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.

How Well Do We Supervise Resident Surgeons?

By:  David Kashmer (@David Kashmer)

 

I was recently part of a team that was trying to decide how well residents in our hospital were supervised. The issue is important, because residency programs are required to have excellent oversight to maintain their certification. Senior physicians are supposed to supervise the residents as the residents care for patients. There are also supposed to be regular meetings with the residents and meaningful oversight during patient care. We had to be able to show accrediting agencies that supervision was happening effectively. Everyone on the team, myself included, felt we really did well with residents in terms of supervision. We would answer their questions, we’d help them out with patients in the middle of the night, we’d do everything we could to guide them in providing safe, excellent patient care. At least we thought we did . . . .

 

We’d have meetings and say, “The resident was supervised because we did this with them and we had that conversation about a patient.” None of this was captured anywhere; it was all subjective feelings on the part of the senior medical staff. The residents, however, were telling us that they felt supervision could have been better in the overnight shifts and also in some other specific situations. Still, we (especially the senior staff doing the supervising) would tell ourselves in the meetings, “We’re doing a good job. We know we’re supervising them well.”

 

We weren’t exactly lying to ourselves. We were supervising the residents pretty well. We just couldn’t demonstrate it in the ways that mattered, and we were concerned about any perceived lack in the overnight supervision. We were having plenty of medical decision-making conversations with the residents and helping them in all the ways we were supposed to, but we didn’t have a critical way to evaluate our efforts in terms of demonstrating how we were doing or having something tangible to improve.

 

When I say stop lying to ourselves, I mean that we tend to self-delude into thinking that things are OK, even when they’re not. How would we ever know? What changes our ability to think about our performance? Data. When good data tell us, objectively and without question, that something has to change–well, at least we are more likely to agree. Having good data prevents all of us from thinking we’re above average . . . a common misconception.

 

To improve our resident supervision, we first had to agree it needed improvement. To reach that point, we had to collect data prospectively and review it. But before we even thought about data collection, we had to deal with the unspoken issue of protection. We had to make sure all the attending physicians knew they were protected against being blamed, scapegoated, or even fired if the data turned out to show problems. We had to reassure everyone that we weren’t looking for someone to blame. We were looking for ways to make a good system better. There are ways to collect data that are anonymous. The way we chose did not include which attending or resident was involved at each data point. That protection was key (and is very important in quality improvement projects in healthcare) to allowing the project to move ahead.

 

I’ve found that it helps to bring the group to the understanding that, because we are so good, data collection on the process will show us that we’re just fine—maybe even that we are exceptionally good. Usually, once the data are in, that’s not the case. On the rare occasion when the system really is awesome, I help the group to go out of its way to celebrate and to focus on what can be replicated in other areas to get that same level of success.

 

When we collected the data on resident supervision, we asked ourselves the Five Whys. Why do we think we may not be supervising residents well? Why? What tells us that? The documentation’s not very good. Why is the documentation not very good? We can’t tell if it doesn’t reflect what we’re doing or if we don’t have some way to get what we’re doing on the chart. Why don’t we have some way to get it on the chart? Well, because . . . .

 

If you ask yourself the question “why” five times, chances are you’ll get to the root cause of why things are the way they are. It’s a tough series of questions. It requires self-examination. You have to be very honest and direct with yourself and your colleagues. You also have to know some of the different ways that things can be—you have to apply your experience and get ideas from others to see what is not going on in your system. Some sacred cows may lose their lives in the process. Other times you run up against something missing from a system (absence) rather than presence of something like a sacred cow. What protections are not there? As the saying goes, if your eyes haven’t seen it, your mind can’t know it.

 

As we asked ourselves the Five Whys, we asked why we felt we were doing a good job but an outsider wouldn’t be able to tell. We decided that the only way an outsider could ever know that we were supervising well was to make sure supervision was thoroughly documented in the patient charts.

