NC State of Business

In this blog, Marianne Jackson, a physician that has recently emerged herself into the Toyota Production System (TPS) or ‘lean’ philosophy for continuous improvement, explores a very important subject of engaging physicians into lean transformation. Specifically, she focuses her thoughts around the subject of standardization and its meaning to physicians. Not only this subject is relevant and important, but it challenges us to search for common ground to exchange and share knowledge with physicians in one industry in serious operational crisis – healthcare.

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Immersed as I am now in Lean literature and methodology, it is sometimes hard to recall my first reactions as a physician to the words Standardization and Compliance. I am reminded, however, of my negative reflexes when I see the responses of physicians who attend Lean educational sessions. Those who are following along contentedly through Value Stream Mapping and A3s suddenly throw up walls of defensiveness when they hear Standardization and Compliance.

The response of Quality Assurance staff and facilitators often is to become frustrated and critical of us physicians for being too conservative and wedded to our autonomy. They may proceed with improvement efforts without physician participation. I’d like to explore the physician context and in so doing, suggest means for introducing Standardization and Compliance in ways that physicians can accept because physician engagement is critical to the success of the majority of Lean Healthcare transformations.

Lean has only been aggressively adapted to the healthcare market for about a decade. We promoters understand it to be an integrated approach to improving processes and systems using the innovations of all of the workers who touch the process, top to bottom and bottom to top. Prior to Lean, quality initiatives came strictly from the top and often from outside the hospital walls. Regulatory agencies developed and imposed “standards” and only negative indicators of poor outcomes such as infection rates, low APGAR scores and returns to OR without the input of those who provided the care.

Enforcement of “standards” or compliance was given to the Quality Control Officer (intimidating language) whose job it was to comb through charts finding the omissions, failures and faults in order to display them for the Medical Staff for review and report to the Board. Such statistical methods applied to very small sample sizes and minimally meaningful indicators created anger and rejection of the process among medical staff. For example, a physician who had saved a life by diagnosing a post-operative bleed, who took the patient back to the OR was “dinged” and judged as culpable by the indicators. Many of these practices continue today. If an error is caught in a non-Lean regulatory environment, what are the incentives to identify and disclose it if you are going to be penalized?

Physicians work with many sharply competing incentives. Reduce costs, see more patients, make no errors, document to satisfy even the harshest malpractice lawyer, be compassionate, spend more time with all patients, screen for seatbelt or tobacco use, complete required authorizations for HMO’s, coordinate care with all providers, and be prepared to respond to any emergencies. We will resist Standards if they feel like another burdensome injunction to “remember to do” one more thing that is going to be measured.

On being introduced to Lean, physicians are likely to think of it is a means of meeting current reporting requirements while we know it can have much greater impact. I saw a recent example at Scotland Memorial Hospital in Laurinburg. Surgeons began using Lean to investigate why they had deficiencies in meeting SCIPS DVT prophylaxis indicators and why orders for heparin were omitted. When they went on a Gemba walk they discovered the many wastes in their whole pre-operative admission process. They discovered how Lean methodology could be used to simplify, not burden their practices. They discovered how standardization is about having resources, routines and safeguards in place that protect their practice of medicine. Simple examples of standards and routines include having laboratory results reported in an accurate and timely manner, for having outside records available prior to consults, for medication refills ready for signing after checking for allergies, for check lists for pre surgical authorizations and registrations. These examples and others can demonstrate how standardized work can avoid errors, redundancy, waiting, and rework while simplifying medical practice but not constraining it.

To engage physicians, emphasize that Lean Methodology is devoted to establishing processes throughout an organization that reliably support the physician’s efforts. Demonstrate how standardization links the physicians’ work to those who come before and after in the sequence. Compliance with standard work is a means of confidently controlling the mundane work and focusing the physician’s efforts on the exceptional and unusual cases. Physicians will see that the processes associated with standard work assist them to provide individualized care and responsiveness to unpredictable need.

For assurance, we should emphasize what Lean is not – it is not a means of controlling, policing or punishing. It is not a set of Do’s to remember. It is not a denial of individual patient or physician needs. It is not strictly an efficiency tool. And it is not the enemy of innovation. Atul Gawande, MD, in his outstanding book “Better” examines several stories of clinics and practitioners whose outstanding outcomes are many percentage points above the expected. He challenges us to look at that variability for the sources of true excellence. Compliance with standards by everyone in the workflow is not going to eliminate all variability or stifle innovation but it will provide an unprecedented level of support and stability to highly competent physicians who will be able to focus on excellence.

