going management.  

BBQ and Nurse Call

I have noticed that several of my blog posts involve food…diets…etc It’s a true statement that one of my vices is really good food – not pretentiously good food – just plain good food. My pallet is not well refined, but I know when something tastes good and when I am served well.



One of my favorite restaurants is Jack Stack BBQ. Disclaimer: I live in Kansas City and talking BBQ is similar to talking about religion. There are alliances to BBQ that span generations of families. So, to be fair let me list the other greats in the Kansas City: 1)Gates – where “HI MAY I HELP YOU” is shouted at you when you walk in the door, 2) Arthur Bryants - where sweat is integral to experiencing the meal, and 3) Oklahoma Joes - only loses points because of the name.


According to the Kansas City BBQ Society (http://www.kcbs.us/ ), Carolyn Wells Ph. B, tells me it is measured on Appearance, Taste, and Tenderness. To achieve success in competition you must have quality in 5 areas: cooking unit, meat, seasoning, fuel, and most elusive, expertise of the chef.


For those of us with the untrained tongue, the challenge with BBQ is all data to assess are qualitative judgment’s – meaning, based on how I feel at that very moment I have made a judgment call on its goodness. Don’t get me wrong - when you taste a crispy chopped burnt end sandwich with just the right amount of salt, spicy sauce, and for me Cole Slaw on top, you will know what heaven will be like and I challenge anyone to say it’s not good.


So, what does BBQ have to do with Nurse Call? I look at Question #4 “During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it?” Answers: Never, Sometimes, Usually, Always, and I never pressed the call button. I think would I ever answer "Always"?

One of the most concerning aspects of healthcare is measuring qualitative – questions based on “feelings” without creating a reasonable expectation for delivery. For example, asking “Did Jack Stack taste good?” to a random selection of people. (I have heard you East Coast folks think you know BBQ.) My perception of good BBQ is different than a person who prefers Memphis “Dry” BBQ , a North Carolina Vinegar based BBQ, and Texas hunk of meat they call BBQ.


In the next few blog posts I plan to break down question #4 and dig through how we can really expect to build continuous improvement and value from a “feelings” based survey question. How hospitals can use data that is existing in their facility to create quantitative Inidications of Care or what we call IndiCares™.


Just to get you started:


“During your hospital stay” this is a variable length of time. A metric based on an inconsistent variable is not easily understood and does not lend itself to being fixed. The time frame “your hospital stay” could be 1 day, 2 days, 1 week, or in a rare situation 1 month. The variable also could be a “frequent flier” as my favorite Children’s hospital calls their recurrent patients vs a one time in five years visitor. Their time may be short and consistent or random and long. 

We have evaluated data from over 30,000 patient days and the interesting thing about the data it is until you break it down by specific consistent measures there are very few patterns.  You have to stop looking at the data as Spaghetti and create a waffle structure.


A parting thought - If the data is barcoded according to which patient submitted it – why not just look at their nurse call statistics after their stay in comparison to their responses? If you are a hospital and don't know how to do that - call me or email me - I will tell you how to get to your data. 

The Recipe Matters

I love a challenge, and recently I have taken to making cakes. I am not Duff or Carlos, but I am determined to conquer the cake. My weakness is I don’t like recipes – ok, so I don’t like being told what to do, and I feel a recipe is just Betty Crocker’s way of bossing me around. When cooking, her recipes are general suggestions, but unfortunately in baking, it’s an order.

The thing with a recipe in Betty’s book is someone experienced has documented it – it has been verified – and it has made it to the general public. A recipe is successful because the common language used in each step. We are taught in grade school the standard terms of measure – cup, teaspoon, tablespoon, etc. We are also taught time – minutes, seconds, or hours. We are taught by our moms how to “preheat”, and we are taught by the Food Network how to “fold” in an ingredient.