 

The next step was to collect data on our documentation to see how good it was. We decided to rate it on a scale of one to five. One was terrible: no sign of any documentation of decision-making or senior physician support in the chart. Five was great: we can really see that what we said was happening, happened.

 

We focused on why the decision-making process wasn’t getting documented in the charts. There were lots of reasons: Because it’s midnight. Because we’re not near a computer. Because we were called away to another patient. Because the computers were down. Because the decision was complicated and it was difficult to record it accurately.

 

We developed a system for scoring the charts that I felt was pretty objective. The data were gathered prospectively; names were scrubbed, because we didn’t care which surgeon it was and we didn’t want to bias the scoring. To validate the scoring, we used a Gage Reproducibility and Reliability test, which (among other things) helps determine how much variability in the measurement system is caused by differences between operators. We chose thirty charts at random and had three doctors check them and give them a grade with the new system. Each doctor was blinded to the chart they rated (as much as you could be) and rated each chart three times. We found that most charts were graded at 2 or 2.5.

 

Once we were satisfied that the scoring system was valid, we applied it prospectively and scored a sample of charts according to the sample size calculation we had performed. Reading the chart to see if it documented supervision correctly only took about a second. We found, again, our score was about 2.5. That was little dismaying, because it showed we weren’t doing as well as we thought, although we weren’t doing terribly, either.

 

Then we came up with interventions that we thought would improve the score. We made poka-yoke changes—changes that made it easier to do the right thing without having to think about it. In this case, the poka-yoke answer was to make it easier to document resident oversight and demonstrate compliance with Physicians At Teaching Hospitals (PATH) rules; the changes made it harder to avoid documenting actions. By making success easier, we saw the scores rise to 5 and stay there. We added standard language and made it easy to access in the electronic medical record. We educated the staff. We demonstrated how, and why, it was easier to do the right thing and use the tool instead of skipping the documentation and getting all the work that resulted when the documentation was not present.

 

The project succeeded extremely well because we stopped lying to ourselves. We used data and the Five Whys to see that what we told ourselves didn’t align with what was happening. We didn’t start with the assumption that we were lying to ourselves. We thought we were doing a good job. We talked about what a good job looked like, how we’d know if we were doing a good job, and so on, but what really helped us put data on the questions was using a fishbone diagram. We used the diagram to find the six different factors of special cause variation…

 

Want to read more about how the team used the tools of statistical process control to vastly improve resident oversight?  Read more about it in the Amazon best-seller:  Volume To Value here.

Cover of new book.
Cover of new book.

 

Changes To Make To Your System…And Ones Not To (!)

By:  David Kashmer (@DavidKashmer) LinkedIn Profile here

 

Originally published as part of Volume To Value:  Proven Methods For Achieving High Quality In Healthcare

 

Catheter-associated urinary-tract infections in hospitalized patients are considered “never events”—they should never happen. When they do, the hospital is penalized by Medicare and third-party payers. The issue can really burn a hospital. Naturally, hospitals are very interested in ways to avoid UTIs. One hospital I worked at had tried several solutions, and some turned out to be bad choices. They tried taking catheters out of patients before those patients had a chance to develop an infection. That sounds like a good idea because, in general, removing a catheter as early as possible is a good thing, but it’s not good if it’s removed too early. That’s an important distinction that didn’t get made, and catheters were being removed too early for many patients. In critically ill patients, for instance, the catheter may be needed to follow the patient’s urine output carefully. Many ICU patients could not be monitored appropriately once their catheters were removed too early. The hospital also tried out perhaps the worst possible solution, which was just not sending samples for urinalysis so they wouldn’t have to make the diagnosis. Obviously, that’s something we don’t want for patients. If a patient gets an infection, we want to know about it and treat it. At this hospital, when patients did get a urinary tract infection, it was recognized much later.  So what can be done?  What does a good solution to a healthcare system problem look like?

