Healthcare Efficiency tag:www4.asq.org,2008:/blogs/healthcare//3 2008-07-17T04:03:08Z Movable Type 3.2 They're everywhere tag:www4.asq.org,2008:/blogs/healthcare//3.551 2008-07-17T03:56:21Z 2008-07-17T04:03:08Z Dr. Robert Burney Calls for greater efficiency appear constantly.   One proposed solution to the oil crisis is greater efficiency in our automobiles.  General Motors is in danger of bankruptcy, because they didn’t see this in the tea leaves.  Mpg figures are quoted in every new car ad now.  My wife set a personal record last week in our Honda Insight of 85 mpg.  Power companies are scavenging heat out of their exhaust gases to make ~ 30% more electricity with no increase in the fuel consumed.  Productivity of American workers soared almost 10% while wages edges up less than 3%, meaning greater efficiency for goods and services from American factories. 

Like I said, everywhere.  But then, there’s healthcare.  Congress this week declined to reduce Medicare payments to physicians with no thought of asking for better efficiency in the provision of services.  The focus of those who talk about improving healthcare has been first on expanding insurance coverage and second on reducing the demand for services.  This latter effort should eventually improve the macro-efficiency for a given population, but savings are theoretical and well into the future.  On the other hand, improvements in the processes of delivery promise near term returns. 

How to do this?  A new book at ASQ offers some clues.  Here’s a list of key points from the book jacket (with healthcare translations for those who need it:


1. Increase sales by increasing market share.  This brings up the question of whether healthcare is an elastic market or a zero-sum game.  Those paying for care hope the market is finite, but  experience suggests that the volume expands to fit the capacity of the system.  


2. Reduce expenses (labor and non-labor) per sales dollar.  Why do I have to talk to someone to schedule an appointment with my doctor?  I schedule airplane seats, rental cars, and hotel rooms on the internet without human intervention.  Opportunity knocks.


3. Reduce lead times to reduce work-in-process inventory investment.  This draws on concepts from the Toyota Production System and is a difficult concept for many in healthcare.  Example:  Two weeks ago, I checked in to a university healthcare clinic and was directed to a waiting room on the 4th floor.  Upon arrival, I became a “work-in-process.”  Waste, by definition.  Wasting my time and their money (for the chair and waiting room space.)  By contrast, I rarely sit when visiting my dentist.  I arrive on time, and he is ready.

 
4. Reduce setup costs to minimize product and component inventory investment.  To grasp this, think of the operating room.  Go thru the process of setting up for a hernia repair.  How much time is involved?  Ever miss something?  Now suppose that every surgeon used the same instruments and supplies and all these were packaged in one or two sterile packs from an outside vendor.  Standardize and minimize.


5. Maximize capital asset utilization.  Vail, Colorado is a ski resort, right?  Go there in the summer sometime.  So, what happens to your clinic building in the evening or week ends?  I worked in a hospital once that sold bread to the community and take-home meals to employees, thus utilizing their large kitchen for added revenue.  We once rented part of the pediatric ward in a hospital to house day surgery patients who couldn’t go home.  The marginal cost was less than a hotel room.


6. Minimize investment for invoice payment.  Hospital billing in particular is a nightmare.  Irrational, idiotic, inconsistent, unfair, etc., etc., etc.  But it doesn’t have to be.  Change it.  Doctors offices do better.  This area is a key driver of the move to transparency.


7. Maximize knowledge worker utilization by empowering them with financial and practical training related to the above.  Flatten the org chart and empower front line workers to make decisions.  Love them when they’re wrong.  If they don’t make mistakes, they’re not trying hard enough.  Read “Lincoln on Leadership.” 
This book, of course, is not about healthcare.  But if other industries can improve their processes, it’s possible that healthcare could do likewise.  Then, maybe we could all afford to get sick.

]]> Dilemma tag:www4.asq.org,2008:/blogs/healthcare//3.546 2008-06-29T20:57:53Z 2008-06-29T22:37:18Z Dr. Robert Burney Senate Finance Committee on economic aspects of healthcare reform.  He saluted the scientific and social aspects of healthcare but cautioned that it is an economic issue as well, “. . . will affect many aspects of our economy.”  Currently, healthcare represents about 15% of our economy and has been growing at 2.5% faster than the GDP.  (After last week, healthcare may be the only sector of the economy that’s growing at all!)  Interestingly, as the economy sinks, this percentage will rise, as healthcare spending is sticky downward and not really related to the overall GDP.  He cites three challenges for healthcare reform:
1. Access, meaning covering the uninsured.
2. Quality, meaning conformance to academic norms.
3. Cost. And here, he acknowledges the dilemma:  covering the uninsured and/or improving conformance will dramatically increase cost.  
For an economist, his presentation was meager on facts and figures or concrete proposals.  He gives a brief overview of the salient issues in healthcare reform without contributing any new ideas.  He first decries the rising costs, then asserts that the benefits have exceeded the economic cost.  Sounds like a politician.