Documentation of anything requires standard terms and common language. In a recent revelation in speaking with others about my professional passion for clinical alarm data and the picture of patient needs hidden within it, I found that there is not a current standard terminology in the arena of clinical alarm design. Therefore, I am proposing one. Just to set the minds of my readers at ease – Patient Communications Platforms are in my blood. You could say my youth encoded a understanding of clinical alarms into my DNA. I went to my first “nurse call” training before I could drive a car, and had a doll house with RTLS. I am not a novice, however, I am not so proud to think that what I’m proposing can’t be improved upon. Actually, I’d be thrilled if this proposal sparked a debate. So,I challenge all of my readers (all 700 of you) to comment. Collaboration can only occur if we are not so prideful to think we are perfect – if we can agree that little companies have as good of ideas as big companies – if we can solidly stand by saying we must create things for the betterment of healthcare because it’s really about patients – not all about profits.

This is Sphere3’s proposal for common language for documentation of Clinical Alarms. Below is a cascade of action – reaction that can either be generated by a person or the configuration of the clinical alarm system.

Initiating Action:

This is the beginning of the call. It can be manual, such as a patient pressing a button or physiological, such as a telemetry alert. The initiating action can also be a system trigger such as an occlusion or a system creating an alert based on a malfunction or necessary service request. The easy way to remember an Initiating Action is “it’s gotta start somewhere”.

Example:

Patient Press a “Normal Call” button on their Nurse Call System

Patient’s heart beat indicates a “V-Tach”
Notification Action:

How do people know that a clinical alarm has occurred? A Notification Action is the ring, ding, buzz, text, etc. This is the way in which a caregiver knows that an initiating action has occurred – they way they know the patient is in need. There are generally multiple Notification Actions for every Initiating Action. Every Notification Action is an invitation for the Caregiver to interact with the patient or their device.
Example:

Initiating Action = Patient Presses the “Normal Call Button”

Notification Action 1 = The Dome Light is White

Notification Action 2 = The PCT’s Wireless Device buzzes

Notification Action 3 = The PCT receives a Text Message “Normal Call Room #” with the option to “dial back” to the patient room.

Acceptance OR Rejection Actions:
If the Notification Action is the caregivers invitation to interact with the patients need it forces an acceptance of that request or a rejection. Accepting the alert requires an interaction with the patient or their technology. A rejection is a “delay of response” while it could indicate that the call is being ignored, mostly it indicates that the capacity of the caregiver to interact with the workload is challenged.
Example:

Notification Action3: The PCT receives a Text Message “Normal Call Room #” with the option to “dial back” to the patient room.

Acceptance Action 1: The PCT presses “Accept” it “dials back” into the patient’s room, they communicate with the patient.

Rejection Action 1: The PCT is unable to answer the call due to being engaged with another patient.

Escalation Action:

A Patient Communication Platform (aka Nurse Call) has a feature called “always an answer” where it will bounce a call if it’s not handled within a set time frame. Anytime a call is rejected, it bounces either automatically based on timeframe or physically based on a button push. That being said anytime a call is “rejected” technology should be programmed to create an automatic escalation action. Similar to an Initiating Action the escalation action is the technologies methodology of moving the call to the next person or place in line.

Example:

Rejection Action 1: The PCT is unable to answer the call due to being engaged with another patient.

Escalation Action1: Since the call has been “ignored” the technologies internal timer has allowed for a wait time of 2 minutes after which the call is sent to the RN’s wireless device with a message “Normal Call Rm 320”.
Escalations drives additional Acceptance and Rejection Actions, based on time frame. Again, a Rejection Action will create an additional Escalation. The hospital has to decide when the patient request (physiological or physical) has gone on too long, and at what point a failure to respond will generate the final Mandatory Action.
Mandatory Action:

The hospital’s determination of the final phase of the escalation process is the mandatory action. This designation is generally linked to Overtime calls. When a mandatory action occurs, the technology should force a physical face-to-face interaction with the patient. Mandatory Action is a new Initiating Action with a required interaction from staff.

