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.

Symphony of Information

Have you ever heard a 9th grade band on their first few days of rehearsal? I lived it – well a much heavier, awkward, glasses wearing, hair out of control, version of myself. The interesting thing about 9th grade band is everyone has had their instruments for a while so most can make a noise that resembles music, but “musicality” is really lacking. What they teach you in that critical year is how to be “Symphonic” which means taking something that is very complex and diverse and pull it together harmoniously. For a percussionist (like myself) that means - just because you can play the loudest doesn’t mean you should and that following the conductor is not an optional activity.

As I was reviewing data this week (reams and reams of data) I began to notice a series of new patterns. Patterns, within themselves, are fascinating but they get interesting when variations occur. So in musical terms if you have 4 measures of quarter notes and then a measure of 8th notes and then a measure of 16th notes the original pattern varied to a pattern that builds intensity. Intensity builds excitement and excitement builds to the climax of the song. As geeky as this may sound the workflow data we review is often like a musical score to me – sometimes just out of sync.

I don’t know about you but when my mind gets stuck on patterns I have a hard time breaking free. My solution has always been to get in my car and turn the radio up to blaring sound to let my mind focus on the patterns in the music. After a few minutes identifying them, and figuring out the layering it is easier to refocus on something new.  This week was especially overwhelming as we discovered patterns outside of alarms that affect our data points AND that the information is readily available.

That’s when it hit me – the problem with the patterns that I was seeing for this particular hospitals report were that they are simply out of sync with the other dimensions of the unit. (Clear as Mud?) Think of it like a musical score – if the woodwinds are playing 3 measures behind the brass who is playing two measures ahead of the percussion it sounds like noise. However, if the conductor is able to see how the patterns line up and is able to pull everyone into sync then it’s an amazing symphony.

Music at it's base is a complex math equation - music at it's core is art and soul.  The key to making beautiful music is to be able to define where the math ends and the soul begins.  The same is true in clinical workflow design the numbers may speak the "truth" but the answer may lie in the "soul" of the work.  That's what we do - we help the hospital define the math so that the clinicians can better create the soul.

I know this is two months in a row of shameless plugs but we are creating a new dashboard that is unlike anything in the market today.  We have welcomed several new team members in to help us mold the product into something that can quickly help a hospital reduce falls, increase patient satisfaction, and increase safety. 

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.

Changing Lanes

I was driving to work yesterday in the Tahoe (aka Mommy Mobile) since my car (aka Princess) has a flat. As I sped down the road with Cruise Control set – I couldn’t figure out why the Tahoe wasn’t slowing down as I approached a much slower moving vehicle. All of the sudden, I remembered that the Tahoe does not have the cruise control distance feature that Princess has built in to ebb and flow with traffic.  I slammed on the break as to not hit the vehicle in front of me. You see, the Princess car can practically drive itself. You set cruise control and it slows down as it approaches a vehicle and once that vehicle moves out of your lane it resumes its constant speed.

This change in vehicles has caused a number of issues for me this week. I have no hands free calling if I push a button on my steering wheel and say “Call Dad on Cell” it only changes the radio. When I go to change lanes there is no light telling me there is someone in my blind spot. When I go to back up, I actually have to look over my shoulder because the radio does not change into a back up camera picture. All fun and joking aside - This experience really relates to what we are seeing with devices and workflow design in healthcare. (Bet you didn’t see that coming.)

There are really two paradigm shifts. First, there is an expectation that a technology will provide more and require us to “do” less. This does not discount the fact that we still need human interaction. Princess really can’t drive herself, but Ford has developed ways to reduce the amount of action I need to take while driving. They looked at the driving requirements and removed steps out of the process that could be replaced with technology. They also provided technology that could enhance the driver’s ability to make decision. Isn’t that what all technology is supposed to do?

There is a warning that should be going off in your head at this point.  All of this high tech stuff is great but what do you do if the technology is different from unit to unit? What if Med-Surge is driving a Tahoe and Med-Oncology is driving a Princess? Caregivers float between units. They are asked to shift from one process to another without missing a beat. This is the second paradigm shift, technology must be flexible but the flexibility must be tempered by continuity. We ask a caregiver to go from driving a full featured princess car to driving a low featured school bus then we wonder why there are mistakes.

Workflow design should be based in finding commonalities and working to drive similarities between the units. Every car is different but every car has a turn signal, break lights, head lights, and there are requirements to use them within the standard confines of the law. Then that has to be monitored to drive the similarities to be consistencies.

Please heed my warning to all of you in Kansas City – especially those at Cerner because I pass your facility daily - If you are driving home and see a large Tahoe barreling up behind you – I recommend you just change lanes. I am not an aggressive driver but sometimes I forget what technology I have (or don’t have) at my finger tips.

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.  

See - Hear - Paint by Numbers

Those of us who work in automation of process often are asked to take a “look” and “see” what could be done better. Which is really the basics of what we do – visually obtain information and document it so that it can be assessed. However, you may not want to judge a book by its cover.

Several years ago my Dad went to buy a Cadillac. He showed up to the dealership on a Saturday in his old blue jeans, flannel shirt, and his post card which said if he test drove a Cadillac he could get a free pull over. The dealership was empty – not a customer in sight. He entered – found a sales person – and was promptly told that he would need to make an appointment to test drive a Cadillac. Dad persisted showing the card he had received in the mail for a free pull over with a test drive but the sales person made an assumption that he was not someone who would buy a Cadillac and turned him away. Ironically, two weeks later Dad found the model he wanted online with every feature available at a dealership in Minnesota, went there, purchased the car, and drove it home. Based on what the sales person saw he made an assumption and lost the sale. In the same way we may be looking at a process and seeing each interaction but not make the connection on what is occurring.

