Pascal Dennis' New Book -- Andy & Me and the Hospital -- Addresses Healthcare Challenges

One of the top Lean thinkers and coaches, Pascal Dennis, just published a compelling new novel titled Andy & Me and the Hospital: Further Adventures on the Lean Journey . Continuing the story established in his Shingo Prize-winning book Andy & Me, this latest book shows how Tom Papas and his sensei, Andy Saito, face perhaps their greatest challenge yet – a major New York City hospital.

I had the chance recently to ask Pascal some questions, so I’ll reproduce them here followed by his answers:

Why continue the story of Tom and Andy in a hospital/healthcare setting?

Health care represents Lean’s "undiscovered country." In fact, I spend much of my time coaching senior health care executives. In the book, Tom Papas calls health care a "dark realm" – full of risk, but also full of opportunity. If we don't get health care right, it could bankrupt us. But if Lean thinking and methods take root here, we’ll greatly improve people’s lives.

Given Tom and Andy’s background in manufacturing, how can they function in a major hospital?

Every industry entails a series of processes. Health care value streams, for example, typically begin with Registration and conclude with Discharge with various process flows in between. 

Flow depends on standards, connections and pathways – which Tom and Andy are adept at seeing. Their challenge is to learn the language, technology and culture of healthcare, and to translate Lean thinking and methods in a way that’s understandable and motivating for hospital leaders and team members. Translation is a central theme. What does Flow mean for an Emergency Department? What does Quality in the Process mean for an Operating Room or a Pharmacy? What does Strategy Deployment mean for a major hospital?

Why this book in particular?

I want to answer some basic questions. What does a Lean transformation in a hospital feel like? What overall approach should we take? What kind of leadership and behavior change is needed? How do we develop and engage people? How do we improve processes? How do we build a management system? How do we translate what Deming called the "profound system of knowledge"? 

At the same time, I want to provide a clear and simple guide to Toyota thinking and methods, how they fit together, and the spirit that animates them.

Why a sequel to Andy & Me?

Readers seem to connect with Tom and Andy. For me, they’re real people with problems, doubts and weaknesses. Transformation is hard, life is hard. Tom and Andy struggle with difficult problems and they only partially succeed. But that makes all the difference. Another of the book’s core themes is that the sensei has to grow and change, just as much as the deshi. Tom and Andy’s journey and relationship are hopefully a useful metaphor. 

For those who have read Andy & Me and the Hospital: Further Adventures on the Lean Journey: Feel free to post your comments.

Ideas Transformed the Culture at Baylor Scott & White Health

Last month, an important book titled The Power of Ideas to Transform Healthcare: Engaging Staff by Building Daily Lean Management Systems, authored by Steve Hoeft and Bob Pryor, MD, was published. It details Baylor Scott & White Health’s journey from just one-of-many to one-of-the-best idea generating, staff engaging, Lean Management System building healthcare organizations in the world. I had the chance to speak with Steve about his book, and one of the main questions I asked was: "Why haven’t more healthcare organizations seen successes from choosing Lean as a methodology to transform and improve their culture?" Here is his complete response: 

Let’s start with an even more basic question. If you are a healthcare leader at any level, ask yourself, “Do we have good employees working in our organizations? And, do we think they have ideas for improvement?” If so, how many ideas have your staff brought forward and implemented this week? How about this month? Does anyone even ask them? And, if they did, have leaders helped build quick-feedback systems so they can Check if their ideas worked (Plan, Do, Check, Act)? Next, ask yourself the only Lean question – “Why?” 

From those questions, Dr. Bob Pryor, then CEO of Scott & White Health (before merging as equals with Baylor Health Care System in 2013) and I accelerated our previous project-based continuous improvement journey by teaching all leaders to build systems for daily improvements.

 At last count, we see over 2,000 ideas implemented every week! When we just did improvement “projects,” we didn’t see that many ideas tried out in a year! Our culture is changing. We are building a culture of continuous safety, quality, morale, service, finance, respect, and... everything improvement! You asked a good question. Now that a dozen or more healthcare systems have seen sustainable successes applying the Toyota Production System (TPS) aka Lean principles in healthcare, why haven’t more organizations seen successes?

