Buena suerte, hospitales de Madrid. Lean es mejor.

Speaking of Lean process improvement, it appears that the folks running hospitals in Madrid could use some help. Check out this article on smartplanet, entitled, "Madrid hospitals look to free beds." The lede:

Spanish hospitals are looking to speed up check in and check out processes, without cutting patient care.

So, officials from sixteen hospitals in the city are getting together to share ideas. The article notes that most hospitals do have programs and objectives geared towards greater efficiency, but that they are “siloed” from department to department and problems often feel a “domino effect.”

As everywhere, there are some cultural problems that can complicate the situation:

[B]esides emergencies, Spanish hospitals shut down Friday afternoon until the busiest time of Monday morning, often keeping patients there two days longer than necessary. After congestive heart failure, the most popular cause of a longer length of hospital stay is simply the fact they were admitted on a Friday.

The medical director of the private Madrid Hospital Moncloa, Carlos Zarco described some services of hospitals functioning on the weekends as a great idea, but essentially “imposible” and very expensive in Spain. He said that profitability would go down, but he does think departments like radiology should be open on weekends.

Claro, imposible. I think this is an example of focusing on the hardest solution, rather than redesigning every day work flows to eliminate waste and inefficiency. Instead of bringing administrators together to analyze the problems from on high, it is time for them to go to gemba and watch the obstacles and work-arounds that the front line staff face every day.

Uncool and unLean taxi batching at Logan Airport

One of the things you learn from Lean is that batch processing is often inefficient and wasteful compared to continuous flow processes.  I have sometimes used this blog to illustrate this phenomenon, like at this bakery and, ironically, even at the food service line of a Lean conference.

I saw another example when I arrived at Logan Airport late at night this past week and was waiting for a taxi.  Here's the scene behind me.  Counting those in front of me, at least 50 people were in line at Terminal B, with more showing up every minute.

Taxis were arriving in groups of three to five as they were sent over from the parking lot at which they are required to wait.  In between, the dispatcher required all passengers to wait behind a chain.  (By the way, note the signage!)

Then the taxis arrived and parked at the curb. 

Only then would the dispatcher allow the batch of three to five passengers groups past the chain.  It would take them about a minute to reach their cabs, load their luggage, and sit inside.  Since the cab at the front of the line was furthest from the chain, its passenger would have the longest distance to walk and take the most time to load. 

Only after that first cab was filled and ready to leave could any of the ones behind it proceed to leave.

In between batches, the dispatcher had nothing to do. He even had time to visit a passing MassPort supervisor driving by in his SUV.

I was about number 40 in line when I arrived at the scene.  It took me over a half hour to get into a cab using this approach.  Each batch had three to five cabs, arriving every three to five minutes.  Loading took a minute for each batch.  I had to wait for eight to ten batches. 

Imagine a simple improvement to this system.  Assuming the taxis have to come over in batches from their parking lot, why not have the dispatcher get people ready to load by standing at pre-marked spots along the sidewalk, ready to load luggage and hop in as soon as a car pulled up.

But imagine a further enhancement.  I asked my cab driver, "Did you have to wait a long time at the remote parking lot before being freed up?"  "No," he said, "only about 15 minutes."  I was stunned that this could be the case on a very busy night, with unmet demand at each terminal.

Apparently the overall dispatcher at the parking lot sends a clump of cabs to each terminal, in sequence, when it is a busy night.  With five terminal locations, every fifth group will show up at any given terminal, always in a batch.  That batch takes time to exit the parking lot, and then the next group moves up the line from their parking places.  What if, instead, the dispatcher at the parking lot sent each single cab, on a continuous basis, to the next terminal in sequence?  A steady flow of individual cabs would arrive at each terminal, separated by less than a minute, to be entered by a waiting passenger at the curb.

I'll let our process flow engineers do the math, but I guarantee this approach would have reduced waiting times considerably, both for cab drivers trying to make a living by getting as many trips as possible and for passengers trying to get home as quickly as possible.

Mr. Ness, everybody knows where the booze is.

A quality-driven MD colleague writes with frustration about two problems in his academic medical center.  I often hear similar comments from nurses and doctors, and so I present the examples for your consideration.

This hospital has a poor record with regard to hand hygiene (in the 30% range), and my colleague suggested at an infection control meeting suggested that the rates be publicly posted in the hospital to provide an impetus for improvement.  "I suggested that instead of being embarrassed, maybe we should OWN the data." This, of course, is a standard and accepted approach in quality improvement.  S/he was told that the "the lawyers will not let us do this."  S/he wonders, "Who, exactly, is our primary concern?"

