Toyota for you doc

Toyota for you doc, what will it be for your patients?

In a recent Medscape survey it was found that doctors’ choice of cars were as follows: Toyota (16.73%), Honda (14.8%), Lexus (8.3%), BMW (7.5%), and Mercedes-Benz (5.32%). Ford came in a very close sixth at 5.24%, and Chevrolet came in eighth at 4.13%.

It is apparent that 25% of doctors chose Toyota directly (since Lexus is manufactured by Toyota) and 31.53% come from the the lean methodology (since Honda also follows similar methods) constituting the top two car choices of American doctors. If other Japanese manufacturers were included it would be much more. It is a 2012 survey that means the doctors were probably aware of Toyota’s problems from 2010.

Why would doctor’s chose cars manufactured with lean methodology despite Toyota's recent problems? It is possible that the doctors feel those cars are still highly reliable despite the odd headline problems. The doctors are perhaps really impressed with the degree of honesty with which Toyota has recalled to rectify problems and the degree of humility shown in offering a public world wide apology. It may be the case that Toyota, Honda and those who share their lean philosophy still offer great value for money – doctors also do look for value for money.

What is fascinating is that the majority of doctors, the same doctors who like Toyota lean methodology despite its problems, do not follow the healthcare adaptations of lean methodology despite undeniably proven examples within America. Virginia Mason is a small scale system and Intermountain is a large scale system that has excellent versions of clinical lean (there are others too). There is huge resistance to even begin to look at the methodology.

Human beings and healthcare, are not cars and car manufacturing, so I do understand if we did not want industry people directly applying their methods to healthcare. Clinical lean and healthcare delivery lean is specific and different (as practised at a few places in the world), the translation and adaptation has already been done and fine tuned for nearly a quarter of a century. Clinicians need to show the relevant leadership to make it work in their patch where ever they are in the world.

It is not too much to ask is it, to deliver value to your patient; the same or more value that you expect from your car? I know patients are not cars and healthcare is godzillion times more complex that the automotive industry. That is why I talk about value creation and the application of healthcare specific lean (not other industry lean) from proven systems. Clinicians only have to learn and apply clinical lean in healthcare – if you can learn and practice medicine with all its complexity, applying clinical lean where possible, with its eventual elegant simplicity is a piece of cake. Or is it?

©M HEMADRI

Taste the sampler menu of clinical lean by attending the Clinical Quality Improvement Course

Find some of the high level the outlining principles HERE

Healthcare not similar to aviation but lessons can still be learnt

Healthcare learning from other industries needs a much higher degree of sophistication

When are you in control and when are your patients in control?

When a plane is flying the passengers are not in control. It is the pilot who is in full control. The pilot also has controls on him/her but that control is not exercised by the passengers. Well, when there are 50 to 500 passengers in the cabin it will obviously be a problem to let individual passengers be in control of the flight itself. The passengers do get some control over their pre-made choices such as seats and meals; the passengers also get some control over when they use the toilets and when they can walk about as long as they are prepared to sit down and belt up as soon as they are instructed to do so. It is actually against the law to disregard pilot or cabin crews instructions; you do not have to harm yourself or others as a result, just not following the pilots orders is an offence.

Healthcare has made big noises about learning from aviation. We can argue that there are some similarities and some differences in the way passengers are treated and patients are treated. Just within the context of this short write up, can a chief exec of a small healthcare organisation or a chief clinician of a large unit say ‘we have a large number of patients to treat and hence we cannot accommodate individual patient choices’? Can clinicians tell patients ‘you have a choice over meals but for the rest of your healthcare you will do as you are told when you are in the hospital’? Will it ever become law that if patients’ disregarded their doctor’s instruction in a hospital they will be prosecuted (for potentially adversely affecting other patients care as a result)? Clinicians 'orders' are not orders at all. Of course it is an entirely different debate on whether the patients will get good results even if they followed their doctor's instructions completely.

The similarities between healthcare and aviation or any other industry for that matter are quite limited. This is for the simple basic reason that healthcare is direct and personal to the recipient – as direct and personal as a professional poking fingers and instruments into various orifices with consent in an attempt to make the lay patient better. That directness and ‘personalness’ does not happen in the often quoted ‘ultra-safe’ industries such as nuclear power plants, scheduled airlines, European railways and so on. It is a totally different empathetic human to human interaction where the 'relationship' is the main driver/lever. The synthetic 'have a nice day' with an artificial smile will not work in healthcare. Its a kind of relationship that a pilot or crew might have when the plane has crash landed and they are trying to rescue frightened and traumatised passengers; not something that they would wish to do everyday and that is something that many in healthcare do every day.


That does not mean healthcare cannot be safer than what it is now. It also does not mean that the ultra-safe industries have nothing to share with clinicians; of course we need to learn more from crew resource management methods, etc. It only means that the lessons and methods can only indirectly be applied; the principles have to be adapted and only then adopted. We are really poor in translating the lessons from other industries into healthcare.

I am very passionate about patient safety and quality enhancement. I have learned a lot from other industries including aviation. Healthcare is a risky business. If we attempt a direct application of the principles from other industries, healthcare will continue to remain a risky business. The translation and transfer has to be much more sophisticated than what it is right now. It is possible.