This, in contrast to presentations by Peter Orzag of the Congressional Budget Office who identifies rising healthcare costs as “the nation’s central fiscal challenge” and seems more ready to challenge the benefits of spending more money on healthcare. (See his presentation of 16 June to the same committee.)
(www.cbo.gov)  As have many others, Orzag cites the geographic variation in costs and benefits of healthcare as evidence of an opportunity “to reduce healthcare costs without adversely affecting outcomes.”  Putting numbers to his words, Orzag cites estimates that in a perfect world, 30% of healthcare costs could be saved from this source alone.  He does not, however, mention the 20 to 50% savings that might be achieved by improving the efficiency of individual healthcare services.  He also notes that “restraining the growth of healthcare costs” would increase the number of people who can afford it.
  In other words, reducing the costs of healthcare services would reduce the cost of health insurance and thus make it available to a larger audience without added subsidies.

Orzag shows again (his figure 1) that our aging population will not drive healthcare costs--more expensive services will do that.  Indeed, the cost of individual healthcare services seems to be the sweet spot for controlling costs.  

Unfortunately, neither of these economists offers any plan or incentive for reducing costs. 
]]> The Next Round tag:www4.asq.org,2008:/blogs/healthcare//3.545 2008-06-27T01:30:02Z 2008-06-29T17:00:48Z Dr. Robert Burney RxNT or iScribe, you can send an electronic Rx for any patient to almost any pharmacy.  There are efficiency gains at almost every point in the process, but this is not likely to lower the cost of drugs any time soon.  The primary gains are in safety and time.  Time savings pay for the cost of the system, but there’s not a lot left over.

What about records?  The feds have been pushing electronic healthcare records for several years with the caveat of “interoperability.”  Penetration, however, has not been nearly as successful as e-prescribing.  One of the difficulties is “interoperability.”  This term means that entries in your doctor’s computer would be readable (and understandable) from another computer at another site.  This might be useful if you visit another doctor and need records, but not many people want the feds snooping thru their healthcare records.  Next thing you know they’ll want to listen to your phone calls or monitor your library card.  1984 revisited.  Gains from interoperability seem mostly theoretical or a little far-fetched, and the sacrifices in privacy are huge.  The other problem is money.  A recent study from the NEJM noted few physicians using EHRs in their offices.  (Costs $$ to see this, so no link.)  The docs have their hands out for subsidies, and HHS has responded with $150 million for starters.  Those who have them seem to like them, but the business case is missing--or at least not perceived.  Given the lack of an intrinsic financial reward, it’s not clear why we taxpayers should subsidize something that doesn’t make clear business sense.  There are, of course inexpensive alternatives for small offices.  And those who know and love the VA system can get VistA from www.medsphere.com

From the patient’s perspective, there are Personal Healthcare Records.  Everything about you in a document that you control.  I keep mine on my .mac account.  One weakness of the PHA is that it only contains what the patient enters, but maybe that’s OK.  

But what exactly do we mean by “technology?”  The above comments concern information technology.  Another aspect is the weird and wonderful.  Sophisticated, hi tech approaches that don’t involve IT.  Robotic surgery, invasive cardiology, ECHMO, lasers, laparoscopic surgery.  Technology, in general, is the chief driver of increasing healthcare costs, so these tools don’t always follow the better-faster-cheaper mantra.  Some do.  Laparoscopic cholecystectomy is a shining example.  Inguinal hernia repair by laparoscope is not.  Why do we pay for technology that is more expensive than the way we’ve been doing it for years?  If the result it “better,” show me the money.  Who would say no?

