The value of standard work

"The most important thing we can teach our residents and trainees is the value of standard work."

Imagine if that were the philosophy in every academic medical center. It is the philosophy at the Mayo Clinic, according to Dr. Stephen Swensen, Director for Quality. Dr. Swensen commented on these matters during last week's IHI Annual Forum. I was not able to attend his session, but a colleague did go and reported back to me.

For years, I have been hearing about the quality of care given at Mayo and was having trouble learning what distinguishes the place. I should have figured it out. The simple summary of process improvement is that you cannot design and implement improvement if there is too much variability in your process. Why? First, you cannot design an experiment for change unless you are confident that your change is being applied to a relatively uniform "prior." Second, you cannot measure improvement compared to a base case if there is not base case.
Dr. Swensen talks a lot about the "cottage industry" and "farmers' market" approaches to medicine, as opposed to the Mayo way of standard work, decision support, and forced protocolization. Mayo has a Clinic Clinical Practice Committee that has the authority to set practice standards and methods across the organization. When improvements are discovered, there is rapid diffusion of learning.

When it comes to residents, they must be bronze-certified through Mayo Quality Academy before treating patients. This includes training on simulators before being allowed to practice procedures (like central lines) on patients.

Dr. Swensen also discussed four conflicts in academic medical centers that prevent truly patient centered care:

• Physician Autonomy - As mentioned, a high variation environment is inherently unsafe.
• Financial conflicts - Some care receives higher payments; there are financial conflicts between the doctors and the hospital; and fee-for-service creates conflicts of interest.
• Research - The well-intentioned focus on the mission that "we're here to advance knowledge" can interfere with care.
• Education - The well-intentioned view that "we're here to provide training opportunities" lets trainees practice on patients and causes care to be organized around the training program, rather than vice versa.

As I heard this, I thought about our place. While we have instituted some standard practices, it is clear that we have not gone as far as we might. On the financial front, we have started to move away from fee-for-service, but there is not a uniform payment system across all of our payors. And his comments about research and teaching are often likely to be valid.

I will state immodestly that we are viewed as one of the leaders among academic medical centers with regard to quality, safety, and process improvement. If we still have so far to go, after several years of concerted effort, the academic medical sector as a whole has miles to travel.

Dr. Vollmer and his team continue to tell all

Transparency of clinical outcomes has now become part of the culture at BIDMC, and that is nowhere as evident as in our outcomes for pancreatic resection surgery. These are difficult procedures, where surgical skill matters, but where use of a standardized plan of care (or clinical pathway) makes a large difference.

Our website contains a clear exposition of the results in our hospital. As noted by Doctor Charles Vollmer in our Department of Surgery,

"This summary reflects our initiative for total transparency of the real outcomes from our practice which are available to anyone through our institutional website. We believe this is a unique approach in our specialized field of pancreas surgery, and I would even contend it is rare to see anything like this for any general surgical domains around the country."

Credit for this approach also clearly goes to Dr. Mark Callery, chief of our general surgery division, and also a major practitioner in this particular field.

You can find the website here. The new numbers are about to be posted. Here is a sneak preview, showing the changes from 2007 through 2010.

Volume of Procedures: 82; 73; 86; 89
Mortality Rate: 1.2%; 0%; 3.5%; 1.1%
Length of Stay (Median): 7.5 days; 8 days; 8 days; 7 days
% of Patients Requiring Admission to an ICU: 8.5%; 12.3%; 17.4%; 11.2%
Blood Loss During Surgery (Median): 300ml; 300 ml; 275 ml; 200 ml
% of Patients Requiring Post-Op Blood Transfusions: 14.6%; 26%; 12.9%; 19.1%
Reoperation Rate (within 3 Months): 6.0%; 6.8%; 7%; 3.4%
Readmission to Hospital (within 90 days) Rate: 13.4%; 25%; 29%; 11.2%
Central Venous Line Infection Rate: 0%; 0%; 1.2%; 1.1%
% of Patients Receiving Immunizations Prior to Discharge (for Splenectomy): 100% (all years)

As I have said previously with regard to another topic, if we can post these rates for BIDMC, why can't people from other hospitals? Why can't the insurance companies post them? Where are the public health advocates on this topic? The data are collected regularly by all hospitals. We must get past a culture of blame and litigation and persuade people that transparency works: Real-time public disclosure of key indicators like this (not the untimely publication of "process" metrics) can be mutually instructive and can help provide an incentive to all of us to do better.