HEMADRI

Hand Washing compliance 100%

Hand hygiene 100% compliance at Ellis Hospitals. How did they do that?

Mary Ellen Crittenden, Vice President of Quality at Ellis told us that their board had a 'zero tolerance policy' for non-compliance.

They had a huge focus on clinician buy in and cultural issues developed over many months. They had 'secret shoppers' watching people and built it up the tempo gradually to a stage where they then announced a 'three strikes and you are out' policy.

If some one did not wash their hands:

first time - they were sent home with pay
second time - they were sent home without pay
third time - they were sent home and asked not to come back i.e. sacked

As an aside they had the same policy for their employed and visiting doctors, apparently they did not have to sack any of their more than 1000 doctors

Of course not all their deployments to improve quality were this harshly enforced.
Based on similar attitudes and healthcare lean methodology they have also achieved

495 continuous days without a single central line infection
0 - ZERO infections for hip surgery in whole of 2010 and till April 2011

They are looking forward to many other low or zeros soon (colonic surgery, caesarean sections, etc)

Ellis Hospital system in New York (http://www.ellismedicine.org/Home.aspx) is not exactly Mayo or Johns Hopkins but they have achieved great results.

When will we see this here at our work place? Most of us sooner or later are likely to end up as a patient in our local hospitals; well, it could happen tomorrow. We have to get it sorted before we occupy one of these beds!

The proven methods are available; we can do it if we want.

HEMADRI

PS: As recalled from what was heard at a conference in 2011

Hemadri's Four Fundamental Questions for Clinical Quality Improvement

Hemadri's 4 fundamental questions for Clinical Quality Improvement

1) Do you have local clinicians' agreement on clinical healthcare delivery? (Doing the same thing by all professionals in the same manner for the same condition)

2) Are you measuring the right things in the right manner? (Measuring process and outcomes over time)

3) Do you have a human approach to leadership and management? (In other words do your staff love you, do your patients love you? Working with and enjoying ambiguity and limitations)

4) Can you prove meaningfully that you have shared to others and you have learned from others within your organisation? (Proof that every individual does whole system improvement)


To some of you these four questions might sound like cliches. To some of you these might be stating the blindingly obvious. The questions are not 'lay'; they are highly technical questions with strong theories and some practical examples behind them. There are specific and explicit frameworks, methods and techniques to explore these questions and then to make them happen.

There is a general impression that healthcare does all the four well; especially if you work in healthcare you may be tempted to answer 'Yes' to all the four questions. You may even proceed to argue and 'prove' it. There is much evidence that healthcare in general lacks all the above four. The chances are it will be surprising if many areas of healthcare delivery had even one of these. But once these questions can be answered with a real 'Yes' healthcare leaps into a bright better zone.

Success in Healthcare can be found only if the the answers to all the four questions can be a clearly demonstrated 'YES'.

We explore these at the CQI to some extent. I am hoping that over a period of time I should be able to blog about these things in specific detail rather than in broad general terms. Perhaps even write a book.

© HEMADRI

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Biggest Lean Deployment in the World

The American Army has the largest lean six sigma deployed in the world.

The American army budget is currently more than $240billion
The US Army has deployed Lean since 2006 and saved $19.1 billion dollars
so far. In 2011 alone they are conducting 2111 lean improvement projects
to save $3.6 billion.
They have 5700 green belts, 2400 Black Belts and 175 Master Black Belts
and 48 Lean Deployment Directors. Their return on these investments have
been very good.

Most of the projects have been about logistics but their health care is
also heavily into lean. They have seen great successes.

Here is an interesting anecdote from one of their early projects -
obviously dated but the learning value is undiminished.

According to the principles of lean six sigma, US Army Medical Command
looked into high volume areas, 'waste' and 'customer satisfaction'
problems and found that they had:

The largest army call centre with more than 10000 calls per week
Low customer satisfaction at 68%
Average wait time of 3.14 minutes (wait is one of the classic wastes in
lean)
Call abandon rate of 26% - with a peak time call abandon rate of 49%

Obviously they found this very unsatisfactory and ran a lean project to
improve this. And they improved:

Average wait time reduced to 33 seconds (a six-fold improvement)
Call abandon rate reduced to 3% with peak time call abandon rate down to 22%
Call volume reduced 20% due to less call backs
and so on

These results were far better than the aims they set themselves for the
projects

Apparently the customer satisfaction got worse!!

While people were getting their calls attended in record time they could
not get appointments to see doctors in clinics because the clinics had
capacity and scheduling problems - so the issue was, what is the point
in answering the phone quickly if they could not address the real need
which is patients to see doctors quickly.

Do not despair!

They have since addressed that issue and that has had an even bigger
effect on their call centre

The average waiting time has fallen to 3 seconds (yes, you read it right
THREE seconds - from their starting point of 3 minutes and 14 seconds)!!

There are two messages, a) system wide thinking is difficult but very
important b) it is even more important to solve the real issue (rather
than what is immediately apparent).

HEMADRI

Note: The above is written from my recollection and notes of a brilliant presentation made at the WCBF Lean Six Sigma in healthcare conference 2011; with thanks to the presenters from the US Army Health Command and their collaborators.