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Monday, June 8, 2015

Healthcare Lean Transformation Summit 2015, a reflection

If you don't have this book, get it and study it.

better healthcare, 
an introduction

...Every day hundreds or thousands of people come to medical providers with illness and injury only to be mistreated and overcharged. 98% of the time this harm is not the fault of individual caregivers but of our healthcare system in general. Our processes for treating people are so fundamentally broken that mistakes are inevitable.

The debate over whether the nation has a sustainable healthcare system is over. Decades of rising costs and poor quality proved it does not.

The question has been how to address the problems. This is no small query. Not only do we need to mend our disjointed processes for delivering care, we in healthcare need to respond to an array of changing laws, new payment proposals, and quality measures. Those who are not adaptive are about to get run over.

… So many hospitals and health systems are using lean tools that lean healthcare has become a movement of sorts sometimes it is a punchline, unfortunately, because the bad news is that these programs have a fundamental flaw that threatens to derail even the most muscular efforts. In one hospital after another, I see the quest for positive change isolated as a discrete project, divorced from the daily work of managers, separate from the “real” business of the organization. People are stopping at reform when a revolution is required. The result is a vicious cycle of energetic hope followed by failure to create sustainable change…

...I am seeing hope and failure in nearly equal measure teams of clinicians and administrators using lean thinking are making breakthroughs every week as they increase quality and reduce costs. But the essential transformation of the organization is not happening due to some basic misunderstandings about lean in healthcare.

The most common problem I see is that leaders failed to recognize the magnitude of change that will be required and that change extends to the leaders on a personal level. People set out on a lean journey thinking that improvement work will be the job a few staff experts or consultants who will guide some projects. These projects will improve operations; people will learn how to initiate new improvements; and gradually, the theory goes, the organization will become lean. When I see this kind of attempt taking place, it always looks to me like the leaders have simply handed over the keys to the consultants or the improvement staff and expected them to return with something new, high-performing, and sustainable in the place of the old organization. This does not work.

Lean cannot be grafted onto an organization like the limb of a different tree…

So, for the record, lean healthcare is not an improvement program. It is an operating system within a management system that requires a complete.e cultural transformation… The CEO is support staff; his or her job is to identify and remove barriers so that problem solvers, such as inpatient hospitalist physicians and the newest x-ray technicians, can see and solve problems.

Most healthcare organizations could not look more different from the lean model. Management thinking is mostly dissented from how Fred Sloan, the General Motors CEO and dominant force in 20th century business practices in the United States… Sloan philosophies created Management by Objectives.  this common style of leadership creates a situation in which a CEO tells a senior leader, “go out and start a lean initiative. Do what ever it takes. Go fast. We will judge you based on lean's success.”

And that is the beginning of a lean healthcare failure...

At the front line of care, working on teams, I saw that lien would utterly transform our culture if we did this right. Here was an improvement methodology that engaged our front-line people — the same ones who knew the problems he intimately…

…Our leaders should have been learning strategy deployment, visual management, and how to support the model cell. We should have been redesigning the tasks and patterns of our work lives. Instead, we were using old leadership methods and expecting new results...

Now, I know from visiting dozens of hospitals and clinics struggling with the exact same issues that these are symptoms of management by objectives in a lean environment, which simply does not work. Lean demands real, systemwide change by every manager,  starting at the top. Senior leaders cannot delegate a profound cultural shift; they cannot expect others to embrace change while they continue working in the same old command–and–control style, checking the numbers without really understanding how the numbers were or were not achieved…

Now I am ready to say that there is a right way to embark on a lean journey. We…Have discovered a model for a lean transformation networks, and this book describes it through the people who are doing the work. It is a story of many journeys joined together and told through the best practices and fresh ideas found in hospitals and clinics across North America.  The organizations in these pages have not followed precisely the steps I will lay out in this book, but what others and I have learned from their journeys has helped inform this path...

