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January 25, 2019

Flipping the script to improve process

When the James M. Cox Foundation gave Emory $25 million in 2015 to improve patient experiences and outcomes, the donors were driven by a desire to help reduce some of the frustrations that many of us feel as patients. Who among us hasn't at some point been inconvenienced by wait times, delays, and inefficiencies caused not by people--but by an imperfect process?

Indeed, here at Emory Healthcare we have outstanding people doing the most top-notch work possible within a process that needs improvement. That's why we've used the Cox Foundation grant to launch EmPower--a new way of doing business that will flip the script by empowering frontline health care workers to solve problems and improve processes in order to enhance patient experiences and outcomes, as well as their own professional joy.

As Chief Quality Officer Bill Bornstein puts it, "At Emory we get good results from brilliant people using broken processes. [Through EmPower] we are going to get spectacular results from brilliant people using great processes."

Please direct questions and comments to evphafeedback@emory.edu.

Jonathan S. Lewin, MD, FACR
Executive Vice President for Health Affairs, Emory University
Executive Director, Woodruff Health Sciences Center
CEO, President, and Chairman of the Board, Emory Healthcare

Ann Pekarek in a morning huddle with colleagues

New organizational DNA for Emory Healthcare

Every morning, Ann Pekarek, director of cardiology services at Emory University Hospital, starts her day meeting with colleagues around a white board populated with red and green dots, which identify snags in the system that could disrupt the day. They are on the vanguard of EmPower, Emory Healthcare's version of the Lean management system.

Made famous by Toyota, Lean management embodies a process of continuous improvement by empowering frontline workers to solve problems."Lean flips the traditional organizational pyramid, which puts the CEO at the top and the workers at the bottom," says EVPHA and EHC CEO Jon Lewin. "The Lean system puts workers at the top."

This structure empowers the people who work directly with customers and opens up paths of communications. "Lean is built on a profound respect for the people who do the work," says William Bornstein, chief medical and chief quality officer for Emory Healthcare. Lewin, Bornstein, and the rest of the EHC leadership team believe the Lean approach will accelerate achievement of the "quadruple aim" of better patient health, better patient experience, lower relative costs for patients and families, and greater joy of providing care for staff and physicians.

Bornstein stresses that EmPower is not an initiative, and it's not a multi-year project--it's a way to do business. "Lean is not just a series of quality improvement tools," he says. "Tools are part of it, but the real power of Lean is when it becomes the operating system, the way you do your work. It becomes part of your organization's DNA."

Emory Healthcare first dipped its toe in the Lean pool a decade ago, working with the consulting firm Simpler to learn about Lean and to apply Lean tools to specific projects. Ultimately, leadership decided not to take the dive to adopt the operating system outright.

Then in 2015, the James M. Cox Foundation gave $25 million to improve patient experiences and outcomes. "The Kennedy Initiative gave us a launching point to transform the organization using the Lean system," says Greg Esper, who leads the newly established Lean Promotion office, along with Christina Hummel.

The Kennedy Initiative initially focused on improving processes in urology, radiation oncology, cardiology, and transplantation. Now, EHC leadership is ready to begin rolling out EmPower across the system.

The Lean system has five levels, beginning with laying the foundation and stabilizing it and ending with optimizing outcomes. For optimal results, each level should be mastered before the next level begins, since the lessons build on each other.

Each layer has multiple steps, and the first step in laying the foundation is establishing the daily management system. The daily management system, in turn, has five elements--daily readiness tiered huddles, development of process and outcome metrics, development of standard work, development of how to handle ideas for improvement, and planned work cadence.

The first step in adopting a Lean management system is the tiered daily readiness huddles. EUH cardiology services, which has been having daily tiered huddles for more than a year, offers a glimpse of how it works.

Every day, frontline workers from the five areas in cardiology procedures--heart transplant, cardiac cath lab, echocardiography, electrophysiology, and cardiac observation--meet for 10 to 15 minutes in tier 1 huddles. The cardiac cath lab huddle, for example, is attended by the nursing staff, cardiovascular techs, the charge person, materials coordinator, business manager, lab manager, and physicians when available. This team gathers around a white board that has columns for safety, methods, equipment, staffing, and supplies. Items in each of these columns are marked with either a green dot, meaning there are no concerns, or a red dot, signaling something that needs attention--perhaps a piece of equipment has gone down in one of the cath labs, for example, so fewer cath rooms are available and patient flow needs to be adjusted.

