Healthcare is at least a decade behind other high-risk industries

 

 

By:  David Kashmer (@DavidKashmer)

Did you know?  Our field lags behind many others in terms of attention to basic safety.  For those of you who focus on healthcare quality & safety, that’s probably old news.  After all, the Institute of Medicine said exactly that in its To Err Is Human report…from 1999 (!)

Here’s a portion of a recent post I wrote up for TheHill.com which describes exactly that & includes a link to that report:

Healthcare is at least a decade behind other high-risk industries in its attention to basic safety.

In 1999, the IOM published “To Err Is Human,” which codified what many quality experts in healthcare already knew:  in terms of quality improvement, healthcare is at least a decade behind.

More recently, a widely criticized paper from Johns Hopkins cited medical errors as the third leading cause of death in the United States. Even if you don’t agree that medical errors are the third leading cause, the fact that medical errors even make the list at all is obviously very concerning.

First published in TheHill.com


Click here for entire article:  http://thehill.com/blogs/pundits-blog/healthcare/311570-3-facts-about-us-healthcare-that-wont-change-with-the


What you may NOT know is that our field lags when it comes to the adoption of other emerging trends.  For example, here’s a graphic from earlier this year:

Healthcare lags other fields
Healthcare lags other fields

Now, all of that said, I spend a lot of time wondering exactly why we lag in certain key areas.  Here’s what I’ve come up with, and I’m interested in any thoughts or feedback you might have.

(1) Using the word “lag” supposes that the direction everyone else is going is some sort of goal to be achieved or a type of race

It seems to me that the way the graphic above sets things up implies a progression or goal of digitization.  In that graphic, it seems as if we are ranked in terms of progress toward some endpoint of digitization.  Let’s take some time and consider whether framing the situation as progress toward some digital endpoint really makes sense.

Perhaps no one likes technology more than me.  I tend to be an early adopter (and sometimes an innovator) with new devices and software that help me get done what I want to do both personally and for patients.  Yes, I use a Fitbit.  (Not so special nowadays really.) And I use services like Exist.io to look for meaningful correlations across things I do, such as how much sleep I get with how I perform.  This system takes me no time (it all happens under the hood) and sometimes even gives me non-intuitive correlations, which are perhaps the most useful.  Here’s an example of what I mean, but this one is weak and I wouldn’t do anything differently based on it:

linkedincorrelationjpg

The bottom line is, I think, every time I see a Big Data article or learn about how websites figure out things about my health that I don’t even know, well, I think we are pretty much all-in on this progression towards the digitization idea…at least I am!

So, on this one, I believe that (yes) there is a meaningful progression toward digitization across industries and, yes, I feel it’s more useful for healthcare to get on board than it is to lament where things are going or to question whether digitization is meaningful for healthcare…and I especially feel good about it when I remember the days of my training and how I used to have to hunt for Xrays on film, yet now I have the Xray or CT scan on my computer instantly!

(2) In part, we are slower to adopt because we deal with people’s health.

We don’t build cars or fly planes, really.  Although certain lessons learned from other industries are very important, many in healthcare believe our service is different.  Some are even skeptical of whether we should adopt tools that worked well across other industries.  We work with people’s health, after all.  In the United States especially, that’s a very big deal and many regard it as a true calling.  So, being the careful people we are (I often wonder just how risk-averse we are) it seems to make sense to me that our field may be slower than others to adopt new things.  It’s very conservative and maybe even highly adaptive to be that way.

When it comes to certain aspects of our work, like patient safety and quality, I should add here that there are well-worn tools that apply to all services–even services like ours called healthcare.  We should adopt these, and unfortunately are still behind.  I’ll add that adopting these tools helps us as providers even as it helps our patients.  (If you’re interested in specifics, take a look at Volume to Value.)

So, bottom line here:  part of why healthcare may be slower to adopt emerging trends is because we feel very strongly that only the best, well-worn, known tools should be applied to people’s health.

