Sunday, August 30, 2009

Five myths about health care around the world

Okay, it's been an entire week since reporter T. R. Reid, published an interesting article, "Five myths about health care around the world," in the Washington Post (Sunday, August 23, 2009). If offer this link, because our readers may find it useful in debunking the next wild statement they hear about healthcare in foreign countries.

Myth #1. It's all socialized medicine out there. Nope. Only a few Anglo countries, and Cuba. And what about Medicare and the Veterans Administration?

Myth #2. Overseas, care is rationed through limited choices or long lines. Nope. In Japan people don't even bother with appointments.

Myth #3. Foreign health care systems are inefficient, bloated bureaucracies. Not unless you put our system at the top of the list.

Myth #4. Cost controls stifle innovation. And so that would explain French hip and knee replacements? Canadian deep brain stimulation for depression? Wonder drugs from labs in Britain, Switzerland, and Japan?

Myth #5. Health insurance has to be cruel. It's a business! Hm. The last time I looked into this, when I was in law school, the social purpose of insurance was to spread risk, not make money for insurers.

Reid concludes his article with a thought that echoes my own, "Given our remarkable medical assets--the best-educated doctors and nurses, the most advanced hosptials, world-class research--the United States could be, and should be, the best in the world. To get there, though, we have to be willing to learn some lessons about health-care administration from the other industrialized democracies."

Tom Jackson
Principal, Rona Consulting Group
Clinical Associate Professor, University of Washington School of Public Health

Friday, August 28, 2009

Dear Doctor

This past week, I was privileged to facilitate a 5-day kaizen event at the San Mateo Medical Center in San Mateo, California. This was the last of 4 such events focused on reducing expensive (and risky) admissions of CHF (congestive heart failure) patients to the hospital. The events have been funded by the California Healthcare Foundation and the California Safety Net Institute. In our final event, we made a concerted effort to reach out to two of SMMC's clinics, where it is often difficult for CHF patients to get follow up appointments after being discharged from either the ER or the hospital. One of the clinic's doctors graciously agreed to participate in our event for an entire day, but asked for a briefing on lean healthcare before attending. She had not been able to attend the short introduction to lean healthcare that we deliver on Day 1 of each kaizen event. Here is the email that I sent.
Dear Doctor __________,
I would be happy to answer any questions you might have about the "lean healthcare" concept when we meet tomorrow morning. In the meantime, here is a very short introduction to lean healthcare from the perspective of the history of management thinking.
Of course, the lean concept originated at the Toyota Motor Company and it is sometimes referred to as the Toyota Production System. This is an unfortunate name that conveys a misconception. Ultimately, Toyota's method has nothing to do with automobiles or with manufacturing. Toyota's methods all aim at one thing: finding errors and defects in any type of step-by-step process and fixing them in as close to real time as possible. For example, the clinical path for CHF patients is full of defects that we have identified and have been trying to fix over the past four months.
When Toyota thinks about defects, however, it thinks a little more broadly than we normally do. Normally, we think of a defect as a material outcome (i.e. what happened?) that does not meet some predetermined specification. Toyota uses this definition, of course; but it also recognizes another kind of defect, in which a temporal outcome (i.e., when did it happen?) does not meet a specification. In other words, to be "perfect" in a "lean" system in manufacturing or healthcare, the right things must happen and happen on schedule
Toyota sums this dual requirement up in one word: value. A good example of value is ordering dinner for 8 in a nice restaurant. The food might all be materially perfect. But if it is not served to everyone at the same time, there is a temporal defect, and consequently poor value. We have all had similar experiences with our respective families. Mom's salad comes after her entre. Sister Susie's entre comes after everyone has finished theirs. And of course we often have to wait long after we are all ready to leave for the check.... Most industries, including healthcare, are like this restaurant.
Historically speaking, the lean concept integrates two streams of management thinking, one that originated in Bell Labs in the 1920s and 30s that became known as Total Quality Management and another that originated in Ford Motor Company in around 1914 that applied the concept of process flow and time studies to manual operations. Ford's idea was to make cars the way that Andrew Carnegie made steel (in a continuous process) by eliminating all types of waste from operations. Ford used time to measure flow.
It was Toyota that put quality and flow together in the timeframe 1948 to 1963, creating what we know today as the Toyota Production System or "lean manufacturing."

