Pump Up the Process
Cover Story
Written by Jill Rose   
Friday, 01 May 2009
Pump Up the Process - Inside Healthcare - RedCoat Publishing
Corporations that successfully manage complex processes have a huge advantage—in hospitals, it can mean the difference between life and death.
If there is one thing everyone connected to healthcare can agree on, it’s that this industry is complex. And not only is the healthcare system complex, medical treatments themselves are complex. Unfortunately for patients harmed by medical errors, healthcare organizations have
not matured along with those treatments.

“The typical medical care provider is organized in a way that’s inappropriate for delivering the sophisticated treatments and tests that science provides us with now,” said Steven Spear, author of Chasing the Rabbit: How Market Leaders Outdistance the Competition and How Great Companies Can Catch Up and Win (McGraw Hill, 2009).

Spear’s book looks at what highly successful organizations have in common: the ability to skillfully manage complex internal systems, generating almost-constant self-improvement. This ability is, sadly, often missing in hospitals and other healthcare organizations.

Indeed, rather than focusing on process expertise and self-improvement, hospitals are notorious for breeding workarounds (often a subtle signal of great danger) and suppressing problems. The reason is not that stupid lazy people work in hospitals, of course, it’s that healthcare workers are trained in a medical specialty and rarely exposed to—never mind taught—process-oriented thinking.

When these workers learn to think about problems in a holistic way and begin calling out problems so they can be solved, the results are incredible. In Chasing the Rabbit, Spears relates the example of Allegheny General Hospital, which lowered its rate of patients with central-line infections from 37 per year to six and the number of deaths from 19 to one.

Baby steps
Just as with the space-shuttle-related deaths NASA experienced (also discussed in the book), there was no single critical element that required change to lower infection rates at Allegheny. Rather, a large number of small changes involving multiple departments were needed.

A central-line team was created with the mission of observing central-line placement and maintenance to see the microbreaks in routine that might lead to infection. They first saw that even though the night-shift residents on call in the ICU knew that subclavian placements are less prone to infection than femoral lines, they had not been well-trained in these placements.

When called on to place a line, the residents worked around the problem by doing the more familiar femoral-line placement and hoping an intensivist on the day shift would move the line in the morning. “This is typical of broken systems,” noted Spear. “People don’t do the wrong thing, but they can’t do the right thing.”

Two changes came out of this observation. First, all residents working unsupervised in the ICU must be trained in subclavian central-line placement. Second, if for some reason a femoral line is placed, the person doing the placement must clearly indicate to the next shift that the line should
be moved.

At Allegheny, this was first done with a notation on the patient chart. Because the chart is not always at the bedside, this was later changed to a marker on the bed. Still later, because patients are sometimes moved to a different bed, this was changed to a marker on the patient.

“They started with a process where everything was occurring in isolation—the people responsible for training the residents didn’t know the needs of the ICU. The resident at night worked in isolation from the intensivist. When people encountered a problem, they worked around it,” said Spear. “Now, they look at the process, and when they see problems, they solve them.”

This type of problem management was then applied to central-line maintenance, so that rather than working around problems (extra hand washing because gloves weren’t in the room, trying not to touch the patient if a gown wasn’t available), nurses were supplied with a maintenance kit including gloves, gown, drape, disinfectant, applicator, and sterile bandage.

Spear noted that five kits were first developed to test the solution (another characteristic of high velocity organizations), leading to a re-ordering of materials. In the test kits, the gloves were at the bottom, forcing nurses to unpack sterile materials with their bare hands.

Get the spirit
This process can be used to improve any healthcare procedure or problem, said Spear. In the book, he talks about Ascension Health, which reduced pressure-ulcer rates to 93% lower than the national average and birth-injury rates to nearly three-quarters lower; Virginia Mason Medical Center, which cut emergency-room visits for migraines by half; Mayo Clinic, which reports a reduction of more than half in medical injuries at its hospitals; and the pathology department at the University of Pittsburgh Medical Center, which cut the error rate in a screening test for cervical cancer by half.

Perhaps the most public example of healthcare process improvement is the Spirit program at Beth Israel Deaconess Medical Center. Paul Levy, CEO of BIDMC, has documented the progress of the program on his blog (http://runningahospital.blogspot.com) since it began. Spirit stands for Solutions Promoting Improvement Respect Integrity & Teamwork, and the program is based on Spear’s work in organizational process improvement.
 
In February 2008, Levy wrote: “The common characteristic of high performance organizations is not their ability to design perfect and complex production or service delivery systems. Rather, it is their ability to discover great systems. They do this by managing their workflow to encourage people at all levels to call out problems, to ‘swarm’ together to solve those problems, to share this process of discovery with others in the organization so that the solutions are diffused widely, and to cultivate the skills of people throughout the organization to be involved in this kind of constant improvement.”

Spear points out that Levy’s public documentation of problems found and solved at BIDMC goes against the basic tenets of hospital management, in which problems are ignored, workarounds are common, and harm done to a patient results in a call to a lawyer, not a blog entry.

Indeed, there is the potential for people hearing about problems being solved at BIDMC to assume that this hospital is a risky place for treatment. But in fact, a recent Boston Globe exposé found that outcomes at BIDMC are better than at competitors Mass General and Brigham and Women’s for many procedures, and Spear said that as healthcare consumers become more savvy, they are realizing that a lack of data is much more likely to indicate a problem than a wealth of it. Indeed, he predicts that, eventually, hospitals that are not practicing process improvement will be seen as not merely complacent but potentially criminal.

Spear advises hospital executives to focus on the importance of process and the dangers of workarounds. “The thing about workarounds is that a lot of them are well intentioned, innocent best efforts. But it’s important to remember that what killed the crews of two space shuttle missions was a bunch of nit-picky things that people had dismissed as being inconsequential,” he said. “If you have a process that involves multiple interdependent steps performed by various specialists, you have to define how the work is supposed to occur, and that is typically absent in hospitals.”
 
< Prev   Next >