(3) Sometimes we are slower to adopt because much of the push to adopt has come from outside

About three months ago, I’d just finished speaking at a quality improvement conference in Philadelphia.  This one had over a thousand participants from diverse companies.  It really ran the gamut from Ford to Crayola to large hospitals to DuPont, and each participant was focused on quantitative quality improvement.  After my talk, there were lots of questions.  One really struck me in particular:

“How can you improve healthcare quality when you still get paid even when things are bad?  I mean, when I make a car if there’s a quality problem and it comes back, I eat that cost…”

This audience member really hit it on the head.  Isn’t it difficult to advance topics like quality (where healthcare is a decade behind) if you’re still reimbursed even when there’s a quality issue?  What he’d hit on is the tension between a pure fee-for-service model versus value-based reimbursement.

I was able to tell him that healthcare is transitioning, right now, away from being paid even when there’s a quality issue to a model where reimbursement is much more focused on value provided to patients.  I also shared with him that things aren’t easy, because we all have to agree on what exactly value and quality means in healthcare, but that we are getting there.  We talked about how buy-in from everyone in healthcare for quality initiatives (and more rigorous, quantitative ones), I think, will increase in the next 10-15 years as a result.  Sure enough, I think we can see this is already happening:

lssjpg
Click image for entire article.

Our conversation reinforced for me that much of the quality push, and digitization push, has come from outside of healthcare.  When the adoption of electronic health records and other forms of digitization are incentivized via meaningful use initiatives, and the HHS department explains that more and more of reimbursement will be tied to value-based metrics, it’s clear that a significant portion of the push to adopt emerging trends has come from outside what may be considered the typical traditional healthcare sphere.

Items that were typically hailed as improvements in healthcare, over the last hundred years, included game-changers like general anesthesia, penicillin, or the ability to safely traverse the one to two inches between the heart and the outside world with cardiac surgery.  (Prior to the development of cardiac surgery, some famous surgeons had previously predicted that route would forever be closed!)

Now, especially to physicians, it can be harder to see the value in moving in these directions.  Many in healthcare feel they are pushed toward them.  Yes, every physician wants the best outcome for the patient, yet seeing quality as the systematic reduction of variation along with improvement in the central tendency of a population is not always, well, intuitive.  Given the backdrop of the very specific, individualized physician-patient relationship, it can be challenging to understand the value of a quality initiative that sometimes seems to play to eliminating a defect which the patient in front of the doctor seems to be at low (or even no) risk for.

I’m not saying whether any of this is good or bad, and I’m only sharing what is:  we may be slower to adopt these trends in healthcare because they have often come from outside.  Rather than commenting on whether this is good or bad, it seems to me that the trend does explain some of why the field is slower to adopt these changes.

Having worked in healthcare for more than a decade through many venues, from cleaning rooms in the Emergency Department to work in the OR as a surgeon, I can share that yes we in healthcare are behind other industries in terms of adopting key trends.  However, I believe this is much more understandable given the nature of our work that directly (and individually) affects quality and quantity of human life, as well as the fact that (for better or worse) much of the impetus to adopt these trends has come from the outside.  I consider it my responsibility, and all of ours as providers, to be on the lookout for ways in which we can adopt well-worn tools that already exist to improve quality and digitization in our field.  Let’s make our call to action one where we get on board with these trends for at least those aspects that we reasonably expect may improve our care.

Obamacare boasts largest day ever Thursday on HealthCare.gov

@DavidKashmer (LinkedIn profile here.)

 

President Obama announced Friday that more individuals signed up for insurance on HealthCare.gov on Thursday (12/15) than on any single day since the launch of the low cost Affordable Care Act exchanges three years ago.

Greater than 670,000 people signed up for coverage ahead of the Dec. 15 cut-off date for Jan. 1 insurance.

The traffic congestion caused the Centers for Medicare and Medicaid (CMS) to announce late Thursday that a new cut-off date for enrollment would be Dec. 19. HealthCare.gov handles enrollment for 38 states. Time limits for state exchanges vary, however several now permit enrollment for Jan. 1 insurance for a number of extra days.

