Another way of looking at healthcare improvement

A personal experience

A friend of mine was diagnosed in Sep 2013 with a tumour next to his lung. He was referred by his hospital to another city hospital for consultation.

He waited until mid-November before contacting his GP who in turn rang the first hospital. It was then discovered that his file was not forwarded to the city hospital until a while later but because he moved to a new property in 2012, he should really be seen by a third hospital. Meanwhile, he waited.

I only discovered his plight in mid-December. Immediately, I assisted him via my contact and managed to secure an appointment for him to see an oncologist from the city hospital. After his appointment the following week, he was told that he needed a scan.

By late December, the letter has not arrived even as Christmas and New Year break are happening. I am wondering from the perspective of harm what has the system done to him in terms of making him wait and whether we could have done something about it? I am thinking whether someone who does not know the health system could have actually waited longer? I am sitting here and working through the degree of physical and psychological harm that is impacting my friend because of the systemic failure?

Reducing harm currently

In New Zealand’s healthcare, quality improvement is seen within the context of some static events. For example, the Health, Quality and Safety Commission (HQSC) reported in its Serious and Sentinel publication of 2013 the following static events: 

From the analysis, it is obvious that ‘Falls’ is indeed a major event responsible for 51.72% of all serious and sentinel events. If we expand the category of ‘Clinical Management Serious Adverse Events’, you will realise that it covers off the other activities like ‘Diagnosis’ and ‘Treatment’[1].

These events tend to be treated as separate, unrelated and, if I may say, siloed. If ‘Falls’ is the largest component, then our challenge is to organise improvement activities around how to reduce falls. We end up treating each event as its own entity or effectively a time-limited, finite project.

Across other industries

However, organisations outside healthcare are learning that it might be better to see them as linked.

Banks, telecommunication and manufacturing companies, for example, are adopting a process approach to looking at improvements, following the Lean principles developed by the renowned Japanese car manufacturer, Toyota and its accompanying Toyota Production System (TPS).

In New Zealand, telecommunication companies like Vodafone and Telecom are strong believers of processes to lead improvement because lean focuses on the customer and what is important to them (value) while attempting to eliminate the aspect of waste. Lean also allows us to track the elements of time and quality (defects) within the system.

Lean process improvement’s fundamental principle lies in the fact that none of us work alone and that we are all part of an overall process. A time/ quality defect is usually a systemic reason rather than a people issue.

In other international healthcare organisations

In healthcare, making improvements through understanding their processes is still in its infancy.

Perhaps the most prominent adopter of LEAN process improvement is Thedacare.Thedacare is the largest healthcare provider and employer in Northeast Wisconsin employing more than 6,100 staff in 43 sites and five hospitals, serving more than 250,000 patients. Thedacare used process management to deliver improvements by reducing defects, improving patient outcomes, eliminating waste and removing unnecessary costs through its unique improvement system, the ThedacareImprovement System (TIS).

John Toussaint, the former CEO who is a pioneer in this journey, has written a well-regarded and easy-to-read healthcare improvement book titled ‘On the Mend’ in 2010.

In an article published by www.mayoclinicproceedings.org[2], ThedaCare clinic reported the following:

• Reduced inpatient total cost of care by 25%
• Improved patient satisfaction to nearly 100% of patients rating their care 5 of 5
• No medication reconciliation errors occurred for patients in hospital units served by care teams that include a pharmacist over the past five years.

Then, there is the Ottawa Hospital (TOH)[3], which became the 2013 winner of the Best Start-Up Business Process Improvement Programme awarded by the Process Excellence Network[4]. TOH set about integrating their processes to technology in order to drive improvement.

Organisations, including some in healthcare, are looking at improvements from a lean flow process perspective.

Strengths of Process Flow

What does process flow offer us that are different?

When we recognise that all organisational activities are arranged as a series of events, we can begin to see the benefits. Toussaint, in his book, On the Mend, shared four advantages as follows:

• It allows us to focus on patients and design care around them
• It identifies value for patient and gets rid of everything else (waste). This ‘waste’ can be defined as the elements of time, $, and poor quality
• It minimises the time to treatment and through the course, and
• It energises the work practices of continuous improvement every day in every area

More than that, it also frees staff to work collaboratively across the organisation, recognising the impact each has in his/ her own area of responsibilities and on another. It gives a chance for everyone to see the ‘big picture’ while not losing sight of the patient as their main focus.

How can we make process flow work?

Like Telecom and the bank, we can divide a patient’s events into these discrete parts[5] as follows:        

• Assess and Diagnose
• Consult and Plan
• Admit
• Care,
• Cut (Surgery),
• Stay (Ward),
• Treat
• Discharge or Transfer
• Prevent

The objective is to rally people together to work collaboratively on enhancing that which are valuable while eliminating that which are unnecessary.

Challenge to think differently

Problem solving can be approached at different angle. What ThedaCare has done is to demonstrate to us that there are other ways that we can look at improving safety in patients. Instead of taking the traditional problem solving route, Toyota has shown us another approach and ThedaCare has adapted Toyota’s lean for their use.

Rolf Smith[6] highlighted seven levels of change as follows:

LEVEL 1:	Effectiveness	DOING the right things
LEVEL 2:	Efficiency	DOING things right
LEVEL 3:	Improving	DOING things better
LEVEL 4:	Cutting	Stopping DOING things
LEVEL 5:	Copying	DOING things other people are doing
LEVEL 6:	Different	DOING things no one else is doing
LEVEL 7:	Impossible	DOING things that can't be done

In New Zealand, this approach towards looking at improving safety in healthcare would be at Level 6 but it would be a Level 5 in America because a few healthcare organisations have already began the journey.

Borrowing ideas across industry and from Toyota is not new. Boeing, the global leader in aircraft manufacturing did that too for its main money earner, its 737. Where once the 737 was produced by bringing workers to the plane, it has reversed the journey to bring the plane to its workers through the ingenuous use of a conveyor belt – a flow approach.

It was a Level 5 in the car industry but a Level 6 in aircraft manufacturing. The result was astronomical as follows:

• Reduced assembly time from 22 days to 11 days
• Reduced WIP inventory by 50%
• Reduced number of crane lifts - from 8,000 crane lifts/ month to 3 crane lifts/ airplane
• Up production to 47 planes per month

Coming back to my personal experience

It is mid-January 2014 and my friend is yet to receive his appointment to get his scan done[7]. I have been involved in improvement for years – from newspapers, to telecommunication, and then banking. I have seen the benefits as well as carried out some end-to-end process projects using Lean.

It identifies waste and value to a customer quickly. It advocates collaboration between members in that process. After seeing what happened to my friend, I believe that Lean would provide better value to make improvement.

Sensei888
4 Feb. 14