There are many reasons, but we would say the main reason is still denial. Throughout the history of healthcare, leaders were able to use heuristic rules that reinforced their thinking, which was, “What has worked in the past, will work again now.” Coin in, gumball out. But, as healthcare environments change even faster, what worked in the past will not work in the future. Think of how quickly healthcare finance and reimbursements have already “reformed.” The need to change may not appear bigger (yet) than the pain of changing for some. For many, it will be too late. 

Another important reason is that we have relied way too much on low-level, leader-absent improvement projects by small teams. Maybe consultants have added to this myopic focus because projects are easy chunks to schedule and “sell.” But, consultants leave, improvement teams disband, and the changes often slide right back to where they started. 

There is a better way! And, it can engage more staff, while aligning them around common North Star goals. At Baylor Scott & White Health, we still do great continuous improvement training and projects. But, we also use hoshin kanri to align all staff’s North Star goals (CEO Joel Allison’s Vision 2020), and build Lean Management Systems to bring forward their full brainpower daily and close the gaps! 

Our leaders teach all employees that they wear two hats. They are to do their jobs well (follow their standard work), and they are to improve their jobs every day (make it easier, get rid of waste). We also promise to give them the tools to do this, and that their leaders will help build systems to allow them to try out their ideas. Something changes inside a staff member when they bring forward an idea in a pre-shift huddle, their team tries it out, they see that it worked, and then a leader thanks them. It changes in a very positive way when they see a meaningful measure move toward their goal and get recognized. The staff member goes home that night, gathers his or her family around, and says: “Kids, if I wasn’t working at Baylor Scott & White, that place would be going to heck in a hand basket. I am helping achieve all our goals with my ideas. You should have seen how happy the team was today when my idea worked! I knew it would. I think I’ll bring up another idea next week.” 

Organizations often ask for ideas from staff on teams but few have done so to the extent and with as much success as we have thus far. In the book, Bob and I share our experiences building a wide culture of continuous improvement over the past eight years at Scott & White, now Baylor Scott & White -- including our successes and failures. We weren’t smarter than other health systems. Maybe we were just more desperate, given the challenges we wrote about. 

Our new book offers insight on how to engage staff and garner ideas through projects, goal alignment and creative use of huddles. It also presents ways that your good staff members can try out their ideas without spending time away from their work. It works.

What do you think of Steve's thoughts on the power of ideas to transform healthcare? I'd particularity like to see comments from healthcare leaders and practitioners who are currently on a Lean or continuous improvement journey.

Lean is the Medicine that Healthcare Systems Require

Last month, an important book titled The Lean Prescription: Powerful Medicine for Our Ailing Healthcare System, authored by Patricia Gabow and Philip Goodman, was published, and it details how Denver Health became the first healthcare organization to be awarded the Shingo Bronze Medallion Prize for Operational Excellence. 

I had the chance to speak with Patricia about her book, and one of the main questions I asked was: "Why should healthcare organizations choose Lean as a methodology to transform and improve their culture and results?" Here is her complete response: 

Let me go back one step from this question and first answer an even more basic question, “Why must healthcare organizations transform at all?” Pondering this question is what led me to Lean. There is a national-level answer and an organizational-level answer to this question. I contend that the USA doesn’t have the best healthcare system in the world. Fortunately, both the state and federal governments are taking a wide array of steps to begin to address the issues of coverage, cost, quality and care co-ordination. But the fruits of the policy changes will only occur if individual healthcare systems are transformed. 

My 40 years in healthcare, first as a practicing physician and then as an administrator, convinced me we needed transformation at an organization level. Standing in any clinic or any hospital unit tells you we are basically doing things like we did when I was an intern more than 40 years ago -- we have new drugs and new technologies, but most of our processes are the same. We need transformation in all our healthcare institutions and that will require clear (and new) methods to achieve it. We must identify, prescribe, and administer some powerful medicine to the system. 

