This Is What Happens When You Respond To One Bad Case

By now, you know how I feel about responding to one (or a few) cases with big changes to your system.  Now I know that sometimes cases are so extra-ordinary, dramatic, or horrific that something has to be done owing to public pressure, legal issues, or some extenuating circumstances.  But, guess what, it turns out that responding to one (or just a few) cases leads to a worsening of your system’s performance.

Remember…responding to just one case leads to a worsening of your system’s performance.

Don’t believe me?  I don’t expect you to!  I didn’t believe it either until I learned about statistical process control.

I remember a video I watched that really drove this point home for me.  And I’ve spent more than 30 hours online looking for a copy of that video to share with you, my healthcare friends, so that you’d share in this revelation with me!

Beneath, I’ve shared a link to this incredible video.  Remember, as you watch, that the process involved could be manufacturing a part, caring for a patient, or arriving on time for a trauma activation…the processes and data involved don’t know (or care) when it comes to using the powerful tools of statistical process control!

The process involved could be manufacturing a part, caring for a patient, or arriving on time for a trauma activation…the data involved don’t know or care when it comes to using statistical process control!

Bottom line…adjusting a system based on one extraordinary case leads to worse outcomes overall.  That’s why it’s so important to use the tools of statistical process control and to improve your system as a whole…because doing that will get us much further and will eliminate those extra-ordinary cases in the future.  Adjusting based on an attention-getting case will often just make things worse!

Click the link or photo beneath to view this incredibly useful demonstration.  (Source:  by the way, this video is from a Villanova University course on Lean Six Sigma…and it’s the best I’ve ever seen on this topic!)

Trauma Program Operator’s Manual – Kindle edition

About four months ago, I heard about another trauma program medical director who had to give a presentation about the open abdomen because of local politics at their center.

They weren’t really asked.  They were pretty much told they had to because staff were concerned–staff said they’d never seen those procedures done so often at their center.  And the staff’s uncertainty was being stoked by some influencers who did NOT want trauma to succeed or grow.

And guess what else:  this was the third time I saw the scenario repeat in the last three months.

Every time, the medical director was a good surgeon who had already done a lot of teaching about the use of damage control surgery and the use of the open abdomen before being “asked” to give that presentation.  What was going on at the center was standard care delivered was being delivered in a standard way to patients who needed it.  And it was being done at a center that knew it needed to improve.

These medical directors had taken a role where a hospital service either need to be greatly improved or they had been asked to start that very service.

But not everyone wanted it to succeed.

Despite good intentions, dedication, and great training each director left the center less than a few months later.  This made me start to wonder:  how often does that happen?

Then I started to consider sharing all of the themes I’d seen repeat across Trauma and Acute Care Surgery  centers–the awesome ones that made for success and the horrible ones that helped yield collapse.

I decided to share a type of program manual (an operator’s manual) for anyone who participates in a trauma program in any way.  It would include a lot more than the scenario that repeated so much and had tipped me off to write the book in the first place.

Whether you want to learn about trauma finance, trauma process improvement, the common pitfalls seen when trauma “comes to town”, or one of the many themes that repeat across centers, the Trauma Program Operator’s Manual can answer many of your questions and accelerate your ability to achieve excellence in trauma care.



From’s book summary:

If you’re involved with a trauma program in any way, this manual is for you. It’s filled with useful, hard to find info that helps guide your trauma program to excellence and beyond. Are you a Trauma Program Medical Director, Trauma Program Manager, nurse, ER physician, trauma registrar, practicing Trauma surgeon, or C suite member? This manual offers, in a conversational tone, specific tools and techniques from a previous Trauma Medical Director and Chief of Surgery. Interested in whether the culture issues you’re seeing with your Trauma program are normal? Wondering about specific quality improvement techniques in Trauma? Curious about audit filters and what they mean? The Trauma Program Operator’s Manual contains hard to find info and more that helps your trauma program succeed.


Source: Trauma Program Operator’s Manual – Kindle edition by David Kashmer MD MBA FACS. Professional & Technical Kindle eBooks @

Spectacularly Wrong In Surgery

Here are some quotations that highlight just how wrong predictions can be when it comes to Surgery and Healthcare.

Click the link below the photo to take a look at the full entry for some all-time highlights!

These predictions are the sort that are so spectacularly wrong that they live on in the lore of the hospital and sometimes even blow up on the people who made them.They serve as reminders, routinely, of just how off things can be when it comes to predicting trends in Surgery and Healthcare. They warn us about how far off we can be even when we’re sure about what’s coming next.So, here’s a lesson in uncertainty when it comes to the future. Think about these next time you want to make a prediction in public!

