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Tuesday, June 4, 2013

Lean Healthcare Transformation Summit 2013

Really looking forward to this. Will be meeting and speaking with the heavy hitters of the Lean movement. Mark Graban will be there. We will certainly have a good discussion.

This book is excellent.
A Minute to Learn, a Lifetime to Master 

The basic concepts of Kaizen might seem simple at first. Ask your employees for ideas. Say yes to most of them. Let people implement their own ideas, but help them as a servant leader, if needed. Document the improvements simply. Recognize and thank people for their improvements. Share the ideas with others. The term “Quick and Easy Kaizen” refers to employees identifying and implementing easy improvements that can be done quickly. Creating, growing, nurturing, and sustaining a Kaizen program is neither quick nor easy in a department or a healthcare system. Leaders need to help initiate and support Kaizen, while working tirelessly to create the conditions that encourage people to openly identify problems and work together with their colleagues on improvement. Kaizen requires leaders at all levels to actively make time to inspire, coach, mentor, and recognize people...
The Kaizen culture is about gaining control of one’s work, workspace, work life, attitude, and destiny. It is about creating a safe and secure future for you and your organization. It is about enabling your organization to become and remain the service provider of choice in an area. It is about thinking and learning how to make the world a better place in every way— starting with healthcare practices, not broadly, but in a specific department and workplace. When people gain more control of their world, they are happier...
In healthcare, the primary customers are patients and their families. Within a Kaizen culture, they are happy with the services being provided because the customers have been studied and understood and the value they want and need is delivered to them each time, exactly when it is needed. Furthermore, as the engagement studies earlier pointed out, a top-ten engagement driver is an organization that focuses on customer satisfaction. Employees define success as high-quality care and great service to patients and families. Employees realize that, if they can deliver better service to patients, they are contributing to revenue growth and the long-term strength of the organization, as well as their own job security.
Studies suggest that high employee satisfaction correlates with patient outcomes and lower rates of medical errors. A Towers Watson study concluded, “It was found that employees’ views of empowerment, career development opportunities and teamwork influenced engagement. Further, employee engagement was a key predictor of patient satisfaction, leading to an increased likelihood that patients would recommend the network’s hospitals to others.” It might seem reasonable to conclude that there is causation, not just correlation between these factors.

Every morning I scour the 'net with a variety of search terms and phrases, e.g., "meaningful use." This beauty just popped up.

Meeting Meaningful Use Criteria and Managing Patient Populations: A National Survey of Practicing Physicians
Catherine M. DesRoches, DrPH; Anne-Marie Audet, MD; Michael Painter, MD; and Karen Donelan, ScD
Background: Meaningful use, as defined by the Centers for Medicare & Medicaid Services, will require the aggregation of patient data to enable population assessment. Little is known about the proportion of physicians who are able to meet meaningful use criteria or their use of electronic health records (EHRs) to manage patient populations.

Objective: To evaluate physicians’ reports of EHR adoption and ease of use and their ability to use EHRs for patient panel management.

Design: National mailed survey of practicing physicians (response rate of 60%).

Setting: Late 2011 and early 2012.

: 1820 primary care physicians and specialists in office-based practices.

: Proportion of physicians who have a basic EHR and meet meaningful use criteria and ease of use of computerized systems designed for patient population management tasks.

Results: A total of 43.5% of physicians reported having a basic EHR, and 9.8% met meaningful use criteria. Computerized systems for managing patient populations were not widespread; fewer than one half of respondents reported the presence of computerized systems for any of the patient population management tasks included in the survey. Physicians with such functionalities reported that these systems varied in ease of use. Physicians with an EHR that met meaningful use criteria were significantly more likely than those not meeting the standard to rate panel management tasks as easy.

Limitation: Ease-of-use measures are subjective.

Conclusion: Few physicians could meet meaningful use criteria in early 2012 and using computerized systems for the panel management tasks was difficult. Results support the growing evidence that using the basic data input capabilities of an EHR does not translate into the greater opportunity that these technologies promise.

