How Lean Principles Apply to End-of-Life Medical Care

A thoughtful segment on 60 Minutes recently explored the thorny issues surrounding the costs of caring for people at the end of their lives. It struck me that some of those issues relate to lean principles.

The story, reported by Steve Kroft, noted that last year, Medicare paid $50 billion just for doctor and hospital bills during the last two months of patients' lives – and it has been estimated that 20 to 30 percent of those medical expenditures may have had no meaningful impact.

I was particularly struck by comments from Dr. Ira Byock of Dartmouth-Hitchcock Medical Center in Lebanon, N.H., who leads a team that treats and counsels patients with advanced illnesses.

By law, Medicare cannot reject any treatment based upon cost. It will pay $55,000 for patients with advanced breast cancer to receive the chemotherapy drug Avastin, even though it extends life only an average of a month and a half; it will pay $40,000 for a 93-year-old man with terminal cancer to get a surgically implanted defibrillator if he happens to have heart problems too.
"I think you cannot make these decisions on a case-by-case basis," Byock said. "It would be much easier for us to say 'We simply do not put defibrillators into people in this condition.' Meaning your age, your functional status, the ability to make full benefit of the defibrillator. Now that's going to outrage a lot of people."

In lean operations, we argue in favor of standard work – doing something the same way every time. What Byock is arguing for is not exactly the same thing, but the principle is similar.

And before you argue that not all patients are the same – which is true – consider the words of David Walker, former head of the Government Accountability Office and how head of the Peter G. Peterson Foundation. He commented in the story that this is not just about medical care, but what government pays for medical care.

“Let me be clear: Individuals and employers ought to be able to spend as much money as they want to have things done. But when you're talking about taxpayer resources, there's a limit as to how much resources we have."

One other lean concept I’d like to mention is that there must be complete information about what is happening in order to choose the best course of action. In lean terms, that typically means choosing the right improvement, and measuring its results. I mention the concept here in a slightly different way, in terms of choosing the most appropriate course of action based on a full understanding of the likely impact of that action.

The 60 Minutes report noted that studies have shown most dying patients and their families would prefer the last days be spent at home (though most end up dying in hospitals). But to make a choice, patients and their families must understand the situation – which is often not the case, according to another person interviewed for the segment, Dr. Elliott Fisher, a researcher at the Dartmouth Institute for Health Policy.

"At some point, most doctors know that a patient's not likely to get better," Kroft remarked.
"Absolutely," Fisher agreed. "Sometimes there's a good conversation. Often there's not. You know, patients are left alone to sort of figure it out themselves."

I was once involved in a difficult, end-of-life decision. The fact that the doctors involved were clear and honest about the situation was important and helpful.

Dealing with these kinds of issues is one of the toughest aspects of improving healthcare. Perhaps lean principles can help.

Culture Change is Key to Reducing Diagnostic Errors

Can lean strategies help doctors make fewer diagnostic errors?

Most healthcare process improvement efforts focus on preventing treatment errors – making sure patients are given the correct course of treatment after a diagnosis has been made. But diagnostic errors also occur, an issue I wrote about nearly a year and a half ago.

I’m revisiting that issue now because a new survey has shed some light on diagnostic errors. A group of researchers led by Gordon Schiff, MD, associate director at the Center for Patient Safety Research and Practice at Brigham and Women's Hospital in Boston, asked doctors to describe – anonymously – diagnostic errors they had made or witnessed.

Their findings, published in the Archives of Internal Medicine, are based on the responses from the doctors, who reported 583 errors. An article in Physician Leadership News described the findings.

The two most frequently listed conditions involved pulmonary embolism and adverse drug reactions, including overdoses and poisoning. Lung cancer diagnostic mistakes ranked a close third, followed by colorectal cancer, acute coronary syndrome, breast cancer, and stroke.

The doctors failed to: order tests, report the results to their patients or follow-up when testing revealed abnormal findings.

As it turns out, lab and radiology testing errors, including test ordering, test performance, and clinician processing, accounted for 44% of the missed diagnoses, which was the greatest share.

Most lean advocates would probably suspect that system problems contributed to the errors, as much or more so than physician error. The article, by Heather Comak and Cheryl Clark, discusses that issue.

While the notion of overconfident, arrogant physicians being the cause of diagnosis error is not wholly wrong, those qualities alone are certainly not the reason that misdiagnoses are made, said Schiff. Other factors include spotty follow-up, time pressure, failure of physicians to share their uncertainties, malpractice fears, defensiveness, and inadequate feedback.