We physicians are not necessarily resistant or obstructionist when it comes to Lean or quality improvement efforts. The Lean transformations of Virginia Mason and Theda Care were led by physicians. Engaging physicians is critical for success in Lean Healthcare. As a facilitator, sensei or change agent, success will be when you find the ways to align the Lean principles with the physicians’ goals – they are not incompatible. The true transformation in the medical culture will be achieved when this alignment results in trust and cooperation among all providers of patients’ care.

Written by Marianne Jackson, MD, MPH
Forwarded by Lukasz Mazur, Ph.D.

Perspective is a very powerful thing. Over the past few years my primary interaction with the medical industry has been that of a continuous improvement expert. Recently I had the opportunity to experience things from a different perspective: not as a consultant but as the family member of a patient who required minor surgery. From the moment we arrived at the center we were greeted by courteous people, each who took the time to introduce themselves and to explain their function in ensuring that things went smoothly. With each new person came the introduction and explanation of purpose and with most of them several common questions. Among these were questions necessary to confirm identity as well as the presence of any medical allergies. This treatment was consistent from the moment we arrived until the moment we left after a successful procedure.

It wasn’t until we stopped to pick up the prescription for medication that a problem arose. It appears that even though several nurses had asked about medical allergies, the information did not get properly communicated or applied, the result being that the prescribed medication contained ingredients which would have brought about an allergic reaction. Fortunately the error was caught before the medication was taken but it very easily might not have been.

How does information so important and gathered so many times not make a process fail safe? The right questions were asked, but somehow the information didn’t make it to the place it needed to be. As we employ computerized and other complex systems to manage information we mustn’t lose sight of what is most important: that the right information is gathered, analyzed and applied at the right times. It isn’t bigger, more complex information systems and more protocols that are needed. Rather, we need to keep our focus on simple, concise, standard work systems on which we can rely time after time to produce consistent, effective results.

If you work in the healthcare industry, you may be interested to know that OSHA has been talking about you! Here's the scoop -- Federal OSHA is planning to develop outreach training for healthcare workers! Conceptually similar to the 10 and 30 hour courses offered to general industry and construction, the end product will be tailored to meet the unique needs of healthcare workers.

As a starting point, OSHA recently hosted a meeting where stakeholders were invited to bring their ideas on what targeted training for healthcare should look like. Representating the Southeastern OSHA Training Institute and NC State’s IES, I had the opportunity to join 11 other participants in Washington DC where we offered our thoughts and opinions on how to best meet the safety training needs of healthcare workers.

At the end of the half-day meeting, we had consensus on 2 things: (1) the risk of illnesses and injuries among healthcare workers is very real; and (2) the challenges of developing targeted training are very complex!

IES will continue to work with OSHA on this project, and would like to hear from you. If you have thoughts and opinions on the safety training needs of healthcare workers and how to meet those needs, please send them our way. Here are some questions to get you started:

• What specific safety and health hazards should be included in safety training for healthcare workers?
• What types of workers (RNs, EMTs, Lab Tech, etc) or work places (hospitals, long-term care, home care, etc) should be targeted?
• What are the barriers to participation in OSHA training for healthcare workers?
• Regardless of what OSHA develops, what can IES do to support safety in the healthcare industry?

We pay a 23% premium for healthcare over our G5 economic competitors (Britain, France, Germany, Canada, Japan). You might argue about their metrics, but, I think that most of them are credible. Let us face it! We pay a LOT for healthcare in U.S. Wait a second! All these other countries have socialist systems where the government owns the healthcare. OK! Let me STOP here. My point is that:

1. At least 44 thousand and at most 98 thousand people die each year due to preventable medical errors.
2. We spend twice as much on healthcare as we do on food.
3. We spend more on healthcare than the Chinese spend on everything.
4. Healthcare spending has grown faster than the GDP almost forever.
5. …

This list could be very, very long. The bottom line is that healthcare expenses in the U.S. are higher than any other country, and the reasons are everywhere. Yet, in the recent opinion piece in the Wall Street Journal titled “Why ‘Quality’ Care Is Dangerous” by Jerome Groopman and Pamela Hartzband the authors call for a “time out” in the progression of our healthcare system towards increased accountability and improved quality.

