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Narrator: Welcome to The Lens, hosted by Catalysis. Where we get a glimpse inside healthcare organizations that are transforming to a culture of improvement to deliver continually higher value outcomes for patients, staff and communities. Visit createvalue.org/thelens for more information about Catalysis.
Peter Mariahazy: Thank you for tuning into The Lens. I’m your host, Peter Mariahazy. Today I am thrilled to be joined by Steve Shortell, Dean Emeritus and Professor of the graduate school at the School of Public Health and the Haas School of Business at the University of California in Berkeley. Steve also co-leads the Center for Healthcare and Organizational Innovation Research and the Center for Lean Engagement And Research. Steve is here to share with us the latest research on improvement efforts in healthcare and, very importantly, the connections to measures of quality. We are also deeply appreciative that Steve also serves as a member of the Catalysis Board of Directors.
Hi Steve, thank you for joining us today.
Steve Shortell: It’s good to be with you, Peter.
Peter Mariahazy: Steve, can you just take just a moment and, and beyond what I’ve said, introduce yourself to the listeners and and just so that they get an idea of of what your days are like.
Steve Shortell: Sure, well I’m very active here at Berkley, to the extent we all are here on Zoom now, of course. I have a very active research portfolio and a lot of it has been around the CHOIR's determinants of quality of care. Throughout my career, uh, it’s been an area of research of great interest to me, particularly, looking at the organizational characteristics and processes that promote quality of care. We’ve been delighted to have the support of Catalysis, and others, for our research center because we’re trying to shed some evidence that’s going to be useful to the field in terms of, of really eliminating the waste that we have in this country and delivering healthcare. And that’s been highlighted, I think, by COVID-19 and the ability to respond to that quickly so I look forward to our questions and discussion.
Peter Mariahazy: Yep, I’m very excited as well, Steve. A couple of years ago the research center, CLEAR, conducted significant research of healthcare organizations in the US. To get our listeners caught up, can you give us a high-level summary of those findings.
Steve Shortell: Yes. Back in 2017 we worked with the American Hospital Association on doing a national survey of the lean management system, organizational excellence, in the nation’s hospitals and, uh, Peter, we have data on over 1200 hospitals and we found out at that point in time that about, uh, 69% reported doing some aspect of lean. And it was actually about 61% when we corrected for non-response, uh, bias in the survey. So you have uh, roughly, uh, 60% of the nation’s hospitals reporting doing something around lean. However, only about 12% of those were what we would call mature and we measured that a number of different ways: number of years doing it, number of operating units doing it, even self-reporting. And so the depth of the implementation uh, uh, isn’t there in many of the nation’s hospitals. So, what we did though, we were able to analyze those hospitals (that) reported doing lean, with a lot of at least self-reported performance measures. And we did find out, as you would imagine, that those, uh, doing lean, and doing more of it, in terms of implementation, had greater self-reported performance. But that was just self-report, and so what we then went on to do, and that paper by the way is in the Joint Commission Journal, uh on Patient Safety and Quality. What we then went on to do is to look at some independent measures, uh, objective measures of hospital performance organization-wide. And these, uh, included the publicly available measures such as, uh, in-patient adjusted expense per discharge, uh, the Medicare spending adjusted as well, standardized mortality across, uh, many of the operation procedures. We also looked at the HCAHPS scores and things of that sort. We looked at profit margins and so on. And what we found there was, and we were only able to look, Peter, at the adoption at that point in time, because our measures were in 2017 and we didn’t have performance data independently, uh, in 2017 or 18 so we had to wait for that. I’ll talk about that in a minute. But we found relatively little relationship between merely lean adoption and these other measures. We did find, however, interestingly, that those hospitals doing lean had lower Medicare spending per beneficiary than other hospitals in the United States and that was, uh, significant. So that was, our work, uh, back a couple of years ago.
Peter Mariahazy: Well, th-thank you, Steve, and, and you’ve got some exciting papers in for review. In fact, I think one of them is with the Joint Commission, tell us what is going on with those papers and where they are in status for review.
