TEDxUCLA 2011: Minding, Mining, Mending, Mapping
One patient at a time
Good afternoon, and this is a real, real honor for me. If I could just start by telling a story.
So about four years ago, I’m a child and adolescent psychiatrist trained here at UCLA, and had the opportunity of taking care of lots of kids: kids with autism, mental retardation, schizophrenia. I was running our practice in psychiatry here at UCLA and running our psychiatric hospital.
Our psychiatric hospital, probably one of the number one hospitals in the country taking care of both children, adults, and geriatrics with psychiatric problems. And I’m the happiest guy in the world. Not looking for anything else to do but do a little administration and provide care directly to patients.
And then I got asked a question. I got asked a question: Do I want to run all the UCLA hospitals? The guy who’s in charge leaves to Texas. And the first thing I do is call my mom and dad and I tell my dad, “You better send me some ties because all these guys wear ties and I don’t have enough ties to do the job.”
So I walk — we’re in our old buildings then — and I walk from our old psychiatric hospital down the hall into the new hospital. I’m sorry, into the medical hospital. Still old building. And I probably spend two, three, four hours a day knocking on the doors, sitting down on patients’ beds, introducing myself, giving out my card. Everyone I meet gets my cell phone. And I say to the patients: how is the care? How are we doing? How are you doing? Is there anything I can do to assist you with your care?
So this is a 2.2 billion dollar operation. We take care of a million and a half patients a year. We do more organ transplants than any hospital in the United States. We just did our first limb transplant. We get five patients per day by helicopter. We have Nobel Prize winners on the staff.
And I have no idea what I’m doing.
So I sit down and I learned two things. It took me about three months to learn these two things.
I learned that, number one, we do perform miracles. We can take a liver and chop it in pieces and give it to different people like nobody else can do. Parents told me over and over, “They never got it right until we came here. And you guys figured out what’s wrong with my child.” I heard that over and over.
The other thing that I learned, and this was very clear, was the place was dirty. Nobody knew who was in charge of their care. The hot food was never hot. I went into a neurointensive care unit and our nurses had IV bags around their neck and I said, “What’s going on in here?” Well, every year when it gets really hot, the air conditioners break. So this is how we cool ourselves down.
Now, I’d gone to med school and I knew it was good to keep neuro patients cool. But the neuro patients weren’t cool if our nurses were cooling themselves down with the IV bags.
I actually learned we didn’t have enough wheelchairs, and we didn’t have enough bedpans. So we’re rated U.S. News and World Report, #3 hospital in the United States, #1 in the West since those rankings began, and two out of three patients would not refer us to a friend.
We were literally saving their lives, but God forbid you came here. I don’t know what our mission statement was in four years ago, but it should have been something like, “Aren’t you lucky you get to see us?”
So we’d come across, we’d come across as, “We’ve got the best doctors, the best nurses, and just wait in line. And we’re very provider-centric, and we’ll see you when it’s just the right time, and you should be thankful.” Actually, for those of you that live in this town, if you got sick, you went to Cedars or St. John’s. If you were dying, you came to UCLA. If you need a particular knuckle transplanted or some particular procedure, we had the only person that did it. But if you had choices, you went to those other sides out of UCLA.
So I thought, and I had some great mentoring who told me to stay singularly focused on something. They said, “With this new job, you’ve got to just pick one thing and stay focused on it.” So I thought, “A-ha!” Took me about three or four months. We’re going to focus on the patient.
And so I go home after telling audiences like this, “This is what we’re going to do,” and a third of the people would look at me in complete disbelief. “Why we put a psychiatrist in charge?” Another third, another third were on the fence, and then another third would come up with tears in their eyes and they’d say, “You’re so inspiring.” And I’d say to my wife when I got home, “I’m talking about getting bedpans, and people think I’m very inspiring.”
So we embarked on that change. And actually, four years ago — Best Hospital according to U.S. News and World Report in the Western United States, two out of three patients would not refers to a friend — and we’re rated 38th percentile on two key questions: that “refer us to a friend” question and “rate us on a scale of 1 to 10.” We were in the 38th percentile.
But more importantly, or as importantly, there were, there was a medical director who now works for me. Actually, no, I was part of the leadership team running the psychiatric hospital. When you move to the head of the table, you become much funnier. Everybody starts laughing at your jokes.
So I’m now at the head of the table with the same sense of humor, but much, much funnier. And, and this medical director says to me that his father died at UCLA a couple years ago. And when his dad died, he got the runaround about trying to find his body by our team. And this is an inside guy. This is a guy in leadership.
And his wife had just been recently diagnosed with breast cancer. And UCLA invented the PET scan, UCLA invented herceptin, #1 treatment, personalized treatment all over the world for breast cancer. And he didn’t think UCLA would be the right place to take care of his wife because of that terrible experience he had with his dad.
So I said, “If we can’t even take care of ourselves, we should close.” So we immediately canceled all marketing. No billboards. I said, “There can’t be any billboards if they don’t tell the truth of what we’re doing.” And slowly but surely, we made some improvements.
