But take a look anyway, if you have an interest in process improvement in hospitals. This is a collection of my best posts on this topic.

Friday, June 10, 2011

"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.

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