Signups rose regularly this passed week. On Monday, greater than 325,000 citizens selected plans on HealthCare.gov. On Tuesday, more than 380,000 Americans selected plans on HealthCare.gov, marking two of the largest traffic days in HealthCare.gov history.

Great Healthcare Quality Projects Repeat Themselves

 

David Kashmer, MD MBA MBB (@DavidKashmer)

As healthcare adopts more and more of the Lean Six Sigma techniques, certain projects begin to repeat across organizations.  It makes sense.  After all, we live in the healthcare system and, once we have the tools, some projects are just so, well, obvious!

About two years ago, I wrote about a project I’d done that included decreasing the amount of time required to prepare OR instruments.  See that here.  And, not-surprisingly, by the time I had written about the project, I had seen this done at several centers with amazing results.

Recently, I was glad to see the project repeat itself.  This time, Virginia Mason had performed the project and had obtained its routine, impressive result.

This entry is to compliment the Virginia Mason team on their completion of the OR quality improvement project they describe here.  I’m sure the project wasn’t easy, and compliment the well-known organization on drastically decreasing waste while improving both quality & patient safety.

Like many others, I believe healthcare quality improvement is in its infancy.  We, as a field, are years behind other industries in terms of sophistication regarding quality improvement–and that’s for many different reasons, not all of which we directly control.

In that sort of climate, it’s good to see certain projects repeating across institutions.  This particular surgical instrument project is a great one, as the Virginia Mason & Vanderbilt experience indicate, that highlights the dissemination of quality tools throughout the industry.

Nice work, Virginia Mason team!

Warning: Will Your Quality Improvements Really Last?

David Kashmer, MD MBA MBB (@DavidKashmer)

 

 

OR turnaround time is a classic opportunity for quality improvement in hospitals. The surgeons typically say it takes way too long to clean and prepare the ORs.  The materials management and housekeeping staff often add that they’re doing everything they can to go as quickly as possible–without sacrificing their safety or doing a bad job for the patient.  Anesthesia colleagues may add that they too are going as fast as possible while completely preparing the rooms and maintaining patient safety.  However, the rest of administration will remind the team of an estimated cost of OR time so as to put a face on the costs associated with that downtime when no one is operating in the ORs.  I’ve seen these range from as low as $50/minute to as high as $100/min!

 

Here’s a classic quality improvement project

 

Here, then, is a classic project that involves many stakeholders,  shared OR governance, and an obvious opportunity to decrease what many hospitals consider non-value added time (VAT).  I bet it’s a project that your healthcare system has performed before, will perform soon, or is eyeing as a potential for significant quality improvement.

And you know what?  Even if you’ve gotten this challenging project done in your healthcare system, the issue may not be behind you my friend.  Let me tell you why…

Once upon a time, at one hospital, the goal of an important quality improvement project was to reduce that turnaround time in the operating rooms.  And wow had it ever worked!

The team had adopted a clear definition of turnaround time, and had used a DMAIC project to significantly decrease that time–it was almost like a NASCAR pit crew in there.  It was safe, orchestrated, complete, and really helped the rest of the staff improve OR flow.  The time required to turnover a room had also become much more predictable, and this decreased variation in turnover times was also a big help to patient flow and scheduling.

The team used several classic tools, including a spaghetti diagram to decrease wasted motion by the “pit crew” team, a kanban inventory system, and a visual control board to notify all of the players in the process (Anesthesia, Surgery, Pre-op Nursing, & the holding room) when the operating room was ready to go.  They saved days worth of wasted motion (time spent walking) for the OR prep crew when projected out over a year’s worth of turnovers.  The OR staff could complete about one extra case per room per day.  Truly amazing.

…but only three months later, the turnaround time had crept back up again to where it had been before the changes–a median of 25 minutes per case.