Primary Funding Source: Commonwealth Fund and Robert Wood Johnson Foundation.
How much more behind the times can one get? "News" means new information. JUNE 6th update:

This dated and misleading "news" is being uncritically re-reported in the Health IT press.
Meaningful use incentives ascend past $14.5B
June 06, 2013 | Diana Manos, Healthcare IT News
As of the end of April, the federal government has paid out $14.6 billion in EHR incentive payments, according to Robert Anthony, deputy director of the HIT Initiative Group at the Centers for Medicare & Medicaid Services’ Office of E-Health Standards and Services.

At the Health IT Policy Committee meeting on Wednesday, Anthony said the numbers were the most current available and show an increasing number of providers are interested in the program. There were 395,000 eligible providers and hospitals in “active registration” in the federal meaningful use program--out of a total pool of 532,000.

Though Medicaid providers lag behind Medicare providers in the program, CMS is encouraged by the steady increase in Medicaid eligible providers signing up to participate. To date, there are some 13,000 Medicaid meaningful users. “We’re seeing more and more come in month-to-month,” Anthony said. “In April, 3,200 came in and demonstrated meaningful use.”...


Seamless trip from LAS to MCO. Made it to the hotel just in time for registration and the opening evening reception. Attendance is about 600. I have a feeling I'm about to encounter a lot of fine minds.


Very nice keynotes this morning. Lots to continue to think about.

Denis M. Donovan, MD. Interesting fellow. A psychiatrist. Skeptical of Lean getting tipping point traction.

John Toussaint,MD. I have both of his books, hardbound and Kindle editions

Francois de Brantes,
Chet Marchwinski, LEI Communications Director
One submitted comment challenged the assertion that "variation is the enemy." That's a misreading of the intent of that statement. We have to differentiate between random variation and causal variation. Deming 101 ("assignable causes"). Recall? You have to "stabilize" a process by removing all special cause variation, so that all that remains is random variation around a process mean, prior to attempting PDSA, lest you commit the QI sin of "tampering" with an unstable process?


Below, a track session on "Leveraging Information to Improve Patient Care." From the title, I thought it might entail discussion of data mining techniques using health IT and/or discussion of Lean methods for health IT software QC/QA/QI.

Wrong on both counts. I asked for a show of hands. Not one person representing HIT software development. Neither did there appear to be any stats people in the room. These were all IT Department Ops people. Decent presentation of useful material to an SRO crowd, but not really what I was hoping for. If anything could use a dose of Lean methodology, it's Health IT software development.

Helen Macfie, Pharm.D., SVP, MemorialCare
The venerable Paul O'Neill, former ALCOA head and Treasury Secretary.

Nice main ballroom crowd for Mr. O'Neill's talk.

Erratum: I broached the topic of "Health 2.0" and "Matthew Holt" during breakfast.

Blank stares. Silencio.

Lean, meet Health 2.0. Health 2.0, meet Lean. C'mon, people.

To be fair, Not-Invented-Here Tribalism can be found everywhere one looks, and, the Health 2.0 crowd is more narrowly focused on Health IT. Moreover, as George Packer recently observed in the New Yorker in his fabulous piece "Change the World," a peculiar, eclectic narcissism pervades the high tech Bay Area / Silicon Valley region:
In 1978, the year that I graduated from high school, in Palo Alto, the name Silicon Valley was not in use beyond a small group of tech cognoscenti. Apple Computer had incorporated the previous year, releasing the first popular personal computer, the Apple II. The major technology companies made electronics hardware, and on the way to school I rode my bike through the Stanford Industrial Park, past the offices of Hewlett-Packard, Varian, and Xerox PARC. The neighborhoods of the Santa Clara Valley were dotted with cheap, modern, one-story houses—called Eichlers, after the builder Joseph Eichler—with glass walls, open floor plans, and flat-roofed carports. (Steve Jobs grew up in an imitation Eichler, called a Likeler.) The average house in Palo Alto cost about a hundred and twenty-five thousand dollars. Along the main downtown street, University Avenue—the future address of PayPal, Facebook, and Google—were sports shops, discount variety stores, and several art-house cinemas, together with the shuttered, X-rated Paris Theatre. Across El Camino Real, the Stanford Shopping Center was anchored by Macy’s and Woolworths, with one boutique store—a Victoria’s Secret had opened in 1977— and a parking lot full of Datsuns and Chevy Novas. High-end dining was virtually unknown in Palo Alto, as was the adjective “high-end.” The public schools in the area were excellent and almost universally attended; the few kids I knew who went to private school had somehow messed up, The Valley was thoroughly middle class, egalitarian, pleasant, and a little boring.

