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.

Monday, October 31, 2011

Ohio steps backward on transparency

After expressing enthusiastic support for many quality initiatives by hospitals in Ohio, I must report with disappointment an action by their trade association to dismantle the state's hospital transparency website.  This article summarizes:

The Ohio Hospital Association (OHA) is backing a piece of recently introduced legislation that would free hospitals from the requirement to report performance data such as measures of heart and surgical care, infection rates and patient satisfaction.

The reason?  Alleged duplication of effort with the CMS Hospital Compare website.  According to an OHA spokesperson:

The time and effort spent on reporting the data to the state as well as the federal government reduces the resources Ohio hospitals can devote to patient care.

To which I reply, "Bull twaddle!" (This is a family blog, or I would use stronger terms.)

First, let's acknowledge that the data presented in the the CMS site is old, very old.  It accomplishes little or nothing with regard to transparency.  As I have noted:

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.

Second, let's be real about the amount of time this state-run site "takes away" from delivering patient care.  This data would be collected regularly by hospitals, as part of delivering patient care, even if there were no federal or state reporting requirements.  It is not an incremental responsibility.

Next, the Ohio Department of Health says:  “It was an unfunded mandate for ODH to collect the information and make it public."
To which, I can only repeat the above, "Bull twaddle!"

Since when does a state agency get to complain about unfunded mandates from the legislature that supervises it?  (You only get to complain about unfunded mandates if a higher level of government imposes a cost on a lower level of government.)  The staff of the agency get funded every day they work there.  This is a matter of priorities.  In any event, this is a gross overstatement of the amount of effort needed for this task.

I am willing to bet that a graduate student or health care club at OSU, Case Western, or one of the other fine schools in Ohio would gladly set up and maintain a voluntary website for the Ohio hospitals.  Each hospital could enter through a password-protected portal to enter real-time data about the metrics that are of value in pursuing important quality and safety goals.  At virtually no cost.  It would take seconds, not even minutes or hours, to enter it once a month or once a quarter.  As I have noted:

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.

Come on, Ohio.  Don't step backward.

Monday, October 17, 2011

Congratulations to Peter Pronovost

Peter Pronovost has been elected to the Institute of Medicine.  Bravo!  This is so well deserved.  Here's a summary of his work from Newswise.

A professor of anesthesiology and critical care medicine and surgery at the Johns Hopkins University School of Medicine, Peter J. Pronovost directs the Armstrong Institute for Patient Safety and Quality at Hopkins and is senior vice president for patient safety and quality for Johns Hopkins Medicine, where he has transformed the way hospitals around the world think about bloodstream infections.

Peter Pronovost has brought a scientifically rigorous yet common-sense approach to eliminating medical errors and unnecessary harm, shaping the national conversation about patient safety in the process. His biggest success so far: the much-heralded, cockpit-style, five-step checklist for doctors and nurses designed to prevent central-line associated bloodstream infections (CLABSIs). The simple checklist, coupled with a program that promotes a culture of safety, has transformed the way hospitals think about bloodstream infections, which kill more than 30,000 patients a year and sicken many thousands more. Thanks to Pronovost, these infections are no longer seen as a cost of doing business. They are preventable.

Pronovost and his team have dramatically reduced ICU bloodstream infections throughout the state of Michigan and exported that success to hospitals across the nation and the world. His program is now in place in 47 states, Puerto Rico, the District of Columbia and in many countries throughout the world. As he spreads the message that CLABSIs can be virtually eliminated, he is also using these strategies to prevent other harm, such as surgical-site infections and pneumonias contracted through the use of ventilators.

In 2008, Pronovost was awarded a MacArthur Fellowship, or “genius grant,” from the John D. and Catherine T. MacArthur Foundation for exhibiting exceptional creativity and showing the promise to make important future advances based on a track record of significant accomplishment. That same year, he was also named one of Time magazine’s “100 Most Influential People.”

He is the author of the book, “Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us Change Health Care from the Inside Out,” published in 2010. He is also author of more than 200 research articles.

Wednesday, October 5, 2011

The Lean dentist

The next speaker I am hearing at the "Made Lean in America" conference is Sami Bahri, DDS, author of Follow the Learner: The Role of a Leader in Creating a Lean Culture.  The book describes how this organization, the Bahri Dental Group, transformed its work and thinking from a traditional batch-and-queue approach to one focused directly on the needs of the patient, not on the needs of the practitioners.

Sami related how his practice in Jacksonville, Florida was growing unsustainably.  His solution to complexity was to "hire more people," but he soon realized this was not the answer.  "I wanted to get rid of the problem.  I needed to find a theory.   With a theory, you can make quick decisions."  He then became aware of the Lean philosophy and the work of Jim Womack and others.  Reading a number of books, he figured out how to apply Lean manufacturing ideas to his practice.

