Seeing things clearly in the Netherlands

In the post below, I summarize a conference held today at Jeroen Bosch Hospital in 's-Hertogenbosch (den Bosch), in the Netherlands, entitled "Quality and Transparency in Care and Training." In addition to the conference, today was a significant day in that a new website was launched by the hospital to present quality and safety data to the public and to the hospital's staff.

As explained by Dr. Marjo Jager, patient quality specialist, Jeroen Bosch has a strong commitment to transparency as a key element of process improvement in the hospital. The leadership of the hospital views transparency as the most powerful way to reduce preventable injuries, but also as essential to successful and ethical responses to patients and to safeguard employees.

Marjo noted that preconditions for successful implementation of transparency are a culture of learning rather than blaming and judging; ownership by those who deliver care; significant participation by physicians in designing new care regimes and setting an example; and strong support from the board.

Above you see an action shot of the moment of truth, as staffers Miriam Casarotto and Bart Deijkers prepare to push the "activate" button on the new website.

Beyond the website, the hospital is also posting clinical data on patient care floors for all to see. They are experimenting with locations and topics, and this is all bound to change with experience, but the commitment to openness is evident, even when the numbers indicate a need for improvement.

Here, for example, is the current scoresheet with regard to pain management on one of the floors. The hospital clearly indicates a result less favorable than they would like, accompanied visually with a cartoon face that is not smiling.


In contrast, note this one with regard to avoiding decubitis ulcers (bedsores), which indicates performance at the hoped-for standard of care.

Congratulations to the administrative and clinical leadership of the hospital, and for the support provided by its board, for these significant steps in improving the quality and safety of patient care.

Borrowing safety ideas in the Netherlands

I just attended and presented at a conference at Jeroen Bosch Hospital in 's-Hertogenbosch (den Bosch), in the Netherlands, entitled "Quality and Transparency in Care and Training." It was held on the occasion of the opening of an entirely new hospital, following a merger with two other hospitals in the city (Bosch Medicentrum and the Carolus Hospitals). Hospital administrators and clinicians from throughout the country attended.

Our MC for the day was Jozein Bensing, professor of health psychology at the University of Utrecht. Relative to today's topic, she is most known for a paper she published a few years ago documenting that 1700 people per year unnecessarily die in Dutch health care facilities. This report gave substantial impetus to improvements in patient safety in the country's hospitals.

Jozein chairs the quality and safety committee of Jeroen Bosch's supervisory board (the equivalent of the board of trustees of a US hospital.) She said that the hospital has a goal of being the safest hospital in the Netherlands and plans to do so by "practicing what you preach" and learning as much as possible from others, in the health care field and beyond.

So it was appropriate that the chair of the symposium committee, Marck Haerkens (CEO of Wings of Care), and his colleagues decided to bring in the lessons of quality and safety from other fields. They see parallels with airline safety, and so we heard from Pieter van Vollenhoven Chair of the national Safety Board; Jos Nijhuis, CEO of Amsterdam's Schiphol Airport, and Tames Oud, head of training for Transavia Airlines.

Tames suggested that, while aviation and medicine are two different worlds, there some striking similarities, such as highly motivated professionals and critical processes. In both worlds safety and quality depend on effective cooperation between different disciplines. Like Captain Sullenberger back in the US, Tames asserted that the medical community could benefit from Crew Resource Management (CRM). Its objective is to reduce incidents (and worse) due to lack of situational awareness and team cooperation. He noted that CRM training makes people aware of the relevance of the human factor in team performance, and aids in creating a blame-free environment for people to work in.

In addition, Scott Higginbotham, mission manager at NASA's Kennedy Space Center, presented on "Safety and Mission Assurance." (He is seen here on the right with Willy Spaan, the hospital's CEO.) Scott's primary responsibility is to lead the multi-disciplinary team of engineers and technicians that assemble and test the experiments and satellites that fly aboard the Space Shuttle and the International Space Station. A summary: Manned spaceflight is an incredibly complex and inherently risky human endeavor. As the result of the lessons learned through years of triumph and tragedy, NASA has embraced a comprehensive and integrated approach to the challenge of ensuring safety and mission success. His presentation provided an overview of some of the techniques employed in this effort.

Regular readers of this blog will know my topic: I presented the experience of my former hospital with regard to its goal to eliminate preventable harm for its patients. I explored the hospital’s success in improving quality and safety for patients, endorsing public transparency of clinical outcomes, and engaging in process improvement driven by front-line staff.