I think Lean is that medicine. The power of Lean lies in the fact that it is both a philosophy and a tool set. The Lean philosophy teaches us that transformation is built on the two pillars of Respect for People and Continuous Improvement. These should always have been the pillars of healthcare. Even if healthcare had to wait for an automobile manufacturer to teach us this, we can embrace it. 

In my decades in healthcare, I, as others in healthcare have tried many approaches to reducing cost and increasing quality. Lean was the most powerful approach I had ever seen. There are few, if any other, approaches that hit the target on quality, cost and employee empowerment. 

For example, other approaches that reduce costs at best can hope to keep quality the same and keep employees neutral about both the process and outcomes of the cost reductions. Because Lean focuses on getting rid of waste that shouldn’t have been there at all, its focus can’t be argued about -- who wants to defend waste? Because Lean is built on respect for people, the Lean tools that let us see and eliminate waste can be used by every employee. You don’t need a PhD to use an elegantly simple tool like a spaghetti diagram. Every employee becomes an engaged problem solver. We gain an army of problem solvers -- it is no longer just up to executives to make our systems better. 

While these are the intellectual reasons why Lean is the methodology for healthcare organizational transformation, the real “proof is in the pudding.” At Denver Health we realized over $192 million of hard financial benefit, achieved outstanding quality such as having the lowest observed to expected mortality of all academic health system members of the University Healthsystem Consortium and having 83% of our employees say they understood how Lean helped us maintain our mission. Lean is the method that hits the bull’s eye on cost reduction, quality of care, and employee engagement. How could you not use such an approach? 

What do you think of Patricia's thoughts on the power of Lean to transform health systems? I'd particularity like to see comments from those in the healthcare sector who are currently part of a Lean initiative.

The Denver Health & Hospital Authority -- The Results Are In

Over on the Hospitals and Health Networks site, I read this great article about the Denver Health organization's incredible benefits resulting from its six-year Lean journey. Patricia A. Gabow, CEO of the Denver Health and Hospital Authority, believes the $135 million financial benefit since 2006 is a result of the adoption of Lean management techniques. In addition, in 2011, the hospital evidently saw "$46 million in financial benefits from Lean projects."

Other than the amazing benefits discussed in the article, I found this detail quite interesting: "There are 16 value streams and an organized method for picking improvement projects. Some are short term, others extend over multiple years, such as revenue cycle, the OR and community health. Each value stream has an executive sponsor and a steering committee that meets monthly. Gabow reviews metrics for all of the value streams and rapid-improvement events every month."

What do readers working in the healthcare industry think of this format for value stream maps? Are your maps used in the same fashion?

After winning the coveted Shingo Prize for Operational Excellence (the first healthcare organization to achieve this feat) , Denver Health now offers its own Lean Academy. Check out the video presented at the Shingo Award ceremony:

Improving Healthcare in the Lehigh Valley

I recently read this interesting white paper titled Using Lean Management to Improve Access to Both Psychiatric and Medical Care, authored by Dr. Michael W. Kaufmann, the chairperson of the department of psychiatry at the Lehigh Valley Health Network. He documents four quality improvement projects using Lean methodology. The four projects focused on: a collaboration plan for medical floor transfers, inpatient psychiatry units, an ancillary reduction project, and an emergency department LOS (length of stay) reduction project.

The most revealing section explains the two main reasons for the success of the projects: 1. A collaborative, interdisciplinary approach, which ultimately results in a “peaceful, silo-busting approach." 2. Buy-in from key stakeholders.

What are your reactions to the results and the lessons learned?

NYU Langone Medical Center Embraces Lean & Six Sigma

The NYU Langone Medical Center partnered with the Institute for Management and Executive Development (IMED) at the Rutgers University School of Business in Camden, New Jersey to become a "world-class" and "patient-centered" medical facility according to this article on the Rutgers University Continuing Studies site.

Martin Costa, the director of Organizational Development and Learning at NYU Langone Medical Center, is now the director of the new Lean Management Office as well. He states that, other than the benefits of waste-reducing pilot projects and increased operational efficiency, "we are creating a different atmosphere here in terms of how people identify, address, and collaborate on solutions." It appears this initiative is not focusing merely on cost-saving activities, but creating a cross-functional, team based culture.

