The quality coalition is a group of healthcare providers which include Gundersen Lutheran and ThedaCare. They have worked hard to make sure language was included in the healthcare bill that allows for value to be defined and rewarded.
We have known for years that significant geographic disparity exists in healthcare payment. In fact, the Dartmouth Atlas tell us that in the markets that deliver the best quality and lowest cost, the payments are the lowest. Medicare pays better for worse quality more expensive care. This is certainly one reason that U.S. healthcare costs are skyrocketing.
What the Secretary of HHS has agreed to as evidenced by the following letter to the quality coalition, is to charge the Institute of Medicine with studying the issue of defining healthcare value and reporting the findings to HHS. The IOM should consider working with the Healthcare Value Leaders Network to create the measures for value. The network has received one grant from the RWJ Foundation and has submitted grant proposals to the Commonwealth Fund and will be submitting a AHRQ grant shortly on the subject. With our Network of now 30 organizations implementing whole system transformations using lean, there is a robust environment to study both the metrics for value and also the actual delivery of better value to the patient.
The sooner we get to actual value measures, the sooner we get to payment approaches that work to reduce cost and improve quality in healthcare delivery.
This is the final segment in a nine post series on the core components of organizational transformation using lean.The topic is part of the rubric of People and is about organizational culture.
Corporate culture is difficult to define because it is so confusing most people steer away from writing about it. By culture I mean to describe a pattern of behavior that is widespread and ingrained in a particular group, until it is expected and sometimes codified. When people in healthcare talk about the culture of shame and blame, they refer to a common set of expectations in the medical field about how transgressions are – and are not — handled. Only recently have people in healthcare started to talk about the damage shame and blame has caused.
As disciplinary models go, shame and blame has a distinct advantage: it’s fast and easy. A cursory glance at a situation is all the evidence needed to decide on a culprit. And feeding the rumor mill with the guilty party’s name is infinitely easier than launching an investigation and then going through channels to issue an official reprimand. But shame and blame has a terrible price.
In that environment, there is no motivation to report errors or safety issues. If staff is blind to error and its cause, there is little hope for improvement. Lucian Leape recently published a set of recommendations for changes in medical education. (http://www.createhealthcarevalue.com/blog/post/?bid=147)
In the report he describes the damage being done by our present apprenticeship education process for physicians in which the attending doctor berates, embarrasses, and belittles medical students in front of their peers. I believe this builds distrust, anger and creates autocratic dictators that are unable to effectively work in a team environment. Lucian Leape comes to a similar conclusion in his paper.
How do we build a culture of improvement? It starts with the two pillars of lean which are continuous improvement and respect for people. In previous blogs we have discussed the methodology of continuous improvement. The continuous improvement methodology is very important because without it the next important pillar, that of respect for people is not possible.
Respect seems intuitive, but it is a complex idea, especially in the workplace. As a leader, to have respect for staff usually means giving lip service to peoples’ concerns, to say that you hold them all in high regard. This is often a polite lie.
Respect actually means wanting everyone on staff to have meaningful lives, and working actively toward their fulfillment. As at Toyota, this is such a critical element of a lean healthcare organization that it is a foundational principle. In many ways, it is inseparable from continuous improvement, even though it is distinctly different.
People are not very different in their basic needs. Everyone wants to feel needed, to be an integral part of a team doing good work. Respect for people means helping everyone become integral to the larger team, to find fulfillment in their work through empowerment. By empowerment, we mean giving people the tools to become problem solvers and then creating the working conditions that applaud solving problems instead of sweeping them under the rug. Without a continuous improvement environment, people become frustrated because they do not have the tools or the permission to fix problems. A lean healthcare organization trains people in problem solving, then respects their opinions and experience enough to let them take the lead on improvement. In this way, you can see how respect for people and continuous improvement intertwine to form the bedrock foundation of lean healthcare.
Don Berwick has been working his entire career to improve health care. Now, he may have his best chance yet.
Yesterday, several news sources announced that President Obama would nominate Don Berwick to be the next CMS director. This follows almost 4 years of the agency’s lead position being vacant. With the recent passage of the health care bill it’s important to have a qualified and respected leader in this position to guide change.