As I have noted before, there are often misconceptions as people talk about “transparency” in the health care field. They say the main societal value is to provide information so patients can make decisions about which hospital to visit for a given diagnosis or treatment. As for hospitals, people believe the main strategic value of transparency is to create a competitive advantage vis-à-vis other hospitals in the same city or region. Both these impressions are misguided.

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.

Many thanks to the symposium's major organizers, Marian de Bont and Dr. Kees Smulders, secretary and manager, respectively, of Jeroen Bosch's quality section (seen here) for their invitation and for planning a day of interesting and insightful talks.

In the post above, I include recent activities of Dr. Smulders and his staff with regard to new approaches to transparency in their hospital.

Will we ever get to this point?

An April 5 article in the Financial Times presented the story of a number of German industrial groups that have found success by selling manufacturing skills to external clients. Entitled "Profits of Inside Knowledge," the story focuses on Lean process improvement expertise. Here are some excerpts:

[A]fter the Porsche management brought in Japanese lean production techniques, overhauling the German company’s inefficient production system and network of suppliers, they discovered that there was demand from suppliers for their expertise.

The secret to the consultancies’ success lies in a rather unusual approach. Unlike most consultancies, Fischer Prozessberatung and the German sports car maker do not proffer legions of immaculate suits fresh from business school but rather experts from their shop floors.

“Some of our consultants go to the assembly plants of engineering companies and, after three days, start moving around machinery with a crane to improve production efficiency. Which consultancy would do something similar?” asks Eberhard Weiblen, Porsche Consulting’s chief executive.

As we consider the possible value of Lean in the hospital world, is it too much to imagine the same thing occurring in health care? Imagine a hospital getting so good at reducing waste that it would be asked by its medical device suppliers or other vendors to assist in making those companies more efficient.

Well, maybe we are getting a little ahead of ourselves. First, let's get good at this in the clinical setting. As Jim Womack says,

"But they are different." Not!

Whenever I talk about the spectacular work Brent James and his colleagues have done with process improvement at Intermountain Health, someone says, "But they are different." These comments are often based on prejudice. It reminds me of the folks in the US automobile industry who initially said of Toyota's use of Lean principles, "It will never work in America. Those Japanese are different. They are so much more compliant than Americans." Then, those competitors discovered that Toyota factories in the US, with American workers, also effectively used Lean. And ate their lunch.

What do they say about IH? They talk about the homogeneity of the population in Utah, meaning that there is a predominantly Mormon population. They subtly suggest that Mormons are somehow more complaint with regard to health care treatment, have fewer health problems, or that the doctors are more likely to follow orders, or something equally foolish. Here's the more accurate description:

The IH network of twenty-three hospitals and 160 clinics provides more than half of all health care delivered in the region. Intermountain’s hospitals range from critical-access facilities in rural areas to large, urban teaching hospitals. Although Intermountain has an employed physician group and a health insurance plan, the majority of its care is performed by independent, community-based physicians and is paid for by government and commercial payers.

We need to recognize that the work done at IH is the result of thoughtful, hard work, and the application of the scientific method to improving patient care. It is documented in this article by Brent C. James and Lucy A. Savitz in Health Affairs: "How Intermountain Trimmed Health Care Costs Through Robust Quality Improvement Efforts." (June 2011, 30:6) Here's part of the abstract:

Since 1988 Intermountain Healthcare has applied to health care delivery the insights of W. Edwards Deming's process management theory, which says that the best way to reduce costs is to improve quality. Intermountain achieved such quality-based savings through measuring, understanding, and managing variation among clinicians in providing care. Intermountain created data systems and management structures that increased accountability, drove improvement, and produced savings.

Since I can't give you a cite to a free copy of the full text -- (Ugh, like JAMA!) -- here are some more excerpts. The whole thing is about reducing variation and conducting experiments to improve key processes. Note the involvement of physicians! This did not come about as a result of payment "reform," financial penalties for "never" events, or Joint Commission surveys.

[In the early days of the effort, we focused] on the processes of care delivery that underlie particular treatments, rather than on the clinicians who executed those processes—the “measurement for improvement” approach.... [T]he system was eventually able to document significant declines in physician variation. Physicians led almost all of the changes themselves. Declines in variation were associated with large declines in costs, while clinical outcomes remained at their original high levels.