Now I only get 18 minutes and I’m down to 12, so I’m going to jump, fast-forward in the story. We went from 38th percentile to 99th percentile. We’re the #1 rated academic medical center in the United States on those two questions. And among 6,000 hospitals — this is teaching, non-teaching, urban, rural, small, big, whatever — we’re consistently rated many of our units in the 99th percentile on “would you refer us to a friend” and “would you rate us on a scale of one to ten.”
And how did we do it? We did a one patient at a time.
We changed our mission statement to “healing humankind, one patient at a time, by alleviating suffering, promoting health, and delivering acts of kindness.” I’m positive we’re the only academic medical center in the United States that has kindness in its mission. But we’re very, very focused on that next patient.
So to help change an organization like that, picture this: I give the talk to our department chairs. “I think we need to focus on patients.” Fifteen people in a room: Chairman of Medicine, Chairman of Surgery, Chairman of Pediatrics, Anesthesia, Psychiatry, Neurology, Neurosurgery. All men, with one exception. All bald or have white hair, no exceptions.
So I say, “We need to change and focus on patients.” And I’m talking to guys who have invented the organ that they’re responsible for. This guy invented the kidney. And so this is a group that’s been around a long time. They’re in those seats for important reasons, and they don’t think that we can actually do it.
One of them has a mom who gets sick and is treated back in New York at New York Presbyterian Hospital. He goes back to visit her. And when he visits his mom, he sees that the nurses there are all picking up trash on the ground. The head of the intensive care unit comes up to him and says, “How’s it going?” And he starts answering medically about how his mom’s doing. And the doctor says, “No, I want to know how you’re doing. How are you doing with all of this?” So he comes back and I got one champion on my side.
We take a group of 22 people back to New York Presbyterian and kind of see what they’re doing, kind of start to buy into it. And then we made big changes in our emergency room.
So our emergency room here in Westwood, I don’t know how many of you have ever been to the old one, which was across from Ralph’s groceries on Le Conte, a beautiful entrance and underneath a parking lot, it looks like a bomb shelter. So that emergency room was in the 16th percentile in patient satisfaction. You’d have to go far around the country to get a lower one. And the group that, we have a hospital in Santa Monica campus, is run by an outside group, that emergency room was in the 25th percentile.
And this guy comes and tells me, “I want to take over that guy’s business because that’s an outsource group and, you know, we’re leaving money on the table. I should get to do it.” And I said, “That totally makes sense. But I’m telling both of you guys, you’re both out of here if we can’t get to 75th percentile patient satisfaction.” 75th percentile is a C when I went to high school, and that isn’t even very good.
So they started and they turned a conference room — we haven’t moved into any new buildings designed by I.M. Pei, billion dollars, this hasn’t even come in the story yet. So they take a conference room and turn it into this thing called a fast track. “Fast track” meaning four out of five patients that come to an emergency room don’t need a bed. They need to be treated and sent back out to their car.
Now, if you came into our emergency room four or five years ago because you were a visitor and you’d run out of medicine and you needed it, it was Sunday night and you needed somebody to write an inhaler, or you were cooking and you cut your finger, or you twisted your ankle playing football, you would expect probably about a nine, ten-hour wait because you would hear things like, “Well, we have heart attacks. Gunshot victims. We’re really, really backed up.” And you dropped to the bottom of the list.
So what we did was kind of bifurcate those two groups. If we didn’t think that you needed a bed, we took you into a conference room, an old conference room, and we treated you there. We fixed broken ankles and all that kind of stuff in chairs. Well, we hit 99th percentile patient satisfaction for that group.
Fast forward. Now if you go to our emergency room in Santa Monica and you’re not treated, you’re back to your car — counting the time it takes us to get your valet car — in under 52 minutes. Here at UCLA were about 90 minutes, with our goal of dropping it below 90 minutes. That’s for all patients that don’t require a bed.
And with our organ transplant population, they know if you’ve received a liver transplant and you live in Bakersfield and we’ve taken care of you and you get sick, don’t stop at the hospital in Bakersfield. So they know to come here and they come to our emergency room.
So our emergency room in Westwood is particularly crowded. But if you were to cut your fingers tonight, we’d be able to treat you in under 90 minutes. Actually, experience is so good at Santa Monica I recommend twisting your ankle and trying our experience.
So the question is, how did we make that change? Well, I still spend two to three hours every single day knocking on doors, sitting down on patient beds, and asking how the care was. I ask if there’s anything I can do to assist them, and that includes putting on stockings, helping patients to the commode, hanging IV’s, helping nurses move patients, transporting patients, explaining what’s going on.
But now when I go in the room, there’s about four or five business cards just like mine from executives in our organization that have also written down their cell phone numbers. So we made it mandatory that everybody makes rounds. We make rounds, structured rounds in the middle of the night, in the middle of the day.