HERE’S HOW BAD (AND GOOD) SOLUTIONS LOOK

In its attempt to solve a problem, the hospital chose bad solutions that, in some cases, actually made patients sicker. Bad solutions often have a certain look about them: they’re solutions that are difficult to implement, are expensive, are otherwise prohibitive, take multiple steps to get done, don’t work or just generally make things worse.

 

What do good solutions look like? Above all, a good solution is implementable. A good system makes it easy to do the right thing and hard to make a mistake. A good system is error-proof because the playing field is tilted toward making it easier to do the right thing. In designing the system, the questions are always “What’s easy for the physician or healthcare provider?” and “What’s the right thing for the patient?” and “What’s doable?”

 

ONE POTENTIAL “RIGHT SOLUTION”

 

If a patient comes to the hospital with an existing UTI, then the hospital isn’t generally responsible for it as a hospital-acquired UTI that the patient received in their institution, and therefore the hospital doesn’t get penalized. (Of course, the hospital is still responsible for diagnosing and treating the patient properly.) Obviously, the key is to test patients at admission, especially ones who are at high risk, to find out if they already have a catheter-associated UTI or that they’ve come in with a UTI even if no catheter is present on their arrival. The test is very quick, inexpensive, and easy. To make it a routine part of admissions across the hospital, however, isn’t always easy. At one hospital where I worked, the center had to decide what changes to make to its system to ensure that every patient, not just the obvious high-risk ones, was automatically tested for a UTI at admission. The solution was fairly obvious: allow nurses to obtain the test, via a standing order from physicians that included certain criteria regarding for who should receive the test and results. The urinalysis becomes part of a comprehensive outside hospital (jokingly nicknamed the “OSH” for “outside hospital”) workup for patients who come from other hospitals, nursing homes, rehab centers, or even retirement communities. These facilities are like “outside hospitals” because their patients are similar to transfers arriving from other hospitals “outside” the one we’re describing. This urinalysis test doesn’t hurt the patient at all, it’s very inexpensive, and there’s very little to no downside risk. This small, simple change turns out to be a big help for the patient and the organization. The comprehensive approach catches not only UTIs but also other problems, such as deep venous thrombosis. That’s another condition that can penalize the hospital if the patient develops it during a stay, so it’s better to know if they’re coming in with it, both to prevent a penalty and to get treatment started right away. Deep venous thrombosis can kill a patient. Part of the OSH workup in the hospital where I worked included a test for deep venous thrombosis.

 

A good solution is one that is easy to implement, straight- forward, and turns out to bolster other quality and safety issues. The best solution makes it easier to do the right thing. In the case of catheter-associated UTIs and deep venous thromboses, the hospital set up standing orders from a physician that empowered ER nurses to order the tests.

 

With the DMAIC process—define, measure, analyze, improve, control—you’ll often end up with several can- didate solutions. How do you filter through the changes that you want to make and the guiding principles to come up with the best solution? In the case of catheter-related UTIs, you’d want to find a way early in the process to identify patients who arrive with one. You’d want to define what you’re measuring. It’s very important to align the measurement with the intervention, and vice versa. Are you looking at the percentage of patients who have a urinary-tract infection? Are you looking at reducing the number of hospitalized patients who have one, measured monthly? The endpoint measurement really matters here, because when you implement the program, you may well see an increased rate of urinary-tract infection in hospitalized patients. That’s because now you’re looking for them, so you’re finding them. But on the other hand, with your new program in place, the rate of hospital-acquired catheter-associated urinary-tract infections should be lower.

 

That leads to a further measurable endpoint: savings from not being penalized by the cost of poor quality. Part of your UTI rate project may include a SIPOC diagram. Many patients come to the emergency room with catheter-associated infections that they got in their nursing home, or a pre-existing urinary tract infection / colonization even if no catheter is present at that time. So, you can look at nursing homes as suppliers who send you patients. One way to reduce the number of patients coming in with UTIs would be to do outreach to the nursing homes to help them manage catheters better and be more aware of the symptoms of an infection. Or you could do outreach only to the nursing homes that send you the most patients with infections. You could make sure that attending physicians who round on nursing homes are sensitized to the problem. But you also have to be aware of the scope of your project and realize that you can’t always influence the people who send you patients. Solutions that work are realistic and within the criteria the team selects.