Here is an interesting part about how to provide constructive feedback to the doctors, in a manner that persisted in reducing variation:

[T]he clinicians’ experience showed that the guideline was almost never perfectly appropriate for a patient. The clinicians had to adapt the guideline to each patient’s particular needs. Morris’s team recorded all of the adaptations as variances and reported them back to the clinical team treating the patient. The members of the care delivery team sometimes modified the guideline in response to the variances, to reflect the realities of care more accurately. In addition, clinicians often modified their practices to follow the guideline as closely as they could.

But focus matters. You don't change the entire organization at once:

Not all processes are equal in size and effect. Some are the “golden few”—the relative handful of processes that make up the bulk of the care that a clinical organization delivers. . . . Intermountain sought to identify this relatively small subset of key processes.

We divided Intermountain’s work processes into four subgroups: clinical processes associated with specific clinical conditions (clinical programs); clinical processes that are not condition specific (clinical support services, such as pharmacy or imaging); processes related to service quality (patient perceptions of quality); and administrative support processes. We identified and then prioritized the processes within each subgroup.

We found that 104 clinical processes—roughly 7 percent of the 1,400—accounted for 95 percent of all of Intermountain’s care delivery.

And, now look at how this changed the hospital-centric view of care:

Our focus on key clinical processes had a major secondary impact. These processes represent the entire care continuum that patients experience, without concern for the location of the care, such as home-based, clinic-based, or inpatient care delivery. Correctly managed, they lead naturally to patient-centered care. Instead of selling clinic visits, hospitalizations, or technologies to prospective patients, a health system organized around key clinical processes finds its business model driven toward population-level health. This means shifting the focus to modifying the factors that cause disease, with the goal of avoiding future costs for care, instead of responding to health problems only after they appear.

Whether you call it Deming or Lean, it is the same thing. The steps are straightforward and logical and completely consistent with the good intentions and scientific training of physicians: Document process waste and inefficiency using the wisdom of the front-line staff; reduce variation to standardize care as much as possible; conduct scientifically based experiments to improve the standard process; spread the story of effective solutions; repeat. Over and over.

The result is higher quality, lower cost, more patient-driven care and less anecdotal medicine. The government and the payers are not necessary participants in this process. The profession can do it on its own. If it does not, the government and the payers will force upon you an approach that is crude and ineffective and will simply make you resentful.

Now, let's graduate to Lean 404

I am borrowing some slides recently presented by James Womack, of the Lean Enterprise Institute, as a follow-up to my previous post about adoption of the Lean philosophy in an organization. If the description there was Lean 101, this is Lean 404.

It is one thing to talk about reducing waste in a process and to learn techniques for doing so. It is another thing altogether to create the management competencies that permit this kind of process improvement to take place on a sustained basis. As Womack notes in the first slide above, most organizations do not have the competencies in place to do that.

In the slides below, he sets forth the difference in management approaches between the traditional view and the Lean environments. (Here is a similar oral description from a thoughtful doctor.)



How do you get there? The key is to have the nerve to experiment. Instead of thinking in traditional vertical silos and reporting relationships, you need to have enough confidence in people to let them think along the entire value stream of a given process. This empowers them to redesign the way work is done, extracting waste, improving worker satisfaction, and delivering more value to customers. In a hospital, where the customers are patients, "more value" can actually mean avoiding life-threatening errors and omissions. It can also "simply" mean a more pleasant experience; e.g., less time spent waiting to be seen in an ambulatory clinic.

Think about the organizational and leadership issue in soccer terms. Imagine that, as a coach, you try to improve your team by thinking separately about the forwards and how they will play and be evaluated; and then the midfielders; and then the defense; and then the goaltenders. Of course, that would be silly. The game is played horizontally -- not only across a field, but also across the various position players. As you reduce waste -- mishandled balls, poorly directed passes, and other miscues -- it is the interaction of the entire team, irrespective of vertical definitions, that leads to success. Your job as leader (coach) is to promote those interactions and engage all participants in process improvement. Yes, those goaltenders need their own specialized training, too; but your job as coach is the one Womack ends with below -- helping people figure out how to integrate the horizontal process improvement approach with the vertical organizational needs.

How do you get Lean?

Lean is not a program. It is a philosophy of management and of organization in a firm or institution. The LEAN approach to things is based on the concept of reducing waste in a process. In a typical clinical process in a typical hospital, over 90% of the steps taken to deliver care are wasteful, and it is not unusual to be able to reduce that by half. The results are better patient care and better financial results. (Regular readers have seen lots of examples of this from my former hospital.)

