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!)

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

Life, Liberty, & The Pursuit of…Healthcare?

By:  David Kashmer (@DavidKashmer)

In America, we long ago declared that people are created with rights.  Among those are Life, Liberty, and the Pursuit of Happiness.  Our famous Declaration of Independence states that those well-known rights are some among others.  If our Declaration were penned today, what contemporary ideas would be enshrined in the document?  Would a modern Declaration list a right to healthcare among our unalienable rights?


I share this question, which I’ve asked to more than 223 (and counting) medical students and resident surgeons, to highlight a fundamental issue in America—and I won’t share my own answer.  The point of the exercise here, in fact, is to put forward certain thoughts on the rights we all accept and whether there is another potential right that we don’t seem to have a consensus about as Americans.


On one hand, how exactly can we pursue a meaningful life, personal liberty, or our happiness without health?  Does it lurk behind our other unalienable rights as a necessary pre-condition?  If we are unable to be mobile, to experience life, or to pursue our liberty…well, isn’t health and healthcare a necessary pre-requisite “unalienable”?  Would Mr. Jefferson include that in his list if he were to write it today?


Yes, asking the question like that, out of historical context, suffers from some real problems.  Mr. Jefferson did not write in modern times and of course the document would be different.  Times are different now as are the related issues.  Healthcare is remarkably different than the field that lead to President Washington’s wooden teeth.  (By the way, in fact that is a myth about George Washington.  His dentures were not made of wood.  Look here.)


Anyhow, the issue is not really about whether Mr. Jefferson would include healthcare in a modern rewrite of the Declaration of Independence.  That question is a device used to frame a conversation.  Would we make healthcare a right if we created a list of our key rights today?  If humans have certain rights, and only some inalienable examples are listed in our Declaration but not all of them (remember “among these are Life, Liberty, and the Pursuit of Happiness…) would we list healthcare as another item if we revisited the list?  It is the spirit of the question, and the conversation it creates, which makes me ask many of the healthcare providers with whom I work.


Of the 223 I’ve asked, the overwhelming majority have answered that yes, healthcare should be considered a right…but then things get messy.  Conversation usually turns to a related question:  “How much healthcare is a right?” All of it?  Anything we want as patients (even if some type of care won’t do anything to help us pursue life, liberty, or happiness…) despite the healthcare provider’s judgment on efficacy?  Should it be every extraordinary skill we have in modern medicine?


The conversation gets complicated, and staff consider with me the various complexities of considering healthcare as a right.  Participants start to wonder what’s worse:  an overly paternalistic physician deciding what’s best for the patient with a devil-may-care-what-the patient-thinks attitude (Dr. House!), or when we as patients demand anything (and everything) without really understanding how a treatment, unlikely to help, will drain the system.


Back when healthcare consisted of bleeding patients with leeches, this conversation was probably a whole lot easier and less complex!  After all, when treatments were ineffective and cheap, well, it wouldn’t really be an issue to consider in writing your Declaration to King George.  After all, wooden teeth and leeches don’t really do much anyways.


In fact, the conversation sometimes gets even worse.  If we have time, and aren’t interrupted by a critically injured trauma patient arriving in the ER, sometimes we wonder about another important parameter of the discussion:  “Is healthcare a right if it costs so much that it cripples your country’s finances?  What if it’s so costly that it affects whether your society as a whole can pursue life, liberty, and its happiness?” Difficult question.  It goes to the balance of individuals’ rights versus the rights of society.  That’s never easy.


Right now, in the US, we spend an outrageous amount on healthcare, especially for the quality outcomes we see in terms of our longevity and infant mortality measures.  By far, year after year, we spend a larger percentage of our GDP on healthcare than any other country.


Fellow citizens, this is exactly where we stand:  a fundamental struggle between whether or not healthcare is a right, and, if so, how much?  This issue reverberates, I think, throughout policy choices and current town halls across the US.  Its consequences reach from healthcare insurance company board rooms to the halls of Congress to my own dinner table when family wants to discuss.  Now, we see it in the current discussion of Obamacare versus the GOP offering of what comes next.


Do we force insurers to cover people who have legitimate issues that put them at a higher risk to those insurance companies, and make the companies do that at inexpensive prices?  Do we revamp the system and attempt to foster individual responsibility for healthcare in an attempt to cut costs?  Do we mandate that individuals buy insurance?  Is it to be an individual solution to our healthcare issue or do society and government solve the issue?  Is healthcare a right or a privilege and, if it’s a right, how much is a right?


Now I’ll share with you all how I resolve this every day in my practice as a surgeon.  (Shhhh, don’t tell…)


…I don’t.  I don’t solve it at all.  I don’t even offer a solution.


Here’s what I do:  I respect patient autonomy.  I teach patients (or their proxy if the patient can’t understand or tell me what they want) and they decide what they want to do.  I arm them with the relevant knowledge (as much as I can without giving them a medical education) and I ask them what they want.  I do that at 3am and 3pm and every hour in-between.  And I make a recommendation usually too just to let them know my thoughts.  Then they decide based on what we can do and how likely it is to help them.  The question is which of the options is worth it to them based on where we can predict it will get them and what they’ll need to go through to get there.