Thirty-five years later, the average house in Palo Alto sells for more than two million dollars. The Stanford Shopping Center’s parking lot is a sea of Lexuses and Audis, and their owners are shopping at Burberry and Louis Vuitton. There are fifty or so billionaires and tens of thousands of millionaires in Silicon Valley; last year’s Facebook public stock offering alone created half a dozen more of the former and more than a thousand of the latter. There are also record numbers of poor people, and the past two years have seen a twenty-per-cent rise in homelessness, largely because of the soaring cost of housing. After decades in which the country has become less and less equal, Silicon Valley is one of the most unequal places in America.

Private-school attendance has surged, while public schools in poor communities—such as East Palo Alto, which is mostly cut off from the city by Highway 101—have fallen into disrepair and lack basic supplies. In wealthy districts, the public schools have essentially been privatized; they insulate themselves from Shortfalls in state funding with money raised by foundations they have set up for themselves. In 1983, parents at Woodside Elementary School, which is surrounded by some of the Valley’s wealthiest tech families, started a foundation in order to offset budget cuts resulting from the enactment of Proposition 13, in 1978, which drastically limited California property taxes. The Woodside School Foundation now brings in about two million dollars a year for a school with fewer than five hundred children, and every spring it hosts a gala with a live auction. I attended it two years ago, when the theme was RockStar, and one of Google’s first employees sat at my table after performing in a pickup band called Parental Indiscretion. School benefactors, dressed up as Tina Turner or Jimmy Page, and consuming Jump’n Jack Flash hanger steaks, bid thirteen thousand dollars for Pimp My Hog! (“Ride through town in your very own customized 1996 Harley Davidson XLH1200C Sportster”) and twenty thousand for a tour of the Japanese gardens on the estate of Larry Ellison, the founder of Oracle and the country’s highest-paid chief executive. The climax arrived when a Mad Men Supper Club dinner for sixteen guests—which promised to transport couples back to a time when local residents lived in two-thousand-square-foot houses—sold for forty-three thousand dollars.

The technology industry’s newest wealth is swallowing up the San Francisco Peninsula. If Silicon Valley remains the center of engineering breakthroughs, San Francisco has become a magnet for hundreds of software start-ups, many of them in the South of Market area, where Twitter has its headquarters. (Half the start-ups seem to have been founded by Facebook alumni.) A lot of younger employees of Silicon Valley companies live in the city and commute to work in white, Wi-Fi-equipped company buses, which collect passengers at fifteen or so stops around San Francisco. The buses—whose schedules are withheld from the public—have become a vivid emblem of the tech boom’s stratifying effect in the Bay Area. Rebecca Solnit, who has lived in Sari Francisco for thirty years, recently wrote in The London Review of Books, “Sometimes the Google Bus just seems like one face of Janus-headed capitalism; it contains the people too valuable even to use public transport or drive themselves. Right by the Google bus stop on Cesar Chavez Street immigrant men from Latin America stand waiting for employers in the building trade to scoop them up, or to be arrested and deported by the government.” Some of the city’s hottest restaurants are popping up in the neighborhoods with shuttle stops. Rents there are rising even faster than elsewhere in San Francisco, and in some cases they have doubled in the past year.