Steve Shortell: Yeah, it is exciting, and this is our updated research we’ve been able in the past year to get, uh, 2018 performance data. So, we can now analyze what hospitals were doing in 2017 in actually implementing lean, and the, uh Association that, well and it’s maybe it’s not a totally cause, but with 2018 performance data a year later. And what we have found in the paper under review with the Joint Commission now, is uh some ugh more robust relationships with some of these performance measures. So we looked at the number of operating units, uh, up to 29 operating units in hospitals that are actually, uh, doing lean, and we correlated those, Peter, so that we had a valid measure with separate measures we had of leadership commitment and daily management system use, uh, of the training index and so forth. And they correlated well and so the number operating units is our measure of implementation and the greater the degree to which hospitals are really implementing lean we found statistically significant lower adjusted inpatient expense per admission, lower adjusted unplanned 30-day readmissions, above the national average in making, uh, safe use, uh, of imaging. In other words, better use, uh or, less use of low value care and more use of appropriate imaging. And we also found significant relationships with the patient experience scores as well. We did not find relationships with mortality per se, Medicare spending, or indeed profit margins as such, uh but, you know, but there’s still these encouraging relationships with some of these other kinds of measures. So that paper is under a revise and, uh, resubmit. We’re uh, we’ve improved it, I think, with some good feedback from reviewers and hopefully that’ll be out sometime in the coming year.
Uh, and then Peter, I have a doctoral student here at Berkeley. And what we were able to do, our Center is part of a national center partnered with the Dartmouth Institute, Harvard, in the high-value healthcare collaborative. And that initiative collected data, on hundreds of hospitals around the country as part of an ARC-funded, comparative hospital performance initiative. And what we were able to do, is we were able to overlap, or match, our national survey with this other survey and we found 223 common hospitals that reported to both. And that enabled us to then look at, uh, our measures of implementation: years doing it and so on. With these fine grain process measures of quality of care and, uh, what we found is very interesting and I’ll talk a little bit about them. Namely, we found that the hospitals doing lean, or put it this way, the greater the number of years they were doing lean, we found positive associations with greater uh, electronic health record decision support, they were doing more of that, than hospitals doing very little lean. They had greater quality information management participation, they made greater use of evidence-based guidelines, and they made greater use of support for care transitions. And in order to build that out a little bit, I’ll give you some idea and the listeners of what we’re talking about in terms of those behaviors.
The evidence-based guidelines were for written down and approved congestive heart failure, acute coronary syndrome, hip fracture, community acquired pneumonia, sepsis, pre-eclampsia, neutropenic fever, inpatient radiology and serious mental illness. And when you looked at the EHR decision support, we asked if those tools were used for some of the same conditions, I just mentioned, uh as well. And then when you look at whether or not, for example, the relationship with quality-focused information management. We asked them whether or not they used that information and collected it only. Or did they really use it for internal quality improvement. And we asked that for preventative services, patient experience, overuse of medical tests, did they feed that back to their physician’s staff, under use of medical tests, acute coronary services, clinical quality measures, and cost of care.
And then finally, on the care transitions. What we found hospitals doing more lean, did better with transitioning care. We found that, in terms of reducing the risk of readmissions, if they did Medicare, medication reconciliations, telephone follow-up within 72 hours of discharge, in home follow up 72 hours of discharge, standardized processes were in place to follow up with primary care or specialty care. Discharge summaries were transmitted to the clinicians that accepted the care of the patient after they were discharged from the hospital. That the use of the patient navigator or care manager while the patient was in the hospital and did they use the care manager or health coach post-discharge. So the bottom line is that hospitals really implementing lean did significantly better on all of those kinds of metrics than those not doing lean.
So that is new information. That paper has been accepted in the journal called Quality Management in Healthcare. And we think that will also come out sometime in 2021.
Peter Mariahazy: That’s great news and, and, you know, Steve, that really ties to, um, our previous podcast with Dr. John Toussaint. Talked about um, you know, efficiencies in healthcare and, and being able to change the payment model so that the incentives are more driven towards quality and patient care. And what’s interesting, as you were reading some of those specific items, to me, thinking of it, that as someone outside of, if you will, the industry and as a patient, you’re caring more for me. You’re providing me the services to make the, the healthcare process much more, uh, comfortable and gratifying. So, it sounds like it’s all tying together and, and you’ve done a great job of collecting the data to support that and show that it, it works.
