Observations on Operations » aidet

Checking the Promise of Quality

astanowski — Wed, 17 Feb 2010 14:06:05 +0000

During the recent snowstorms in the East, one of my friends told me about an arrangement that he has with a neighbor. The neighbor has a John Deere tractor, and ploughs the snow from their driveway. In return, my friend, who is a tool and die maker, fixes their tractor when needed. He said that he certainly gets the better of the deal, because a John Deere rarely breaks!

In the 2005 book, The John Deere Way, David Magee reports on Deere’s commitment to quality and customer service. Quality extends far beyond the John Deere product lines and dealerships. The total quality effort is what employees see…that quality in their daily work ultimately results in quality that the customer sees when they “get behind the wheel of a new yellow Deere 710 backhoe loader.”

Hospitals and tractors are certainly different animals, but the importance of quality processes is shared. In a recent blog (2/8/2010), Bob Wachter reviews Atul Gawande’s Checklist Manifesto. The insightful point that Wachter makes is that “the public is so unsettled by our patient safety and quality flaws… (because) they assume that we do know the right thing to do, but simply screwed it up.” Wachter quotes Gawande: “… under conditions of true complexity – where the knowledge required exceeds that of any individual and unpredictability reigns – efforts to dictate everything from the center will fail. People need room to act and adapt.”

Says Gawande: “In a world in which success now requires large enterprises, teams of clinicians, high-risk technologies, and knowledge that outstrips any one person’s abilities, individual autonomy hardly seems the ideal we should aim for. ..what is needed, however is discipline…discipline is hard – harder than trustworthiness and skill and perhaps even than selflessness. We are by nature flawed and inconstant creatures. We can’t even keep from snacking between meals. We are built for novelty and excitement, not for careful attention to detail. Discipline is something we have to work at.”

Despite demonstrating that checklists produce results, there is resistance to their use because of the (1) Master of Universe mentality (Rock Star; Fighter Pilot; Hero), (2) our jobs are too complex to reduce to a checklist, (3) checklists are too rigid and don’t force us to look up and see and think ahead of what’s in front of us.

Gawande finds two pitfalls in our resistance – the fallibility of human memory when it comes to mundane, routine matters that are easily overlooked under the strain of more pressing events and secondly, people can lull themselves into skipping steps even when they remember them – after all certain steps don’t always matter…until one day they do.

The similarity to a manufacture of a tractor is startling – Gawande is stating that the people need to see the quality that they are producing, and be aware that it is quality based on an established process (like through a check list). Gawande gave a great example of a cleanliness checklist used in intensive care units in all Michigan hospitals in 2003 to eliminate infections. Said Gawande (in his New Yorker article that inspired the book): “ In December, 2006, the Keystone Initiative published its findings in a landmark article in The New England Journal of Medicine. Within the first three months of the project, the infection rate in Michigan’s I.C.U.s decreased by sixty-six per cent. The typical I.C.U.—including the ones at Sinai-Grace Hospital—cut its quarterly infection rate to zero. Michigan’s infection rates fell so low that its average I.C.U. outperformed ninety per cent of I.C.U.s nationwide. In the Keystone Initiative’s first eighteen months, the hospitals saved an estimated hundred and seventy-five million dollars in costs and more than fifteen hundred lives. The successes have been sustained for almost four years—all because of a stupid little checklist.”

Within hospital operations, I’ve seen how the successful application of a process called AIDET (Acknowledge, Introduce, Duration, Explanation and Thank You) when applied to support service workers creates a positive reaction within patients and leads to higher patient satisfaction scores. AIDET is a mnemonic device which really does serves as a checklist to support service workers when interfacing with patients. Click here to read Quint Studer’s application of AIDET.

Like Deere, quality impacts the cost structure at hospitals in every area of the business. Successful hospitals see quality as all pervasive, and instill the camaraderie, discipline and processes in place to create a culture of quality. “The promise of quality always comes first” is from Magee’s work about Deere. Gawande would add that in hospitals, the process that ensures quality (a checklist) is part of that promise.

Hand washing and AIDET

astanowski — Wed, 17 Jun 2009 13:22:38 +0000

I silently stood in the hall and watched as food trays were delivered through the “host/hostess” process at CHRISTUS Santa Rosa, a 978 bed hospital complex in San Antonio Texas. CHRISTUS is truly one of those exceptional hospitals, a Health Grades distinguished hospital 6 years in a row, a Magnet Hospital, and a top employer in the San Antonio area. The thing about CHRISTUS Santa Rosa is despite being a large hospital; it has a human scale feeling to it. And the staff reinforces this.

Before the hostess grabbed a lunch tray to deliver to the patient room, she checked precautions in each room, used the hand sanitation dispenser located outside of each room, and verified that the tray was the correct one for each patient. Like rhythmic clockwork, I watched the AIDET process in action: (A) acknowledge each patient by their name, (I) introduce themselves, (D) duration – let patients know who long you will be in the room, (E) explain step by step what will happen, and ask the patient if they had any questions, and (T) thank the patient. The hostess asked if there were anything else that the patient needed as they had the time to help them, and then thank the patient for their time, or followed by an “it’s my pleasure” in response to a patient thanking the hostess. And the process began anew for the next patient in the next room.

The hostess did not look harried, although she had trays to deliver. Each patient was made to feel as if they were the most important person in the hospital. Hand washing served to minimize infections; AIDET served to improve satisfaction; being part of something bigger lowered employee turnover rates every year in the past three. It’s not surprising that CHRISTUS Santa Rosa is the market leader in acute hospital in patient satisfaction in its area, and continues to grow its patient base.

How does your hospital’s support staff engage patients? Have you measured its impact?

A First Class Approach

astanowski — Wed, 04 Mar 2009 15:00:18 +0000

On my way to attending the ACHE Congress, I took USAir from Philadelphia to Chicago. I hit the seat lottery, and was upgraded to first class. Just before the plane began its descent to O’Hare, the flight attendant went to every person in the first class cabin, and thanked each of us by name. Looking each directly in the eye, she said that on behalf of USAir, and also for herself personally, she wanted to thank us for flying USAirways. Her comment was sincere: “I know that I owe my job to your flying USAir. And I want you to know that I appreciate it.”

I thought of this interaction and implications in healthcare. At ARAMARK, we use the words “Key Words at Key Times” to describe how we educate our associates regarding their patient interactions. Two sessions I attended were also related to the consumer experience. What’s interesting is that although the speakers came from different perspectives, the process was very similar. Gail Scott called it the “Act With TACT Model” — where TACT stands for:

- Take Ownership
- Acknowledge and Apologize
- Communicate and Correct, and
- Thank, Track, Trend and Learn.

Tom Tull and Candace Jennings of Mountain States Health Alliance (TN) defined a foundation for service excellence – called WOW – Values in Action. This process involved:

- First Impressions
- Personal Appearance
- Caring Customer Service
- Communication
- Patient Information and Education
- Customer Interactions
- Respect
- Etiquette
- Commitment

The presentation that CHRISTUS VP Mike McBride and I did focused on Succeeding in the Patient-Centered Age of Healthcare. It defined the AIDET (Acknowledge, Introduce, Duration, Explanation and Thank You) technique popularized by the Studer Group in guiding patient interactions. A copy of the presentation can be downloaded here.

Whatever the acronyms and approach, it appears that leading health care organizations are focusing on making a positive impact the customer experience which includes a scripted support staff interaction. These folks will succeed in the post-recession future! To kick off my first Blog posting … I’m interested in hearing about approaches that your health care organization has implemented, and affects they have had on outcomes.