Medicine is at a crossroads. Tried-and-true techniques have failed to yield needed improvements, and in some cases, the remedy instigates new woes. Now forward thinkers in healthcare are tapping a new fount of knowledge—industry—and learning best practices from unlikely sources like mattress factories, fast food franchises and evangelists.
It’s no secret that healthcare is in crisis. With the average patient in a hospital intensive care unit contending with 1.7 medical errors each day, the most vocal critics might characterize patient safety as an oxymoron. Performance incentives are perverse; under the current fee-for-service reimbursement model, providers are paid regardless of outcome. And when anything goes amiss, a culture of silence, rather than accountability and learning, pervades. Standardization—which is key to boosting efficiency, reducing errors and controlling costs—is the exception, rather than the rule.
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Despite its critical condition, there are pockets of progress. Johns Hopkins Medicine in Baltimore, has led a crusade against preventable infections and pioneered a five-step checklist to help providers prevent the hospital-acquired bloodstream infections that kill more than 30,000 patients a year and sicken thousands more. The model has been applied in 47 states and around the world and inspired the book “The Checklist Manifesto: How to Get Things Right” by Atul Gawande.
The orthopedic surgery department at Brigham and Women’s Hospital in Boston, standardized knee replacement management, and, in the process, halved the cost of knee implants while also improving recovery to the point at which the average patient is discharged nearly one day earlier than under its previous every-surgeon-for-himself model.
Seattle Children’s Hospital has streamlined its pharmacy ordering process to achieve 90-minute medication turnaround in 95 percent of cases, up from the pre-process improvement mark of 80 percent.
How have these organizations bucked the middling status quo that permeates healthcare? Not by learning from their peers. Former Centers for Medicare and Medicaid Services Administrator Donald Berwick, MD, once famously quipped that hospitals that achieved top laurels amongst their peers were “the cream of the crap.”
Instead, these organizations looked far and wide for new models and processes, tapping some unexpected sources for solutions.
Take, for example, Seattle Children’s Hospital. Fifteen years ago, when the hospital embraced its goal to be the best children’s hospital in the country, it surveyed the local pediatrician community. Physicians agreed that Seattle provided high-quality care, but issued a couple of caveats. “They told us ‘we have trouble getting patients’ appointments, and you never call us back,’” recalls Howard E. Jeffries, MD, MPH, medical director, clinical effectiveness.
The documented access and communications issues, coupled with internal recognition of inappropriate care, spurred the hospital to contract with Joan Wellman, a performance improvement consultant and founder of Joan Wellman and Associates. Her response was both bold and spot-on. “You aren’t going to find what you need to make these changes in healthcare because no one is doing what needs to be done to make these changes.”
The hospital agreed, and embarked on its decade-long performance improvement project. Read on to learn more about how and where these pioneers located springs of knowledge.
From the mattress factory to the OR
One hallmark of Lean performance improvement is study trips. Several years ago, the general surgery team at Seattle Children’s traveled to a mattress factory in Japan to discover what could be learned. The very successful factory made approximately 100 kinds of twin beds, but only 10 of these beds were sold frequently, says Jeffries. Despite the unpredictable nature of its business, the factory delivered 24-hour delivery from the time of order.
The mattress factory achieves these results by reserving space in the daily schedule to build whichever of 90 types of uncommon mattresses might be ordered. “They planned for the unplanned,” explains Jeffries.
The surgery team looked for parallels and found them in central line placement, a common surgical order that the team often could not accommodate due to a lack of capacity. Instead of the more permanent central line, patients were given a temporary PICC line and then placed on a wait list for the central line. Thus, children were subjected to double the number of sedations and two procedures.
After the visit to the mattress factory, the team squelched the problem by creating space on one surgeon’s daily schedule for central line requests.
At the intersection of evangelism and science
The patient safety improvements achieved at Johns Hopkins should be viewed as a social movement, says Peter J. Pronovost, MD, director of the Armstrong Institute for Patient Safety and Quality at Johns Hopkins Medicine. Pronovost refers to the three-legged stool that underpins successful intervention:
- Measurement and accountability;
- Culture change; and
- A checklist or standardized work process.