]]> Magic Bullets tag:www4.asq.org,2008:/blogs/healthcare//3.542 2008-06-19T03:44:31Z 2008-06-19T04:03:30Z Dr. Robert Burney Leapfrog group survey of P4P programs disclosed that the primary motivation was “improving quality and reducing variation.”  The first rule of quality is consistency, so reducing variation is definitely a virtue.  The term is not well defined, however, so we’re left guessing what varies less.  If a process sometimes takes 5 minutes and sometimes 5 hours, it’s hard to make it better.  Results are all over the map.  On the other hand, if it takes 2 hours, plus or minus 3 minutes, you can work to make that 1 hour because he basic process is under control.  
Quality, on the other hand, is a vague concept.  As noted previously, quality  is defined by the customer.  In the case of P4P, the payor defines quality, and the parameters are not what the average patient would specify.  For example, most P4P criteria look to national standards such as HEDIS or the NQF.  These generally reflect what academics think  is “good” for the patient.  And usually, they’re right.  It’s just that patients don’t think that way.  Patients assume the technical aspects of healthcare are ensured by the hospital, accrediting or licensing organizations, etc.  If aspirin is “good” for patients with chest pain, then, of course every ER would give every patient with chest pain an aspirin. The ER patient defines quality as a wait time of less than 30 minutes.  (Yes, it is possible.)  Or available free parking.  Or no out-of-pocket expenses.  Patients also value the cleanliness of the facility and the friendliness of the staff.  Haven’t seen these criteria in anyone’s P4P program (tho some do incorporate the CAHPS survey).  Interestingly, P4P programs don’t generally include cost, so it’s not clear that the payers benefit either.   They’re paying providers to conform to a third party’s idea of what constitutes “good” care, without regard to its economic benefit.  Doesn’t sound like this is a transforming concept.

Some P4P programs include the presence of electronic record systems--a concept that has been greatly oversold, particularly when you add “interoperable” to it.  Think about it.  Do you really want someone at CMS in Washington perusing your medical record?  Next thing you know, they’ll be listening to your cell phone calls or monitoring your library books.  Heavens!  

One problem noted with the second P is the validity of the measures, particularly with a single physician practice.  If they metric is Hgb A1c, and you only have 3 diabetic patients, it’s hard to tell if you’re doing a good job or not.  Or you might get dinged for not doing a PAP smear in a woman who’s had a hysterectomy.  In other words, data collection is problematic and expensive.  

Some try to include patient safety, but that’s also very hard to measure.  The rare “never events” are, well, rare, so they’re not reliable indicators of the safety culture.  Attempts to collect data on near misses will likely suppress their reporting and thus defeat the safety climate you’re trying to promote.  

So, at the end of the day, we have a program (P4P) that sounds as if it should improve healthcare . . . until you try to implement it and discover it’s not as easy as you thought.  Even programs that have been deemed successful haven’t reduced cost (not an aim) and haven’t reduced wait times or out-of-pocket expenses for patients.

Time to chamber another round.





]]> Competition tag:www4.asq.org,2008:/blogs/healthcare//3.538 2008-06-05T03:27:05Z 2008-06-05T03:50:44Z Dr. Robert Burney what about healthcare?  Currently, there is competition to insure patients but no competition for the patients’ business.  Third parties pay the same whether you do a good job or a poor one.  CMS is making threats about not paying for mistakes, but it’s not clear what that means, and a lurking suspicion that it will mean nothing for hospital revenue.  
True, there is P4P, but the first P is tiny, and the second P stands for conformance to rules that have never been shown to make much real difference to anyone.   So no real competition there.  
And how would you know if one hospital or provider was “better” than another?  Well, there is “hospitalCompare” and the JCAHO publishes some results of their surveys.  But it’s not clear that anyone makes purchase decisions based on such data.  It’s also not clear that the data they publish is important to anyone but themselves.  Has anyone ever asked patients what they want in a hospital or primary care provider?  Would it matter?  Patients don’t really have much choice, so why ask.  I listened to a presentation last week by some folks from Marriott Hotels.   They know EXACTLY what their customers want.  In the hotel business, it does matter.  

So, maybe we should foster more competition in healthcare.  We’d sell more shoes, and the bathrooms would be clean.   But some argue that a hospital monopoly is better for consumers.  Inova Health System is planning to acquire Prince William Hospital in Northern Virginia, giving them essentially 100% control of all the hospitals in the area.  Even Inova admits that the deal would raise prices in the area and thus increase healthcare costs to consumers and businesses.  The FTC and the VA attorney general have weighed in against the deal, but Inova claims the quality of care will improve if they control everything.  

Where is the motivation or incentive to improve if there is no competition?  There is a certain amount of corporate culture that might improve a failing institution.   Beyond that, it kind of depends on what you mean by “quality.”  I was always taught that quality was defined by the customer.   I guess the officers of Inova are the customers.  