Newly designed processes helped physicians complete all note taking and close patient files while still in the exam room with the patient. Physicians agreed that their documentation was better in this new process, since they did not have to remember the details of many appointments over a busy day…

“Lien has been a tipping point toward cultural integration for us,… we always had a culture focused on service. Now we all know how to make improvements, too. Physicians assistants and nurses — they know how to identify a problem and create an action plan. We are speaking a common language.” (Michael Conroy, MD)...

Values are the highest beliefs and aspirations of the leaders; these are what steer the company… Principles guide behavior, which should always lead toward satisfying the organizations values…

Remember that values should strike at the heart of our humanity. “Becoming lean” is not a value…

Redesign your management system to support the lean transformation….

After personally witnessing a few epic battles between lean change agents and the good people of human resources I recommend that you forge an early partnership with HR…

One of the hallmarks of a lean transformation: support services — HR, finance, IT — shift focus from producing their own inward looking reports to actively supporting the organization’s improvement efforts…

Everyone  in a healthcare organization goes to work every day to save lives, to restore health, to avoid harm…

This is the path [lean] we have discovered for transformation: lay the foundation, building models sell, establish the values and principles that will guide the work, create a central improvement office, redesign the front line management system, and spread the work throughout the system. Then realign the organization’s policies and practices, especially in human resources, finance, and information technology, to support this work there will be barriers and curveballs, such as new payment schemes and medical education system that keeps churning out heroes instead of team players but we will work through those, too.

This pass goes beyond the action plan that I laid out in my 2010 book, On the Mend,  to focus more clearly on management and the entire organization…

Leaders rarely consider changing the interconnected system. Just as a patient’s health is not limited to a heart or kidney alone, it is true that healthcare improvement is not just about new cancer therapies or central line infection reduction projects. Lean healthcare is about creating a biologic organism in balance. Let’s get started.
Indeed. Time's a'wastin'.

There were 5 Keynotes and 18 concurrent Learning Sessions during #HCsummit15. Below, the title slides from those I was able to witness.

The Learning Sessions were all packed with Lean projects outcomes data. I was already a believer, but in the wake of these presentations, I think the positive evidence is pretty overwhelming (though some might raise a "publication bias" objection).

I have to say, I have new respect for the RIE (Rapid Improvement Event) tactical component method sometimes called "Agile" after attending the Salem Health session. I had a bit of skeptical sport with "Agile" and "Six Sigma" a few years back in my post "Single Source of Truth." 
Six Sigma" accords us a couple of lovely metaphors: [1] the boundary within plus or minus six standard deviations around a process average, assuming a perfectly Gaussian ("bell curve") dispersion, and [2] all those cool martial-arts green and black "Belts."...

In the software realm, "Agile" ups the allusive ante.

Will this be a hot new business line of professional certifications? Lordy. Agile Grasshoppers to Agile Samurai? And, to further jumble the metaphors, will they be donning rubgy attire for "scrums" and track gear for "sprints"?
While still always wary of Dilbert Zone fad potential, the folks from Salem taught me something.

I hated to miss out on the other Learning Sessions. I've downloaded all of the presentation slide decks and will study them all closely. The decks alone comprise a ton of material. I have Adobe Acrobat Pro XI, so I combined all of the slide deck PDFs. The result was a 70.4 mb, 557 page master document.

I keyword-searched for "Just Culture," and the only place I found it cited was in Beth Daley Ullem's amazing Keynote address.

The presenters from Salem Health in particular stressed the priority of "people and processes" (in that order) over the "magic boxes" of technology. I could not agree more, notwithstanding that I am nominally a "Health IT" guy.

apropos, consider John Toussaint on page 171 of "Management on the Mend."
I strongly recommend that any organization using lean thinking as an organizing methodology build its principles using the Shingo model.
  • Respect every individual;
  • Lead with Humility;
  • Seek perfection;
  • Ensure quality at the source;
  • Employ scientific thinking;
  • Focus on process;
  • Think systematically;
  • Create constancy of purpose;
  • Achieve transparency through visual management.
[Bullet list breakout mine. A lot of that is Deming 101.]