Why is Dr. Berwick qualified to be this person? Crossing the Quality Chasm, a report from the Institute of Medicine describing the medical errors and deaths occurring in American hospitals was authored by Dr. Berwick and others over 10 years ago. This was the first time the quality of American medicine had come under significant scrutiny and it was Dr. Berwick who had the courage to tell all of us we need to do better. Well, Medicare/Medicaid needs to do better, a lot better, and it’s going to take a leader with his courage (and knowledge) to take on the status quo and get us redirected toward incenting and delivering much better and lower cost care.Dr. Berwick has that courage and experience.
The priorities at CMS need to change and Don knows this. He is a big supporter of changing systems so as to improve. The systems of reimbursement are clearly broken and need to change. We reward the least efficient lower quality organizations with our present reimbursement system and that must change. We need to have the data. Physicians and other health care workers change when they are confronted with the facts. The facts related to hospital and physician performance must become transparent before change will happen. Finally we have to change how we deliver care.We have shown as others have that there is at least 40% waste in the present delivery system.
At the Health Care Value Leaders Network we have begun to show how waste can be removed. The framework for this change will be published shortly in our book “On the Mend”
How can we help Dr. Berwick succeed assuming the president does nominate him and the senate confirms him? We need to be willing to change the way we are delivering care. We need to engage in experiments in our own institutions and we need to scale our learnings across the industry. We need to be willing to enter into pilots and research studies which are designed to show that lean health care can remove massive waste and lower cost at the same time improving quality.We need to learn a new management system. One that supports the front line workers and ultimately delivers defect free care to our patients. We need to stop bellyaching about not getting paid enough and figure out how to better use the huge resources we already have to decrease the cost of care for the government and our employer customers. We’ve got a big responsibility as providers to help Don. Let’s come together to get it done!
Oh, and by the way, assuming he is nominated, please call your senator and tell them to ratify Don as the next CMS director.
HBR published an article on “industrial metaphor” in healthcare and how physicians respond to this.
This article was published on the HBR blog and is focused on the pitfalls of implementing lean in healthcare. The words are important and the article helps to define how to use the words to achieve an effective lean implementation in healthcare.Sachin Jain M.D. wrote case studies for Michael Porter including the one on ThedaCare and is the co-author of the piece.
The House passed its version of the Senate Health Bill and it now goes back to the Senate. We still have a big cost problem that hasn’t been addressed though.
Assuming the senate uses the reconciliation procedure, the house version of healthcare insurance reform is on its way for signature by President Obama. This is the culmination of many months of arguing among democrats, as no republicans ever participated. The 2300+ page legislation focuses mainly on insurance company regulation and allowing for 32 million more Americans to be covered. My argument has never been about whether all Americans should be covered or whether onerous insurance policies should be lifted. My argument continues to be that nothing in the legislation addresses the continued cost increases that are going unabated at 6-8% per year.
As we have written in many articles and blogs, the fundamental problem in America’s health care is that costs are too high (twice as high as many other western nations) and quality is average at best. Is there anything in the bill that addresses the fundamental problem? Well, I must admit I haven’t read the new house bill so maybe they added some language about this, but I doubt it. We couldn’t get even simple non-controversial language in the bill to simply study whether organizations implementing lean in healthcare can radically reduce costs and improve quality.
We are going to spend 940 billion dollars more over the 10 years and we will reduce medicare payments to hospitals and nursing homes by 500 billion, and increase taxes on people making more than $200,000/yr to make up the difference of a few hundred billion. These changes in and of themselves are tolerable (not cause for joy); but what happens if we don’t attenuate the 6-8% increase in the medicare cost and commercial insurance costs? We will be back for more taxes and further provider cuts.
The work isn’t done with this bill. We at the Healthcare Value Leaders Network are doing the real work on health reform. Let’s hope we and others implementing process improvement and continuous improvement can make breakthroughs on the real fundamental problem.
St. Mary’s in Madison has undergone a massive nursing training program related to the tragic death of a teenage OB patient.Will what they have done make a difference to prevent other accidents?
I know the leaders and doctors at St. Marys in Madison.They are dedicated,competent,caring people and belong to a great overarching organization lead by a visionary CEO.We all were very sad to learn of the terrible thing that happened a few years ago. How could it be? A great hospital with great doctors and staff.The fact is it happens every day in many American hospitals and everyone feels horrible but usually settles back into the bad practices that allowed it to happen in the first place.