Myself and the team I’m on don’t look at whether any patient is insured and nor do we care.  That’s how I do it.  And even if I think the decision a patient makes is not the one I would make or recommend, we execute their plan and continue to help them.  They are the boss even when the situation is difficult, great, or something else.


Usually, that clears the situation up.  I understand when I read literature that paints physicians as custodians of resources and expensive tests.  After all, our country has a huge problem with healthcare costs.  However, the patient is the ultimate arbiter of their healthcare.  It seems to me to be a strange place to be to ask the surgeon to indirectly manage the costs of healthcare and other society-level issues and yet focus clearly on the interests of the patient.


Take a minute and think about doing that.  Now think about doing it at 2am.  Now think about doing that many times over.  Now imagine doing that with a patient who is critically ill and meeting you for the first time.  It’s a tough at bat every time.  That’s what we do.  I want you to know that because where the rubber meets the road on this discussion is typically when you meet someone like me at 2AM in an Emergency Department, and we are forced (in our first meeting) to discuss whether your family member with late stage cancer would want a surgical procedure for an acute problem…even though fixing that problem won’t improve their quality and quantity of life.  They can’t tell me because they’re “out of it” and so I turn to you as their proxy.


After I educate the patient (or you) about what can be done, I share how likely we are to improve the situation with a particular treatment.  I even make a recommendation.  But remember, your surgeon is up to bat at many hours of the day and night.  And we are at bat a lot in situations where you or your family is critically ill and sometimes near death.  It’s challenging to manage all those things in shaking your family member’s hand for the first time when time is of the essence.  I can usually help give you a sense of how likely something is to help you, but imagine how that conversation would go if I went on to say “it’ll help you some, but it’s really expensive.”  Ouch.  It’s not a great idea to put cost management on the surgeon.


Really tough to balance the probabilities of a treatment helping you, the effort required on your part, and then asking you to balance whether it’s worth it for the cost.  Tough to ask you to do that.  Tough to ask me to do it.  Especially if you, the patient, are really sick.


This article calls upon all of us, comfortable now in normal hours instead of in a difficult situation at a 2AM Emergency Department, to begin to make up our mind as a country about whether (and how much) healthcare is a right.  In fact, the time we should decide is before we are ever faced with such a terrible decision.


Nowadays, our current state is that we do the best we can.  It would help us a lot to have clarity on the topic of whether healthcare is a right or a privilege because it would make what we can do for you much more clear.  The clarity of black and white, not the gray of indecision, helps us a great deal in achieving the bright lights and cold steel of the operating room should that be what you need.


My resolution for all of these complex issues is to educate whenever possible and execute the choice you make about your care.  I’ve never met a patient where my concern is whether you have insurance or whether I can save money on your care.  I don’t know what that patient looks like in whom I could apply the society level issues to individual care.  Would that patient look like my daughter?  My parent?  So where I have resolved this issue in my practice by arming you with what I know in a situation, making a recommendation, and then respecting your decision, it sure would help if our society writ large would solve some of these issues.  It would help at 3AM in the Emergency Department and it would help as we look to revise Obamacare.


There are cost-savings opportunities in healthcare.  Lots of them.  Importantly, many are not rooted in the individual conversations between patient and their doctors, and instead flow from system-level waste.  With my quality improvement hat on, I can share that it’s a good idea to build better systems rather than rely on one-off conversations at odd hours that vary greatly from case to case if we have an interest in eliminating waste in our system.


Whichever approach you like to improving healthcare, a consensus on whether, and how much, healthcare is a right would make it much easier.  Our indecision as Americans, I think, lurks behind our current situation and many of the interactions in healthcare every day.


So on a day to day basis with each patient, one after the next, I do not resolve the issue of whether it’s Obamacare, a GOP plan, healthcare as a right or healthcare as a privilege…but I ask that question about the Declaration to prompt discussion.  I’ve asked more than 223 times now.  Because, as I see every day at work, the fact that we as Americans struggle with this fundamental issue affects so much in the lives of people and their families.  There is no easy answer, yet now is the time to realize for our own goods that we are called to action to solve our healthcare issue as a country in order to pursue our happiness.  It is time to work to enshrine our thoughts on where and how exactly healthcare fits in our lives.  Let’s get this done to make our next 3AM at bat, whether as doctor, nurse, or patient much better for everyone.  Should Mr. Jefferson have one more item on his list?




David Kashmer is a trauma surgeon and Lean Six Sigma Master Black Belt.  He writes about data-driven healthcare quality improvement for, and  He is the author of the Amazon bestseller Volume To Value, & is especially focused on how best to measure value in Healthcare.

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 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

Click here for entire article:

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 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:


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:

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.

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

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.


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?


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?”




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.



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.



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.