 

Good quality projects never die.  And if you plan them right, they don’t even fade away.  –Anonymous

 

Nobody noticed, at first, that the turnaround times were slowing down from great to just pretty good again, until one day the OR got very backed up because a couple of turnarounds took 40 minutes. The Chief Surgeon wasn’t happy and didn’t hesitate to tell anyone she could how she felt.

What had kept the gains from being sustained? (You’ve probably seen these culprits before.) It was a combination of factors. Two new people started in the OR; one longtime employee in the facilities-services department had retired. The new people weren’t educated all that well about the turnaround system, and they also didn’t know exactly where everything was yet.  But that wasn’t the real problem.

 

Failure is much more likely when there’s no control plan

 

In fact, the quality-improvement team hadn’t built a control plan into the system. The first sign they may have had a problem was when the Chief Surgeon fired off an angry e-mail to the rest administration and most of the staff.  The signal should’ve come much earlier, when the variation in turnover times increased unexpectedly.  That signal could’ve been noticed weeks before.

How?  The team could’ve used an ImR control chart (more on that here) to notice that the range of times for room turnover had gone out of control.  The team could’ve had someone, a process owner like the OR administration, positioned to sound the alarm that the process needed to be solidified when, weeks earlier, several other turnovers took an unexpectedly long time.

Fortunately, in this case, the project team recovered.  They quickly deployed an ImR chart and also reviewed their data.  The Chief Surgeon had been correct:  yes, those cases did take an unexpectedly long time when viewed in the context of the OR’s data.  A root cause analysis was performed and the quality team quickly realized that several issues lined up to make those times take so much longer.

After addressing the issues, the team was back in full swing only a week or two later.  The pit crew was back at it, and the NASCAR-like precision had returned.

 

The take-home

 

The lesson:  creation of a control phase plan to maintain the good work you & the team have done is an essential part of quality improvement projects.  Without an excellent control plan, it is very difficult to maintain the improvements you’ve made as a foundation for future improvements.  Failure to plan a control phase is, unfortunately, planning to fail.

 

Excerpt originally published as part of Volume to Value:  Proven Methods for Achieving High Quality in Healthcare

How One Team Used Data (Not Intuition) To Improve ED Throughput

By:  David Kashmer, MD MBA (@DavidKashmer)

 

 

Most hospitals want to improve throughput…

 

Have you ever worked at a hospital that wanted to improve its ED throughput?  I bet you have, because almost all do!  Here’s a story of how advanced quality tools lead a team to find at least one element that added 20 minutes to almost every ED stay…

 

Once upon a time…

 

At one hospital where I worked, a problem with admission delays in the emergency department led us far astray when we tried to solve it intuitively. In fact, we made the situation worse. Patients were spending too much time in the emergency room after the decision to admit them was made. There was a lot of consternation about why it took so long and why we were routinely running over the hospital guidelines for admission. We had a lot of case-by-case discussion, trying to pinpoint where the bottleneck was. Finally, we decided to stop discussing and start gathering data.

 

Follow a patient through the value stream…

 

We did a prospective study and had one of the residents walk through the system. The observer watched each step in the system after the team mapped out exactly what the system was.  What we discovered was that a twenty-minute computer delay was built into the process for almost every patient that came through the ED.

The doctor would get into the computer system and admit the patient, but the software took twenty minutes to tell the patient-transport staff that it was time to wheel the patient upstairs. That was a completely unexpected answer. We had been sitting around in meetings trying to figure out why the admission process took too long. We were saying things like, “This particular doctor didn’t make a decision in a timely fashion.” Sometimes that was actually true, but not always. It took using statistical tools and a walk through the process to understand at least one hidden fact that cost almost every patient 20 minutes of waiting time.  It’s amazing how much improvement you can see when you let the data (not just your gut) guide process improvement.

 

The issue is not personal

 

We went to the information-technology (IT) people and showed them the data. We asked what we could do to help them fix the problem. By taking this approach, instead of blaming them for creating the problem, we turned them into stakeholders. They were able to fix the software issue, and we were able to shave twenty minutes off most patients’ times in the ER. Looking back, we should probably have involved the IT department from the start!