St. Mary’s has not done that.They have trained their nurses in something their consultant calls “just culture”. All 20000 employees have been trained after this case. According to the consultant the model is designed to “address risky behaviors before they lead to the death of a patient,coaching those who make risky decisions,such as failing to wash hands before touching patients or skipping important checks in administering medications”. It’s hard to argue with the that. My question is this enough and is the problem fixed not only at St. Marys but for all of us.
Recently John Grout and I published an article on mistake proofing in healthcare (see articles by John Toussaint at the bottom of the page) in which we give concrete examples of how to build a care process that can’t fail. In the St. Mary’s case there was apparently an error proofing process in place for the medication which ultimately led to the demise of the patient but it didn’t work.As the designers of healthcare process we struggle to build quality(and error proofing) into to every patient care process.The reason there are so many mistakes in healthcare is that we haven’t done a good job of this.
If a new standard work process is implemented, then it needs to be carefully audited to determine if the process is being followed.If not, training needs to occur and performance measured until leaders are satisfied that the process is in control with little or no variation as the goal.These concepts are basic lean ideas which have been shown to work over and over.
We know St. Mary’s went through a training program which presumably has established new behavioral expectations for nursing performance. I assume this also means new standard work for medication delivery. But if this new standard is not being constantly audited and performance feedback given to the staff on a daily basis it’s possible the problem could occur again. Of critical importance,the defective medication delivery process must be truly error proofed as described in our article.With the high staff turnover health systems face sustaining an improvement is very difficult and it is one of the reasons we must measure and audit results constantly. Implementing an entire system standard methodology for improvement as I’ve described in my recent blog series is the only way I know to sustain gains made in point improvement projects like the massive retraining St. Marys has done.
We all hope this mistake never occurs again in any hospital. Hope is not enough, however, we need a methodology which engages every employee to identify defects and then perform plan-do-study-act improvement cycles that create new standard work which is then carefully audited to ensure compliance.This is the only way to break the terrible trend.
It’s been very encouraging to see results in U.K. and Sweden confirming lean in healthcare works all over the world.
I have spent the last few days in Sweden and visited St. Gorans hospital in Stockholm and the Lund University Hospital Lean Healthcare conference where I gave an address. I can say that there are committed leaders trying to transform their organizations in both places.The results are quite remarkable. Wait times in the ER at St. Gorans have dropped by half and door to balloon can be accomplished in less than 30 minutes!This all related to 5 years of redesign work using lean principles. At Lund standard work for executives is being developed and led by their committed CEO and the massive silos of academic medicine are being scaled and slowly dismantled.
In the U.K. Bolton hospital continues to post remarkable gains on their 5 year lean journey.Their stroke value stream work has led to a 23% reduction in mortality and their work on creating a care team which carefully assesses risk of pre-surgical hip patients has resulted in a 75% reduction in mortality.In addition wait times have plummeted in the ER. Their next challenge? Develop an end to end value stream for patients from the primary office who require hospitalization and then reduce hospitalization rates.Right now they get penalized for reducing hospital admission rates(sound familiar) but the CEO forges on because he knows it’s the right thing to do.
These examples encourage the work we are facilitating in North America as it confirms dramatically better care can be delivered to all patients everywhere.The difference in Sweden is political leadership is engaged in the discussions. There were two national level politicians(one was the former health minister) at the lean meeting for the whole day in Lund! They thoughtfully listened,took notes and then made comments at the end of the day and pledged support of the work being done to redesign the system.
This 7th blog on organizational transformation again is under the rubric of process, standard work, and it is a key part of the Methodology of lean.
Standard work is the codified work sequence that comes about as a result of improvement activity. When a care process is changed the staff and physicians delivering that care act differently based on what the new process is telling them to do. These new processes are designed by front line nurses and doctors in an attempt to take waste out of an existing care process leading to better outcomes for staff and patients. Unfortunately standard work is sometimes derided by health professionals as “cookie cutter” medicine or “cookbook” medicine. It is seen as taking away the autonomy of the doctor.In reality it actually frees more time for critical thinking. Let’s explore why.