Source: Spectacularly Wrong In Surgery | David Kashmer | Pulse | LinkedIn

The Surgical Lab Digest: 2017

It’s that time again!  2017 is nearing a close, and this is the time of year that The Surgical Lab offers a digest of some of our most viewed (and controversial) posts.  Take a look at the Amazon entry for the 2017 digest, including posts like Healthcare Is A Decade Behind Other Industries and other key posts from the year!



Source: The Surgical Lab Digest: 2017 – Kindle edition by David Kashmer. Professional & Technical Kindle eBooks @

Cost is NOT the threat to US healthcare quality

Guys, listen:  on my recent daily read through of articles on healthcare quality, I ran across one that made me want to share.

It all started with a quote that “Cost is the number one threat to quality in the United States…”


Before I jump in and comment on the quote, just a few things.  First, the person who gave the quote is really very excellent and quite intelligent.  Second, sometimes what we say in the context of an interview doesn’t exactly come across correctly once the article is written out and distributed out there for all of us to see.

For instance, I’ve done interviews for USA Today and several other publications…all with excellent reporters attached to each article.  No matter how good they are, sometimes they select something for the final article that doesn’t really make sense out of the context of the interview.

Maybe some of that is what happened to Peggy O’Kane with her quote I describe above.  (Click the link at the bottom of the entry for the full article including her quote.)

Now, allowing for that:  the idea that cost is the number one threat to quality in the United States is, to my mind, a cart-before-horse type statement.

It’s way off the mark.  Here’s why:

  • Even low level quality improvement projects in healthcare routinely recover $300,000+ from the Cost of Poor Quality (COPQ).
  • US healthcare spends around 14% of its GDP to achieve a median life expectancy that is usually ranked worse than 20th in the world.

If these facts weren’t enough, here’s just a sample off the top of my head that highlights how much cost is incurred by a healthcare lab owing to poor quality:


Originally shared on LinkedIn by Jennifer Dawson


Each answer option in Ms. Dawson’s question is a well-known truism in quality improvement circles.  (She asks which one best highlights long term cost savings to be had via investment in quality.) But look at choice D–that demonstrates how costs for the lab are increased by Cost of Poor Quality (or COPQ).  Reducing that COPQ would allow for improved profits to the hospital.  A poor level of quality is a great deal of the REASON for higher costs…and that level can be improved.

That’s the whole point here:  given the performance of our system overall (and, by the way, our health system can do some awesome things) it is exactly backwards to claim that cost is a threat to quality.  In fact, it’s the other way around.

For all you healthcare colleagues out there, let me say it this way:  you wouldn’t say a patient’s abdominal pain is a threat to their perforated gastric ulcer.  So don’t blame the symptom that is high healthcare costs on the real issue:  healthcare system quality.  It’s just plain backwards.


Cost is the number 1 threat to quality in the United States,” said Peggy O’Kane, founder and President of the National Committee for Quality Assurance. “It hurts the ability of doctors to do a good job. We have a lot of high deductibles that stand in the way of getting the kind of primary care and chronic disease management care that people need.

Source: Cost is top threat to care quality, and fixing that can repair our broken healthcare system | Healthcare IT News

Secrets Of Applying Value Added Time Concept in Healthcare

Ahhh Healthcare…few things are straightforward with you aren’t they?  For those of you following along, take this as one more example of the special nuances of applying classic quality concepts in healthcare:  value added time.

In other fields, value added time (VAT) has a relatively straightforward application.  It’s often defined as time spent in a system that contributes value for which the customer will pay.

But oh, Healthcare…you wily creature:  who is the customer we are talking about here?  Who gives the Voice Of the Customer (VOC) that we use to reconcile the process?  Let me share how I’ve applied the concept of VAT to healthcare processes before…

First, we have to remove ourselves from all the buzz and worry about what perhaps should be in Healthcare and focus on what is:  the third party payer of some kind (government, insurance company, someone else…) is the person who reimburses for services provided.  Sometimes patients pay for their own care.

Bottom line:  in general, these third party payers decide whether (and how) to reimburse for services rendered based on the note written by the “provider” (whether that be the physician, the advanced practitioner, or someone else).

…and that’s where the VAT finds its application.

Amazingly, if you haven’t seen it before, the VAT in many systems is only about 1% of the time spent in the system (!) Only 1% of the time we spend doing something is actually contributing value.  In healthcare, what is that VAT?

One way to look at it is that the VAT in providing care to a patient is the time spent writing the note.

Now, of course, what we write in the note has to be things we did or thought about.  So if we write we took out an appendix, well, we actually need to have done just that.  Writing down things we didn’t do is inaccurate and may even hurt the patient.  It’s also probably illegal.