In the story above the sales person was focused on how Dad was dressed. Sometimes consultants are focused on what they see and don’t balance it out with what they hear. The verbal interaction with staff – explaining why an observed process had a specific method is critical. The trick is asking the right questions – in the right sequence – to elicit the honest response. Questioning people on how and why they do specific workflows is really an art blended with a science. (Anyone who tells you different is selling you something) The science is the sequence and the information needed to be gathered that provides patterns. The art is the phrasing and interaction. It’s the way you respect their environment and their specific personality.

The final point in workflow modeling is being able to develop a picture of what is occurring without looking or hearing anything. I heard a story on the radio of a woman who had lost her sight. She described how she could see objects with her hands. The form, the texture, the edges all became data points in her mind and she was able to create a picture of what she was holding. In the same way that you can look at the data that comes out of devices, integration software, systems, etc and begin to build a pretty extensive picture of what is occurring on the unit. It’s basically paint by numbers for geeks – a series of “If and Then” statements that when you put them together in the right order create a very in depth picture.  Just like when a doctor looks at a patients chart – the data creates a picture.

We have had a pretty busy month at Sphere3 - which means the blog has taken last place.  Topics are always welcome please send them through to kgovro@sphere3consulting.com

When Our Use becomes "Meaningless"

I recently read a blog post by Regina Holiday that was both incredibly moving and really thought provoking. Regina lost her husband to cancer and has recounted the experience throguh art and speaking. She has gained national attention because of her patient’s rights movement her voice emphasized through murals. Sometimes words are not enough.
She along with other noted leaders like E-patient Dave are paving the way for more information - better information- to let patients make informed decisions. The point that stuck out to me was the concept that the medical information could be presented to the family in a format as easy to read as the Nutrition Facts label. While I don't want to discount the difficulties to do this nationwide with consistent standards - it just makes sense. People didn't understand what everything on the nutrition label meant initially, but now most of us know sodium # high = bad. (I could soap box for days on the unhealthiness of the US and our unwillingness to read the label and make good choices but that's a different post for a different blog)
All of the “bring it to basics” mentality brought me to reflect on the creation of Sphere3. It came out of frusteration that all the creatvivity in the world associated with integration was thwarted due to the difficulties associated with trying to communicate the functional process. (that was a mouthful) In other words most geeks want to tell people "how" it's done instead of "what" will occur.

The "what" to me is like writing a book or a movie - there are characters, there are scenes, ther are props, and if all is done correctly there are great reviews. It makes what we do in integration design look really simple, which is good. My theory (which is shared by many) is a Nurse needs to be concerned with the patient and things that cannot be replaced by technology. There is nothing more frustrating then being handed additional technology to “make life better” which just complicates life more. Nurses should spend a majority of their time helping people – not fiddling with unnecessary technology.
This is a scene from my own life – and I encourage you to remember a scene from yours that will help you focus on the clinician and the patient. Remembering that the technology should be complimentary – the people should be the main focus.

One night, when BFB (Big Fat Baby - see our story) was in the hospital, he was having difficulty breathing. The Oxygen reader (aka 02 Sat) began it ring. I was "sleeping" in the chair next to his bed, my head propped against the side of the crib my hand holding the fat fingers. I turned my head to see the machine (which I had learned to read a few days prior) and the numbers where dropping. At first, I thought his toe thing is loose, so I unwrapped him to find it firmly attached. I began to follow the cable to the machine to make sure it wasn't unattached. As I did the door opened and in came the RN, followed by the Respiratory Therapist. "Please step back Kourtney" she said stepping between me and my bundle.


In my head all I could hear was a warning announcement saying "Warning! This is not a drill...".My heart stopped and everything around me seemed to be in slow-motion as the night nurse and Respiratory Therapist (among others) began poking ,prodding , and suctioning (to this day I can hardly look at that suction when I walk into a patient room for work). His skin looked gray, his fat arms barely fought the team as they suctioned, and worst of all - he wasn't crying. So, I took on the role for him. Crying dosen't really describe what I was doing - sobbing unconctrollably - the kind of experience where you know at the end of it you will look like a prize fighter. David had emerged from the bed in the back of the room and tried to comfort me. We didn’t want to watch but it was like a train wreck that we couldn't help but watch. As it ended and it seemed as though someone gave the "all clear" signal - the nurse turned to me and I said "is he going to make it through this?” She was experienced, had as many gray hairs as my mom, and had kept her cool the entire time. The kind of person you want in a foxhole with you - bullets wouldn't faze her. "The worst is almost over" she said as she touched my arm and smiled. Though she didn't say it I knew she was saying "he's going to be fine". After the group left the room - I returned to my watch post at the side of the bed, reached in, and my fingers were met by the firm grip of BFB.

A Nurse’s primary role is to care for the patient - do things that we can't do ourselves. Her secondary role is to assure you - in a way that few can - that all will be ok. Neither of those things can be replaced by technology.

Our job as "technologists" - "integrators" - "geeks" is to enable these people to do what they do best - help with people. If what we do gets in the way of those roles our use is meaningless.