The article’s lead does a good job of summing up the issue:

Under laws in more than two dozen states and new Medicare rules that went into effect earlier this year, hospitals are required to report infections — risking their reputations as sterile sanctuaries — or pay a penalty. That’s left hospital administrators weighing the cost of ‘fessing up against the cost of fines.

So, in effect, the administrators are faced with weighing the financial impact of lost Medicare payments vs. the financial impact of telling the truth about their infection rates. This is, in my mind, yet another symptom of the General Motors style of management that is taught by every MBA program in the world.

It also suggests that there is a viable alternative of continuing to maintain the illusion that it is not a problem.

Is it a problem? Hospital infections kill about 90,000 people a year in the USA. Compare that with the 40,000 or so that are killed in traffic accidents, and you get the idea.

Add to that the fact that the patient ends up getting billed (and usually insurance pays the bulk) for the treatment of these infections.

Fundamentally this is about quality, and the problem is certainly not limited to health care. (it is just that lives are at stake)

How does your company respond when there is a known issue that is impacting quality?

If you deliver a defective product or service, do you charge your customers for the rework? This is not a facetious question. Some companies do.

Do you avoid collecting information for fear of revealing the true magnitude of a problem?

Do your workers fear bringing it up when they are directed to carry out inappropriate actions, or actions which violate the company’s written policies and procedures?

Is it OK to improvise outside of your known process in order to get the part out the door?

Back to the hospital – we know how to tackle this problem. It is merely extremely difficult. That doesn’t make it impossible. I am glad it is getting attention. I am disappointed that it takes government generated threats of visibility to get action.

Fed from: The Lean Thinker. Copyright © 2012, Mark Rosenthal

NPR: Hospitals New Face Pressure to Reduce Infection Rates

But that conference was on Friday. I arrived in-country on Monday morning at 7:30am. By 10:30 am I was in sterile scrubs in an operating room observing a knee replacement operation. (I was told of this agenda while on the way there, at about 9:30.) I’ve got to say it was quite an interesting experience, and here is my public, if belated, thanks to Dr. Jacob Caron, who graciously brought me into his domain. Thanks, also, to his patient for allowing me into this bit of her life as well.

The experience was fascinating, and enlightening. Here is the core value-add of a long and complex process as the patient is moved through the various stages of treatment. And at that core, things are organized, quiet, efficient. Of course it is nothing like an O.R. on television. Drama is the last thing a real-life surgeon (or patient, for that matter) wants in the O.R.

The work flow of instruments caught my eye. We all know that the surgeon asks for the instrument he needs, and the O.R. nurse hands it to him, usually anticipating his request.

But there is a return flow as well. As the surgeon is done with an instrument, he puts it down as he asks for the next one. The O.R. nurse then quickly picks it up, wipes it (if necessary), and re-orients it so she can pick it up quickly when it is needed again.

None of this is really surprising with a little thought. I imagine the tight circle around the patient is organized pretty much the same way in every operating room in technologically advanced countries. In manufacturing, we use the “like a surgeon” analogy to describe how team members who directly add value should be supported.

Later that afternoon, I was touring the ward where the orthopedic surgery ward with the supervisor.

They are working on kaizen, they have an Problem – Improvement board and do a decent job keeping track of things that disrupt work.

“No time” seemed to come up a lot as a reason for the nurses. And, from what I know of the workload of hospital nurses, this is not a surprise either.

But where does their time go?

Let’s consider that nurses are the front line. Yes, the physicians get the attention, but aside from cases like surgery, it is the nurses who actually deliver the care to the patient. In other words, though the physicians design the care, it is the nurses who actually carry it out.

So here was my question / challenge to the audience at the conference:

No operating room in the developed world would ever tolerate a situation where the surgeon had to go look for what he needed to deliver care to the patient. The surgeon’s world is fully optimized so she can devote 100% of her attention to the patient.

Yet, in those very same hospitals, all over the world, we tolerate – every day – conditions where nurses, who are also primary care providers, spend too much of their time fighting entropy, looking for what they need, improvising, dealing with interruptions – all of the things we would never tolerate in the O.R.

Why the disparity?

Fed from: The Lean Thinker. Copyright © 2012, Mark Rosenthal

Some Healthcare Observations

The Chicago conference turned out to be very Six Sigma centric – in spite of having Mike Rother as a keynote. But that is history.

I want to reflect a bit about this podcast. I invite you to listen yourself- it is an interesting perspective from a senior executive who discusses her own learning and discovery. I will warn you that you may have to “register” on the web site – though you can uncheck the “send marketing stuff” box. I will also say that the interview’s sound is pretty bad, so it is hard to hear the questions, but I was able to reconstruct most of it from context.

What is interesting, to me a least, is that the methods and experiences are pretty standard stuff – common to nearly all organization undertaking this kind of transformation.

A summary of the notes I took:

They have to deliver hard budget level savings on the order of 5% a year for the next several years. That is new to them as a government organization.

They started out with an education campaign across the organization.

Initial efforts were on increasing capacity, but those efforts didn’t result in budget savings. In one case, costs actually increased. They don’t need more capacity, they need to deliver the same with less.

They have identified process streams (value streams), and run “rapid improvement events.”

Senior people have been on benchmarking or study trips to other organizations, both within and outside of the health care arena.

They are struggling to sustain the momentum after the few months after an “event” and seeing the “standard” erode a bit – interpreting this as needing to increase accountability and saying “This is how we do things here.”

“Sustaining, getting accountability at the lowest level is the biggest challenge.”

In addition, now that they are under budget pressure, they are starting to look at how to link their improvements to the bottom line, but there isn’t a standardized way to do this.

They believe they are at a “tipping point” now.

