Lean methodology in healthcare in 2015

Lean still has its skeptics and dismissive naysayers when it comes to its asserted utility in healthcare (or service industries more broadly). I am not among them. Review my inaugural KHIT blog post (a.k.a. the "REC Blog") of more than five years ago, on May 10th, 2010.

See also my initial review of Dr. John Toussaint's excellent book "On the Mend" in my July 30th, 2010 post.

Dr, Toussaint will be keynoting at the now-sold out 2015 Lean Healthcare Transformation Summit in Dallas this week.

I have my press pass, and will be on my way to Dallas early in the morning. I hope John's latest book will have been released and will be available at the conference.

See my May 11th, 2015 post. My favorite John Toussaint quote:

"Manage processes. Lead people."

A principle still lost on many in positions of authority. From another of my Toussaint reads:

Physicians face the most disruptive changes. For 5,000 years—since the Egyptians began attempting disease intervention rather than making sacrifices to shrines—doctors have been paid for doing procedures. Even barbers in the Middle Ages were paid by how many leeches they applied, no matter the outcome. Doctors have enjoyed a high and often mystical status in society throughout history. Many resist changes to healthcare out of fear of losing that status. 

To maintain their position as trusted leaders, however, physicians now need to get out in front on healthcare redesign. Beginning in their own practices, physicians need to organize care around the needs of their patients, learn to recognize waste—what the patient does not need—and eliminate it. Surgeons, internists, and other specialists working in hospitals need to work with administrators and staff to map and understand the entire value stream of the patient experience. Considering the way in which medicine has fragmented into so many specialties, doctors can no longer imagine that they are the sum total of the patient experience. 

While working with others to improve the patient experience, physicians will need to become team members instead of independent autocrats. Good doctors will still maintain a special position on healthcare teams in light of their advanced knowledge and ability to share that with others. But the day of the cowboy doctor who rides in on a white horse, scribbles down some instructions, and rides off into the landscape are numbered. In an environment where professionals work the scientific method—PDSA—together to improve care, that cowboy doctor is an anachronism. 

Standardizing care and emphasizing evidence-based care guidelines will help these team efforts. When nurses and assistants are trained to use care guidelines, they become more adept at seeing issues before they arise and planning better care for patients. Support staff becomes more valuable to physicians when equipped with these tools. 

Some doctors still deride evidence-based care as “cookie-cutter medicine” and fear that care guidelines and standardized processes will dictate how they care for patients. This is not true. Guidelines are there to ensure that everyone in the care process knows the best evidence-based practices for caring for common conditions. And process standardization is the only way to reveal and reduce variation. Rampant variation obscures our ability to see waste and error, to correct our processes, and care for patients. Physicians need to stress science over the art of medicine. Nothing can improve until processes are stabilized and then standardized. Only when processes are controlled can we work as a team to improve.

Toussaint, John (2012-05-28). Potent Medicine: The Collaborative Cure for Healthcare (Kindle Locations 2097-2117). ThedaCare Center for Healthcare Value. Kindle Edition.

So, "Lean"? Absolutely. "Six Sigma"? Not so much (my substantive stats background notwithstanding). Some of my misgivings can be found sprinkled across a number of prior KHIT posts.

Lean has a useful Occam's Razor simplicity to it. You can quickly teach the basic concepts to clinical staffers having only a high school diploma.

Not to imply that it's without a few inherent liabilities.

I anticipate an enjoyable week of learning and reporting in Dallas. I will be probing people in particular on the implications of "Leadership" and psychosocially healthy workforce culture.

...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).

to wit:

Fair and Just Culture, Team Behavior, and Leadership Engagement: The Tools to Achieve High Reliability

In health care we excel in defining projects and tackling them with zeal, yet the end result, particularly in the safety-based ones, is that most do not achieve the desired outcomes. Instead, projects suffer from inadequate design, and we harvest, at best, modest results. Five years after the IOM report “To Err Is Human” there is general consensus that we have not accomplished our goal to appreciably decrease harm, and have little solid evidence that the delivery of health care is safer and more reliable (Kohn, Corrigan, and Donaldson 2000;Leape and Berwick 2005). Other industries, those labeled “highly reliable,” have a more systematic approach to achieve greater success...

A Fair and Just Culture is one that learns and improves by openly identifying and examining its own weaknesses. Organizations with a Just Culture are as willing to expose areas of weakness as they are to display areas of excellence. Of critical importance is that caregivers feel that they are supported and safe when voicing concerns (Marx 2001). Individuals know, and are able to articulate, that they may speak safely on issues regarding their own actions or those in the environment around them. They feel safe and emotionally comfortable while busily occupied in a work environment, able and expected to perform at peak capacity, but able at any moment to admit weakness, concern, or inability, and able to seek assistance when concerned that the quality and safety of the care being delivered is threatened. These workers are comfortable monitoring others working with them, detecting excessive workload and redistributing the work when appropriate to maintain safety and reliability...

That paper is nine years old. Is the "Shame and Blame" culture still the prevailing one? Does one speak truth to power at one's peril?
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UPDATE

Jerome Carter, MD has a new post up at his great EHR Science site.

Moving from EHR Systems to Clinical Care Systems – It’s all about Architecture and Design
by JEROME CARTER

AMIA’s EHR 2020 Task Force Report has joined the chorus of those calling for better EHR systems that can act as smart clinical care assistants. As with similar reports, there is a call for improved usability and workflow support. Now that AMIA’s voice has been added to the list of organizations acknowledging the need for significant changes in EHR systems, the key question, of course, is how to bring about the desired changes.

Software functionality always boils down to architecture and design. Current EHR systems are conceptualized and designed to be repositories of patient data, which is very different from the smart clinical care assistants with the workflow support everyone is demanding. Creating smart clinical care assistants will require more than simply tweaking current EHR systems and new, more robust, data models...

Indeed.

Information model
Every current EHR system has a proprietary data model.   Interoperability requires the complex task of translating between two arbitrary data models. Interoperability would be more tractable if there were a shared information model that everyone could reference...

I continue to have concerns that HL7® FHIR® will comprise a comprehensive shared information model.

TUESDAY OFF-TOPIC ERRATUM

Been blogging about the western states drought lately. Interesting to fly into Dallas and see all the flooding everywhere. Lots of damaged streets and neighborhoods along my route to my hotel too.

BTW: Use twitter hashtag #HCsummit15 to share your experiences.
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More to come...