Healthcare Efficiency

In comments on and off line, I’ve been asked for examples of what excellence in healthcare service would look like.  Here, we’ll ignore the technical and focus on the service aspects of the healthcare experience.

Some years ago, I listened to a USAF general addressing his troops.  He asked how many would like a certain program extended to their families, and all hands went up.  He turned slightly to his left and said, “Sergeant, Make that happen.”   OK, a little command and control there, but it’s also and example of leadership.  Good leaders make good things happen. They create a culture of excellence and a compulsive drive to provide excellent service.  This also means empowering the troops to do so without asking permission, and to be wrong sometimes.

Example: We asked surgery patients to show up one hour prior to OR time.  Mothers complained that they sat for most of that time with a hungry, unhappy child while their family at home struggled to get off to work or school without their morning resource.  So, we changed it to 30 minutes for kids having ear tubes.  This came from listening to our customers and making it happen.  One nurse made her pre-op visit in the parking lot so mom wouldn’t have to waken a sleeping tot.  And she didn’t ask permission.

Example: I take my spouse for surgery, and the surgeon comes out to say he’s through.  What do I want?  To see her.  I want to be the first thing she sees when she opens her eyes.  Yes, against all sorts of rules and customs, but a good leader can make that happen most of the time.  And what do I want next?  Out of there.  Here, a competent anesthesiologist can make that happen by careful planning.  This is--or should be--a shared goal with the institution.  Every patient hour in the building costs money in RN time.  A more rapid discharge reduces costs and makes everyone happy.

In general: It’s a culture thing, and that’s created by leadership.  A compulsive desire to please the customer.  

But does it matter?  Does anyone in healthcare care if the patient is happy?  I suspect not, really.  We heard at the NQF meeting yesterday that hospitals don’t regard patients as customers--it’s physicians, because they generate revenue.  True, you don’t want very unhappy patients, but is it worth the extra effort to truly delight them when they’re just a passive participant?  

How does this relate to efficiency?  Most of the items that please patients also make money for the institution.  Raise your hand if you want to vomit in the recovery room.  Or stay twice as long as planned.  Or have a wound infection.  Shared goals.

Posted by Dr. Robert Burney at 08:24 PM | Permalink | Comments (2)

My cookbook lists these as small distractions, tasty tidbits.  Not exactly appetizers.  So, let me comment on comments and add a few small thoughts:

1. Quality is satisfying customer needs or desires.  There are levels of satisfaction, from merely OK to delightful.  I love to fly on Midwest airlines with someone who has never done that.  Wow!  Satisfy a need before the customer knows he has it.  The Sony Walkman is a classic example.  (Who asked for a portable tape machine?)  Apple does this regularly.  (That's why I own their stock.)

 

2. Satisfaction is the difference between what you expect and what you get.  I expect a long wait at the airport.  Especially at Dulles.  Especially with United.  So, I'm not unhappy when it happens.  I recently called a Lexus dealer at the midpoint of a long trip, because the fan wasn't working well.  He picked up the car in 20 minutes, installed a new fan on time and on budget, and washed the car.  Delightful!

 

3. Before my trip, I took the car to have the front wheels balanced.  The tire store did that, on time and on budget.  But it didn't solve the problem.  It was the rear tires that were out of balance.  They did what I asked but didn't do what I needed.  Satisfied, yes, but not delighted.  Lower expectations. 

 

4. ISO 9001:2000 requires you to determine customer needs and measure how well you're meeting those needs.  That's a new concept in healthcare.  We tend to take a paternalistic view and assume we know what the patient needs.  The IOM definition of quality talks about technical aspects of healthcare--achieving the expected result, improving the patient's health, etc.  But for most patients, that's a given.  We expect technical excellence.  Now, let's talk about starting on time, no pain post op, free parking for my wife when she comes to visit, etc.  

 

5. Communication is a key to satisfaction.  The customer must know exactly what you will deliver.  Then, they will be happy when you do so.  I have been amazed at how long patients will wait for ambulatory surgery if you keep them informed of the progress in the OR.  (We set kitchen timers for reminders.) Remember, communication goes both ways.  We recently had an unhappy patient who arrived from overseas for a consultation but didn't know where to go.  Our office had sent a message but failed to confirm that she received it. 

 

6. To truly delight a customer, you've got to give him something he didn't expect.  Last year, I ordered a computer from Apple.  They promised delivery in 7 to 10 days, and it arrived on day 11.  Not a big deal, but i mentioned it on their post-delivery survey.  Someone called!  A live human who spoke English.  Turns out, the delay was with FEDEX.  "But they work for us, and we take responsibilty for their performance."  She sent me a credit on my next purchase.  Marvelous!  I didn't expect a survey.  Didn't expect a call.  And didn't expect a credit.  Nice to see them accept responsibility for their suppliers. 

 

7. In a dying gasp, the Republican administration is calling for "Value-Driven healthcare purchasing.  By this, they mean electronic health records, reporting on performance, transarency of pricing, and incentives for quality care.  No new ideas, and no money behind it.  Fluff.