When an improvement activity occurs their is a plan than must be developed.This plan is based on certain back round evidence which is collected before the experiment is designed to test a hypothesis. For example, the infection rate is twice as high in the inpatient surgery center at hospital A vs. hospital B. We first observe the better performing hospital by observing a large number of surgeons washing their hands.We observe the time spent, the process of cleaning each finger, and the variability in the process from surgeon to surgeon.We do the same thing at the poorer performing hospital. We find in the poorer performing hospital that many surgeons are washing their hands differently.The next step is to formulate a hypothesis: If all surgeons washed their hands the same way and washed them in accordance with the best evidence for hand washing technique would infection rates at Hospital A go down?
Now we are ready to test or actually do the experiment. A new hand washing process is established by having the surgical medical director take the existing evidence on hand washing and present that to the surgical committee get feedback from them and then create standard work for hand washing. The new standard work is then piloted with a few surgeons to determine if it is the appropriate process for all the surgeons. Now we study the consequences of this new protocol and find that all the pilot surgeons comply with the process and believe it is effective.
We now are ready to act on the new standard work for hand washing. The surgical committee recommends that the new process be established as the standard for all surgeons in the O.R. Of course, after the usual “you can’t make me” the new process is implemented. The process up to this point has involved many surgeons who understand there is an infection problem in the O.R and are willing to help fix the problem even if they are not directly the surgeons having the infection problem.The key to success is buy-in of the surgical leadership and massive upfront communication on the issue with focus on the problem as a process problem not blaming any specific surgeon.In some cases unblinded data on each surgeon is used to assure compliance but only after all the above actions have been taken.
The new standard work is again studied over the next 3 months. The study is focused on two things: Compliance to standard and outcomes. Compliance to standard can be accomplished in several ways.In one case we installed video cameras which only showed hands not faces. This way we could show non-compliance in a non blaming way to the committee. The other way is to directly observe which is more intimidating but successful if surgeons buy in to it.
At the end of three months infection rates had dropped by half and compliance to hand washing standard work was at 100%. The study showed the plan was working. The auditing and measurement part of this experiment continues as part of the managers standard work. As long as outcomes and compliance to standard work remain at the appropriate target a new pdsa cycle is not necessary.
Now, how does this standard work process for hand washing (cookbook medicine) help the surgeon spend time on more important things?It should be fairly obvious that if he doesn’t have to take care of all the infected patients he has more time to treat patients that need his help.He also gets dragged in to fewer meetings regarding reducing infections and the most important point is his patients have better outcomes.
Standard work is a critical component to creating reliability of patient outcomes. Although this is a simple example the concept can be applied to all specialties and all processes in a hospital or clinic.The error I see most often with standard work implementation is lack of a process owner for auditing compliance to standard work.As soon as auditing is discontinued the process spins out of control and variation returns.
This paper titled, Unmet Needs, outlines a number of fundamental flaws in the present medical education system.
I have commented in presentations,in articles,and now in a book the Lean enterprise Institute will publish in June that the shame and blame culture instilled in our medical schools is our biggest barrier to patient care improvement. This paper by the Patient Safety Institute clearly outlines the problem and makes suggested changes regarding medical education.
For example, the fact that professors of medicine are allowed to berate,belittle, and attack medical students in public forums is appalling. It is fundamentally disrespectful and it fosters ill will and a culture of hiding mistakes. We all have our stories of this behavior manifested in our teachers. How many of us had teachers that encouraged us to discuss our mistakes or taught us how to solve a problem or root cause an error. In 4 years of medical school it never happened once to me.
In order to revolutionize the industry we must destroy the shame and blame culture, we must learn pdsa (plan do study act) problem solving and we must learn how to follow and audit the standard work that emerges from pdsa. In my experience there are no full time faculty in medical schools competent to teach any of this. Lucian Leape is absolutely right in his analysis of the gigantic gap in medical education.In fact this may actually be one of the root causes of the entire healthcare cost and quality crisis. LLI-Unmet-Needs-Report
Other leaders who will be presenting at this event include Paul O’Neill,Dr. Richard Shannon and Steven Spear.
I attended this event last fall and found it quite provocative. Healthcare leaders looking to change themselves and their organizations using lean should attend.