 

Significant decrease in median wait time and variance of wait times

 

Fascinatingly, not only did the median time until admission decrease, but the variation in times decreased too.  (We made several changes to the system, all based on the stakeholders’ suggestions.) In the end, we had a much higher quality system on our hands…all thanks to DMAIC and the data…

 

Excerpt originally published as part of Volume to Value:  Proven Methods for Achieving High Quality in Healthcare

 

Here’s Why Business Education Is Important For Physicians

By:  David Kashmer MD MBA FACS (@DavidKashmer)

What’s dangerous is not to evolve.  –Jeff Bezos

Once upon a time, a young man went to work every day providing an invaluable service for his local community.  The work was considered essential, in fact, to help make sure people were safe and were able to get done what they needed to get done in order to live their lives.  Now, that position no longer exists in our society.  The job:  lamplighter.  It could’ve been milkman or a host of others.

Oh, did you think I was leading up to a job in Healthcare?  No problem!  Insert radiology file room clerk (not many around since the dawn of the electronic medical record and PACS integration).  Colleagues, here’s the point:  if you think of Healthcare as static, well…stop!  The story I share above about lamplighters could easily be another role in the hospital or perhaps, some say, an entire medical specialty.

I invite you to think of Healthcare, and your role in it, as more like navigating an ocean instead of walking a beaten path.  And in oceans, my friends, things happen.  Unexpected weather, accidents at sea, and moments of amazing calm are each represented in different measures at different times.

Let’s talk about the tumultuous state of Healthcare.  Like me, you’ve seen:

  • increasing numbers of employed physicians and declining numbers of private practices
  • significant time spent (more than 20% of our days in many reports) on documentation in electronic health records.
  • increasing focus on defensive medicine owing to many factors including the modern climate of tort law

Now, let me be clear:  I’m not commenting on whether this is bad or good…I’m only saying that this just is.

Ok, now let’s get to where we’re going:  in order to navigate the highly complex ocean of Healthcare, physicians need tools.  And, unfortunately, we often weren’t given these tools in medical school.  Now, I agree that medical school should help us understand disease & its treatment.  We should focus on the basics of baking the cake of how to deliver excellent, compassionate care to people.  Much of the rest is icing.  We may even learn how to be lifelong learners…but what then?  

Nowadays, we have needs that medical school didn’t directly address:  we need a different mental model because times in healthcare have changed.  Why?  Because the only constant thing is change.  The Affordable Care Act, the ongoing transition from a system focused on volume of services delivered to one centered on value of care delivered, and a swell of other influencers have made the practical side of what it means to provide care very different than what the tools we took from medical school were designed to address.

So what about these situations where the waves surge so high that our boat is threatened?  What about situations where we have no map or compass?

Tools for the ever-changing landscape, ones that build strategies, teach us how to maintain the financial viability of our practice, or otherwise guide us in this often-challenging ocean…well, those tools are not included in our medical textbooks.  Those tools, ones that enable us to provide high quality care, create a new practice of our own, or to allow us to practice at a higher level as an employed physician…those tools are more typically found in business textbooks.

How exactly is a Relative Value Unit (RVU) defined?  What exactly is an acid test ratio, and what does it tell me about my practice?  How can I create a system in my hospital as an employed physician that helps me provide routine, excellent care?  These questions, and others, are answered by a toolset that we’ve often seen little of in Healthcare.  These are more commonly found in the business world and those are the ones that help us navigate amidst an uncertain future.

So, once upon a time, an entire job disappeared.  Don’t be the next lamplighter and wind up snuffed out by a towering wave of disruption.  Build a better map to navigate what are sometimes treacherous waters–waters which will likely become only more challenging to traverse in the years to come.

 

Here’s How To Sustain The Improvements From Your Quality Project

David Kashmer (@DavidKashmer, LinkedIn profile here.)