The buses carry their wired cargo south to the “campuses” of Google, Facebook, Apple, and other companies, which are designed to be frilly functioning communities, not just places for working. Google’s grounds, in Mountain View—a working-class town when I was growing up—are modelled on the casual, Frisbee-throwing feel of Stanford University, the incubator of Silicon Valley, where the company’s founders met, in grad school. A polychrome Google bike can be picked up anywhere on campus, and left anywhere, so that another employee can use it. Electric cars, kept at a charging station, allow employees to run errands. Facebook’s buildings, in Menlo Park, between 101 and the salt marshes along the Bay, surround a simulated town square whose concrete surface is decorated with the word “HACK,” in letters so large that they can be seen from the air. At Facebook, employees can eat sushi or burritos, lift weights, get a haircut, have their clothes dry-cleaned, and see a dentist, all without leaving work. Apple, meanwhile, plans to spend nearly five billion dollars to build a giant, impenetrable ringed headquarters in the middle of a park that is technically part of Cupertino. These inward-looking places keep tech workers from having even accidental contact with the surrounding community. The design critic Alexandra Lange, in her recent e-book, “The Dot-Com City: Silicon Valley Urbanism,” writes, “The more Silicon Valley tech companies embrace an urban model, the harder it becomes for them to explain why they need to remain aloof. People who don’t have badges aren’t just a security risk.”

The industry’s splendid isolation inspires cognitive dissonance, for it’s an article of faith in Silicon Valley that the technology industry represents something more utopian, and democratic, than mere special-interest groups. The information revolution (the phrase itself conveys a sense of business exceptionalism) emerged from the Bay Area counterculture of the sixties and seventies, influenced by the hobbyists who formed the Homebrew Computer Club and by idealistic engineers like Douglas Engelbart, who helped develop the concept of hypertext and argued that digital networks could boost our “collective I.Q.” From the days of Apple’s inception, the personal computer was seen as a tool for personal liberation; with the arrival of social media on the Internet, digital technology announced itself as a force for global betterment. The phrase “change the world” is tossed around Silicon Valley conversations...
The technology industry, by sequestering itself from the community it inhabits, has transformed the Bay Area without being changed by it—in a sense, without getting its hands dirty. Throughout most of Silicon Valley’s history, its executives have displayed a libertarian instinct to stay as far from politics and government as possible. Reid Hoffman described the attitude this way: “Look what I can do as an individual myself—everyone else should be able to do that, too. I can make a multi-billion-dollar company with a little bit of investment. Why can’t the whole world do that?” But the imperative to change the world has recently led some Silicon Valley leaders to imagine that the values and concepts behind their success can be uploaded to the public sphere...
Technology can be an answer to incompetence and inefficiency. But it has little to say about larger issues of justice and fairness, unless you think that political problems are bugs that can be fixed by engineering rather than fundamental conflicts of interest and value. Evgeny Morazov, in his new book “To Save Everything, Click Here,” calls this belief “solutionism.” Morozov, who is twenty-nine and grew up in a mining town in Belarus, is the fiercest critic of technological optimism in America, tirelessly dismantling the language of its followers. “They want to be ‘open,’ they want to be ‘disruptive,’ they want to ‘innovate,’” Morozov told me. “The open agenda is, in many ways, the opposite of equality and justice. They think anything that helps you to bypass institutions is, by default, empowering or liberating. You might not be able to pay for health care or your insurance, but if you have an app on your phone that alerts you to the fact that you need to exercise more, or you aren’t eating healthily enough, they think they are solving the problem.”

Steven Johnson, the author of many books about technology, recently published “Future Perfect: The Case for Progress in a Networked Age.” Johnson argues that traditional institutions and ideologies are giving way to a new philosophy, called “peer progressivism,” in which collective problems are solved incrementally, through the decentralized activity of countless interconnected equals—a process that mirrors the dynamics of the Internet. In politics, peer progressivism could mean the rise of “citizen journalists” tweeting and posting on social media, or an innovation that Johnson calls “liquid democracy,” which would allow you to transfer your vote to a friend who is more knowledgeable about, say, the school board. In this thin book, Johnson takes progress as a given, without seriously considering counter-arguments about stagnation and decline. It would be foolish to argue that America’s mainstream media and political system are functioning as they should, but it’s worth wondering if “peer networks” really have the answers. An essay in the journal New Media & Society, by Daniel Kreiss, of Yale; Megan Finn, of Berkeley; and Fred Turner, of Stanford, points out that a system of “peer production” could be less egalitarian than the scorned old bureaucracies, in which “a person could achieve the proper credentials and thus social power whether they came from wealth or poverty, an educated family or an ignorant one.” In other words, “peer networks” could restore primacy to “class-based and purely social forms of capital,” returning us to a society in which what really matters is whom you know, not what you could accomplish.