Schiff likened this last factor to the lawn sprinkler system that goes on automatically, regardless of whether it has rained that day. Instead of acting in a closed-loop system that provides feedback about whether diagnoses were right or wrong, often physicians work in an environment that does not allow for this follow-up or does not attempt to capture this feedback.

The article goes on to note that cultural biases and culture change – the most difficult aspect of any improvement effort – are at the heart of the situation.

Another way of thinking that has become ingrained in most physicians is the idea that an overconfident, perhaps wrong diagnosis is better than not diagnosing a patient at all. Most patients don't appreciate when their physicians don't seem decisive about a diagnosis, and historically, physicians have been more successful when they confidently make a diagnosis, said Croskerry. Additionally, physicians validate their ability to make diagnoses when they are confident.

"Physicians tend to place a lot of faith in their own diagnoses—most physicians think it's the most important skill that they have," said Croskerry. "It's a lot easier, if you give the patient wrong medication, to admit to something like that than to actually admit to your thinking processes having gone astray. People take that far more personally..."

Both Schiff and Croskerry agreed that more emphasis should be placed on physicians admitting to their patients uncertainty about diagnosis and that more work needs to be done at an earlier stage, perhaps in medical school, to introduce the idea of feeling comfortable with uncertainty to physicians. Additionally, Schiff said the question of physicians admitting a diagnosis error is first and foremost about a patient safety culture.

"This idea about patient safety culture—creating a system where people can honestly look at errors in a blame-free way, learning from mistakes and improving from those, rather than covering them up or having to defend them—is so central for us learning," said Schiff.

It is going to take a long time and a lot of work to achieve this kind of culture change. I hope this new survey will contribute to that effort.

Book Talk: Lean Safety

I’ve often heard people argue that the lean tool of 5S – whose five words are most commonly listed as sort, set in order, shine, standardize and sustain – really ought to be 6S, and that the sixth “S” should be safety.

Regardless of where you stand on that debate, if you believe safety is important in the workplace – and everyone should – then you may be interested in Lean Safety: Transforming your Safety Culture with Lean Management by Robert Hafey, a new book we are publishing next month.

Hafey, who has 40 years manufacturing experience and has been active in the Association for Manufacturing Excellence, emphasizes that building a top safety program requires building a world-class safety culture. He demonstrates how basic Lean tools are as applicable to safety as they are to Lean, such as the A3 problem-solving process and the facilitated kaizen blitz.

Additionally, he establishes standards and metrics for safety management that are clearly definable and measurable. That is also consistent with a lean approach, where any improvement should be definable and measurable.

Companies adopt lean strategies for a variety of reasons – improving time to market, increasing capacity, reducing costs. If your focus is on improving safety, then this book is for you.

Do you have a question or comment about a book(s) that you would like addressed in Book Talk? Email me directly at Ralph.bernstein@taylorandfrancis.com.

Do Benefits Come Out of Your Printers? They Will With Lean

Like IBM and HP, Xerox is a technology company that transformed itself from just being a hardware provider into a services company as well. (You may not think of Xerox as a technology company, since it doesn’t make computers, but what else would you call printers, copiers and fax machines?)

What is interesting about Xerox is that they promote Lean Six Sigma as an essential part of their expertise. There are plenty of lean consulting firms, but not many (if any) that are focused on document and information management.

Xerox understandably boasts about its accomplishments. I’m writing about them today not to discuss whether Xerox is a good company, but to note how lean initiatives can yield big benefits in regard to something as unglamorous as printing.

Procter & Gamble hired Xerox to manage its worldwide print operations. According to the Environmental Leader website, Xerox “has been able to help P&G cut operational costs 20-25 percent by helping control when and how printers, copier and fax machines work… At P&G, it’s predicted that the improvements will cut printer-related power usage by 30 percent and paper consumption by 20-30 percent.”

Earlier this year, Xerox issued a news release describing its work with KeyCorp.

The financial services company reduced operating costs by more than $6 million over six years, working with Xerox to better manage the volume of documents flowing through its 120 offices - and the costs associated with printing, sharing and updating them…

Using a Xerox Lean Six Sigma-based assessment, Xerox Global Services and KeyCorp evaluated employees' daily work processes to design a document management strategy that saves millions on print costs. By decreasing the number of output devices, like printers, fax machines, copiers and scanners, from 10,000 to 3,500, KeyCorp also boosted productivity, reduced paper consumption, decreased power usage and eliminated tons of landfill waste…

While I believe any statement in a news release should be taken with a grain of salt, I’m sure KeyCorp wouldn’t have agreed to the release unless there were some truth to what is being said.