After the publication in 1999 of To Err is Human, the healthcare industry has been forced to pay considerable attention to the methods of quality (and safety) developed at Bell Labs. Meanwhile, as healthcare costs continue to spiral out of control (and access is further restricted to marginal populations), more attention is being paid to the methods of flow developed at Ford and perfected at Toyota. 
Another way to put this is that, under pressure to improve its dreadful quality and it horrific cost (compared to other nations, especially), U.S. healthcare is moving from being a craft-based industry to being a modern knowledge-based or, in the unique phraseology of healthcare, evidence-based industry. Incidentally, all of Toyota's methods are based upon the rigorous application of scientific thinking.
The counterintuitive truth of the matter is that by focusing on quality and safety (First, do no harm), healthcare can decrease cost as well (Time is money). In other words, the two streams of management thinking mentioned above can be integrated. They are not in conflict, as many people still believe. Moreover, it has been shown in several implementations (Virginia Mason Medical Center in Seattle and Park Nicollet in Minneapolis are two major examples) that Toyota's management methods apply in a surprisingly straightforward manner to healthcare processes.
The result, after a lot of hard work, is reliable healthcare processes that are devoid of workarounds. Not only does this greatly improve quality it also reduces the amount of time and energy involved, and significantly reduces both the cost of delivering care and the risk of harming patients instead of making them better.
How good can it get with lean healthcare? Well, in many instances cost can be cut in half and quality rates begin to approach 100% (i.e., zero defects). Of course, this does not happen overnight. Also, zero defects, we mean zero defects in the clinical process. The clinical outcomes frequently depend upon the participation of the patient, over which we have some influence but no absolute control.
Can lean healthcare be applied in a clinic? Absolutely. My partner, Patti Crome, as Senior Vice President of Virginia Mason did it in multiple clinics sprinkled throughout the Seattle area.
I look forward to meeting you tomorrow. Thanks for making time for us.
Best regards,
Thomas Jackson, JD, MBA, PhD
Principal, Rona Consulting Group
Clinical Associate Professor, University of Washington School of Public Health
[m] 503.880.8622
transforming healthcare; pursuing perfection

Tuesday, August 25, 2009

Lucky, or good?

David K. Wessner
President, CEO
Park Nicollet Health Services

Last week at our weekly operations stand up review it was noted that we had gone for 8 days without a patient fall. The concern was that we would "jinx" the result if by talking about it. While the comment was playful and light-hearted, it exposed a deep belief that much of what we do and accomplish is a result of blind luck and that we best not anger the gods of luck if we expect to improve.

As absurd as that interpretation may sound, it describes a cultural norm in health care that is reluctant to design for a perfect outcome for fear that the uncounted uncontrolled variables would frustrate the best efforts of an earnest team.

We've all had those frustrations. The patient that tries to help out his nurse by getting to the bathroom on his own this time, or, a patient who is not identified as a falls risk because they are in the hospital to mend from a fracture from a previous fall and are not considered ambulatory. It's always something.

Lean learning would lead us in a different direction. As each of our teams experience a fall and then asks why 5 times we learn what root causes we can eliminate as a future risk to patient safety. As our leaders encourage those teams to accept no risk as acceptable and design counter-measures that reduce just one risk at a time we begin to drain the swamp.

Examples of counter-measures implemented to prevent falls (provided by Autumn Anderson, RN MS, Director):
  • Hourly Rounding: this includes purposeful visits to the patient’s room every hour by the RN or NA and ensuring they are not in pain, do not have to go to the bathroom, are positioned comfortably in bed, and have everything they need within reach. These are the most common reasons hospitalized patients get out of bed without assistance.
  • Low Beds: The RNs on all units can place an order for a low bed. This is a rental bed that is delivered by an outside company, however we have a small kanban in CSR with two beds that are immediately available for use. The bed also come with a “gym mat” that goes on the floor in case a patient rolls out of bed. The beds all have alarms built in them that sound when a patient attempts to get out of bed without assistance. These beds are low to the ground for good reason- a person must use their thigh muscles to get out of bed, and the lower you are the more muscle you have to use to get from the sitting to standing position. Falls risk patients typically do not have this leg strength.
  • Post-Fall Huddles: These huddles have evolved over the last year, and they now included the 5-Whys process. Huddles occur on the floor after a fall occurs and before the next shift starts. The flying squad RNs facilitate this huddle, and they assist staff and leadership with understanding defects.
  • There are currently andons on the door before you enter a patient room. Yellow “falling star” signs indicate a patient is at moderate risk for falling, and red “falling star” signs indicate high falls risk.
  • Patients will have a yellow falls sticker on their armband starting 8/24/09, which indicates they are at risk for falling. RNs view armbands when they are giving medications.
  • Patients at risk for falling also have the yellow falls sticker on the Kardex, which RNs review and update at the beginning and throughout their shift.
  • The Falls Leadership Team communicates is involved with the SAFE from Falls initiative from the MN Hospital Association, and we also communicate with other organizations throughout the United States. This provides us with evidence based practice and educates us on new initiatives that may not be published at this time.
  • The Falls Workgroup meets monthly. This workgroup consists of RN representatives from each unit. They have standard work which includes the monthly meeting, auditing patients on their unit for appropriate falls assessment and interventions, collaborating with unit leadership, and providing positive peer feedback or recommendations for improvement.
  • There is Visual Daily Management on in the Visual Control Room where Nursing Leadership has daily huddles at 11:30am. This tool keeps track of the date the last fall occurred, the unit it occurred on, the number of days since the last fall, and the record number of days. There is also a Visual Daily Management tool on each unit that keeps track of individual unit information.
  • Red slippers (instead of regular grey hospital slippers) are going to be trialed for three months on two units starting 9/1/09. Other facilities in the United States have used this andon for high falls risk patients, however there is a lack of evidence regarding its success.
  • Posey sitters for beds and chairs are pads that patients sit on. When a patient attempts to get up on their own, and the weight is taken off of the pad, the alarm sounds.
  • Defective shower chairs have been removed from the hospital. It was found that these shower chairs caused three patient falls. We have a new vendor for shower chairs.
  • The Falls Leadership Team has a Kaizen Event planned in September that will help us better understand the relationships between falls risk assessment, assistance level, mobility level, and the activity level the clinician orders.
So I would rather be good than lucky, and these sound applications of lean concepts create real safety for our patients.

