More to Learn Than Fear From Ebola

ebolaEbola is scary. Though I try to allay my fears with practicality and common sense, I am – like many Americans – very concerned. The unknown is always scary. I wanted to start with that assertion to place the rest of my observations in context.

We will, I expect, ultimately pull through this latest threat to our lives better than our current fears would predict. Assuming we do, when the dust settles and the national media moves on to cover the next threat to our lives we are going to be left with some very useful case studies that we (hopefully) can use to assess how and why the healthcare industry continues to be unable to effectively embrace and utilize quality process improvement.

Of course, we will have to get past the blame game, name-calling and talking heads wanting to put the fault upon political philosophy rather than where it rightly belongs: the human beings that are involved in the promulgation of guidelines and regulations, the implementation of guidelines and regulations and the adherence to guidelines and regulations.

Already today pointed fingers are flying around Dallas like roof shingles might during a Texas size tornado. Texas Presbyterian hospital administration is accusing the media of sensationalism (go figure). A nurses union is blaming the hospital for not protecting its workers. The CDC blamed – then didn’t – the hospital for not following protocols and guidelines. How George Bush is avoiding blame down there I can’t figure.

Finger pointing in times of crisis is an innately human characteristic that only few people can avoid. Those folks that do avoid it tend to make very good leaders, and unfortunately apparently have an abhorrence for public office. But in a very real sense the finger pointing underscores how far the US healthcare delivery system has to go to change the systemic cultural aspects that impede progress toward quality improvement.

As I have shared in this space before, my colleague Nathan Ives and I wrote a white paper a while back: Aligning Healthcare Organizations: Lessons in Improved Quality and Efficiency from the Nuclear Power Industry. I believe it is informative and particularly relevant today to compare the relative safety records of both the nuclear power and airline industry safety records to healthcare. The potential wide scale impact of an epidemic raises our collective consciousness to view healthcare safety on a par with tragedies in those other industries in a way that one death at a time simply does not, however right or wrong that may be.

Though somewhat dated, there was an interesting journal article written in the December 2003 issue of Quality and Safety in the Healthcare: Applying the lessons of high risk industries to health care. In it the author notes the exemplary safety performance achieved in the oil and gas and aviation industries. And then examines why healthcare – an industry with comparable high risks – has not done nearly as well.

As the author notes, “health care has always taken medical dangers seriously, so the culture cannot be pathological. The lack of systemic risk management suggests that the culture is, at best, reactive, even though there may be the occasional proactive area.” Though we have seen the industry try and address these inherent cultural differences over the past decade since this research was conducted, we only need to look at the flying fingers in Dallas to realize not much progress has been made.

Organizational process improvement leading to the type of sustainable quality and safety that has been achieved in other industries and disciplines cannot and will not be achieved through regulatory compliance alone. It requires a paradigm shift in the thinking and attitudes of healthcare industry participants who have been effectively able to resist change for a long time. If you are looking for a silver lining in this scary period we are living through, it could be that Ebola accelerates that paradigm shift. I do believe we have more to learn than to fear.

  ~ Sparky

P.S. See you at the LeadingAge Conference in Nashville! We’ll be in booth 1829.

The Virginia Mason Experience

Prospering by Standardizing Processes and Improving the Patient Experience by Andis Robeznieks, Modern Healthcare.

Dr. Gary Kaplan, chairman and CEO of the Virginia Mason Medical Center in Seattle Washington was recently interviewed about his experience of integrating Lean manufacturing process improvement at VMMC. Paul Plsek, a management consultant, has also written a new book about that experience: Accelerating Health Care Transformation with Lean and Innovation: The Virginia Mason Experience.

Below are a few excerpts from the interview:

On Organizational Change Management
Change is very, very hard in healthcare. We have learned a lot about change management. Not everybody wanted to come along. There were perhaps 10% who were early adopters, 10% who were very resistant to any kind of change and probably 80% of the people—and I’m talking about physicians, nurses and others—in the middle, just sort of saying we’ll see what happens and this too will pass.

I think we surprised people with our perseverance. Today, we’re possibly the furthest along of anybody in healthcare who’s consciously deployed a management method for more than a decade. But the most significant accomplishment is understanding that the pathway to improving quality and safety is the same pathway to lowering cost, and that involves relentlessly taking waste and unnecessary variability out of our processes. This creates a much higher quality, better patient experience.

It creates an opportunity for people to be empowered to use their best thinking to redesign their work. Our staff, who are closest to the work, are the ones who redesigned the work and in so doing reduced the burden of work.

On Physician Resistance
Traditionally, physician autonomy has been thought to be the sine qua non of professionalism, and that only we know what’s in the best interests of our patients. At Virginia Mason, we’ve been able to move from that approach and we understand that healthcare is impeded, not facilitated, by the notion of physician autonomy. Our physicians are actively engaged in supply-chain initiatives that standardize prostheses. One of our early rapid-cycle improvement events in 2001 was standardizing laparoscopic cholecystectomy trays, enabling us to save $700-$800 for every case by getting all the surgeons to realize that customized setups were unnecessary. We found is that if we eliminated nonvalue-added variation, the result is we create time for the value-added variation that differentiates individual physicians from each other and for patient preferences.

On Measurable Improvement
One of the things I’m most proud of is we’re the only hospital in the U.S. to be named by Leapfrog a top hospital in every year that designation has been given. We reduced cumulative nurse walking distance in the hospital by 750 miles per day, which freed up more than 250 hours of time for direct patient care.

On Measuring Outcomes
Outcomes measures have eluded us in healthcare for a long time. We’re getting better, but it’s a challenge. The entire continuum of care is a challenge to measure, given that we have patients coming in for care from Alaska, Montana and across Washington state, and Walmart and the Pacific Business Group on Health send patients here for heart and spine and total joint care. So it becomes quite difficult at times to measure the entire continuum of care.
One of the interesting things we’ve learned is that standardizing processes is really important even when there is no incontrovertible double-blinded study evidence. The standardization in itself allows us to measure and then it allows us to eliminate defect-prone situations. If a team of people do things nine different ways, that creates opportunities for defects to occur, and that’s what we want to eliminate.

On the Impact of Healthcare Reform
We welcome the changes that are here and are coming. More transparency is critical, and it plays right to our sweet spot. If we are able to improve quality and safety and lower costs, that’s going to allow us to succeed in a marketplace that’s more driven by value than volume. We see reform as a catalyst to accelerate our work, and it’s going to help move the entire industry in ways that will improve quality and lower cost.

Policy Issue
VMMC’s process improvement initiative was launched before and thus independent of the influences of the Affordable Care Act. But of course it was not launched in a free market vacuum independent of industry regulatory influences. Dr. Kaplan welcomes the future impact of healthcare reform as an inducement – or at least catalyst – for change at healthcare organizations that don’t have the predisposed wherewith all to affect the kinds of change accomplished at VMMC.

Others are going to disagree. They will argue that innovation and performance improvement flourish best when individuals’ inherent incentives to act in their best interests are rewarded by market-driven rewards. But is that even remotely possible to achieve in an industry that is already so heavily regulated that market-driven incentives are but a myth that stand in the way of collaboration and coordination?