Even the most ordinary or mundane operations can be improved with a lean approach.

Problems in Connecticut Hospitals Are Swept Under the Rug

Hiding mistakes is a bad idea, and definitely contrary to any type of lean or other improvement strategy. You can only improve if you know what you are trying to improve, which means having complete and accurate information about the current process and the problems that are occurring.

Not long ago I wrote about a positive trend among some hospitals to admit mistakes – to patients, amazingly enough – and try to learn from them.

But on the heels of that information comes a disturbing report from the Hartford Courant that information about “adverse events” in Connecticut hospitals is now rarely available, thanks to revisions lobbyists obtained in state law.

The legislature in 2002 ordered hospitals to disclose all serious patient injuries "associated with medical management." But after the first reports were made public, hospital lobbyists persuaded lawmakers to rewrite the statute in 2004, limiting the types of adverse events that must be divulged and promising to keep reports secret unless they led to an investigation.
State health officials had given assurances that the new law would shed more light on serious medical errors. But an analysis of health department records, death certificates, medical examiner reports and lawsuits shows it has had just the opposite effect.
Since the law was revised:

· The state has investigated dramatically fewer adverse-event cases, with about three out of four reported events now closed without a formal inquiry — keeping them hidden from the public — including more than 50 cases in which patients died.

· Narrower reporting requirements have allowed hospitals to keep more medical mistakes secret even from state regulators, with reports to the state immediately dropping by more than half.

· Even after lobbyists pushed for more narrowly defined reporting rules, some believe hospitals still are not reporting all incidents mandated by law, but the state has never attempted to determine whether or not hospitals are complying.

The article, written by Matthew Kauffman and Dave Altimari, notes that mistakes are indeed taking place.

The details of more than a dozen sexual assaults are concealed in the health department's files, along with at least 30 cases in which sponges or other objects were left in patients' bodies after surgery, a Courant analysis has found. Information on hundreds of serious falls is also kept under wraps by the department, as are the particulars of at least half a dozen cases in which newborns died or were seriously injured during childbirth.

I hope the Courant’s article will help prompt a reversal of the changes to the law.

Should Efforts to Improve Hand-Washing Include Posting Names?

We’ve all heard about efforts by hospitals to reduce infection rates by having employees wash their hands more often. But what are the best tactics for achieving that goal?

A recent article by Health Leaders Media describes the techniques used at Barnes-Jewish St. Peters Hospital (BJSPH) in St. Peters, MO. They succeeded in getting more people to wash their hands regularly. But I have mixed feelings about how they did it.

Basically, they used a carrot-and-stick approach: They praised people who had good hygiene and criticized those who didn’t – privately at first, then publicly.

The first efforts involved handing out “You’ve been spotted” cards.

For positive reinforcement, some of the cards were flagged for incidents where the receiver has been spotted using good hand-hygiene practices. These cards includes a $2 coupon good in the hospital cafeteria or gift shop—enough for a cup of coffee or candy bar, or they can be saved up to buy lunch. Funding for these coupons came from the infection prevention budget.

And then there are the other cards, which read, "We are putting you on the spot for not using hand hygiene."

The reason the cards look nearly identical is to prevent any sort of embarrassing scene for the people involved. It's impossible to tell from a few feet away whether you've received a positive card or negative.

This approach worked, but not as well as officials hoped. So they took it a step further by posting names of all spotted employees – the good and the bad.

To temper the negative reinforcement of posting names—which helped improve compliance as well—BJSPH added an additional, and very public, way of rewarding those who were spotted using proper hand-hygiene processes.

"Any [month] we meet or exceed our goal, we will take the names of everyone who was recognized as doing a good job, put their names into a drawing, and have a 'hand hygiene hero' drawn in the cafeteria," says Kathleen Dougherty, RN, MSN, manager of professional practice and leadership development at BJSPH.

The cafeteria is shared by staff and guests alike, so the congratulatory ceremony—including Bonnie Tyler's 1980s hit "Holding Out for a Hero" playing loud and clear—can be witnessed not only by staff, but also the people using the hospital and their visitors. There's a gift involved for the winner of the drawing as well (a $25 gift certificate) and, in months where the goal is exceeded, multiple names are drawn.

Winners' pictures are taken and posted throughout the building—even built into screen savers on hospital computers.