This is not the only example.  Sentara Health Care is doing the same thing in the Norfolk/Virginia Beach area.  

At the end of the day, however, it really doesn’t matter.  Creating a monopoly can’t reduce competition that didn’t exist in the first place.  



]]> Another Voice tag:www4.asq.org,2008:/blogs/healthcare//3.537 2008-06-03T03:31:08Z 2008-06-03T03:39:20Z Dr. Robert Burney one of a series of posts about P4P, Arnold Milstein talks about waste and cites a Congressional Budget Office consensus report that estimates waste at 35% of current healthcare expenditures.  Think about that.  If you’re involved in healthcare, roughly a third of what you did today provided no added value to your patients.  This includes both what you did and how you did it.  The “what” aspect is commonly referred to as  unnecessary  care--not supported by current science, the stuff that makes headlines in the Dartmouth Atlas, the reason care in one area is more expensive than care in another area even though the results are the same.   Remember the anesthesia resident who said pre-op tests must be useful, because “we get them every day!”  Then someone looked carefully and found they were pretty much without value.
There are also errors of omission.  We have rules about hypertension, asthma, diabetes, and immunizations.  Not hard to know what to do, and it’s not hard to do it.  The hard part is making sure that it is done every time and that you act on the results.  That’s why you get the big bucks.  
The other part of the waste equation is process efficiency.  How many clerks does it take to check a patient in?  This is Toyota Production System (TPS) stuff.  Lean processes.  Just-in-time delivery.  Pull instead of push.  Potential savings run to 20% easily from this source alone.  When you add this to the “what” savings, it’s not hard to come to a total of 35%.  

So what!  Nobody’s salary depends on these kinds of savings.   Those who suffer are the low and middle income Americans who represent the uninsured and have no voice in this discussion.  Savings of 35% would easily pay for health insurance for everyone without adding any more money to the healthcare system as a whole.   So why don’t we do it?  The  reasons are complex but boil down to incentives.  Currently, no one’s paycheck is affected by the efficiency of the healthcare system they work in.  The single most effective way to change this would be price competition at the individual service level.  If you have to compete on price, you will find ways to become more efficient or you will find another occupation.  

Milstein posits three classic approaches to shrinking America’s “35% waste-line.”
1. Deny care to those who can’t afford it.
2. Tax health insurance to pay for healthcare for the rest.
3. Improve the efficiency of healthcare delivery.
One and two represent aspects of our current system and thus define the problem.  They are not solutions.  That only leaves number three.
Milstein somewhat naively suggests that motivation to improve efficiency can come from education, appeals to a “sense of responsibility,” consumer incentives, and P4P.  Some of these may help at the margins, but none is likely to drive the kind of improvement that is needed.  
We know how to do this.  The technical ability is there.  The missing pieces are the will to do it and the courage to demand that it be done.


]]> Crystal Ball tag:www4.asq.org,2008:/blogs/healthcare//3.531 2008-05-17T19:56:09Z 2008-05-17T20:09:33Z Dr. Robert Burney

“If you don’t know where you’re going, any direction will do.”  Most of the vocal forces in healthcare today seem headed in the direction of spending more money in the future.  Both Obama and Clinton advocate expanding health insurance to the currently uninsured, tho with slightly different approaches. 
The Commonwealth Fund recently published a proposal to expand Medicare and Medicaid to cover the uninsured.  In a fascinating slight of hand, they assert that the costs of their proposal would be partially offset by lower administrative costs.  Of course, they neglected to mention that the administrative costs for the uninsured are currently zero.  But this does resurrect the myth that the government can provide health insurance with a lower administrative cost than a private, for-profit insurance company.  While it’s true there are economies of scale (Medicare is huge), the government totally lacks the motivation to control costs.   Furthermore, Medicare has financial problems now, and it’s not likely they would welcome more obligations.

Nevertheless, it does seem likely that, come the revolution, we will see some proposal(s) to expand health insurance to the uninsured.  This will cost money--probably more than covering the currently insured, due partly to pent-up demand.  Any such plan will almost certainly include a mandate for everyone to play.  Can’t have the healthy invincibles opting out.  The California plan would have been an interesting model if the falling economy hadn’t sunk it prior to launch.  Everything costs money.