At another meeting, the chief nursing officer asked why there had not been more progress made with regard to central line infections in the ICUs.  It turned out that there had been meetings with  the bedside staff which identified a number of problematic workarounds they had created. However, the team was limited in what they could do because decisions about equipment and kits are made based on cost, away from the bedside. The CNO was upset because the local folks had not shared with her what they had already done and wanted to know why they hadn't told her about these problems – while acknowledging she couldn't do anything about them.

My friend summarized: 

I explained that if she wanted to find out what was going on – she need only walk onto the unit and ask.

This all reminds me of the scene in The Untouchables. Elliot Ness talks about busting Al Capone if only he knew where he was making his booze. Sean Connery's character (Jimmy Malone) takes him to a post office across from the police station.  Ness can't believe the booze is there. Malone says, "Mr. Ness, everybody knows where the booze is. The problem isn't finding it, the problem is who wants to cross Capone."

The problem isn't knowing HOW to fix this problem. It's doing what it takes to accomplish that -- over-ruling the lawyers and accountants and doing the hard-work to change the culture. This can't happen if the C-suite leads from meeting rooms.

These stories exemplify the huge cultural schism in the country between the minority, those institutions that have taken on the quality and safety agenda and internalized it into their decision-making and process improvement efforts, and the majority, the ones that have not.  Each year at the IHI Annual Forum, I hear from nurse managers and young doctors asking, "What can I do to get my CEO/CFO/CNO/Board of Trustees to support us in what we know must be done?"

I want to state this as clearly as possible:  The leaders of academic medical centers and medical schools are failing to be the leaders the country needs at this time. In their failure, they sow the seeds of burdensome governmental and regulatory requirements, for those in policy positions will see the vacuum and will fill it. In their failure, they persist in accepting the view that "these things happen," and are personally -- yes, personally -- responsible for thousands of preventable deaths and injuries each year.  This is the most significant ethical issue facing the profession, and they simply fail to accept responsibility.

Bravo to Brent James

Dr. Brent James last week was awarded Columbia Business School’s W. Edwards Deming Center for Quality, Productivity and Competitiveness. As described in the press release:

The Deming Cup grew from the center’s drive to highlight the achievements of business practitioners who adhere to and promote excellence in operations – the Deming Center’s area of focus. This award is given annually to an individual who has made outstanding contributions in the area of operations and has established a culture of continuous improvement within their respective organization.

Dr. James was recognized for his pioneering work in applying quality improvement techniques that were originally developed by W. Edwards Deming and others, in order to help create and implement a “system” model at Intermountain, in which physicians study process and outcomes data to determine the types of care that are most effective.

Imagine that, improving clinical care is consistent with efficiency in the health care system.  This has to be another lie, just like that stuff about Pronovost saving lives and reducing costs by reducing the rate of central line associated bloodstream infections.  Or assertions by that trio of fraud, Spear, Toussaint, and Kaplan.

This stuff can't be true.  If it were everybody would be doing it.  Right?

Back on January 15, 2009, I published a post entitled "What does it take?", in which I expressed frustration with the slow pace of process improvement in hospitals.  What followed in the comments was a virtual seminar by some of the country's leaders in the field.  They are still worth checking out.  Brent offered his point of view:

Paul, you have put your finger on what I regard as THE core task of the present generation of the healing professions. It is very clear that we are in the midst of a transition. The term of art that is usually used to describe the present state – and which Don Berwick so eloquently explained (at least, at the level that an individual physician would experience it) – is “the craft of medicine.” It’s the idea that every physician (or nurse, or technician, or administrator, etc.) is a personal expert, relying primarily on their personal commitment to excellence. In a very real sense, every physician occupies his/her own universe, with its own reality, truths, physical constants. As a physician I might say to a colleague, “What works for you, works for you. What works for me, works for me. Let’s both stay focused on the patient – our core fiduciary commitment to put the patient first in all things – and that will guarantee the best possible results.”

David Eddy said it most eloquently: This core assumption of the craft of medicine is scientifically untenable.

As a direct result of some solid research around this fact, the healing professions are in the midst of a major sea-change, a once-in-a-century shift: We’re moving from “medicine practiced as individual heroism” to “medicine as a team sport.” The kinds of tools you’re talking about make perfect sense in a team setting, but almost no sense within the craft of medicine.

Don is right in calling it culture change. However, we are well past the tipping point. There is strong evidence that the professions have committed to a new course and are actively moving. It’s the difference between 5% of the profession “getting it” (where we are now), and moving to a point where it is standard, accepted, background business essentially all of the time.

The key change concept was perhaps best expressed by Winston Churchill: “People like to change; they just don’t like to be changed.”

I am also deeply impressed by Roger’s classic text on change: Diffusion of Innovation. He describes bottom-up change, by sharing results (both data and word of mouth) from initial thought leaders (his “early adopters”). That has worked very well for us, and makes the change fun – rather than something that a bunch of external “know nothings” are trying to do to you.