One could argue that we’re talking about changing behavior rather than improving a process, but I can’t accept that. Yes, we are talking about changing behavior, but hand-washing is also a step in hospital processes.

Is BJSPH using a lean approach? I wonder, because they are using after-the-fact feedback to achieve change rather than seeking to ensure that hand-washing occurs in the first place. Does this approach show respect for people? Are there other, better ways of making hand-washing an integral part of processes?

I’ve never been involved in process improvement in a hospital, so I can’t say. If any of you have thoughts on this, please add your comments below.

Book Talk: Critical Success Factors Simplified

What are the critical success factors for your business? If you’re not sure, a new book we are publishing later this month could be helpful.

Critical Success Factors Simplified: Implementing the Powerful Drivers of Dramatic Business Improvement simplifies the identification, measurement, and use of CSFs to successfully implement strategies, manage projects, and improve processes. It provides effective measurement techniques for tracking progress, highlighting problem areas, and facilitating improvements.

The book highlights key indicators for determining the appropriate course of action, then demonstrates how to use these indicators to achieve success in anything from deploying strategic initiatives and managing a process or a project, to recruiting, playing blackjack, or buying a house.

Critical Success Factors Simplified is written by Marvin T. Howell, also the author of Actionable Performance Measurement – A Key to Success. He is a professional engineer, a retired Lt. Colonel, USAF, in the Air Force Civil Engineer division, and a consultant with his own quality and industrial engineering company.

Do you have a question or comment about a book(s) that you would like addressed in Book Talk? Email me directly at Ralph.bernstein@taylorandfrancis.com.

IKEA Designs Products for Easy Shipping

Lean advocates often focus on linking the design process to manufacturing, with ease of manufacturing an important consideration when a product is being designed. I’ve also heard that ease of servicing should be (and for some companies, is) a consideration for some products, such as automobile engines.

But have you ever considered ease of shipping as part of your design process?

I saw a demonstration of this concept while watching a recent episode of the “Ultimate Factories” program on the National Geographic channel.

This particular episode focused on IKEA, the Sweden-based furniture manufacturer and retailer that makes and sells nearly 10,000 items in about six factories and 296 retail stores.

IKEA makes inexpensive furniture, often in pieces that the retail customer must assemble at home.

The company is constantly developing new products. And one of its requirements, the program noted, is that not only must the product meet IKEA’s standards of quality and affordability, but its components must fit into a flat box for shipping. This makes shipping easier both for IKEA and for the customer who purchases the product and takes it home.

I believe some food companies take this approach as well – not with the food products themselves, but with their packaging, so that the products can be easily shipped to, and displayed in, supermarkets.

Do any of you have experience with making shipping considerations part of the design process? Share your experience below.

Nurses Need a Dose of Lean in Battle Against Medication Errors

Nurses, who play a major role in distributing medication to hospital patients, are trying to take a leading role in stopping medication errors. That is the good news. The bad news is that they are focusing their efforts in the wrong direction.

A recent article from Health Leaders Media describes a study led by Linda Flynn, RN, PhD, associate professor at the University of Maryland School of Nursing. Flynn is also the project director and principal investigator of this Interdisciplinary Nursing Quality Research Initiative (INQRI)-funded study.

"Nurses are the safety net that keeps patients safe from experiencing a medication error," said Flynn. "Our question was, what are the factors that impact this nursing safety net—what are the factors that help nurses in doing their job to intercept medication errors before they reach the patient, and what are the factors that serve as barriers to this safety net?"

The study looked at medication errors, and efforts to stop them, at New Jersey hospitals.

Flynn and her team interviewed 50 staff nurses from 10 hospitals, transcribed the interviews, and analyzed the lines of text for patterns and commonalities. They found that nurses take seven routine steps in the name of medication safety:

1. Conduct independent review of the medication administration record (MAR) in comparison with the medication order
2. Perform a focused assessment of the patient prior to administering medication
3. Question rationale
4. Prioritize face time with physicians
5. Encourage patients and families to be the last line of defense for a medication error
6. Advocate with pharmacy to ensure timeliness of medication delivery.
7. Clarify orders/handwriting with physicians

Of these processes, Flynn and her team found that numbers 1, 3, 5, and 7 were significantly associated with fewer medication errors.

The problem here is that the focus is on “intercepting” medication errors, to use Flynn’s word. As any lean advocate can tell you, the focus should be on preventing errors from occurring in the first place.

