Better can be cheaper
A book mentioned before, “The Pittsburgh Way to Efficient Healthcare,” makes several good points about roadblocks to improvement efforts. One phrase that we hear about every initiative is “the importance of leadership.” You would think that demonstration of a better way of doing something would be enough to convince the world to jump on board. However, life just doesn’t work that way. Machiavelli wrote, there is nothing “more uncertain of success, or more dangerous to manage than the establishment of a new order.” Those who bring change “make enemies of those who derived advantages from the old” and find lukewarm support from new converts who fear adversaries and doubt new things not proven by experience. Strong leadership is required to overcome these barriers, and the effort must be repeated frequently.
This principle is demonstrated repeatedly in Grunden’s book. Improvements can be made in one location, but a systematic improvement throughout a hospital or healthcare system requires leadership.
PRHI, the subject of the book, grew from a group of Pittsburgh business leaders who approached the local healthcare sector as a business. The basic premise was that patient safety and quality of care would restore the fiscal health of the local healthcare industry. For most healthcare workers, this is not intuitive. Improvements cost money and take time. No one has a surplus of either. Juran once addressed this by having a line item added to his company’s budget for the cost of poor quality. All the rework, rejects, and warranty work came here, and the total was greater than the company’s profit. The corresponding items in healthcare might be time spent looking for something that’s supposed to be on that shelf, or trips out of the OR for something the surgeon needs that isn’t there. Waste. Re-taking an xray because you can’t find the one that was taken yesterday.
The PRHI effort is based on the Toyota Production System (TPS), and one key tenet is use of pull rather than push in processes. That means you don’t send work to the next step until that step asks for it. The example in the book is a pharmacy that pushed IV medication bags to nursing units, only to find that many were not needed by the time they arrived and came back to the pharmacy. Waste. In my surgery center days, we pushed patients into the pre-op waiting area as soon as they arrived. Patients then sat in their favorite hospital attire and waited for the OR to be ready. Granted, most times were short, but not all. The variation was huge, and some patients stayed there for hours. We could prepare patients comfortable in 30 to 40 minutes, and could have waited for the “pull” signal from the OR. Patients would have been more comfortable in the general waiting area, and we could have reduced staffing in our expensive pre-op area. Where was Toyota when I needed them?
Most of the book is examples and case studies of improvement projects. Some are trivial--turning down water pressure to keep splashes from setting off the GFI switch. Others are monumental--zero central line infections in the ICU. But all are based on application of TPS principles to healthcare. Sometimes the $$ savings are documented, but for others, you have to read between the lines. Time savings are quoted in reductions in stay or time to complete a task. These are not always translated into $$. However, when you save 10% of the time to complete a nursing task, you just created a new nurse FTE for every 10 nurses performing that task.
You come away from this book thinking, “So, why doesn’t everyone do this?” The answer is part Machiavelli but mostly leadership. Someone once remarked that “the problem with healthcare is that there is no one in charge.” By that he meant that there is no one who’s job or bonus depends on running that process as efficiently as possible.
This principle is demonstrated repeatedly in Grunden’s book. Improvements can be made in one location, but a systematic improvement throughout a hospital or healthcare system requires leadership.
PRHI, the subject of the book, grew from a group of Pittsburgh business leaders who approached the local healthcare sector as a business. The basic premise was that patient safety and quality of care would restore the fiscal health of the local healthcare industry. For most healthcare workers, this is not intuitive. Improvements cost money and take time. No one has a surplus of either. Juran once addressed this by having a line item added to his company’s budget for the cost of poor quality. All the rework, rejects, and warranty work came here, and the total was greater than the company’s profit. The corresponding items in healthcare might be time spent looking for something that’s supposed to be on that shelf, or trips out of the OR for something the surgeon needs that isn’t there. Waste. Re-taking an xray because you can’t find the one that was taken yesterday.
The PRHI effort is based on the Toyota Production System (TPS), and one key tenet is use of pull rather than push in processes. That means you don’t send work to the next step until that step asks for it. The example in the book is a pharmacy that pushed IV medication bags to nursing units, only to find that many were not needed by the time they arrived and came back to the pharmacy. Waste. In my surgery center days, we pushed patients into the pre-op waiting area as soon as they arrived. Patients then sat in their favorite hospital attire and waited for the OR to be ready. Granted, most times were short, but not all. The variation was huge, and some patients stayed there for hours. We could prepare patients comfortable in 30 to 40 minutes, and could have waited for the “pull” signal from the OR. Patients would have been more comfortable in the general waiting area, and we could have reduced staffing in our expensive pre-op area. Where was Toyota when I needed them?
Most of the book is examples and case studies of improvement projects. Some are trivial--turning down water pressure to keep splashes from setting off the GFI switch. Others are monumental--zero central line infections in the ICU. But all are based on application of TPS principles to healthcare. Sometimes the $$ savings are documented, but for others, you have to read between the lines. Time savings are quoted in reductions in stay or time to complete a task. These are not always translated into $$. However, when you save 10% of the time to complete a nursing task, you just created a new nurse FTE for every 10 nurses performing that task.
You come away from this book thinking, “So, why doesn’t everyone do this?” The answer is part Machiavelli but mostly leadership. Someone once remarked that “the problem with healthcare is that there is no one in charge.” By that he meant that there is no one who’s job or bonus depends on running that process as efficiently as possible.