A leading figure in the spread of Lean to hospitals is John Toussaint. He was CEO of ThedaCare, in Wisconsin. After leaving that position, he founded the ThedaCare Center for Healthcare Value to spread the word about this approach. The Center has released its first DVD, a 44-minute video that highlights strategy deployment as a core part of the Lean management system at ThedaCare. Here's a summary:

The video takes you to multiple locations at ThedaCare and Appleton Medical Center, including the senior leadership "visual room" and two inpatient units. Toussaint, current CEO Dean Gruner MD, and COO Matt Furlan describe how strategy deployment helps align the entire organization and their improvement efforts around their "true north" objectives for measurably better care. You will also see front-line managers describe how they drive daily continuous improvement in alignment with ThedaCare's mission, vision, and strategy.

Several hospitals around the country have joined to create a Healthcare Value Leaders Network as they implement the Lean philosophy. Established in June 2009, the network now consists of 36 member organizations that have joined to collaborate and share their lean methods and experiences. The goal of the Network is to accelerate each organization's "Lean journey," allowing each member to progress more quickly and more effectively than they could on their own.

If I were on the board of trustees of a hospital facing a whole variety of financial and clinical issues, I would be asking the senior administrative and clinical leadership how they intend to reap the patient care and financial advantages that come from the Lean approach. If you are in that role, see what answer you get when you ask the question.

Getting transparency right

This is about transparency, when it is useful and when it is not. The term is now an established part of the health care lexicon, but there is little substantive discussion about how it is being used.

As I said in an article in Business Week over three years ago:

There are often misconceptions as people talk about "transparency" in the health-care field. They say the main societal value is to provide information so patients can make decisions about which hospital to visit for a given diagnosis or treatment. As for hospitals, people believe the main strategic value of transparency is to create a competitive advantage vis-à-vis other hospitals in the same city or region. Both these impressions are misguided.

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.

Now, there rises an additional misconception. The perversion of the transparency concept that has evolved rides on the desire of CMS and private insurance companies to use publicly published outcome data to financially reward or penalize hospitals. As expected, this is raising hackles. The complaints often heard from hospitals are ones we have discussed before: "The data are wrong." "Our patients are sicker."

I am not going to accept those complaints, but I am going to suggest that the usual government mandates for transparency of data provide little basis for the kind of process improvement we need in hospitals. What's wrong with these mandates?

For one thing, the data are old. While you cannot manage what you do not measure, trying to manage with data that are a year or two or more older is like trying to drive viewing the road through a rearview mirror. The principles of Lean process improvement and other such systems suggest that real time "visual cues" of how the organization is doing are essential. Why? Because that kind of data is indicative of the state of the organization right now, not what existed months or years ago. Such data are collected in hospitals on a current basis. If their main purpose is to support process improvement, they do not need external validation or auditing to be made transparent in real time.

For another thing, the choice of data in the government's approach to transparency is externally imposed. Process improvement occurs when the people who do the work jointly decide what areas of change are important. We need to trust that the clinicians and administrators in hospitals, working with their patients and boards of trustees, are better able to decide on quality and safety priorities than the government or its agents. We want the hospitals to be transparent about the metrics they choose, knowing that their doctors, nurses, other staff will value the results highly and act on them.

Finally, the payers' approach to transparency creates attention on meeting certain outcomes, rather than stimulating a desire to design and implement a comprehensive structure to achieve better outcomes. A wise colleague said recently, "Obsession with outcome without obsession with structure will fail."

Captain Sullenberger talked about this in another respect: "A checklist alone is not sufficient. What makes it effective are the attitude, behavior, and teamwork that goes along with the use of it."

In summary, transparency of data alone is not sufficient. What makes it powerful in establishing creative tension in an organization are: The currency of the data; the fact that the metrics being made transparent have been chosen by those involved in the process improvement efforts; and the fact that the transparent outcomes are supported by a structure of ongoing process improvement.

As we have seen by examples on this blog, those hospitals that have been most effective in the challenge of process improvement have not done so because a government agency is making their clinical outcomes transparent. They have done so because the administrative and clinical leadership, strongly supported and encouraged by boards of trustees, have made it clear that this kind of effort is a top priority. More and more places each month have discovered the importance of transparency in supporting their efforts. How this takes place will be specific to each hospital, but it is clear that, to be effective and sustainable, change must come from within.