Some people have argued that transparency will lead to doctors trying to avoid the high risk cases. I know from personal knowledge of some of their patients that such is certainly not the case with Dr. Vollmer and his colleagues. Note, too, that they make no attempt to risk-adjust the metrics above. These are all-in figures.

No such thing as random failure

Joseph Gavin, Jr., who died in November, was an aeronautic engineer who was intimately involved in the design of the first manned craft to land on the moon. He was also a key player in the rescue of the Apollo 13 astronauts. He was a remarkable fellow, and I had a chance to hear a tribute to him during this past week's meeting of the MIT Corporation. (He was in the class of 1941.)

One of the quotes ascribed to him during the presentation was, "There is no such thing as a random failure."

In this discussion board, a commenter says, with regard to that quote, "Amazing when you look at things now, that in the avionics industry of the time 'random' failures were acceptable! As he says, there is (almost) no such thing as a random failure... Everything has a cause, and in a safety critical system (or one-shot system like this), every failure cause has to be designed out..."

It strikes me that there is a parallel with medical care. I have discussed the problem of "These things happen" that often characterizes the delivery of care. I noted:

Several years ago, we had that attitude in our hospital with regard to certain types of medical outcomes. For example, we were content with our level of central line infections because we were below the national average. After all, these things happen. Then our chiefs of medicine and surgery said, "No, they don't have to happen. When they happen, people die. We are going to insist that we achieve zero central line infections." And then they got to work. As I have noted below, it is not an easy problem to solve, but it is worth the effort, and you can improve.

The science of process improvement can be applied to the delivery of care, as it has been to other high performance service and manufacturing industries. I hope my readers will excuse the degree to which I focus on this topic, but I cannot imagine a more important subject to cover.

This week, several thousand people will be attending the IHI Annual Forum to learn and trade information and stories along the theme of Taking Care. Maybe, if we learn well enough, we can say that "these things" no longer happen.

Here's Ethel Merman, to make the point in her own way. (If you cannot see the video, click here.)

Enthusiastic Transparency

The State of Washington posts a variety of information about hospital infection rates. The latest addition to this is the publication of surgical infection rates. The website provides data on infections following three important types of surgeries: cardiac, orthopaedic, and hysterectomies. The Washington State Legislature required the data to be collected and made public in House Bill 1106 in 2007 and House Bill 2828 in 2010. Here is a section of the press release from the Washington State Hospital Association:

“Washington’s hospitals are enthusiastic participants in providing this new information about surgical infection rates,” said Carol Wagner, vice president for patient safety at the Washington State Hospital Association. “We believe that public reporting helps hospitals improve, assists consumers in making good decisions about hospital care, and creates collaboration between hospitals and quality experts.”

“Hospitals are dedicated to the care and comfort of our patients. In most cases, the data show good results, though there are also areas for improvement. Our member hospitals are working hard to implement changes to stop surgical infections, and we expect the results to get better and better,” concluded Wagner.

Washington State’s infection reporting program is considered a national leader. The National Conference of State Legislatures highlighted Washington, along with nine other states, in its recent report, "Lessons from the Pioneers: Reporting Healthcare-Associated Infections."

Note, too, the publication of central line infection rates and ventilator pneumonia infections.

I like the sound of that: enthusiastic participants. Congratulations to the WSHA for their part in helping bring this about and to the Washington legislature for their leadership.