Example:
Normal Call has not been answered in 4 minutes.

Mandatory Action: Due to escalation past allotted time frame the technology changes the alert verbiage to “Overtime Room 320” and tones at the main console and duty stations in all caregiver work areas on the unit. Additionally, the PCT and RN’s wireless phone receives a text message “Overtime Room 320” with no capability to call into the patient’s room. The call can only be cancelled at the patient’s bedside.

Now, let’s get back to baking cakes. Here is what I’ve learned in my most recent experience. There is a certain amount of discipline that comes with baking. To try to get creative on the basics is the best way to really ruin a dessert. Getting the basics of a cake right makes for a great foundation. But, the real fun and creativity begins once you have solid knowledge of the basic fundamentals of a cake. You see, I’ve now learned how to take a basic recipe and make an exciting dessert for my family—its about the secret additives, the substitutes that have just a little more interest in flavor, the interesting style of presentation, and complimentary chemistries of toppings, sides and coffees.

Clinical Alarms is the same thing. You have to know the basics and assure the foundational strategies in clinical alarm design were applied. BUT, once that is accomplished, there is so much more that can be done to enrich the patient and caregiver experience with request and response.

The documentation above associated with each phase is laid out similar to a process chart used in lean, however Sphere3 has created a methodology that is easy to understand and see at a glance. I will create a blog series on each phase of the process if there is feedback on this, but if there is not then we will just leave it as one persons attempt to create some normalcy to the market.

Comment Back – Ask Question - Email me kgovro@sphere3consulting.com if you don't want to post a comment – join this conversation.

It’s not “IP” it’s about creating something we can all use. This shouldn’t be an uneven playing field - this is Sphere3 stepping up and saying it's about the patient - not about the technology.  If alerts are designed incorrectly in the extreme case someone could die – in the most likely case a patient is dissatisfied with their care.

Patient As a Consumer

Coca-Cola is test marketing a product called the “Free Style”. It’s a box (isn’t everything) that allows the customer to select their Coke product, and even Mix n Match the flavors. If it were just a pop dispenser it wouldn’t be so interesting – what IS interesting is that the box is daily providing information back to head quarters about which products were selected, how specialty blends were selected, etc…in essence a direct information feedback loop of what people want.

Every Hospital has a “Free Style”- it’s required by code and it’s providing multitudes of data that reveal how a patient wants to be cared for on a daily, hourly, even minute by minute basis. The Nurse Call System is alive with information that indicates how a patient’s stay is going. Interestingly, this immediate patient feedback tool is often dismissed as something required by code. It is more about safety then about information. While many nurse call systems are reaching beyond the safety realm and designing abilities for requests – the data is inefficiently and ineffectively managed by the hospital.  HP made a great point in their focus group the Patient must be viewed as a consumer and we must cater to their needs.  The way to do this is to understand their communicated requests.

It’s got to be seen as more than just a safety tool – it’s got to be seen as a tool that lets the patient tell their story.

Let me dream weave with you for a while…… If a patient is consistently asking for a blanket could we automate the heating system to kick on and raise the temperature?  Yes, if we knew they were asking specifically for a blanket.
If a patient is consistently asking for water or ice chips, could a model be created to preemptively provide them with a glass of water before they ask? OR is that indication of something occurring physically that needs to be checked by a doctor? OR for you safety nuts – what do you do a little while after you drink 6 glasses of water that could cause a fall? OR could the information automatically be cross referenced with the EMR data and could IBM’s Watson decide a lab needs to be ordered?

I know that sounds space age but the information is all there – it just takes looking at it, creating a model, and well…the hard part getting everyone to talk together in a common language.

Just to get you thinking – why isn’t the nurse call system called a nurse call system – are they stewardesses or are they clinicians? It needs to be labeled the patient communication platform and IF it is a patient communication platform……why does it only reside within the hospital?

