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.

Kudos to Glen Cove Hospital

The folks at Glen Cove Hospital are on a roll. Last October, they were listed by the New York State Department of Health as having the lowest central-line associated blood stream infection rate in medical-surgical intensive care units among 113 non-major teaching hospitals in the state. At the time, they had gone over two years without an infection of this sort.

A few week ago, I met Maureen White, RN, from North Shore-LIJ Health System, who told me that the record was now over 2.5 years. This morning, I confirmed that with Jeanine Woltmann, RN, in the Infection Control department.

As of April 30, Glen Cove had gone 1223 ICU patient-days without a central line infection. An outstanding accomplishment by any measure.

How did they do it? Was it some government regulation? Was it incentive payments from the insurance companies or Medicare?

No. They did it because they wanted to do it. Here's the magic solution:

"The superior results at Glen Cove are the result of a collaborative effort between nursing, infection control and physician staff," said Brian Pinard, MD, chief of surgery. "These clinicians have consistently put their motivation and caring into action to reduce the risk of infection while caring for patients."

The culture of patient safety in hospitals has changed dramatically in the last several years, according to Dr. Pinard. He explained that, prior to 2005, there was a common misconception in healthcare that some hospital infections were unavoidable and beyond anyone's control. He said the path to the perfect record began with the hospital's embracing the Institute for Healthcare Improvement's 100,000 Lives Campaign and its emphasis on preventing medical errors and infections.

The hospital's initiatives included communication through daily inter-professional rounds, education, and monitoring of various programs, among them hand hygiene, sterile practices and the use of universal safety protocols. This led to excellent outcomes, improved patient safety, decreased length of stay, a decrease in mortality and cost avoidance, according to Dr. Pinard.

In other words, the people at Glen Cove Hospital do not accept or believe the premise that "these things happen." I again repeat the wise words of Ethel Merman, and also present the original scene from It's a Mad, Mad, Mad, Mad World:

Now what kind of an attitude is that, 'these things happen?' They only happen because this whole country is just full of people who, when these things happen, they just say 'these things happen,' and that's why they happen! We gotta have control of what happens to us.



If you cannot see the video, click here.

U of M: How're they doing? Your call.

The University of Michigan Health System has done exemplary work in improving the quality and safety of patient care. Perhaps the most visible success, as part of a statewide effort, was to eliminate central line infections in ICUs for extended periods of time. But UofM has a broad-based program beyond this, which gets support from the senior leadership and participation throughout the organization.

The system is also very open about its clinical outcomes and the status of its process improvement. As noted on this website:

This site shows where we're doing great and where we can perform even better. The site also offers information about quality care, quality measures, and what quality really means to the most important people in our community: you - our patients and families. While quality reports from other sites may be a year old or more, the reports on our website show the most up-to-date measures of quality and safety at the University of Michigan Health System.

People are then invited to explore more deeply. I recently did, but rather than offering my opinions about the site, I thought I would ask you to take a few moments to click through it and offer your views here. Knowing the folks at this system, I am sure they would like to have the benefit of your suggestions and ideas about the content and design of their presentation.

Breathing more easily

Do you remember this post from 2009, where I praised Children's Hospital Boston for an asthma intervention program that provided advice and assistance to families? The summary:

Using a combination of interventions (e.g., counseling about drug dosages, HEPA filters for vacuum cleaners, rodent control measures), they dramatically reduced the number of asthmatic incidents for the children in several of Boston's neighborhoods. A subsidiary benefit was a huge reduction in the number of emergency room visits.

Well, now comes the business issue, summarized in an excellent article by Cheryl Clark at HealthLeaders Media.

It costs about $2,600 per child, but avoids $3,900 in hospitalization costs over a two-year period, hospital officials say. Elizabeth Woods, MD, who directs the hospital's initiative, says cost analyses point to a 1.46 return on investment. The hospital has papers in press that illuminate its progress.

So, where's the problem?

"That's a saving to society, not to the hospital," Woods says.

So here's a great program, but one whose success could hurt the hospital's bottom line, one that costs money and reduces business.

This, of course, is the argument for bundled payments for chronic illnesses and/or capitated payments for all medical service. In this article, Atul Gawande leaps to that conclusion. And there is something to be said for that.

But the short term business analysis sometimes fails to account for all of the items that inure to the benefit of a hospital for doing "the right thing."

Here's a sample of that broader view, the reduction in ventilator associated pneumonia and other hospital acquired infections in a hospital's intensive care units. As above, the direct result was a reduction in costs to insurance companies, Medicare, and Medicaid, and a commensurate reduction in revenues to the hospital. But, and this is a big but:

On the business front, it has contributed to a reduction in length of stay in our ICUs. We were able to avoid the multi-million dollar capital cost of expanding our ICU capacity. Indeed, we were able to create capacity out of the existing facilities and improve throughput.

Hospitals today often face limitations on their ability to raise capital. Avoiding a new fixed expense like that, while effectively creating capacity, can make business sense even if some short-term revenues are lost.

Also, some hospital costs are variable, not fixed. Some of that $3900 saved at Children's Hospital, for example, is certain to be related to supplies that will no longer need to be purchased. Likewise, some portion of nursing and respiratory therapy resources can either be reassigned to other cases, or if the trend is long-lasting, simply avoided by having fewer staff people over time.

And, of course, as noted by the CHB official, "Some of the losses might be made up by not providing worthless or futile care."

So, before we make the leap to a new payment regime, let's be a bit more complete in our analysis.

HHS recognizes top performers

Speaking of best practices, check out this announcement from the US Department of Health and Human Services.