Speaking of which, the American public is focusing more on money these days than healthcare.  Problems paying for ______ (fill in the blank) top the list of concerns.  Not surprisingly, those with less income suffer the most.  Of those earning under $30 K per year, 63% had “serious problems paying for gas.”  Stay tuned, folks, it will get worse.  I don’t personally have that problem, but then I make more than $30 K, walk to work, don’t drive much, and my car gets 65+ miles per gallon. 

The Institute for Healthcare improvement has launched a new initiative, “Triple Aim” that includes:


  • Improve the health of the population.  This is an important and welcome focus on public health.  Too many pundits point to statistics on longevity, infant mortality, etc. as an indictment of U.S. healthcare, whereas these are really public health issues.  Improving the health of the population will decrease the demand for healthcare.  Taking one more step back, improving air and water quality will improve the health of the population.  This seems axiomatic, but many fail to make the connection.  Try getting the EPA to admit that coal fired power plants will adversely affect polar bears.  Or conversely, that reducing emissions will improve the health of those living downwind. 
  • Enhance the Healthcare Experience of Individuals.  Partly, this means improving customer service--common courtesy--by healthcare providers.  But partly other things, like efficiency of time, coordination of care, reducing errors, etc.  The interesting part is that almost all of this is free or actually pays a dividend.  You just have to want to do it.
  • Reduce the per capita cost for the population.  At last (perhaps), someone is hinting at efficiency.  In most cases, they are talking only about reducing the amount of healthcare provided to the population.  Hopefully, IHI will also address the cost of individual healthcare services.  We referenced Porter and Teisberg’s book in the last post.  Effective competition would go a long way toward achieving these IHI goals, but it would require a major restructuring of our payment system.

Mirror, Mirror on the wall
What’s that in my crystal ball?
A fuzzy picture’s all I see
Of what the healthcare plan will be.


]]> Doing it right tag:www4.asq.org,2008:/blogs/healthcare//3.530 2008-05-17T17:44:08Z 2008-05-19T03:03:23Z Dr. Robert Burney No one goes to work intending to do a poor job.  With the possible exception of work slowdowns and similar temporary political strategies, no one tries to provide inferior goods or services.  But that is sometime the result.  Why?  
Last week, I read a book, Fatal Care, which is a compilation of events you don’t want to happen in your hospital.  Looking past the human drama, there are a few recurring themes that resonate with cases we have reviewed in my system.


Busy.  Not only that, but one consequence of being busy is that we skip steps that are designed to protect us from making errors that harm patients.  Routine checks that every nurse does before administering a medication--except when she’s busy.


Carelessness.  Picking up the closest syringe rather than the one intended for your patient--a syringe someone else had put down rather than dispose of properly across the room.

 
Procedures.  No one follows the rules, because there aren’t any.  The antithesis is rules that are so ancient and arcane that no one follows them anyway.


Protocols.  An ER doc once told me, “If you complain to me of the worst headache in your life, you get a CAT scan.  Period.”  That’s a protocol.  Then you follow the procedure for ordering the CAT scan.

 
Management.  Some smart person said, “The job of management is not to make people work but to make it possible for people to work.”  I came across a very old NEJM article yesterday that concluded that interns make fewer mistakes if they don’t work 24 hour shifts.  Well, gee whiz.  


History.  We must learn from the experiences of others.  The airline industry has certainly demonstrated the benefit of sharing our mistakes and near misses so that everyone doesn’t have to make every mistake.  Some preventive actions are mostly unnecessary but cheap insurance.  (The time out before surgery comes to mind.)


You can probably add to this list, from your experience, from the literature, from Root Cause Analysis of problems in your institution.  The point here is that there is a finite list, and we should have a strategy for each category.  Checklists help.  Pilots do this.  So do anesthesiologists.  The busier you are, the more necessary the checklist becomes.
Human beings make mistakes.  We all do.  We must design our systems to prevent the inevitable human errors from reaching the patient.  FMEA.  Another example of the migration of quality control principles from industry to healthcare.

But, does it pay?  There is some question about the financial return for quality initiatives.  The current Pay for Performance initiatives are not shining examples of the value of improvement.  They tend to pay for trivia that doesn’t improve anyone’s bottom line.  On the other hand, PRHI and others have demonstrated dramatic savings from preventing central line infections.  Doing it right does pay,  depending on the definition of “right.”  Compliance with someone else’s idea of what good healthcare should be may not add value.
I recall a Baldrige Award winner (manufacturing) showing a sign they used to have in their shop, “We make it nice, ‘cause we make it twice.”  Essentially everything they did came back for re-work.  Imagine thier bottom line when they finally got it right, and rework went from 100% to less than 1%.  We don't often get a chance to do it over in heatlhcare.