Falls and HIT Polic Committee Measure Concepts

Yes, the title gives it away this is a serious one. I read recently on a blog that the HIT Policy Committee is creating “measure concepts” that will be applied into meaningful use standards. At the very bottom – in fact the last one listed – is "Measures of fall events and screening". While we each are passionate about one item or another on that list, I believe there is some low hanging fruit that could easily be picked off and taken care of quickly AND provide the hospital with real “meaningful” savings.

The tricky thing about falls is that you are dealing with a patient. Patient’s actions, movements, attitudes, and even behaviors are a challenge to categorize into the neat and tidy little boxes that EMR vendors need to have strong governance in documentation standards. That’s a mouthful that says patients don’t follow the rules. The key is to look at the patterns of patient behaviors, staff behaviors, and other key dynamic factors then balance them with some static information. That is where you will find the answer to identifying Key Performance Indicators that link to predictive modeling for falls.

I know, I know you have never heard me use so many $20 words in one sentence. The answer is all ready there in the data. Think of it like seeing a Picasso – some people look at a Picasso and see random shapes, meaningless strange pictures and some people look at it and can interpret a story. I see the story in regards to the data surrounding falls. I had a great experience the other day with a hospital that “got it”. While I presented the data and our assumptions on the patient behaviors and indicators the staff filled in their specifics surrounding the staff’s behaviors. We see the same thing in the data – over and over again. We see the story.

This data should be in the Medical Record, it should be part of meaningful use standards, and it is part of the patient experience in the hospital. This is low hanging fruit – as my dad would say “easy pickins” – a real problem that is solvable.

I believe the key to reducing falls in a hospital lies in the ability to categorize, capture, and document the behaviors and actions. Believe me there are consistencies that we can currently identify. You just have to know where to look.

Defining What "Matters"

Creating focus can be challenging. I am a firm believer in goals (lots of Zig Ziglar growing up) but sometimes defining those goals is just as hard as achieving them. We may create a visionary goal, but not understand the detail to make it achievable. Many times our inability to identify what “matters” leads to failure, and our lack of understanding of the information produced creates a foggy understanding of success. That’s why it’s critical to be able to break things down into digestible chunks so we can quantify the achievement (or failure) towards our goals.

My six-year old struggles with spelling – if you have read my blog long, you know it’s genetic. In September his third spelling test score was a D. As soon as I saw that paper, I emailed the teacher to request a conference. The teacher explained that they had 20 words and 10 phonics per week, and the importance of good penmanship. (All I heard was 20+10= 30 items per week to learn!)

That information in hand, I devised a plan of action for home study. The plan was simple break down the materials into daily digestible goals. The next week we hit the ground running. We practiced daily, and he got a D+. To me, this indicated failure of the plan, not the child. We reviewed the goals, made an adjustment to the plan, and the following week he got a C+ then a B. Last week, I am pleased to announce, he had his first A, missing only 1 word!

The reason I am reviewing 1st grade spelling tests is because had I waited for the grade card, my baby would have had a D or F on his grade card. (The C he got broke my heart.) Using indicators, in this case the spelling test, to shine light on a potential problem we were able to thwart a hard to recover disaster of a bad grade card.

Hospitals are faced with a number of challenges – one of which is alarm fatigue. Alarm fatigue is a multi-faceted problem that encompasses everything from noise, to acuity mix, staffing and so much more. If you try to tackle the problem by saying "REDUCE ALARM FATIGUE" that solution is foggy at best.  However, if you look at the issue pragmatically then you can identify the multiple layers each with a “spelling test" indicator. Just like the spelling test above the solution lies in breaking down the problem into digestible chunks and refining those goals based on the outcome of the result.

Shamelss Plug - Our Scorecard is a tool – something that can be used like a spelling test – that along with daily goals and observation could solve the problem. The quarterly trend is much like a grade card. If you wait for the grade card to correct course – then you may be too late.
My advice for today – look at everything as a solvable problem. When the problem is too big – break it down as many times as it takes to become understandable and digestible.

Keep it Simple Sweetie.....