Bullet points 1-3 in particular are pure "Just Culture." I'll repeat my "Talking Stick" observation of about a year ago.
My recent posts have ruminated on what I see as the underappreciated necessity for focusing on the "psychosocial health" of the healthcare workforce as much as focusing on policy reform (e.g., P4P, ACOs, PCMH), and process QI tactics (e.g., Lean/PDSA, 6 Sigma, Agile), including the clinical QI Health IT-borne "predictive analytics" fruits of ""Evidence Based Medicine" (EBM) and "Comparative Effectiveness Research" (CER). Evidence of psychosocially dysfunctional healthcare organizational cultures is not difficult to find (a bit of a sad irony, actually). From the patient safety-inimical "Bully Culture" down to the "merely" enervating emotionally toxic, I place it squarely within Dr. Toussaint's "8th Waste" (misused talent).
Again, healthcare delivery, particularly in the acute care setting, is an irreducibly, persistently high cognitive burden enterprise. Avoidable interpersonal conflict and stress is inimical to effectiveness, and is at its worst a patient safety issue.

See also my post of June 20th, 2014, "Continuing on the three-legged stool riff: more on "Just Culture," workforce engagement, and leadership in healthcare."

"SEEK" perfection, indeed. But, David Marx reminds us that errors are inevitable notwithstanding our best prophylactic efforts. Reducing their frequency and consequences is contingent on both the way we construct our fault-mitigating systems and the way we react toward others when mistakes occur. Reflexively disrespecting others-- either as a cultural ethos generally or  in the wake of error (e.g., the still far-too prevalent "Shame and Blame" culture) -- is not Shingo, not Lean. "Leading" autocratically and judgmentally is not Shingo, not Lean.

BTW: on the topic of "error," I highly recommend this delightful book.

Elevator speech: We all pretty much think we're right about everything all of the time, and are episodically mortified to be publicly found to be wrong. Assuming we're right about everything is a fundamental source of human conflict, given that those who disagree must be either woefully ignorant, intractably stupid, or evil.
Why is it so fun to be right? As pleasures go, it is, after all, a second-order one at best. Unlike many of life’s other delights—chocolate, surfing, kissing—it does not enjoy any mainline access to our biochemistry: to our appetites, our adrenal glands, our limbic systems, our swoony hearts. And yet, the thrill of being right is undeniable, universal, and (perhaps most oddly) almost entirely undiscriminating. We can’t enjoy kissing just anyone, but we can relish being right about almost anything. The stakes don’t seem to matter much; it’s more important to bet on the right foreign policy than the right racehorse, but we are perfectly capable of gloating over either one. Nor does subject matter; we can be equally pleased about correctly identifing an orange-crowned warbler or the sexual orientation of our coworker. Stranger still, we can enjoy being right even about disagreeable things: the downturn in the stock market, say, or the demise of a friend’s relationship, or the fact that, at our spouse’s insistence, we just spent fifteen minutes schlepping our suitcase in exactly the opposite direction from our hotel. 

Like most pleasurable experiences, rightness is not ours to enjoy all the time. Sometimes we are the one who loses the bet (or the hotel). And sometimes, too, we are plagued by doubt about the correct answer or course of action—an anxiety that, itself, reflects the urgency of our desire to be right. Still, on the whole, our indiscriminate enjoyment of being right is matched by an almost equally indiscriminate feeling that we are right. Occasionally, this feeling spills into the foreground, as when we argue or evangelize, make predictions or place bets. Most often, though, it is just psychological backdrop. A whole lot of us go through life assuming that we are basically right, basically all the time, about basically everything: about our political and intellectual convictions, our religious and moral beliefs, our assessment of other people, our memories, our grasp of facts. As absurd as it sounds when we stop to think about it, our steady state seems to be one of unconsciously assuming that we are very close to omniscient...
What is true of our collective human pursuits is also true of our individual lives. All of us outgrow some of our beliefs. All of us hatch theories in one moment only to find that we must abandon them in the next. Our tricky senses, our limited intellects, our fickle memories, the veil of emotions, the tug of allegiances, the complexity of the world around us: all of this conspires to ensure that we get things wrong again and again. You might never have given a thought to what I’m calling wrongology; you might be the farthest thing in the world from a wrongologist; but, like it or not, you are already a wrongitioner. We all are.