But placing the note at the center of the universe for VAT does some important things.  Consider some important questions that come up routinely:

  • If the note is so important for VAT, shouldn’t we make it easier to create the note by improving the user design of Electronic Health Records?
  • If the note is so important for VAT, shouldn’t we embed coders and billers more directly in our systems that create them….even at night and on weekends?
  • If the note is so important for VAT, shouldn’t we encourage collaboration between coding staff and the providers creating the note?

The application of VAT in healthcare, in this way, has some interesting consequences for how we improve the value in our systems.

In healthcare there are some special issues in application of this definition.  For example, who is the payer in the situation?  When we say value-added time as anything for which the customer will pay, who is the customer? We usually use a third party payer’s perspective as the answer for “who is the customer” because they are usually the ones actually paying for the services and systems.  Rather than talk about who should be paying for services in American healthcare we, instead, focus on who does.  In this respect we treat the third party payer, the source of funds, as the actual entity paying for use of services. This also has some interesting consequences.  The third party payer, in fact, bases their payment on physician, surgeon or healthcare provider notation.  In fact what they actually are paying for is the tangible product they see which is the note.  Again, the note the physician, advanced practitioner, or healthcare provider supplies is what the third party payer reimburses.  In fact, they also use that as a rational to decline payment.  Consider how, if we gave a service but didn’t write it down, we would not be reimbursed.

Source: Takt Time and Value Added Time in Surgery and Healthcare Processes – The Healthcare Quality Blog

Here’s the current state of healthcare…

Once again, we see the current state of US healthcare at the forefront in the news.  What’s the current state?  Read on…

In a nutshell, we have the world’s most expensive healthcare and only middle-of-the-pack outcomes on key metrics.  Yes, you can argue about why or lament just how sick our patients are…but, bottom line, we’re a long way off.

Take a look at the excerpt and the opinion piece below to learn more about the current state of US healthcare and what lurks behind the public discourse on the health of our US healthcare system.

Nonetheless, a real debate over healthcare would begin with an accurate diagnosis of our ailing system. We have the world’s most expensive healthcare, and despite the superior quality of American providers, science and technology — our life expectancy and infant mortality rates are the middle of the pack among developed nations. The cost, quality and patient experience of care varies widely among doctors and hospitals. Despite billions of dollars of investments in information technology, medical records still don’t follow patients across providers, and we lack the real-time data insights that fuel quality improvement in other industries. Finally, our healthcare system emphasizes treating people when they are sick — not keeping them well.

Source: The healthcare debate we’re not having | TheHill

The Lack Of Quality Reporting Standards In Healthcare Is Epidemic

Come on now, you had to know about this problem with healthcare quality reporting.  No?  Well don’t take my word for it.  I’ve previously written about the lack of standards when it comes to defining value in healthcare and how we really can’t blame patients for misunderstanding healthcare value.

And now, this:  a recent JAMA online first that talks all about how we don’t have standards when it comes to healthcare quality reporting.  Oh boy don’t we!

Once upon a time, I worked for an organization that claimed it had no catheter associated urinary tract infections or central line infections in the ICU for more than two years!

Was this organization incredibly adept at quality improvement initiatives?  No, not really.  Had it closed its ICU to patients?  (That may be the only way to truly prevent those nosocomial infections.) Nope, sure hadn’t.

Several issues were at play, including a stubborn refusal to diagnose those infections even when they were obviously present and contributing to patient morbidity and mortality.  Can we blame them?  I’m not sure…there are plenty of pressures to avoid “never” diagnoses from CMS.

I’m not saying that makes it ok to ignore these diagnoses, but it does make it more understandable.  Hospitals didn’t create these incentive games, after all.

In any event, a lack of definitions and reporting standards regarding quality endpoints doesn’t help!  Take a look and click the link below to review the latest JAMA take on just how many issues we have with standardization of quality issues.  One more reason our field is a decade behind others in terms of quality improvement.

Although hospitals and physicians are perceived as trusted entities, these organizations have an incentive to present themselves in a positive light. This conflict of interest should be less pronounced when outside entities, such as the Centers for Medicare & Medicaid Services (CMS) or the Leapfrog Group, report to the public about health care quality.Evidence suggests that some organizations may be providing potentially misleading information to the public. For instance, one hospital stated on its website, “Come to us, we have no infections,” without stating which types of infections were included, how this performance outcome was measured, or how long the hospital had gone without an infection.5 Even though there has not been a systematic study of the accuracy of the quality data reported by hospitals and physicians on their own websites, concerns are likely to increase with the number and types of measures now being reported (eg, patient experience, costs), some of which may be more meaningful to patients.The potential for misinformation is understandable given the absence of standards to guide the reporting efforts of hospitals and physicians.

Source: Transparent Standards in Quality Reporting by Health Care Organizations | Health Care Reform | JAMA | The JAMA Network