And these are non-clinical people. So my Chief Information Officer, Chief Human Resource Officer, Chief Financial Officer, they, they didn’t quite get that we were in a health care organization because every time we started a meeting, it could’ve been, “We’re in Costco.” We talked about revenue and beds and it was like a numbers game. It was all numbers. But there was no story about our patients.
Every single meeting that we start we either have a patient come, read a patient letter, or talk about one of our incredible, incredible successes or one of our incredible, incredible failures with one of our patients. So the ability to tell stories helped move the organization.
Then the other thing we did is if you were a nurse and you had worked at Kaiser and you had the skills to take care of cardiovascular patients and we needed somebody and you passed your fingerprints and our recruiters liked you in a half-hour interview, you got a job at UCLA. That’s how it worked in healthcare.
So we put in place a program designed by Ritz Carlton called Talent Plus. Every employee now that comes into UCLA Health system — we’re about 17,000 employees strong — must meet a criteria on Talent Plus that looks for things like service-minded. So not only do you have to be a nurse that doesn’t have a felony that’s worked and has a good job description at Kaiser and our recruiters like you. We want really people that will go that extra mile.
In one hour, we had a nurse opening position. In one hour, we got 4500 applications. So in what could be described as a nursing shortage, we really have the ability to pick absolutely the best people.
And then once we get you on board, we actually tell you and monitor what you’re doing. We did some incredible things. So if you talk to our patients and listen to our patients in an academic medical center, they’ll tell you they don’t know who’s in charge of their care. That there’s 19 doctors and there’s 19 people, doctors, nurses, and staff that come in per hour to their room. First hospital in California, we put everyone in uniform. So now you know if they come in the royal blue scrub, they’re an RN. If they’re in the khaki, they’re what we call a care partner. If they’re from transport, they have a different look.
We’ve also required that people introduce themselves. Ask permission before they examine or touch you. Explain what’s going on. Exit courteously. Look for problems and try to personalize care. That program, which a lot of hospitals have, we call our See I Care program. It’s an acronym for what we do, but we measure it.
And I sit in rooms and actually watch it happen, and it’s unbelievable. A couple colleagues of mine, two doctors, recently got sick and they said to me, “You can’t believe how important it is that the transporter who’s taking you into the operating room actually looks in your eyes, tells you his or her name, and explains what they’re doing.” These are guys that have worked at UCLA, trained at UCLA, got sick, and all of a sudden they say the person who is most important to you is this transporter.
We invented a thing called the Lift Team. You know, nurses have to move patients to prevent ulcers, move patients to make them more comfortable, and you get a lot of costs for nurse disability because people hurt their back moving patients. So we’ve got big burly guys, their uniform is black, they call themselves Men in Black, and they go walking around and they help move patients. They get paid twelve bucks an hour.
Again, Talent Plus. Ritz Carlton has a cutoff of 75, we have a cutoff of 90 and above.
Patient dies. Family is gonna go down to the morgue to see their loved one. They say, “We don’t want to go unless that guy from the Lift Team will come with us.” The guy from the Lift Team’s on his day off. Call up. Lift Team member comes in, goes down with the family to visit the patient.
Yesterday, I’m making rounds. I meet an elderly man whose wife is dying of metastatic breast cancer. She’s never had a grandson, has had a granddaughter. Her daughter lives in San Francisco and is pregnant. We have the daughter flown down. She’s going to deliver at our Santa Monica facility and then Grandma is gonna get to see her grandson. But doesn’t look like we’re gonna make it. Transfer the daughter with the baby, grandson inside, to Westwood. Induce labor. It’s probably going to take about 48 hours. 24 hours later, baby’s born, brought inside, and Grandma gets to see her.
To me, that’s how I’d want care if it was someone in my family. And those stories have really positioned us to what we think is now the best in an absolute terrible industry. So I’m so proud that our patient satisfaction is in the 99th percentile.
They’re writing books about us. So this book — but it’s actually, it’s a sad story at the end — so this book, Joseph Michelli, writes The Starbucks Experience, a bestseller. He writes this book on us, it comes out two weeks ago. #1 book on Amazon four days in a row. #1 book, Wall Street Journal. #1 book on New York Times. Bestseller.
But it’s terrible. 99th percentile. Not — it’s a good book. But 99th percentile means that 85 out of 100 patients would refer us to a friend or rate us on a scale of one to 10. That means there’s 15 patients out of 100 that did not receive care that was of the highest level of compassion, care that was safe, care that was delivered with the highest quality, care that I’d want if God forbid somebody in my family came to UCLA. So our work is not done.
I think I have 20 seconds left. You guys have, some of you are taking tours of our facility later today. Some of you gonna see our heliport and some of you are gonna see one of our advanced operating rooms.
I ask you a favor: as you walk through our building, if you see anybody who’s lost, please go up to ’em. If you see any trash, please pick it up. If you see anybody who’s crying, please put your arm around them.
So as you enter our building, I ask you to become part of our healing team. And I appreciate your time today. Thank you.