Schulz, Kathryn (2010-05-25). Being Wrong: Adventures in the Margin of Error (pp. 3-4, 9). HarperCollins. Kindle Edition.
"Wrongology," LOL. Gotta love it.


I would love to just keep writing this morning, but PG&E has notified us that we're fixin' to have a protracted (~ 4-6 hr) neighborhood power outage shortly for some repairs. Swell. gonna be the hottest day of the year here thus far (~102F in my 'hood), and still no rain in sight.


Power's back on. Good thing; feels like Vegas outside today.

How about an excerpt from Chapter 10 of Management on the Mend?
Barriers to the work

Barriers are like enemies. We need to know them — what they look like and where they hide — in order to successfully navigate the trouble they cause. And some of the barriers are hidden behind pretty good camouflage.

Numerous obstacles to a lean transformation come from within an organization, many of which have been described in previous chapters. But the most difficult barriers may be lurking outside of healthcare. The three biggest barriers are medical education programs that churn out heroic individuals instead of team players, the lack of publicly available outcomes data for quality and cost, and perverse payment incentives. To be fair, most of these barriers are in direct response to the way doctors traditionally practiced medicine.

Physicians said that doctors should be solely in control of patient care and the doctors know best. Medical schools have been churning out autocratic, heroically minded positions ever since. Physicians have not collected data on patient outcomes and have entered contracts with insurers to keep secret all Payment information. So the public is largely blindfolded while making healthcare choices. The medical profession clings to a system in which providers are paid for work piecemeal and Bill separately for each instance of service. So we have a system that pays for procedures instead of for health.

These arrangements are now outdated and counterproductive, especially for lean systems that have invested significant resources to improve patient care. In lean health systems, we have to spend time retraining positions to see waste and potential for harm. We work hard to get patients into and out of treatment faster — reducing waiting times, creating shorter hospital stays — and therefore get paid less...

Together, we need to pressure academia, the centers for Medicare and Medicaid services (CMS), and private insurers to correct their incentives and align with a lean system that puts patients first and is always working toward better quality at lower cost...
OK, let's stop right there. apropos of the foregoing, specifically the latter paragraph and directly in line with Doug McKeever's CalPERS Keynote, comes this Academy Health article.
The latest on reference pricing

However you feel about reference pricing, the latest paper on the subject by James Robinson, Timothy Brown, and Christopher Whaley is worth knowing about. As Robinson and Brown found in an earlier study, the approach can make a large impact on the market — affecting market shares and prices — at least for specific, elective procedures.

As Nicholas Bagley and I explained, with reference pricing, “insurers set the price they’re willing to pay for a given service or procedure, typically pegging it to a price at which it can be obtained at good quality.” Policyholders then pay the difference if they obtain that service or procedure for a higher price. That is, in contrast to copayments for a fixed amount for a procedure, with reference pricing, the policyholder is on the hook for the entire amount (the marginal price) above whatever the insurer pays. That’s why it only makes sense for elective procedures for which consumers can conceivably shop and plan, and in markets for which there is ample competition so they can do so.

The recent study considers reference pricing* by the California Public Employees’ Retirement System (CalPERS) for cataract removal surgery, which began in 2012. This is in the context of the use of reference pricing by CalPERS for hospital outpatient procedures more generally: it set those prices to those charged by ambulatory surgical centers for the same procedures.