David K. Wessner
President, CEO

Park Nicollet Health Services
6500 Excelsior Blvd.
St. Louis Park, MN 55426

Tuesday, August 11, 2009

The paradox of lean healthcare

Welcome to Lean Healthcare Grand Rounds, a blog devoted to the people and the organizations that are transforming healthcare through the application of the principles of the Toyota Management System.

Since the publication in 1999 of Institute of Medicine's report To Err is Human, the need not merely to reform but to transform healthcare in the United States is painfully clear. So, how much better does healthcare need to be? Mike Rona, former President of Seattle's Virginia Mason Medical Center, makes the case that the goal should be zero defects. See J. Michael Rona, "97.1 Percent Perfect," Journal of Healthcare Management 50:2 March/April 2005. Possible? Using the Toyota Production System, Virginia Mason reduced Ventilator Associated Pneumonia (VAP) by 92%. See J. Michael Rona, "The American Health Care System: A Wasteland of Opportunity," Future State, Summer 2007.

What about cost? The Institute for Healthcare Improvement's President, Donald Berwick, estimates that the waste in healthcare is at least 30% of healthcare production costs. If we could eliminate this, it would be worth $780 billion per year (.30 x $2.6 trillion = $780 billion), or--in the cost savings for one year alone--enough month to pay for a plan that the White House Office of Management and Budget estimates will call $1 trillion over the entire decade! Possible? Virginia Mason reports an average cost reduction of 50% as the result applying the Toyota Production System. See Rona, "The American Health Care System: A Wasteland of Opportunity."

As Steven Spear maintains, Toyota's methods offer us a way to transform healthcare from inside, today. See Spear, "Fixing Healthcare from the Inside, Today," Harvard Business Review (September 2005). In other words, the healthcare industry should transform itself. Alas, our present approach as an industry and as a nation is, of course, to transform healthcare from outside, eventually, if ever. Apparently we view healthcare reform as a Hobson's choice between providing access to our 40 million uninsured on the one hand and reducing cost on the other. And quality? It hasn't come up yet during the course of our public debate, has it? In the August 3rd edition of Newsweek, Samuelson says, "The [Obama] administration had to make choices: it could emphasize expanded insurance coverage ("access") or cost control, but not both." As a result, if the present legislation is passed, Samuelson expects healthcare costs to rise substantially. Read the complete Newsweek article: "Health 'Reform' That Isn't.' Also see Newsweek reporter Jeneen Interlandi's blog post, "Cleveland Clinic CEO Speaks on Healthcare Reform: 'We May End Up Making the Problem Substantially Worse." As Dr. Cosgrove says, "If it’s just access, we will be back in a few years dealing with cost, and it will be even worse."

Access, cost, or for that matter, quality do not necessarily present us with a Hobson's choice, because, costs will fall as we reduce healthcare's long lead times, and quality, well, quality is free. This is why most six sigma programs (originally characterized in terms of quality) have morphed into "lean" six sigma programs. For what appears to be the paradox of lean healthcare is actually a simple formula. If we stop to fix healthcare's problems, from the inside, today, it won't be long before we will find ourselves spending less time dealing with the consequences of poor quality. And as we waste less time mopping up after ourselves, the cost of healthcare will come down. Thus what appears to be a Hobson's choice is in reality a false dilemma. With Toyota's philosophy and methodology, we can have it all: all-inclusive access, zero defects, and affordable cost.

This blog will be organized into four major topics of conversation:
  1. The long term philosophy of the healthcare profession--in other words, how should we interpret "Do no harm?" in a way that makes healthcare more affordable to those that need it;
  2. The process of delivering healthcare services effectively, safely, efficiently;
  3. The development of healthcare professionals, managers, and support staff; and
  4. How to turn helathcare organizations into learning organizations.
This is a truly vital conversation. On this depends our national solvency as well as our personal well being. We look forward to your comments.

Best regards,

Tom Jackson, Moderator

Thomas L. Jackson, JD, MBA, PhD
Principal, Rona Consulting Group
Clinical Associate Professor, University of Washington School of Public Health
August 15, 2009