Elizabeth Teisberg is quoted as saying, “better health is less expensive than poor health.”  She is a strong advocate of competition in healthcare as a means to force improved value and lower cost.  Our present system does not provide meaningful competition, and this is one of the reasons costs keep escalating but care hasn’t noticeably improved.






]]> The "C" Word tag:www4.asq.org,2008:/blogs/healthcare//3.499 2008-05-01T03:20:24Z 2008-05-01T03:31:18Z Dr. Robert Burney blog for Health Affairs, Rob Cunningham actually mentioned “cost.”  Of course, he was talking about the cost of health insurance, not healthcare, but we’re getting closer.  He was reporting on the poor earnings report from UnitedHealth Group and quoted them as saying, “business is bad because the company’s products are getting too expensive.”   And he went on to question the wisdom of “trying to buy everyone into a system that we can’t afford.”  In other words, if health insurance is too expensive, why are we planning to buy health insurance for the uninsured?  That constitutes heresy in the Health Affairs world.

A long time ago, someone said, “If ordinary people can’t afford to send their kids to college, what good is education?”  Colleges have, in fact, priced themselves out of the “ordinary” market by offering ever more expensive inducements to attract students.  In healthcare, we are seeing a similar phenomenon where we promise infinite healthcare and provide “insurance” to pay for it.  First, healthcare became too expensive for “ordinary “ people.  Now health insurance is reaching the same point.  Sooner or later, we have to bring down the cost of healthcare, and health insurance premiums will follow.  
But somehow, no one wants to use the “C” word.  Instead, we talk about “value.”  Or talk about reducing the “overuse” of healthcare.  (Translation:  Overuse means healthcare that I don’t think you ought to have.)  A few places that have discovered ways to reduce the cost of caring for some chronic condition complain about lost revenue and hold out their hands for more money.  Let me spell this out:  you discover a new way of caring for, say, diabetic patients, so they don’t need to come see you so often--thus reducing the cost of their care.  Now you have holes in your schedule to accommodate new patients or reduce the time-to-next appointment for existing patients . . . and you’re complaining?  I suppose if there is no one waiting to see you, you might reduce the size of your company, but I can’t see begging for higher fees because you’re doing a better job.        But that’s the complaint from Geisinger, among others. As Cunningham states, “cost-saving innovation is a losing proposition.”  Note, however, that the concept of “cost-saving innovation” means reducing the demand for healthcare services, not the cost of individual healthcare services.  

United’s problems may  be a manifestation of a slowing economy (that’s PC for recession), and employers may back out of health insurance expenses by various means, as suppliers wring their hands over lost revenue.  However, a few low-cost providers will emerge and may eventually dominate the market.  When I bought my first car, GM was ignoring the Japanese.  Today, Toyota is having them for lunch.  In healthcare today, retail clinics provide a limited menu of healthcare services at low cost without appointments.  The GM of healthcare is wary, but keep your eye on the lunch menu. 
]]> Better can be cheaper tag:www4.asq.org,2008:/blogs/healthcare//3.498 2008-04-29T03:27:14Z 2008-04-29T03:34:43Z Dr. Robert Burney 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. 
]]> Hearings yesterday tag:www4.asq.org,2008:/blogs/healthcare//3.494 2008-04-18T03:53:08Z 2008-04-18T04:04:37Z Dr. Robert Burney Peter Pronovost the Hopkins researcher who sparked some controversy when the HHS Office for Human Research Protection terminated his project after he had saved the state of MI $200 K per year.  (see interview:  Their reasoning was that this was “research” and he needed IRB approval.  Makes interesting reading for those fascinated with bureaucracy.  Widespread protests led OHRP to rescind their directive, but only partially.  Stay tuned.  A group from the ASQ will meet Monday with the acting director of OHRP  (ivor.pritchard@hhs.gov )

There are several types of infections to be discussed, and most are included in a new book, “The Pittsburgh way to Efficient Healthcare” by Naida Grunden.  (I bought my copy at Amazon.com.)  Naida wrote the newsletters for PRHI ( www.prh.org ) and has compiled their experience into this book.  The basic theme of PRHI was to use Toyota Production Systems to improve healthcare.  When a production line worker has a problem, they push the red button and everything stops.  A team assembles to analyze and fix the problem, not only for that worker but for the system, so no one else ever has the same problem.  Same idea was used to stamp out central line infections.  When anyone noticed an infection, phones rang, and a team assembled to analyze and strategize.  One ICU reduced their infection rate to zero.  For the year.  That not only saved lives but also saved LOTS of money.   Waxman quoted an IOM estimate that infections cost society $5 billion a year.  That’s Billion, with a ‘B.’  Seems worth doing, regardless of what OHRP says.