Shortly after their tier 1 huddles, managers from each of the five cardiology areas meet with Pekarek in a tier 2 huddle. Using a similar white board with red and green dots, they present issues identified in their tier 1 huddles that were unable to be resolved. Pekarek then meets with department directors from other areas of the hospital and the EUH senior management team in a tier 3 huddle. There she can raise issues that were not able to be resolved in the tier 2 huddle.

The huddle system means that people who are working directly with patients can have their issues heard by top management within a matter of hours. In one case in the electrophysiology lab, for example, three staff members resigned within a few days of each other, and restaffing needed to occur quickly. Getting a position posted normally takes four to seven days. But thanks to the huddle system, Pekarek was able to have all three positions posted by the end of the day.

Eventually, there will be tier 4 huddles, in which leaders of each hospital and the physician group practice will meet along with other members of the senior EHC leadership team.

"These next two to three years will be about establishing the daily management system," says Esper. "The frontline staff and clinicians are the most important part of the team, because they see the patients and families, know the problems, and have the best ideas about possible solutions. In this process, daily, frequent, and standard communication is paramount, so that problems that can't be solved on the front line are escalated rapidly to achieve timely resolution."

Meanwhile, says Lynda Barrett, EHC vice president for strategic planning, the EHC leadership team also has begun using Lean principles to measure progress on meeting strategic goals. Once a month, Lewin and 16 EHC leaders meet around their own white board, dubbed the EHC Visual Management Board. Using red, green, and yellow dots, the board visually depicts areas where the organization is making progress toward meeting strategic goals, where it may have issues, and where it's having problems. "This is also part of the Lean rollout," she says, "but instead of focusing on daily operations, it focuses on long-term strategy."--Martha McKenzie

Helping victims of trafficking

Jordan Greenbaum

Next week, tens of thousands of visitors will thunder into Atlanta for the Super Bowl, bringing an economic bonanza for area retailers, restaurants, and hotels. The nation's top sporting event may also cause a spike in another area--sex trafficking.

Atlanta is already a hub of this sordid trade, thanks to its busy airport, two major interstates, large venues for conferences and sporting events, and a plethora of adult sex businesses. Events like the Super Bowl just bring more opportunities for sex traffickers.

Jordan Greenbaum, adjunct associate professor of pediatrics and medical director of the Institute on Healthcare and Human Trafficking, says trafficked persons may seek care in emergency departments or clinics for many reasons, including treatment of injuries sustained from sexual assault, battery, or suicide attempt. That puts health care workers in a good position to spot red flags that could signal trafficking.

According to Greenbaum, trafficked persons may come in with their trafficker, who may dominate the interaction, rush the visit, and/or pay in cash. The trafficked person may be reluctant to make eye contact or speak. In some cases they may have a tattoo of a type of insignia or name—a brand by their trafficker--or scars from previous injuries. They may also be unsure what city they are in, provide inconsistent information, or be unable to provide an address where they are staying.

If sex trafficking is suspected, a health care worker should find a way to separate the patient from the person who accompanied them. One way to do this is to advise visitors to hospitals or clinics that there is a standard practice of seeing all patients alone. Then intervention or support services can be offered to the patient in private. In Georgia, staff members are required to follow mandatory reporting guidelines for minors and for adults who have suspicious injuries. In other instances, health care workers must ask permission before calling the authorities.

Health care workers can provide the National Human Trafficking Resource Center’s hotline number (1-888-373-7888), discuss a safety plan when going through the discharge process, and make the patient aware of local support services. Workers should not confront a suspected trafficker directly.

Dabney Evans, director of the Center for Humanitarian Emergencies in Rollins, cautions health care workers against letting down their guard after the Super Bowl leaves town. “Events like the Super Bowl provide an opportunity to raise awareness of sex trafficking,” she says. “But trafficking is really an everyday issue that we ought to be working on year round.”

To learn more about human trafficking, visit the Institute on Healthcare and Human Trafficking website.--Martha McKenzie

In brief
Artificial intelligence in health and health care

Today's health care professionals are bombarded by data from multiple sources—diagnostic, claims, financial, psychosocial, epidemiologic, biometric, genomic, and consumer-generated—and health care data is expected to double every 73 days through 2020. The sheer quantity of such data necessitates a fundamental shift in how it is curated and interpreted. Enter artificial intelligence, which has enormous potential to help clinicians, researchers, learners, and patients alike.

The 23rd report of the Blue Ridge Academic Health Group explores the potential impact of artificial and augmented intelligence on health and health care, identifies challenges and emerging risks associ­ated with AI-based technologies, and describes how academic health systems can harness these new capabilities. Read Separating Fact from Fiction: Recommendations for Academic Health Centers on Artificial and Augmented Intelligence. See Blue Ridge website and a list of previous reports.