Steve Shortell: Yeah, yeah and just tying into what uh, you mentioned about John, uh, who you really is you know Peter, and probably many of the listeners, we need to move to health budgets in this country. We need to get rid of the fee-for-service and create risk-adjusted. So that hospitals and everybody have the incentive to innovate, to really implement lean. Although where you’re going to really earn the savings, you’re going to keep them well. Keep them out of the bed, get them discharged sooner, safely to the after care and so on. And engage more in the prevention. And that’s going to be so important going forward. John, and I, and others, are developing something we call, “The Better Care Plan”. Which is designed to pay providers differently. And I think once that kicks in, to the extent it does, you’re going to see lean in, in organizational excellence, I think mushroom around the country. And uh, that still needs to be, uh, needs to be seen. Uh, but, I think, uh, things are headed in that, in that direction.
Peter Mariahazy: And, and, I think as you said earlier, it’s, it’s all about removing waste and improving outcomes for the patient and for the system as a whole.
And secondarily, and, and, probably just as importantly, the caregivers themselves. Um and as we go through this time with COVID, it is absolutely critical that we’re taking care of the whole system. Otherwise, we just don’t have the capacity to keep up and we, and we run into some challenges.
Steve Shortell: Yeah, absolutely. Just on that point, Peter, uh, the, you know, the things that are going to promote this, it does take time. Our data suggests that, and of course, the work of Catalysis, and others, with uh, with folks uh, uh indicates that as well. There is a recent article your listeners may be interested in that came out in The Journal of Healthcare Management. Not, not ours, some colleagues’. That followed Indiana University Health System. And they are one of our research collaborators at, at CLEAR as well. And they looked at five years of rapid improvement events. Five years. And what they found was that in 45% of those events, they documented some benefit. Most of it was in cost reduction, uh first. And then later on it was really in, more time savings. Cost reductions can be the, uh, low hanging fruit and then later on they found that it was saving time, and particularly in the emergency department. Uh, which is, is you know, a good area to start a model cell in. So that’s some evidence, uh, that you know, this does take time. But you begin to get, you know, some benefit. But you can, can look at it as the glass half-full, half-empty. If it’s half-full, 45%...but 55% of the time they, they’ll benefit yet. So, you have to keep working at it.
Peter Mariahazy: Yep
Steve Shortell: But what we have found, we’re now doing a study of the daily management system. With Indiana University and, and others in our research collaborative. And what we have found several things about that’s going to promote this, we think. One is that alignment with True North. With the strategic priorities of the organization and on down to the front line. Ongoing leadership commitment from the board on down is key. Uh, really installing the continuous improvement culture every day, its never-ending. And then the training, uh, that goes with it as well. So, I, I think those are the things we’re going to see uh, uh, kick in as this, uh, continues to move forward.
Peter Mariahazy: Thank you Steve, those are that, that’s a great way to close it as we, talk about the importance of, everybody being behind the strategy and, and the motion within the healthcare system to be able to improve outcomes. So, Steve, do you have any, any final thoughts to share with the listeners real quick?
Steve Shortell: I think my final thought, Peter, would be the COVID recovery, uh, that has to take place now and, uh, the use of, the ways of managing and leading our hospitals and our physician practices differently. Those that have implemented more of the lean principles, the underlying Shingo principles, I think are going to recover sooner. They are going to learn faster, as well about what really needs to be uh, changed. They are going to develop new care models faster: hospital-at-home and related models. They are going to be thinking of creative uses of telehealth expansion and extension particularly in rural areas as we get more, uh, broadband, uh, built out there as well. And so, I think those would be my, uh, thoughts: Is to continue to study this as the nation’s healthcare system begins to really uh, uh eliminate waste big time and reorient totally new ways we need to deliver care from the lessons of COVID-19. And that goes with for paying for it as well. Those who earned their money up front did a lot better because they were free to move resources around. They had earned their revenue by the patients enrolled per capita, etc., uh, versus those that suffered from fee-for-service and are really behind the eight-ball.
Peter Mariahazy: Steve, great way to close that out. Thank you so much for joining us today.
Steve Shortell: You’re welcome, Peter, thank you.
Peter Mariahazy: And all of you, thank you for listening. When the pe-papers that Steve has submitted for publication are ready you will be able to find them at the Catalysis website at createvalue.org. You will also find other resources you that can help you lead in the consistently changing healthcare environment. All of us at Catalysis hope you stay healthy, and, as always, thank those working on the frontline to keep us all healthy. Stay tuned for more episodes designed to help healthcare leaders support their organizations on a journey to organizational excellence.
Narrator: Thank you for listening. Visit createvalue.org/thelens to learn more about how Catalysis can inspire you to accelerate change in your organization.