 

PAPERWORK PROLIFERATION

Most solutions to quality problems in medicine end up creating more paperwork. I rarely see solutions that involve less paperwork. Based on my experience, I estimate that at least 80 percent of the solutions that come out of healthcare improvement projects typically involve more paperwork—another form to fill out, another item on the chart, another checklist.

 

Now, let me be clear:  I do like checklists. They’re useful and have a place in quality improvement. But they’re only one part of a vast arsenal of what you can do to improve a system. Although checklists are a buzzword and hot topic now, a checklist isn’t always the best, most implementable, or most effective solution. It often just creates more paperwork. Checklists can be a good starting point, but they’re often not the most effective solution in the set of all possible solutions.  (They are, however, infinitely better than nothing!) Physicians today often spend about half of their working day on paperwork. A checklist that only adds to the load often isn’t really helping. For residents, the paperwork is even worse. A lot of it just gets dumped on them, and they end up doing mindless clerical work that doesn’t necessarily improve quality. How much of an impact does this have? We don’t know, because we don’t rigorously measure that sort of work. We often don’t really know if it makes any difference to quality. We often don’t know if we’re doing better or worse for having added twenty minutes of paperwork. I advise us all to look to a wider array of interventions than just checklists.

 

ERROR-PROOFING: THE POKA-YOKE APPROACH

When a system is error-proofed, it’s a lot easier for every- one to do the right thing every time and a lot harder to make a mistake. This is the Japanese design philosophy of poka-yoke (pronounced “poke a yoke”), also known as error-proofing, mistake-proofing, or sometimes (rarely) idiot-proofing. The idea is to set up a system that’s as immune to human error as possible. Many mistakes are inadvertent; poka-yoke helps avoid them. In manufacturing processes, where the idea was first developed, poka-yoke is used to prevent mistakes before or while they’re being made. The idea is to eliminate defects at the source. For example, on an assembly line, a poka-yoke solution to putting a part in backward might be to redesign it so that it can only fit when it’s in the proper position, or to color it on one side so that you can see immediately if it’s in place correctly. If a part requires the worker to install five screws, provide the screws in packages of five so that forgetting one or using the wrong screw becomes almost impossible. In healthcare, where we’re dealing with humans in fluid situations that require experience and judgment, poka-yoke changes aren’t generally as straightforward as retooling a part. For example, although we commonly use kits that contain everything needed for a procedure such as inserting a central line, often the procedure doesn’t require everything in the kit, leaving plenty of room for human error. In medicine, we have to make it easier to do the right thing even when the right thing is complex and the people who need to do it are very busy and have a lot of distractions. Under these circumstances, poka-yoke solutions almost always mean making something harder, either mechanically, physically, mentally, structurally, or by creating more paperwork. This sounds counterproductive and more like punishment than help, but in fact, by making it harder to deviate from a process or protocol, the system makes it harder to mess up.

 

Great healthcare poka-yoke solutions are ones that eliminate or reduce the ability to make a mistake and eliminate some piece of paperwork! Some poka-yoke solutions are very simple, such as pop-up messages on a computer screen or making a form easier to fill in correctly (and quickly) by highlighting where the information needs to go. A good example of a simple poka-yoke solution for hand cleanliness is putting hand-sanitizer dispensers outside every doorway. If you have to look around for a dispenser, you might skip sanitizing; if a dispenser is right in front of you everywhere you turn, you’ll probably use it.

 

Curious to read more about examples of solutions that work in healthcare quality improvement initiatives?  Read more in Volume To Value here.