 

Once upon a time, a healthcare quality improvement team celebrated:  it had solved a huge problem for its organization.  After months of difficult work, the team had improved the hospital’s Length of Stay incredibly.  But, three months later, the Length of Stay slid back to exactly where it was before the team spent an entire year of work on the project.  What happened!?

 

One Of The Most Important Steps In A Project

 

The final part of a quality improvement project is setting it up so you get feedback from the system on a regular basis. If you don’t do that last part correctly, you don’t know that things have gone haywire until a problem jumps out at you. All quality improvement projects need a control phase that lets the system signal you somehow to tell you when things aren’t going right anymore. All the work you did on your quality improvement project isn’t really over until you answer the final question, “How do we sustain improvement?”

The answer is using the right tools in the control phase. In healthcare, patients come through the system one at a time, but to get the big picture, Lean Six Sigma often uses control charts after the quality improvements have been implemented. All a control chart can tell you is that a system is functioning at its routine level of performance over time. It can’t tell you whether that routine level of performance is acceptable or not. If you look only at the control chart (especially if you do that too early), everything may look like it’s going fine, but in fact, the performance may be totally unacceptable. This is why control charts shouldn’t be applied until the end of a quality project: the control chart can tell us when the system is performing routinely, yet lull us to sleep. It can tell us the system is performing routinely— yet that routine may be no good.

 

How To Choose The Right Chart

 

Control charts vary, depending on what you’re measuring and how your data is distributed. Your Lean Six Sigma blackbelt is the right person to help you decide which type of chart to use and understand what it’s telling you. You would use a different control for averages over time than you would for proportions over time, for example.

Specifically, in healthcare, we often use a control chart that tracks individuals as they come through the system. It’s called an individual moving range (ImR) chart. (There’s some advice on how to choose a control chart here.) It plots patients and people or events as they come through the system one at a time.

The range is an important part of the ImR chart. Range is a measure of variance between data points. In other words, range shows you how wide the swings are in your data. If you see an unusual amount of variance between data points, the question becomes “Why such a wide swing? What is it telling us?”

 

Applying the Rules

 

If you don’t build a control chart into the ongoing phase of your quality improvement project, and look at it on a regular basis, you won’t pick up the signals that say, “This case is beyond the upper control limit. Something must have gotten out of whack with this case. We have to look into it.” The power of the control chart is it will tell you when things are going off the rails.

To understand what’s going on with your control charts, Lean Six Sigma applies what are known as the Shewhart Rules, which are rooted in the Westinghouse Rules originally devised by Westinghouse Electric. The rules tell what to look for in the control charts to see if a problem is on the way or is already there. Often, obvious signs tell you about a problem. A data point might be above or below the limits set in the chart. In healthcare, we mostly look for variants above the limit, because that often indicates something took too long or didn’t go smoothly. If something is more than three standards deviations beyond what’s expected, that means there’s less than a 1 percent chance it happened at random. You need to look into it.

 

Check The Control Chart On A Regular Schedule

 

Control charts need to be checked on a regular schedule, but they also need to be reviewed if anything external changes the system. The chief of the department might leave as part of personnel shuffle. That means new people who may not understand the system well come in. The control chart should be checked more often to see where the personnel changes may be affecting quality. Remember to make it clear, before the project’s end, exactly who will look in on the chart, when they will do it, and who they should call when there’s an issue.  It’s important that this be someone who lives with the new process as it will be after changes.

A lot can change quickly in just a month or two. The control phase provides feedback from the system when something has gone wrong, or something needs maintenance, or the weeds need trimming.

The bottom line:  plan to maintain the gains you’ve made with your important quality improvement project by designing in a control phase from the beginning!

 

Excerpt above was originally published as part of Volume To Value:  Proven Methods For Achieving High Quality In Healthcare.

Want to read more about advanced quality tools and their uses in healthcare?  Click here.

Cover of new book.
Cover of new book.