I was recently asked why I related healthcare IT to a car in a previous post, and did I think that it made me sound less “techy” or intelligent?    Forgive me while I soap box a bit - One of the things that bothers me about healthcare IT is we use overly fancy words, acronyms, and phrases to describe something really simple. While I understand this is similar in many industries – for example, the dentist yesterday he used 15 different words to describe my sore tooth. It’s the second tooth from the back on the right side people! Bicuspus chomper regularus painfulugus!

It would be easier if we could all just translate a little. That’s why I try to use a lot of non-healthcare and non-IT analogies. Not because I don’t understand – because I do. I understand that to most people we work with the concept is more powerful then a detailed description of the program or Code. The result is more critical then the how.

To those of you who program – don’t get me wrong I understand that the details must be covered and if not then the concept can never occur.  To those of you who live in the concept – the details drive you nuts but without them your vision is just words.  Words accomplish very little.

With everything occuring in Healthcare IT - communicating between technical and non-technical people is critical to making things work right.

What do I know?  I am just a little gal from Missouri…..with a company that takes “Anything that rings, dings, or buzzes and we design the workflow to get it to a wireless gadget that a caregiver carries.”

Grady Health Systems Surgical Service Workflow

At HIMSS I had the opportunity to tour the Surgical Services area of Grady Health System in Atlanta. The visit was facilitated by Centrak and hosted by Hakan Iliken the Director of Anesthesia and Director of Process Improvement. Iliken was an exciting individual who shared his vast knowledge of process design which is rooted in his Industrial Engineering, Software Development, and CEO background. Iliken is in charge of making sure the technology applies and assists the caregivers, patients, and doctors throughout the day. What I found unique about Iliken was his ability to not only look at things through clinical glasses, but also examine it with a business mindset - balancing clinical and business.  The technology implemented was a Centrak RTLS System tied into a Perioptimum tracking board.


According to Iliken - The Goal of the Implementation is to “Improve Surgical Services throughput and productivity by utilizing a system with Real Time Accuracy.” A secondary goal was to "Increase Transparency."

The Primary Goal is “easily” definable – increase utilization, and ultimately increase revenues. Iliken has seen a 10% increase in Utilization during Prime Time. They are mobilizing staff and moving patients more efficiently and effectively, and they are able to identify bottlenecks readily.

One of the key ways that they accomplished documenting efficiency was to utilize the three flexible buttons on the In-touch badge. The way Iliken designed the processes ,which were enabled by the technology, is each button represented the next step in the process – the wow factor in the design is as the badge physically moved into a different area (Pre-OP, OR, PACU, etc) the buttons would change meaning.  Thus, offering extreme flexibility.  For example button 1 (represented by a *) means “Anes ready” in PreOp, in OR it means “Induction Begins”, and in PACU the same button means “Phase 1 Complete”.  To aide in the ease of use color coding was used on the tracking boards in the staff area recording and identifying the patient’s location and specific steps in the process.  Each staff member is provided with a "cheat sheet" that is card sized and fits into the ID badge holder.  In addition, since the button pushes were not tied to a physical item such as a wall it provides for additional future flexibility.

The ability to dissect a process is a powerful tool. Think of it like an assembly line at Ford. Each person in the process touches the product, and with extreme accuracy they can identify where the issue occured. They can also identify if it was a people or process issue.  Can all of this be achieved with RTLS and process design in a hospital? While I am on board with lean and six sigma design and the ability to reduce errors by using strict process – I believe that healthcare at its core is about people helping people. People who are sick and people who are taking care of them – no matter how we try there will always be a people element. Technology is a tool – it’s not always total the answer.  
Stay Tuned for Part Two - The secondary goal, I found most fascinating, probably because of my groupie like appreciation for Paul Levy’s blog. Transparency means no holds bar real data – the truth that bypasses the finger pointing and assumptions.