And that, of course,  is the justification for the subtitle of the book--efficient healthcare.  Any infection adds time and money to the hospital stay, assuming survival.  One study  concluded that the hospital would lose money on every infection, even if insurance fully reimbursed for the care.  Same care, less time, less money, that’s efficiency.

She  talks about resistance to using Toyota methods in a hospital.  “This is healthcare, and a patient is not a car.”  I’ve often wondered what it is that closes peoples’ minds.  Is there something in medical education?  Graduates of the PRHI “Perfecting Patient Care” institute sometimes return to institutions “ill-equipped to accept change.”  Large minds with small portholes.  I once remarked to an anesthesia resident that the tests she had ordered were not of any benefit to the ambulatory surgery patient.  “Oh, they must be useful.  We order them every day.”  

]]> Concept Challenge tag:www4.asq.org,2008:/blogs/healthcare//3.491 2008-04-10T02:42:47Z 2008-04-10T03:26:13Z Dr. Robert Burney Just when you thought there were a few certainties in the healthcare debate!  Prevention is a good thing, right?  It saves money by keeping patients from needing expensive healthcare.  An article in today’s Washington Post challenges this belief under the heading, “Prevention is often more expensive than treatment.”  Both  Democratic candidates have issued positive statements on the benefit of prevention, but McCain doesn’t see life this way.  (Check out an interesting graphic on candidate positions in healthcare.)


How can this be?  Like so many things in life, it depends on how you look at it.  If you’re a politician trying to minimize healthcare costs for the country, then prevention is not a bargain.  The article cites a Dutch study showing that “over a lifetime, healthy people incur the most cost, followed by the obese and then smokers.”  The reason, of course, is that healthy people live longer and thus have more time to spend money on healthcare.  Smokers die early.  Perhaps Medicare should issue free cigarettes to beneficiaries as a cost-cutting move.  I once advised our hospital administrator to open a motorcycle store, because it would be good for business.  Same thinking.  I remember reading (a very long time ago) that it was cheaper to let a few women develop cervical cancer than to do PAP smears on the population.   An HMO in Milwaukee tried this approach--just stamped all the PAP smears “normal” without even looking at the slides.  A few women died, but the HMO made lots of money.
However, if you’re an individual, you want that PAP smear or mammogram or colonoscopy, even if it does cost the healthcare system money.  Another way of looking at the question is to calculate how much it costs for every year of life saved.  Then, of course, you have to decide what a year of life is worth to society.  Would you spend $1,300 per year on each smoker?  How about $160,000 per year for statin therapy?  For more on these ideas, look at books by Louise Russell.

Bottom line:  before endorsing prevention as a strategy, you have to make some hard decisions.  It’s not a magic bullet.  Targeting the prevention efforts to those who most need them may improve the financial return. 

]]> Let George Do It. tag:www4.asq.org,2008:/blogs/healthcare//3.485 2008-03-27T04:11:48Z 2008-03-27T04:20:29Z Dr. Robert Burney Jacob Hacker , writing in the Washington Post last Sunday, advocates this approach.  And he’s not the only one.  Sounds simple, and that should be a warning.  Congress has yet to face the fact that there is a date certain when Medicare as we know it will run out of money.  There are two approaches to this problem:  reduce benefits or raise taxes.  Guess which approach the government will select.  

So, we have Medicare, a program that’s scheduled to go bankrupt in the foreseeable future just taking care of the over 65 group.  And he wants to expand the coverage to everyone (or almost everyone--see details).  That will require a huge increase in funding (taxes).  He doesn’t address the unhappiness that most providers have with Medicare.  Haven’t seen any ads for “practice limited to Medicare patients.”  But I do see practices that don’t take Medicare, plus some that don’t accept any insurance.  And if Medicare is so good as a health insurance plan, why do we have “Medigap” insurance?  Ever try to call Medicare to contest a rejected claim?  It’s entertaining.

Remember when we used to have city hospitals?  A few persist, but most have disappeared because the city fathers couldn’t keep their hands out of the till and off the tiller.  The same could be said of Medicare where Congress can’t resist mucking with the money.   