In addition, it seems change is occurring from the top down -- Martin points out that “one of the most valuable gains is a deeper knowledge of how to be effective as a leader of change.”

Can any Lean initiatives sustain if the leadership of an organization does not embrace and direct the culture change?

Lean "Mentor" Hospitals

Although I always like reading about the successes gained from a lean initiative, I don't mind hearing about them as well! Listen to this news report from Dave Padilla from KCBS in California.

The proliferation of lean initiatives in healthcare during the past five years has been dramatic because of rising costs and the legacy of redundant and wasteful processes. It appears the Contra Costa Regional Medical Center in Martinez, CA revolutionized its operations and the quality of patient care after it adopted its version of a lean management design. The important strides -- most notably, the significant reduction of ventilator-associated pneumonia instances -- has resulted in the facility being named a "mentor hospital" by the Institute for Healthcare Improvement (IHI). Much praise should be given to CEO Anna Roth and her entire staff for the determined effort and measurable results.

Where do you see the potential power of lean making crucial improvements in hospitals and medical facilities? What are the biggest hurdles to not only the successful implementation of the tools but the development of the proper culture?

How Should Insurers Pay Doctors and Hospitals for Healthcare?

In the debate over reforming healthcare, one issue that is rarely discussed is how to reform the way insurance companies pay for healthcare.

One recent change that received a lot of publicity was a decision by Medicare (and some private insurers) to stop paying for treatments required as the result of serious medical errors – so-called “never events.”

A couple of recent postings in The Wall Street Journal Health Blog have explored the issue of reimbursements. One posting noted a push by Blue Cross Blue Shield in Massachusetts to shift away from paying for every procedure to a system in which a flat fee is paid to take care of people, healthy or sick – with bonuses for meeting certain targets concerning patients’ health. (An interesting idea.)

More recently the Health Blog reported on a study published in the Journal of the American Medical Association. The study stemmed from the idea that doctors should be paid for the quality of the care they provide, not the quantity. Some people propose doing that by measuring how a doctor’s practice compares to (or deviates from) national averages for particular quality measures, such as blood-sugar control in diabetics. The study examined whether small practices see enough patients for valid conclusions about quality of care (and concluded that the number of patients is too small at many practices for valid comparisons).

I have problems with that last concept. In any situation where quality matters, we lean advocates believe you should not be striving to match others, but striving continuously to achieve perfection.

However, that begs the question of what should be the basis for payment. The Health Blog notes that the same issue of JAMA that reports on the study also contains an editorial written by Don Berwick of the Institute for Healthcare Improvement, who makes some suggestions.

They include asking patients “how well they feel treated,” to measure qualities such as timeliness and responsiveness. Another possibility, he says, is moving toward measuring actual outcomes that are the reason people go to the doctor: “health, function and comfort.”

From a lean standpoint, measuring outcomes makes the most sense. It all relates to value, which is what lean is all about. Payment should be made for that which the customer defines as value. And if the customer is the patient, value is most likely defined as good health.

But it’s more complicated than that, since medical outcomes cannot be guaranteed. For example, doctors may do all the right things in treating someone critically ill, yet the patient may die anyway. The doctors still deserve to be paid for their efforts.

It is a tricky, complex situation with no easy answers. Any suggestions?

Lean is Basis for Acquisition of Consulting Firm

An item about a consulting-firm acquisition caught my eye the other day. Broadlane, a Dallas-based company that describes itself as a “cost-management company for healthcare providers,” is buying another consulting firm, Healthcare Performance Partners (HPP).

I’m not familiar with either firm, but what I found interesting is that Broadlane is buying HPP because the latter firm’s specialty is providing lean and Six Sigma consulting and training to healthcare organizations.

According to Tom Sherry, chief operating officer, Broadlane, “While Lean and Six Sigma have long been cornerstones of manufacturing, healthcare providers are only now beginning to more broadly implement these approaches to remove waste and cost from their systems while improving quality of care.”

In case you hadn’t heard, it sounds like this lean thing is catching on in healthcare.

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.