Product Life, Technology Life, Workflow Ability - Part 3

Technology Life Decisions are more readily linked to the exciting features that differentiate the products one from another. Some might call them frivolities, some might see them as necessities. Either way they are items that enhance the base goal of the product.

Technology Life Decisions are difficult to make due to the ever changing nature of technology. The “lifespan” for many technology decisions for medical devices is shortened to 5-6 years (sometimes more or less depending on the flexibility of the platform that is being purchased). Hospitals may delay purchase to wait for the next model to be released. Road Mapped items become decision points and actual realities become less critical. Not to say that a product, software, or service that has a vision for the future is unimportant but reality is more critical than vaporware.

Interestingly, the technology life decision points – things that a manufacture or developer creates to differentiate their product - often become base product decisions. Think of power windows. 20 or fewer years ago wasn’t it suitable to have a crank and before that wasn’t it a luxury to have a crank? Power Windows are an enhancement, but because of the end users interest they have become the standard. The point is often the technological enhancements won’t be enhancements for long .

Early Nurse Call Light Systems consisted of one light and one tone. Now we have systems that have unlimited light and sequence capability through LED and unlimited tones by allowing for wave files to be uploaded. Eventually, this will not be a technological enhancement – it too will become the standard.

So how do we bridge the gap between the technological enhancements of the new products and the apparent short comings of previous products. We believe the answer lies in Unifying Technologies coupled with proper workflow design.

For example, in a car, Micosoft SYNC integration allows the information from your mobile phone to download into the car and allows for voice command and hands-free calling through voice command. While all base capability of making a phone call while mobile is available using just your mobile phone, SYNC increases the value of the vehicle by enhancing your experience with the phone.

SYNC’s value is enhanced because of a unifying technology called BlueTooth.
Similarly, all nurse call systems can notify a caregiver of a patient’s need with a light and a tone. However, some can integrate to wireless phones allowing the caregiver to be mobile while speaking to the patient. There is intrinsic value to the time savings that a hospital will find by integrating their nurse call system to the nurses wireless phones. According to our research, over 30 minutes per day per RN or more depending on the style in which the integration is made. However, prior to today all of that is only possible with a unifying technology called Middleware. Interestingly, this "feature" and ability developed by a vendor outside of nurse call is becoming part of nurse call systems. Eliminating the need for a "unifying technology" all together.

Stay Tuned for
Workflow Ability and how you can transition from one platform to the next more easily and over a longer term investment.

Technology Life, Economic Life, and Workflow Life

“What color do you want?” This is the first question I am asked when I go car shopping. (Yes, it does irritate me.) While I see that is an important decision for most people, do people really buy a car for it’s color?

Wouldn’t it be more effective to ask – “Why are you shopping for a car?” This should be the question of every vendor pushing a medical device to a hospital. "Why are you purchasing this product? Why now? What initatives are you trying to solve with this purchase?"

If you look at purchase decisions. Most will fall into one of two timelines or life-spans: Product Life and Technology Life. Product Life is the underlying practical reason for the purchase, and Technology life is the technological enhancements we "can't live without". We believe there is a third area for medical devices that can leverage existing platforms, blend their usage with new product platforms making transitions easier – we call it Workflow Ability.

Technology Life = 5-6 years vs Product Life = 10-12 years

Workflow Ability can extend the Technology Life 3-5 years balancing out the difference between Technology and Product Life. It allows for proper transition between platforms.

So how do we bridge the gap between the technological enhancements of new products and the apparent short comings of a previous investment?

Many hospitals will simply make a Capital Investment and change to the new platform, but is that really necessary? In these economic times is that really a practical decision?

We believe that the first two decision points (product and technology), while important in making a transitional question are lacking in their ability to allow the hospital to make a long-term transitional change. We believe that Workflow coupled with unifying technology can really increase the lifespan of existing platforms thus leverage the hospitals original investment.

This is a LONG post so I am breaking it up into sections.

Stay tuned for more on:

Product Life

Technology Life

Workflow Ability with Unifying Technology