For another example, look at the VA.  I’m a big fan of the VA.  They wrote the book on patient safety in hospitals and pioneered electronic healthcare records (in spite of themselves).  As a government funded, closed panel HMO, they generally do a fine job.  But they are chronically underfunded and struggle to provide excellent healthcare in a difficult environment.  A perfect example of what a government will do when it would rather start a war than pay for healthcare.  

As with all “reform” proposals, the missing detail is the money.  He cites “government’s ability to lower service prices, streamline administration and get a better deal on drugs.” Yeah, sure.  It is often said that Medicare has lower administration costs than private health insurance.  True, there are economies of scale in some things, but there are limits.  Government employees work hard and do a good job (I’m one of them), but let me assure you that they cannot run a health insurance program cheaper than private industry.  Just not in the cards.  Trust me on that one.

It will be interesting to see how this plays out.   Universal coverage of some sort is coming.  Not clear where the money will come from, but probably from multiple sources.   And government will play a larger role, but let’s hope not the only role.

]]> Pay me now, Pay me later tag:www4.asq.org,2008:/blogs/healthcare//3.479 2008-03-14T02:45:32Z 2008-03-14T02:48:05Z Dr. Robert Burney Washington Post:  The EPA ignored its scientific advisers and lowered the allowable concentration of ozone in the atmosphere to 75 ppb from the current standard of 84 ppb.  Their Clean Air Scientific Advisory Committee unanimously recommended a limit of 70 ppb, while the Children’s Health Protection Advisory Committee lobbied for 60 ppb.  Power companies, of course, wanted no change, and their interests triumphed.  The effect of any limits is to reduce the amount of nitrogen oxides etc. that can be released by power companies, and that costs money.  S. William Becker, executive director of the National Association of Clean Air Agencies (local governments) summed it up:  “It is disheartening that once again EPA has missed a critical opportunity to protect public health and welfare by ignoring the unanimous recommendations of its independent science advisers.”

The reason that this is of interest here is the point about health vs healthcare.  If you want to improve the health of the population, reduce the ozone concentration.  Nothing to do with healthcare.  The EPA estimated that reducing the level to 65 ppb could save up to 9,000 premature deaths per year.  But death is cheap.  Those who survive become ill and use the healthcare system.  And those costs go on for a lifetime.  

The point has been made before that the true cost of burning coal is not reflected in the price per ton.  We must include the cost of adverse health effects from air pollution.  We might also include the trashing of landscape by strip mining and the resultant sterilization of local streams by toxic runoff.  How do you account for the lowering of a child’s IQ from breathing heavy metals?  Coal is only cheap when you don’t account for all of the costs.

George was concerned about the near term costs of reducing pollution.  But the effects of air pollution on the population go on forever.  Anyone going to Beijing?]]> Top Ten tag:www4.asq.org,2008:/blogs/healthcare//3.476 2008-03-07T03:00:24Z 2008-03-07T03:17:46Z Dr. Robert Burney
Health Affairs listed their top ten blog hits for 2007 and another list for ytd 2008.    
For 2008, lots of interest in spending--historical levels and predictions.  As a bonus, they also list the most read articles from the journal.  One interesting article in this latter list by Wm. Savedoff talks about what a country should spend on healthcare.  The complexity of the question makes interesting reading.  He makes the classic error, however of linking healthcare spending to population health, as if spending more on healthcare would somehow improve health.  (see previous postings here for more on that!)  He does point out the widely varying expenditures in countries with similar infant mortality and even states at one point, “it is extremely difficult to attribute changes in health status to healthcare spending.”  
An article on “disruptive innovation” (Clayton Christensen, see previous posting here) made the top ten.   His thesis is that innovations in healthcare service will further the faster-better-cheaper cause.  This is, of course, true, but unlikely to happen without some compelling reason.  There are, in fact, examples of “innovations” in healthcare today that perform faster-better-cheaper.  Surgery centers are familiar to me, but there are others.  Hospitals, however will not emulate these processes, primarily because they get paid not to.

For 2007, most articles on the list focused on healthcare reform, the au current topic of that era.  These fell into two broad categories:
    1. Central planning.  Advocates of a single payer system.  I seem to remember that the Russians tried central planning some years ago, and the results were not good.
    2. “The world would be better if I were in charge.”  This only works for the world of the person in charge--typically someone who’s never been in charge before.

Interesting that both lists have an article about the nursing shortage.  

As competitive politicians promise more and more in the coming months, questions will turn more and more to how to pay for more and more.
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