A favorite word in tech circles is “frictionless.” It captures the pleasures of an app so beautifully designed that using it is intuitive, and it evokes a fantasy in which all inefficiencies, annoyances, and grievances have been smoothed out of existence—that is, an apolitical world. Dave Morin, who worked at Apple and Facebook, is the founder of a company called Path—a social network limited to one’s fifty closest friends. In his office, which has a panoramic view of south San Francisco, he said that one of his company’s goals is to make technology increasingly seamless with real life. He described San Francisco as a place where people already live in the future. They can hang out with their friends even when they’re alone. They inhabit a “sharing economy”: they can book a weeklong stay in a cool apartment through Airbnb, which has disrupted the hotel industry, or hire a luxury car anywhere in the city through the mobile app Uber, which has disrupted the taxi industry. “San Francisco is a place where we can go downstairs and get in an Uber and go to dinner at a place that I got a restaurant reservation for halfway there,” Morin said. “And, if not, we could go to my place, and on the way there I could order takeout food from my favorite restaurant on Postmates, and a bike messenger will go and pick it up for me. We’ll watch it happen on the phone. These things are crazy ideas.”

It suddenly occurred to me that the hottest tech start-ups are solving all the problems of being twenty years old, with cash on hand, because that’s who thinks them up...
Read all of it. Worth your time.


CEO panel up first. Good discussion, from a variety of institutional perspectives.

CEO Panel moderator Mark Graban, co-author of the excellent Healthcare Kaizen


Alan Gleghorn, CEO, Christie Clinic

Nice to see someone use the team sports analogy. I use it routinely You have rules, roles, and improvisation in the face of situational variability. The best teams, whether on the court, or field, or in the clinical setting, cultivate ongoing adaptive "court awareness."
Heading home. The always swell Orlando Airport. I got bumped, and got home 4 hours late.
My summary take of the 2013 Lean Healthcare Transformation Summit is quite favorable overall. A couple of the sessions I attended were rather pedestrian, but all of the keynotes and the CEO panel were outstanding. I sincerely thank LEI for having me. I will add more update thoughts as I finish reviewing my notes.

I was struck by the absence of any explicit SPC presentations (Statistical Process Control). I hope these Lean PDSA evangelists uniformly know their basic stats, Old School that such things may be. I would encourage cross-collaboration with the ASQ Statistics Division (of which I'm a long-time member).

LEI needs to work on its staging. The lighting was underwhelming. Take a cue from Health 2.0: brighter spots, and put up racks of backlighting. (Steal staging tech also from HIMSS).

Great lighting. One of my shots of ONC Chief Farzad Mostashari keynoting at HIMSS13 in NOLA
Maybe its my old background as a musical stage performer, CCTV producer, and Las Vegas live entertainment photographer that compels me to be aware of such things, but, they matter for effective live event presentation.

More to come...



  1. Enlightening post is shared by the author which reflects the capability of the firm for offering premium quality based healthcare practice management services to each of their clients. Presently, all of us are being facilitated with the comforts of those firms who are specialized in providing such kind of comforts to individuals.

  2. Thanks for the great pictures and for the mention of my book. I'm sorry we didn't get to talk more at the Summit, but it's crazy with so many people around. Let's follow up by phone.

  3. I'd love to be part of the 2014 summit as a presenter, as I've done my best to spread methods and lessons about the application of SPC to management (as has Mike Stoecklein from the ThedaCare Center).