 

More on any of this, if there's interest. 

 

Posted by Dr. Robert Burney at 09:26 PM | Permalink | Comments (1)

Various states are adopting various plans to provide health insurance for the uninsured.  Results are variable, as are mechanisms to pay for this.  No one coordinated these experiments, so it will be tough to compare results.  But there are things to be learned.  First, of course, no one stopped to think that we are already paying for healthcare for the uninsured.  At least three mechanisms:
    1. Higher health insurance premiums.  From 5 to 15% of your health insurance premium goes to pay an extra fee to providers to compensate for care to the uninsured.
    2. Tax relief.  Hospitals are typically tax exempt institutions.  They are supposed to use the money that would have gone for taxes to support care for the uninsured.
    3. Gifts.  Some people actually give money (or time) to hospitals.  Never to General Motors or Microsoft, but you can do this for the hospital of your choice and write it off your taxes.  I don’t see any volunteers at my favorite local restaurant, but there they are at the hospital.
Problem is, life doesn’t work this way, and these mechanisms are ineffective.  Have you seen a sign, “Free care for the uninsured?”  Statistically, the uninsured under-utilize healthcare. So, we end up pouring more money into a healthcare system that is already the most expensive in the world.  That’s not efficiency.

There are, however, some interesting consequences of coattail add-ons to these state initiatives.  One global effect is that we can see them, because we’re measuring and paying attention.  A report from the Commonwealth Fund reviews some of these.  
Per capita spending on healthcare does not correlate well with mortality.   It shouldn’t, really, but it’s nice to have a number.  Mortality is more related to good genes, personal choices, clean air, and clean water.  But somehow, we can’t put this myth to rest.
Spending more doesn’t get better quality.  No reason that it should, but now we have numbers.  Philip Crosby wrote “Quality is Free” (www.philipcrosby.com) in 1980.  His point was that it is the lack of quality that costs money (waste, rework, inspections), and that is still true today--even in healthcare.  Medicare recently decided to stop paying for some forms of waste and rework.  It will be interesting to see if quality improves.

One sentence in the Commonwealth Fund article gives hope:  “Improving insurance coverage is likely to improve access to care, but the issue of cost will require specific policy strategies.”  In other words, throwing more money at the system will do nothing to reduce cost.  If you want to reduce cost, you have to do something to reduce cost.  Anointing a “Quality and Cost Council” (MA) is not the answer.  Some programs use demand management to reduce the amount of healthcare.  IA used primary care case management to reduce Medicaid spending by 3.8%.  Following protocols for childhood asthma can reduce hospitalizations.  But these do nothing for the unit cost of healthcare services.  And that’s where the real potential lies--improving the efficiency of individual healthcare services. 

Posted by Dr. Robert Burney at 09:17 PM | Permalink | Comments (0)

Matt makes a good point, and I don't think we disagree as much as it might seem.  No, you don't want to get rid of an employee.  Why? Well, it costs money to hire employees.  You have an investment in that person that wil be lost.  Training, experience, all gone.  Besides, she will be unhappy.  And she has friends who will soon know what a terrible institution you are, because you fired her.  Her friends at work will not trust you.  They fear they may be next.  Also, if you eliminate a job, that means you have failed as a CEO to find enough business to keep your employees busy.  All that aside, however, there are situations where you just have too many employees.  So you get rid of the person and the job. 

I don't know what the situation is in that hospital.  Frankly, I'd move at least one of those admission clerks upstairs to replace the volunteer who doesn't work on Tuesdays.  

Lean concepts were developed for manufacturing (Toyota Production System), and the thinking must be adjusted some for service industries--particularly for healthcare.  (Is there another industry where the customer who receives the service doesn't pay the bill?) The basic theme is to eliminate waste, but the trick is defining and recognizing waste.  It's easy to see excess inventory as waste, but what about excess capacity?  What about the ER that is fully staffed but not busy?  And the OR that hasn't started surgery yet, because they're waiting for a lab report?  Or and H&P?  Or a surgeon?  If waiting work is waste in the factory, what is the paused patient in a hospital?  Not quite the same.  There's little money invested in the waiting patient.  Some, but it's not like making a motor and not having a car to put it into.  For healthcare services, a more relevant metric may be the time it takes to do the work.  Or maybe the variance in the times required for a hundred such patients.  If you did it in 20 minutes yesterday, why did it take an hour today?  That's waste.  The goal for an efficient healthcare production system should be to minimize variation in the performance of common tasks. 

 

Iraq has usurped the political thought in  Washington.  Nothing is happening.  Confirmations, SCHIP, universal coverage, budget, . . . all deferred for posturing politicians.  Looks like SCHIP and universal coverage will be hard to deny, but the configurations are not certain.  No one is looking at improving efficiency as a means of paying for expanded coverage.  Price competition is too threatening to the status quo.