Since I am not familiar with hospital processes for dispensing and distributing medication, I couldn’t say how you do that. But I’m sure a solid lean analysis of those processes could lead to improvements that would have a real impact on the number of errors that occur.

If you know what some of those improvements might be, please share them below.

Medicare Should Not Base Payments on Hospital Productivity

While I generally support financial incentives to drive improvements in healthcare – such as Medicare deciding it will no longer pay for treatment of certain medical mistakes – I’m concerned about an approach built into some of the reform proposals making their way through Congress.

According to The Wall Street Journal Health Blog, the proposals claim they will save $172.8 billion over 10 years by making productivity improvements a factor in increases of Medicare payments.

Every year, the feds adjust Medicare payments to hospitals, nursing homes and other facilities to account for inflation. The House bill would add in a second factor: productivity. Because workers’ productivity tends to increase over time, factoring in productivity increases would make Medicare payment increases lower than if they were tied only to inflation.

I can understand the thinking behind that idea. If productivity improvements reduce expenses, Medicare payments shouldn’t have to increase. And if payments are adjusted for productivity improvements industry-wide (I’m not sure whether that would be the case), that gives individual hospitals an incentive to improve their productivity.

The problem is first, productivity can be difficult to measure, and second (and more importantly), it’s the wrong metric.

What exactly will the government use as a measure of increased productivity? The number of patients served by a hospital? The staff-to-patient ratio? The number of procedures, such as X-rays, performed in a given time period?

None of these is a true indicator of whether a hospital is providing the best care to the greatest number of patients. Financial incentives should be tied to outcomes. Not paying for treatment of “never event” medical mistakes is one approach. Another might be to reward a hospital for a reduction in its rate of in-hospital infections – or in its mortality rate. I’m sure there are plenty of others.

I worry that tying payments to productivity will give us more treatment without better quality.

The New Surgeon General Lacks a Degree in Lean

There is a lot I like about Dr. Regina Benjamin, who was recently confirmed as U.S. Surgeon General. I just wish she had some background in lean.

Benjamin has long been dedicated to serving the uninsured and underinsured in the rural south. She believes we need more primary care surgeons and supports greater emphasis on preventive medicine.

She also seems to understand many of the financial issues in healthcare. She operated her own clinic, and kept it going after her office was wiped out by a hurricane – twice. She even has an MBA from Tulane University.

She served as president of the State of Alabama Medical Association, and is a recipient of a so-called “genius grant” from the MacArthur Foundation.

So what’s not to like? I see nothing in her experience that indicates any familiarity with lean principles.

Why does that matter? Interest in lean in healthcare has been growing at a rapid pace, driven by a strong movement to improve the delivery and quality of medical care in the U.S.

Lean can be a powerful means of helping to achieve that goal, as evidenced by the many healthcare success stories. The market for books we publish about lean in healthcare is growing rapidly.

As the nation’s top doctor, the surgeon general can be a powerful voice for spreading the word about the benefits of lean healthcare – if she were aware of it and knew what to say.

By the way, the same could be said about the secretary of health and human services. President Obama’s HHS Secretary is Kathleen Sebelius, a lawyer and career politician who most recently served as governor of Kansas. And while many people have praised her work as governor, I don’t see any evidence of lean knowledge in her background either.

Someone should hold seminars on lean for cabinet officers – with attendance mandatory.

Lean and Ergonomics: A Good Match

In case you missed it (and I almost did), October was National Ergonomics Month.

This designation was created six years ago by something called the Human Factors and Ergonomics Society (HFES) with the stated purpose of focusing “on promoting human factors/ergonomics to corporate executives, students, and the general public by providing information and services to the community.”

Wikipedia defines ergonomics as “the science of designing the job, equipment, and workplace to fit the worker.” I don’t know whether that is a universally accepted definition, but I like it. It is concise and seems to clearly express what ergonomics is all about.

And while my knowledge of ergonomics is limited, I have long believed that ergonomics and lean fit well together. If you regard your workers as an asset, and you have respect for them as people – both lean attitudes – then designing the job, equipment and workplace to fit them makes perfect sense.

Ergonomic improvements can also improve productivity, by making it easier for workers to do their jobs.

Other people have expressed this in much greater depth. If you’d like more information, do a Google search for “ergonomics and lean.” I did, and came up with quite a few hits.

We don’t publish any books specifically about ergonomics, but some of our titles might be of interest, such as our books about Training Within Industry.

Have any of you gained benefits from making ergonomic improvements part of your lean initiatives? Please share your experience below.