Are we just starting? Yes. Are there problems? Yes. Are there great challenges and risks in healthcare improvement journey? Yes. So, what do you think? Please read the piece by Jerome Groopman and Pamela Hartzband and let me know your opinion.

The ability to eliminate unnecessary cost is absolutely critical to health care industry. Total spending was $2.3 TRILLION in 2007, or $7600 per person [1]. Total health care spending represented 16 percent of the gross domestic product (GDP). U.S. health care spending is expected to increase at approximately 7% levels for the next decade reaching $4.2 TRILLION in 2016, or 20 percent of GDP [1].

In 2007, employer health insurance premiums increased by 6.1 percent - two times the rate of inflation [2]. The annual premium for an employer health plan covering a family of four averaged nearly $12,100. The annual premium for single coverage averaged over $4,400 [2]. Experts agree that US health care system is riddled with inefficiencies, excessive administrative expenses, inflated prices, poor management, and inappropriate care, waste and fraud. These problems significantly increase the cost of medical care and health insurance for employers and workers and affect the security of families.

So, how health care system can eliminate waste? The results from my research about medication delivery systems conducted over two years at one community hospital provide some answers to this question.

The results are:
• Fifty two out of sixty three nurses (82.53%) highlighted poor training for medication error reporting and prevention. Six out of six technicians (100%) pointed to the same issues as nurses.
• Fifty five out of sixty three nurses (87.3%) reported confusion about their role expectation with respect to medication error reporting and prevention. All technicians stated similar concerns.
• Fifty four out of sixty three nurses (85.7%) specified lack of feedback as important factor affecting their psychological safety towards error reporting and prevention efforts. Four out of 6 technicians (66.67%) pointed to the same issue.
• All nurses and all technicians (100%) highlighted productivity pressures as the most stress-generating factor on their daily work averting them from medication error reporting and prevention.
• Forty four out of sixty three nurses (69.8%) and three technicians (50%) suggested group behavior influence as another major factor behind poor medication error reporting and prevention.
• Forty eight out of sixty three nurses (76.19%) indicated difficulties with utilizing the mechanisms for medication error reporting and prevention. Six out of six technicians (100%) pointed to the same issues as nurses.

Therefore, based on the ‘voice’ from the front line staff, I propose the following six strategies for waste elimination:
1) First, healthcare organizations should recognize the growing need to advance the understanding about healthcare delivery systems, unnecessary waste, as well as Quality Improvement (QI) programs by health care professionals. This can be done via continuum education training on systems and QI.
2) Second, health care organizations should start recognizing their frontline professionals as assets rather than costs. It is everybody’s job to eliminate waste and to do improvements. Therefore, the role expectation with respect to waste elimination and quality improvement should be well communicated to all frontline employees and continuously supported by managers and administrators.
3) Third, organization-wide and constructive feedback to frontline health care professionals about QI needs to be provided on a continuous basis. My research found that health care professionals who felt neglected and under-informed regarding the changes often responded with low motivation and discouragement towards QI efforts.
4) Fourth, the productivity pressures, often mentioned by frontline workers as one of the major contributing factors causing the low QI efforts, should be offset by redesigning systems that minimize the unnecessary waste during daily work. This should allow health care professional to devote more time to continuous improvement efforts.
5) Fifth, to remove the undesired group behavior, managers should physically spend more time and effort to establish and support a culture of excellence with high commitment to patient safety, waste elimination and QI.
6) Finally, all unit managers should provide active leadership at the unit floor for promoting standardized behavior with respect to procedural compliance. The goal is to eliminate the variability in the process by creating a culture that values procedural compliance. In additions, promoting procedural compliance by the manager at the unit floor can increase the rate of error recognition and QI efforts via root-cause problem solving, enhance the manager’s reputation for patient safety, and increase the confidence of health care professionals in her/his leadership abilities/skills.

I hope that the proposed implications and discussions will help health care organizations to achieve satisfactory improvement in waste elimination efforts. In addition, I believe that the proposed insights into this area have potential to enhance professional development of health care managers and professionals.

1. Poisal, J.A., et al, Health Spending Projections Through 2016: Modest Changes Obscure Part D’s Impact. Health Affairs (21 February 2007): W242-253.
2. The Henry J. Kaiser Family Foundation. Employee Health Benefits: 2007 Annual Survey. 11 September 2006. http://www.kff.org/insurance/7672/index.cfm