There is more, having do to with Ms. Doherty’s personal journey and learning, and knowledge sharing across organizations who are working on the same things, but the key points I want to address are above.

Please don’t think that this interview is as cold as I have depicted it. It is about 20 minutes long, and Ms. Doherty is very open and candid about what is working and what is not. It is not a “rah-rah see what we have done?” session.

As I listened, I was intently trying to parse and pull out a few key points. I would have really liked it if these kinds of questions had been asked.

What is their overall long term vision? Other than meeting budgetary pressure and “radically reviewing” processes, and “transformation.” What is the “true north” or the guide point on the horizon you are steering for?

What is the leadership doing to set focus the improvement effort on the things that are important to the organization? What does the process have to look like to deliver the same level and quality of care at 5% lower costs? What kinds of things are, today, in the way of doing that? Which of those problems are you focused on right now? How is that going? What are you learning?

What did they try that didn’t work, and what did they learn from that experience?

When you say “local accountability” to prevent process erosion, what would that look like? What are you learning about the process when it begins to erode?

The “tipping point” is a great analogy. What behaviors are you looking for to tell you that a fundamental shift is taking place?

As you listen, see if you can parse out what NHS Bolton is actually doing.

Is their approach going to sustain, or are they about to hit the “lean plateau?”

What would the “tipping point” look like to you in this organization?

What advice would you give them, based on what you hear in this interview?

Fed from: The Lean Thinker. Copyright © 2012, Mark Rosenthal

British NHS Executive Talks About Lean

The video was apparently produced to dramatize this piece in National Journal Magazine.

Then again, the air travel industry should not go unscathed here, so for your amusement, the TSA Theme by the Bar and Grill Singers, a group of Texas attorneys whose works include “The Jury Sleeps Upright.”

Fed from: The Lean Thinker. Copyright © 2012, Mark Rosenthal

If Air Travel Worked Like Health Care

I get a referral. The information on the referral slip is the name of the referring dentist (which I can’t read), no boxes checked, and “#31″ in the comments.

I call the specialist and start getting technical questions about what my dentist wants them to look at / look for, etc.

So the process is to use the patient as a conduit for vaguely expressed (in layman’s terms) technical information between highly trained specialists.

Sadly, I think this happens all of the time in the health care industry. It seems that there is so much focus on optimizing the nodes that nobody really “gets” that the patient’s experience (and ultimately the outcome of the process) is defined more by the interactions and interfaces than it is by the nodes themselves.

I am really not sure how fundamentally different this is from a pilot asking a passenger to find the maintenance supervisor and tell the mechanic about a problem with a plane.

The net effect is, as I am writing this, the specialist’s office is calling the referring dentist and asking them what, exactly, they want done.. a net increase of 100% in the time involved for all parties to communicate.

While the national debate is on how we pay for all of this, we aren’t asking why it costs so much (or kills more people than automobile accidents do).

Fed from: The Lean Thinker. Copyright © 2012, Mark Rosenthal

Information Transfer Fail

Patient has an eye exam that is covered by her health insurance.

The doctor’s office bills the insurance company.

The insurance company disallows $29.32 in charges because they are above a contractual amount.

The insurance company sends a check for $29.32 to the patient to cover the disallowed charges when she gets the bill from the doctor for the balance.

Do I even need to frame a “Why?” question here?

I think it stands on its own.

Just scratching my head.

Yes, I saw the statements and the check with my own eyes.

Fed from: The Lean Thinker. Copyright © 2012, Mark Rosenthal

Health Insurance Overprocessing Muda

Unfortunately, it looks like more of the same.

This survey looks at things like technical capability – what kinds of specialty procedures these hospitals can perform, and their general reputation  and then ranks them accordingly.

But where are we asking about the basics?

Which hospitals kill or injure the fewest of their patients? What is the rate of post-operative or other opportunistic infection? How about medication errors? These are the things that all hospitals should be “getting right” and yet the evidence is overwhelming that most don’t. Further, nobody seems to be paying attention to it except tort lawyers.

Now take a look at this post on Steven Spear’s blog, and especially the Paul O’Neal commentary that he links to.

Tell me what makes a “good” hospital?

Fed from: The Lean Thinker. Copyright © 2012, Mark Rosenthal

Looking at the wrong stuff: America’s Best Hospitals: The 2009-10 Honor Roll

The health care debate in the USA is increasingly focused on how to pay (meaning who will pay) to operate a dysfunctional system with costs out of control.

I fully acknowledge that in government circles, this is about the only thing they can address.

But the real question is not “How do we pay?” but “Why does it cost so much?”

The care delivery system itself is error prone, dangerous for the patients (and psychologically dangerous for the providers). The net effect is much of the effort of the dedicated, but overworked, staff is siphoned off to deal with problems and chaos that shouldn’t be there in the first place. But there is no system in place, at least not in any operation I have ever see (including some claiming to be “lean”) that systematically detects, responds, corrects, and solves those thousands of little issues that occur every day. People seem too focused on the “big stuff” that creates lots of press.

The financial system is worse. The processing of payments and claims is inefficient (which is a kind word), error prone, chaotic, unresponsive to issues and problems, and treats the patients as though deciphering the “THIS IS NOT A BILL” statements is the only thing they have to do.

Honestly, I don’t have any ideas here. I just see that we are in a political quagmire debating how to pay for a system that shouldn’t be costing half of what it does… and it isn’t about controlling over payments or sharpening pencils on the billing.

What if one major HMO actually “got it” and became the Toyota of health care. Any takers?

Fed from: The Lean Thinker. Copyright © 2012, Mark Rosenthal

Paying the Bills vs. Dealing with the Costs