New leaders for Structural Heart and Valve Center

The Emory Structural Heart & Valve Center has been selected as the inaugural member of the National Heart, Lung and Blood Institute’s Structural Heart Intervention Network. The new network is made up of institutions participating in clinical studies to help advance minimally invasive treatment options for structural heart disease (abnormalities of the heart's valves and chambers). For more than a decade, researchers at Emory's center have pioneered minimally invasive procedures to treat heart disease, including landmark research on transcatheter aortic valve replacement (TAVR). The first site in Georgia to perform TAVR, Emory has completed more of these procedures than any other health care system in Georgia and is one of the highest-volume centers nationally.

This new membership comes as the center also gains new co-directors. Cardiothoracic surgeon Kendra Grubb and interventional cardiologist Adam Greenbaum join interventional cardiologist Vasilis Babaliaros in leading the center. Read more.

Phase 1 unit opens

Winship's new Phase 1 Clinical Trials Unit, located on the fourth floor of the Emory University Hospital Tower, began treating patients earlier this month. The new facility is triple the size of the original unit and expands access for patients to the critical first phase of testing new cancer therapies. Don Harvey directs the unit. Read more.

License for hep B drug

Drug Innovation Ventures at Emory (DRIVE) recently announced the licensing of ATI-2173, its leading candidate for treatment of hepatitis B, to Antios Therapeutics, a biopharmaceutical company focused on developing antiviral therapies for unmet medical needs. Abel de la Rosa, former chief scientific officer of DRIVE, is co-inventor of ATI-2173 and co-founder of Antios. Read more.

New name for Pharmacology

As of this month, the Pharmacology Department in the medical school is known as Pharmacology and Chemical Biology, a name change reflecting a broadening of vision from the fundamental science of drugs to include drugs as tools targeted to disease-related proteins. Haian Fu is chair. Read more.

$2 million gift funds new directorship

A gift of $2 million from Rollins, Inc., RPC, Inc., Marine Products Corporation, and Rollins family members has funded the naming of the Wilton D. Looney Carlyle Fraser Heart Center Medical Directorship at Emory University Hospital Midtown. Mr. Looney, who passed away in May 2018, had served as a director on all three Rollins' company boards. Read more.

Luella Klein, 1924-2019

Luella Klein, the first female chair of a department in the School of Medicine (Gynecology and Obstetrics) and the first female president of the American College of Obstetricians and Gynecologists, passed away on January 13. A memorial service will be held February 9 at 11:00 in Glenn Memorial United Methodist Church, with a reception to follow. Read more.

New partnership

Emory Healthcare and the Atlanta Legends have entered into a partnership designating EHC as the team's official health care provider. The team is one of eight in the Alliance of American Football's new professional football spring league, which kicks off on Feb. 9, one week after Super Bowl LIII. The Atlanta Legends will play home games at the Georgia State Stadium, in downtown Atlanta. Read more.

Rafi Ahmed (director of the Emory Vaccine Center and Georgia Research Alliance Eminent Scholar) was named a 2018 fellow by the National Academy of Inventors.

Pamela Allen received the Cutaneous Lymphoma Foundation Young Investigator Award at the American Society of Hematology's annual meeting in San Diego.

Anita Corbett (director of the MD/PhD program) received an award for Mentoring in Science from the journal Nature.

Ira Horowitz was named physician group president and director of the Emory Clinic in Emory Healthcare. (He previously served in these roles in an interim capacity.)

Carolyn Meltzer (chair, radiology) was named 2018 Outstanding Researcher by the Radiological Society of North America. Read more.

Raymond Schinazi (pediatrics, research) received the Chevalier de la Legion d'honneur—the French Legion of Honor medal with the rank of knight. Read more.


Jan 30-Feb 1:  Care Coordination and Technology Congress, co-hosted by Rollins School of Public Health and the World Congress. Renaissance Atlanta Waverly Hotel & Convention Center. Register.

Feb 21: Science of Team Science. Georgia CTSA. 1:00-4:00 PM, Morehouse School of Medicine. Register.

Feb 28-March 1: 2nd Annual Georgia CTSA Conference. Callaway Resort and Gardens. More info.

March 21-22: Deeply Rooted: Healthcare Ethics in an Era of Change. 25th Conference of the Healthcare Ethics Consortium. Emory Conference Center. Register.

March 23: Emory Saint Joseph's Hospital Run for Mercy 5K. More info.

May 31-June 1: National LGBTQ Health Conference. More info.

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