The U.S. Department of Health and Human Services today recognized 37 hospital and healthcare facilities for their efforts to prevent – and eventually eliminate – healthcare-associated infections (HAIs), a leading cause of death in the United States.

HAIs are infections that are acquired while patients are receiving medical treatment for other conditions. At any given time, about 1 in every 20 patients has an infection related to their hospital care. These infections cost the U.S. healthcare system billions of dollars each year and lead to the loss of tens of thousands of lives. In addition, healthcare-associated infections can have devastating emotional, financial and medical consequences.

“People enter a hospital expecting to get healthier, not sicker,” said Assistant Secretary for Health, Howard K. Koh, MD, MPH. “We applaud hospitals for their efforts in improving the quality and safety of healthcare for all Americans.”

The organizations are the first to be honored as part of a new national awards program to highlight successful and sustained efforts to prevent healthcare-associated infections, specifically infections in critical care settings. This initial set of awards recognizes critical care professionals and healthcare institutions for their efforts to reduce, and eventually eliminate, ventilator-associated pneumonia and bloodstream infections associated with central intravenous lines.

HHS partnered with the Critical Care Societies Collaborative (CCSC) to develop the awards program. CCSC is a multidisciplinary organization that promotes the exchange of ideas about critical care practice and ICU patient care among leaders from medicine, nursing, pharmacy and respiratory therapy.

Ten recipients were recognized today during the American Association of Critical-Care Nurses’ (AACN) National Teaching Institute & Critical Care Exposition in Chicago. The remaining 27 recipients will be recognized throughout the year at the conferences of CCSC member societies.

Awards were conferred on two levels, according to specific criteria tied to national standards. The “Outstanding Leadership Award” went to teams and organizations that sustained success in reaching their targets for 25 months or more. The “Sustained Improvement Award” recognizes teams that demonstrated consistent and sustained progress over an 18- to 24-month period.

Initial award recipients are:

Achievements in Eliminating Ventilator-Associated Pneumonia and Central Line-Associated Bloodstream Infections
Outstanding Leadership Award

• St. Joseph Mercy Hospital, Ann Arbor, Mich.
• Mercy Hospital ICU, St. Paul, Minn.
• North Shore-LIJ Health System, New York, N.Y.
• Riverside Methodist Hospital, Columbus, Ohio

Sustained Improvement Award

• Beth Israel Deaconess Medical Center, Boston, Mass.
• Detroit Medical Center, Detroit, Mich.
• Lakeland HealthCare, St. Joseph, Mich.
• Norman Regional Health System, Norman, Okla.
• Salem Health Critical Care Services, Salem, Ore.
• Baptist Memorial Hospital-Memphis, Memphis, Tenn.

Achievements in Eliminating Central Line-Associated Bloodstream Infections
Outstanding Leadership Award

• Yale-New Haven Children’s Hospital Newborn Special Care Unit, New Haven, Conn.
• HealthPark Medical Center Open Heart ICU, Ft. Myers, Fla.
• University of Michigan Hospitals & Health Centers Critical Care Medicine Unit, Ann Arbor, Mich.
• Children’s Hospital & Clinics of Minnesota, Minneapolis, Minn.
• Stony Brook University Medical Center, East Setauket, N.Y.
• Rome Memorial Hospital, Rome, N.Y.
• Lehigh Valley Health Network, Allentown, Penn.
• Cook Children’s Medical Center, Fort Worth, Texas

Sustained Improvement Award

• Children’s National Medical Center, Washington, D.C.
• Howard County General Hospital, Baltimore, Md.
• Rochester General Hospital, Rochester, N.Y.
• Akron Children’s Hospital NICU, Akron, Ohio
• Cleveland Clinic Cardiovascular ICU, Cleveland, Ohio
• Medina Hospital ICU, Medina, Ohio

Achievements in Eliminating Ventilator-Associated Pneumonia
Outstanding Leadership Award

• Seton Medical Center, Daly City, Calif.
• University Hospital, Augusta, Ga.
• St. Catherine of Siena Medical Center, New York, N.Y.
• Johnson City Medical Center, Johnson City, Tenn.
• Baylor University Medical Center Truett ICU, Dallas, Texas
• St. Luke’s Episcopal Hospital, Houston, Texas

Sustained Improvement Award

• St. Joseph Hospital Orange, Orange, Calif.
• Huntington Memorial Hospital, Pasadena, Calif.
• Palmdale Regional Medical Center, Palmdale, Calif.
• Saint Anne’s Hospital, Fall River, Mass.
• Carolinas Medical Center NeuroSurgical ICU, Charlotte, N.C.
• Highland Hospital ICU, Rochester, N.Y.
• Providence St. Mary Medical Center, Walla Walla, Wash.

“These awards strive to motivate clinicians, hospital executives, and facilities to improve clinical practice so the healthcare community can not only reduce, but eventually eliminate healthcare-associated infections,” says Justine Medina, RN, MS, AACN director of professional practice and programs. “The awards recognize teams of critical care professionals whose notable achievements lead the way toward achieving this goal.”Last month, HHS launched the Partnership for Patients, a new national partnership with hospitals, medical groups, consumer groups and employers that will help save lives by preventing millions of injuries and complications in patient care over the next three years. HHS has set a goal of decreasing preventable hospital-acquired conditions by 40 percent (compared with 2010 rates) by the end of 2013. Achieving this goal should result in approximately 1.8 million fewer injuries and illnesses to patients, with more than 60,000 lives saved over the next three years. The Partnership for Patients has the potential to save up to $35 billion across the healthcare system, including up to $10 billion in Medicare savings over the next three years.

For additional information, see the HHS Action Plan to Prevent Healthcare-Associated Infections and the Partnership for Patients.