I can see the motivation: the difference in price level between hospitals and surgical centers is stunning...

With respect to Dr. Toussaint's allusions to medical pedagogy and "heroic doctors," I refer you to my "Back Down in the Weeds'" section of my April 22nd post "Doctors and nurses in the trenches."


Interesting. Ran across this link in a THCB post comment. From "How The Ruling Class Impacts Your Health Care and Why They Need To Be Stopped"

...When the managers took over they decided to replace some of the department heads at the periphery.  Suddenly there was no longer a certain department that people counted on and their duties were subsumed by another department. The dislocated clinicians either quit in frustration or were relegated to a more peripheral role in the clinic or hospital. They could no longer support a teaching mission and suddenly that block of knowledge was no longer available to students. These experts were consulted in complicated cases to back up the generalists who were now seeing their patients. The next step by the managers was to suggest that productivity in the larger departments was uneven. They suggested that they had a metric so that would assure that everyone in the department was pulling their weight. When I first heard that explanation, I looked around and concluded it was a myth. Everyone in my department was a hard worker and that was borne out by the actual numbers. The numbers were the real story. The rhetoric had allowed the managers to introduce a system to manage productivity that was completely subjective. But that was all the managers needed to develop a system to manage knowledge workers like production workers even to this day.

Why would anyone want to be a manager? Well it seems like easy work if you can get it. Instead of dealing with complex problems that require you stay current in a certain body of knowledge, interact with people in an ethical way, and have extremely high levels of accountability why not just manage numbers and tell people what  to do - especially people who are as politically inept as physicians and their professional organizations. If I ask physicians that question, I usually hear that being a manager or studying business would just be "too boring." That may be applying a medical metric to business that could be far from the mind of managers. Some business educators and critics have pointed out that over the past 2 decades, there is evidence that managers have developed who are focused on short term results and in some cases "the pursuit of short-term shareholder interest, as well as naked self-interest on the part of managers, into managerial virtues." (reference 2). Instead of a manager who knew and was promoted from within the business and who had a vested interest in the quality of the services and interests of the employees, we now have a class of managers who are mobile, highly paid, and have no particular expertise in the affected business. Piketty notes that the United States has invented a "hypermeritocratic society" of "supermanagers". These supermanagers are typically executives of large firms who have been able to obtain "historically high, unprecedented compensation packages for their labor." He also concludes that "the vast majority (60-70%) of the top 0.1 percent of the income hierarchy in 2000-2010 consists of top managers."(p. 302). I don't know Piketty well enough to say what his conclusions about why this meritocracy exists.  He does point out that it is twice as likely to occur in the financial services industry.

There are interesting parallels in the management of financial services and medicine. In both cases, the managing class came about largely as an invention of federal and state governments. The invention of the manager's tools in medicine (billing and coding, utilization management, prior authorization, managed care) parallels the development of credit reporting and the ability of financial manager to put your savings and retirement funds at risk all of the time without offering you any compensation for the use of your money. Both of these systems are subsidized by huge hidden tax subsidies from American taxpayers...
Definitely not Shingo.


Anxiety over the looming SCOTUS ruling on "ObamaCare" is seriously ramping up in Punditistan. See my March 4th post on the specious waste of time comprising King v. Burwell.

Also, from the tech front...
"Clinical software designs traditionally overemphasize data capture and data storage—user interfaces, usability, patient safety, and clinical algorithms are add-ons modeled after data are specified. And, like most add-ons, they are not as robust as they might be if they were part of the initial design thinking."
From the always excellent postings of EHR Science author Jerome Carter, MD: "The Challenges of Improving EHR Designs for Patient Safety"

Might Health IT benefit from some serious "A3 Thinking"? Some serious Gemba face time by those writing the code?

Just in...

Lesser consensus, though, on EHR impact on other aspects of care (pdf).

More to come...

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