 

The Medical Group Management Assn  has decided that if Medicare reduces reimbursements, they will reduce access for seniors and reduce staff in their offices.  What would happen if office A did this and office B found ways to see patients at the reduced rate and still make money.  Which company would you buy stock in?  Which one will still be in business in five years?  However, in a non-competitive system, it's more productive to whine and threaten.

 

 

Posted by Dr. Robert Burney at 08:27 PM | Permalink | Comments (1)

You don’t often get a second chance in life.  The hospital that inspired my previous posting, “My Operation,” (see June 2006) got one last week when my wife went there for surgery.  Guess what!  Nothing has changed.  Her experience does provide some insight on where the opportunities for efficiency exist in healthcare:  They called the week before for a phone interview.  On surgery day, we took a number at the admissions desk to see a woman 10 feet away and repeat the same information they already had.  In short, the admissions process added no value and could be cancelled without ill effect.  Savings:  salaries of two people, 45 min of patient time, and some space in the lobby.
We were sent to “Two West.”  As we exited the elevator, a woman sitting under a sign saying “Two East” assured us we needed to see her, in spite of the sign.  Unless she wasn’t there, in which case, we would indeed have to search for Two West.  Turns out 2W is a hallway, and no one’s there.   OK, not inefficient.  Just comical, but it doesn’t inspire confidence.  

After 40 minutes, a nurse repeated the same interview we just had downstairs and the week before.  Slow learners.  

Surgeon visit.  Excellent communication.  A+.  Anesthesiologist visit:  two expressed goals (ours)  Keep her warm, and rapid awakening in recovery.  Since the patient survived, the anesthesiologist must get a passing grade.  But just barely.  D-.  She did stay warm, but only partial credit here, because of the method used--a Behr Hugger, an expensive option whose use indicates a lack of attention to other details that are free/cheap and just as effective.  For example, keep the patient warm rather than try to add heat.  For surgery on the arm, why can’t you wear pants into the OR?  And a hat.  And wool socks.
I guess we failed to specify what “rapid” meant, but 90 minutes in acute recovery is beyond anybody’s definition of “rapid.”  Then, it took another 90 minutes before she was able to sit up long enough to be wheeled to the car.  A little over 3 hours for recovery.

The entire recovery process took twice as long as it should have--and I’m being generous.  An extra 90 minutes.  Why is that inefficient? (other than wasting my time.)  Every minute a patient is there, the hospital pays an RN to be there too.  Ninety minutes here, 90 minutes there, and pretty soon, you’re talking about real money.  If there were price competition in healthcare, this place would lose and never know why.  The anesthesiologist has no idea what time we left--he went home before we did.

Is this really his problem?  A personal study of several thousand ambulatory surgery patients showed that recovery time had no relationship with the duration of surgery (shotgun data) but did correlate with particular anesthesiologists.  There were surgical factors for a few outliers, but the key factor was anesthesia.  So yes, it’s possible to do it well.  But you have to have a goal and a plan for reaching the goal.  

As you read about value stream mapping, any step that doesn’t add value is waste.  (admissions)  Any time the patient waits for more than X minutes is waste.  (X = 10)  Why did we come 3 hours before surgery?  I know it’s possible to get a patient from street clothes into the OR in less than 60 min.  Take a lesson.  Less time = less money spent on waste = greater efficiency.

Posted by Dr. Robert Burney at 09:42 PM | Permalink | Comments (2)

Most people regard “earmarks” as Congressional graft and corruption.  Those sometimes  large suitcases of money that Congressman bring home to their constituents.  Putting that aside, the list of egregious legislation begins with farm subsidies.  But second on that list has got to be Medicare Advantage.  In recent history, Medicare paid so poorly that health insurance companies couldn’t make any money selling substitute Medicare programs.  So, Congress sweetened the pot.  But now, the honey pot is being threatened.

Remember SCHIP?  The debate is heating up as the deadline approaches.  Such an appealing program--money to buy healthcare for kids who otherwise wouldn’t get it.   How could anyone be against such a program? And admit it in public?  The big question (as always) is how to pay for it, and one proposal is to take money away from Medicare Advantage.  This would, in effect, take money out of private insurance (Medicare Advantage) and put it into a tax supported program (SCHIP).  The loser, of course, would be the health insurance industry.  

Only a Washington lobbyist could write a letter to the Washington Post (Sunday) opposing current legislation for SCHIP and supporting continued funding for Medicare Advantage.  So, how do you oppose motherhood and support subsidies for private industry?  Karen Ignagni framed it as “pitting children against seniors,” and it makes interesting reading.

In fairness, current legislation on SCHIP seeks to expand the program, and many feel the bills go too far.  Current proposals would probably result in a shift of some children out of paid private insurance plans into tax supported SCHIP plans.  It all depends on where you draw the income eligibility line, and how much of a shift you can tolerate.

Always  interesting but never surprising to see what politicians here will do, in Congress and in mens’ rooms.  Promote popular causes by incomprehensible means--like closing Guantanamo Bay by sending prisoners to Albania.  Albania?  Keeps you on your toes.

Posted by Dr. Robert Burney at 09:17 PM | Permalink | Comments (0)