The checklist was important in the project to reduce infections, he says, but changing social norms was more important. Staff needs to be empowered and accountable; and a team ethic needs to pervade the department. “We helped coach staff and changed their beliefs, so they recognized infection was their problem and they could solve it. It’s part evangelism and part science,” he says. Strategies include developing staff-led safety teams authorized to identify risks, clarifying expected behaviors and tweaking key principles and best practices to local needs.
A key leadership principle is that formal leadership only allows the leader to do two things, says Pronovost: convene meetings and buy dinner. Meaningful change is derived from the informal authority that occurs when people trust a leader and his or her vision.
Take, for example, the spontaneous wave launched at many sporting events. The wave doesn’t spread because the first waver dictates to or pays fellow spectators. Instead, people catch the wave because of excitement, enthusiasm and the desire to be part of something larger than oneself.
The airline industry is a goldmine of lessons and a model for healthcare. Healthcare caught on to the checklist concept 10 years ago, 70 years after aviation adopted it, says Robert J. Szczerba, PhD, corporate director, healthcare initiatives at Lockheed Martin in Oswego, N.Y.
He hypothesizes that healthcare has been slow to follow the path because providers’ incentives differ from pilots. Every time an airplane takes off, the pilot and crew face the same risk of death as passengers. Thus, they are motivated to follow a checklist of simple basic safety steps that reduce the risk of operator error.
Although most everyone on the healthcare team wants to make sure everything is done correctly for patients, someone may be tired or rushed, which can lead to preventable errors. “The same incentive isn’t necessarily there,” Szczerba says.
Another difference between the two industries is the approach to training. Aviation has made rich use of sophisticated simulators. This low-risk, low-cost software provides staff with realistic training on thousands of different configurations, such as a lightning strike or bird trapped in an engine. In contrast, healthcare uses mannequins equipped with proprietary software and interfaces that train providers on a limited number of scenarios.
Finally, unlike healthcare, aviation has mastered device integration. Some physicians (and vendors) claim it is too complex to integrate the 150 devices from 10 different manufacturers found in a typical ICU. “An F35 jet has millions of parts made by thousands of contractors. Yet, it all comes together and works,” says Szczerba, adding that the inability to plug together medical devices stems from “purely cultural” factors.
After the Three Mile Island nuclear power plant accident, the nuclear power industry recognized regulation alone could not address its safety issues, says Pronovost. Nuclear power facilities created the voluntary World Association of Nuclear Operators (WANO).
WANO facilities developed a voluntary peer review process. Unlike regulatory reviews which are often judgmental and carry the threat of shutdown, WANO reviews embrace a culture of learning, says Pronovost. Yet, WANO is not without teeth. The model is ruthlessly transparent. Visiting operators detail their findings from site visits but don’t share their findings with anyone outside of the nuclear plant under observation. That peer-to-peer review could be applied in healthcare, says Pronovost.
Industry is ripe with models for healthcare. Law enforcement, banking and chain restaurants all represent rich resources.
Healthcare has resisted video monitors in the OR and ER, citing privacy concerns, says Szczerba. When law enforcement agencies in metropolitan areas announced plans to equip police cars with video cameras, police unions issued a vehement protest, he says. They too claimed privacy concerns.
The tide turned when unions and officers realized the cameras often proved officers had acted correctly and provided evidence in cases where something had gone wrong. The cameras went from a job-limiting privacy invasion to a lifesaver, he says.
Meanwhile, online banking clearly has mastered the details of instant data transfer that so boggles healthcare. “How many times do physicians have to re-order tests because they don’t have the ability to share information accurately and efficiently?” asks Szczerba.
Finally, Gawande famously waxed enthusiastic about the quality control, cost control and innovation deployed in Cheesecake Factory and other restaurant chains in “Big Med,” published Aug. 13, 2012, in The New Yorker. Cheesecake Factory has leveraged dashboards, data analytics, Lean tools and clear pictorial instructions in its quest for a minimum 97.5 percent efficiency in food stock, meaning a mere 2.5 percent of grocery inventory is thrown away.
In healthcare’s quest to improve quality, value and patient satisfaction while reducing costs anywhere and everywhere from readmissions, staffing and waste, physicians and administrators need to seek out and implement innovative and reproducible solutions.