McAllen, Texas = Boston, Massachusetts

Thoughts as I go through the night prepping for my regular colonoscopy (OK, more than you want to know!) which allows me to be up even earlier than usual and make some observations. I can't yet blame the soon-to-be administered Demerol for any incomprehensible wanderings, and I promise not to write the next post until that wears off.

Atul Gawande has yet another beautifully written article in the New Yorker about health care costs, this time focusing on a particular city in Texas that has remarkably high costs compared to the rest of the country. Of course, he need not have travelled so far. The points he raises have been published for years by our colleagues at Dartmouth, and have been discussed by Brent James and others. And the kinds of numbers he cites, although perhaps not as extreme, also typify health care costs here in Massachusetts.

Brent summarized some of these issues in a talk he gave here about a year ago:

-- Well-documented massive variation in practice based on local medical myths.
-- High rates of inappropriate care.
-- Unacceptable rates of preventable care-associated patient injury and death. (Hospitals are actually the #4 or #5 major public health problem in this regard!)
-- A striking inability to "do what we know works".
-- Huge amounts of waster and spiraling prices that limit access.

While Atul focuses on national policy in his article, let me bring the discussion back to strategic planning for hospitals in general and academic medical centers in particular. It seems to me that there are three overwhelming public policy trends in America:

1) A desire to set an annual budget per person for health care;
2) A desire to limit the growth of that annual budget to a rate equal to or less than the overall rate of inflation; and
3) A desire to reduce the amount of harm caused to patients during hospitalizations.

The successful hospitals (and their associated physicians) will be those who learn to live within these broad formulations, and the most successful with be those who wholeheartedly embrace them. Further, they will need to create integrated networks of care -- whether by ownership or strategic alliances -- with people in other parts of the health care delivery system who have similar beliefs. Finally, they will need to engage in process improvement of the type discussed by Steven Spear to squeeze waste out of the system on the "factory floor."

In Massachusetts, there is only one integrated delivery system characterized by ownership of enough entities to engage in this kind of strategic approach, but that system has not yet demonstrated an ability to deliver care at a lower cost. Indeed, just the opposite. For a place like BIDMC, we will have to rely on finding multi-specialty groups, community hospitals, and others who share our vision of success through improving the quality and efficiency of our service, delivering care in the most appropriate settings, and constantly striving to be "the best at getting better."

Many of you have watched our progress here on this blog and on our corporate website as we feel our way along this path. One of our management techniques is transparency. It is based on a philosophy that you can't get better and you can't hold yourself accountable unless you are exceptionally public about what you do wrong, as well as what you do right. As I have noted elsewhere:

Transparency's major societal and strategic imperative is to provide creative tension within hospitals so that they hold themselves accountable. This accountability is what will drive doctors, nurses, and administrators to seek constant improvements in the quality and safety of patient care.

In this sense, transparency is a necessary but not sufficient element in bringing about transformational change in an organization. But the actual implementation is not easy. You've seen our stories about BIDMC SPIRIT and Lean process improvement here. We view ourselves as babes in the woods in these arenas, but we view part of our role as an academic medical center to share what we have learned with others. We will also ruthlessly borrow good ideas from others in our quest to do better for our patients but also for ourselves as an organization facing the three policy imperatives set forth above.

Luy and Ethel discover gemba

Lean training for our senior executive group continued apace this week. As always, a segment was a return to gemba, the place where work happens and value is created for the customer. Here, SVP for Health Care Quality Ken Sands visits with radiology staff members Michael Hogan and Caitlin Buchsteiner to learn about what visual signals exist in the workplace that give a sense of the status of the pace of diagnostic radiology exams. One part of the Lean theory is that it should be easy for staff members to get at-a-glance information on the status of a given work flow or process.

The classic example of a system in which the workers are disconnected from the upstream aspects of production system is found in this episode from the I Love Lucy show. How many examples of this can be found in your hospital? We find them all over. As always, this is not a case of ill-intentioned people working in a bad environment: Rather it is the all-to-common case of really good people working in an environment that has not been designed to reduce waste. The result is work-arounds, wasted effort, errors, and staff who go home more tired each day than they really need to.

Simply stated, the goal of Lean is to train people to see these examples and also to have the team learn how to address them in a comprehensive and thoughtful way. The idea is not to solve for the complete perfect solution all at once, but to be "very good at getting better."

Caller-Outer of the Month Award #5

Our Board of Directors yesterday presented this month's Caller-Outer of the Month Award to Susan Adams and Lora Morgan, whose near-miss call-out I have previously described. Susan was the ICU nurse mentioned in that story, and Lora was the clinical pharmacist. Please recall that this award is presented by the Board to reinforce the underlying concept of BIDMC SPIRIT -- that each person should be encouraged to call out problems in the workplace and be recognized and appreciated for his or her contribution to safety, quality, efficiency, and a better work environment.

Gemba calls again and again

The training sessions for the senior management in Lean philosophy and techniques continue, in an effort to integrate that approach with the ongoing BIDMC SPIRIT program. Each session involves a visit to a front-line process or clinical area. Here you see Suzanne Albright, a recruiter in our human resources department, explaining the steps in recruiting, screening, interviewing, and hiring to Mark Gebhardt, Chief of Orthopaedics.

Above, you also see the group at play, with a simulation of a meeting to discuss process improvement. Each person is labeled with a characteristic -- unknown to him or her -- that causes the other participants to treat him or her in a stereotypical fashion. The lesson is clear within just a few minutes: If you draw assumptions about your colleagues with regard to their ability to participate fully in process improvement, it is a self-fulfilling prophecy. The result is a diminution of the ability of the group and the organization to learn from one another and achieve the best results.

Returning to Gemba

You may recall that I discussed the Lean training program being taken by our senior management group. A second session was held this week, and we returned as a group to Gemba, the place where work happens, where value is created for consumers. Today's visit was to the pharmacy. SVP Jayne Sheehan, seen above in her "bunny suit", and I observed how things are done in the clean room.

We watched Rena Lithotomes (left), a trainee, and Rosmara Harvey (right), a pharmacist, as they carried out the incredibly precise and important work of preparing dosages of a wide variety of drugs used in clinical settings.

Later in the classroom setting, we compared notes to refine our observational skills and ability to see opportunities for reductions of muda, mura, and muri in our work areas. These concepts have often been used in other industries, but not so much yet in the health care industry. Probably the best example is Virginia Mason Medical Center in Seattle, where CEO Gary Kaplan has made this the hallmark of his administration for several years. We are earlier on the path to adoption of this philosophy in our hospital, merging it into our BIDMC SPIRIT program in a more systematic way over the coming months.