Sami summarized that Lean was an evolution over time of our collective thinking.  We started as craftsmen; then moved to the division of labor; but then, with more complex processes, we had quality problems; then time and motion studies of people led to improvement of functions; and then we learned to follow the product to improve efficiency and improving quality.

Sami said, "I went back and started learning how Toyota did it.  How did Ohno start?  'The TPS started when I challenged the system.' "

Sami noted, "It took him five years to produce a high quality car.  It took me nine years in our practice."

His conclusion after all this time:  "The most important ingredient is people.  Are they learning every day?  If you want them to learn and sustain the system, you need your people."

Speaking of his practice, he noted, "Set-ups stand in the way of one piece flow.  We eliminated these."

Sami defining "leveling" as balancing load and capacity.  The idea was to distribute procedures, according to TAKT time, evenly throughout the schedule.

He had to define "flow" in dentistry.  This resulted in a system of one appointment to see all providers.  The end was continuous treatment, with no delay between providers (just-in-time treatment).

His goal was that the patient's stay time would be equal to the treatment time, eliminating waits, optimizing use of the patient's time but also the providers' time.

The treatment the patient receives changes during the appointment, but the patient location stays the same.  Providers move to where they are needed.  Crossing the functional barriers was key.  The hygienists, whose lives improved dramatically under this approach, ultimately said, "Please don't give me my own room.  I'll go to whichever room the patient is located."

Sami reported on patient satisfaction surveys, showing a remarkable uptick in their views about his office and his staff.

All in all, this was a marvelous presentation by a thoughtful entrepreneur applying the theories of Lean to a new setting.

John Shook on "The big lie about outsourcing"

The keynote speaker at today's "Made Lean in America" conference, is John Shook, CEO of the Lean Enterprise Institute.  He is seen here with Lesa Nichols, whom John describes as a true TPS (Toyota Production System) expert with GBMP (Greater Boston Manufacturing Partnership).  His speech is entitled "The Big Lie About Outsourcing."  I'll try to pick up main points as he talks and relay them to you.

John related two recent conversations with CEOs of two American businesses, one medium sized and one large.  The CEOs at both had outsourced parts of their manufacturing processes, but had concluded, when thinking about the current recession, that they could do better by bringing things back from overseas.  Making things where you sell them seemed to make more sense, if you could do so in accordance with Lean principles.  Indeed, says Shook, outsourcing takes us far from the concept of effective value stream management.  It is not a matter of just the lowest piece price.  But even with a low piece price, it is not always cheaper to go abroad.  The lowest labor cost is not always indicative of total value.  The rush to outsource to garner economies often meant that we lost the core capabilities of our companies.

Value stream dynamics is a way to think about this. 

The ideal supply chain is one with the effectiveness and efficiency of vertical integration, but with the flexibility of looser networks of suppliers.  But that is very difficult to accomplish, and describing it that way can be interpreted as a "a solution to copy," without understanding the real purpose of the relationships.

The key is trust among all the participants in the value stream.  Within a company, TPS/Lean does this is a very specific way.  It is both a social system and a technical system.  When a person sees a problem, s/he calls it out; the manager responds in real time; a root-cause analysis is performed; and solutions are developed and implemented.  The philosophy is, "I'm going to trust the front-line worker to initiate this."

If this is true within a company, it also has to be true between the company and its suppliers.  We should not think of the supply chain (outsourcing) as series of discrete transactions.  Instead, it should be viewed as an opportunity for deep learning.  This creates deep adaptability as things change.  Instead of optimizing discrete transaction points, we want to create an adaptive learning system.

We need to work towards the concept of total system efficiency, not just low piece costs.  How can we synchronize things through this system?  The same kind of trust needed within a company must exist across the corporate relationship, too.  This is very different from what we have seen over the last several years.

We have a great opportunity: To reconfigure value streams, both with and between companies, and make them as rational as possible.

Toasted at the Lean Conference

I'm in Springfield, MA, to attend the "Made Lean in America" conference organized by the GBMP (Greater Boston Manufacturing Partnership), a not-for-profit group whose mission is to sustain a strong and vibrant regional economy by improving the operational profitability and competitiveness of existing and emerging organizations, large and small, through training in Lean and continuous improvement principles.

This promises to be an engaging two days, and I encourage even late arrivals to head over to hear the speakers and shmooze with other Leaners.

We'll start, though, with a humorous, light touch.  GBMP's Bruce Hamilton (seen here) is famous for a short video, entitled Toast, in which he demonstrates the basic principles of Lean process improvement.  How fitting, then that the bagel toasting process at the convention center is anything but Lean!  A batch process, with poorly designed flows, leaves people waiting in line, unsure of what to do next.  Even the toaster itself is in an unstable setting, almost falling off the table!

Some of you may recall my "oatmeal chronicles," from last year's IHI Annual Forum, where the convention center in Florida likewise inadvertently provided a wonderful display of a poor service process.  Perhaps this kind of thing is intended at these kind of conferences, to offer real-time examples of how not to do things, so the attendees can think more clearly about how to do them right.