Management Blog Review 2012: Not Running a Hospital

Posted on January 3, 2013  Comments (4)

Paul Levy started the Running a Hospital blog when he was the CEO of Beth Israel Deaconess Medical Center. Thankfully he has continued the blog, renamed to Not Running a Hospital, after leaving that position. Paul provides a huge number (the lowest number of posts in a month was 32) of valuable posts focused on health care, but worthwhile for everyone interested in improving the practice of management.

Image of cover of Goal Play!

In addition to his blog, during 2012 Paul published a wonderful book – Goal Play!: Leadership Lessons from the Soccer Field. In my first 2012 management blog review I take a look at Not Running a Hospital.

Some of the thoughtful posts by Paul in 2012:

  • How to get better at harming people less – “Imagine what we as a society would do if three 727s crashed three days in a row. We would shut down the airports and totally revamp our way of delivering passengers. But, the 100,000 people a year killed in hospitals are essentially ignored, and hospitals remain one of the major public health hazards in our country.”
  • Medtronic’s Lean Journey – “They knew they would have to think big, but then sweat the details. Over time they figured out how to collaborate.

    There were five stages in the process:

    1 — Define our operating standards, who we aspire to be.
    2 — Set a global expectation to accelerate improvement.
    3 — Develop the ability to assess current state.
    4 — Create ongoing mechanisms to learn and leverage to close gaps.
    5 — Continually check and adjust.”

  • Sarah Patterson informs about Lean – “Would like Va Mason org to operate like an aircraft carrier. How to run a complex business safety.

    Aircraft carrier = an airport on top of a nuclear power plant comprising a bunch of 19 year olds!

    Aircraft carrier needs complete alignment with the mission. If not done well, puts others at risk.

    Aircraft carrier requires an incredible commitment to adoption of standard work. Relentless focus on training.

    Create jobs that are doable. Train people to do them. Hold people accountable to them.

    Adopted TPS=customer first, highest quality, obsession w/ safety, staff engagement, successful economic enterprise

    Senior leader regular gemba rounds to view one aspect of standard work.”


  • photo of Paul Levy

    Paul Levy

    “What” before “Why” – “Lean practitioners spend a lot of time on the 5 Whys, and John’s slide properly incorporates the “why” portion of a problem solving. But he also reemphasizes the need to understand ‘what’ happened. As he said to me before the talk, we often do not spend enough time at the site of the problem to comprehend fully its characteristics and nature. Failing to know what happened means that the root cause analysis can be off track, and the designed solutions therefore will not offer a complete or sustainable solution.”

  • UNM residents start to go Lean “The UNM hospital handles 90,000 emergency room visits per year but suffers from major congestion problems… [14% of patients] leave without being seen because of the waiting times… Our rough analysis — just based on perceptions of people in the room — yielded 853 minutes of gross time spent per patient for work that had a value of 71 minutes. This is remarkably close to the 14 hour average delay that the ED has documented. The next step, if we were actually doing this in the hospital, would be to identify measures that could be taken to redesign the work flow and conduct experiments to see what would be helpful in extracting waste out of this overall process.”
  • The USA health care system is huge and has many factors that lead to ever exploding costs. Some costs can be addressed with improvements that gain better results for less money. Some costs maybe should be considered more controversially, such as is it worth spending given what we will gain. Paul asked this question:

  • What if they had had to pay? – “Here’s the terrible and hard-hearted question I pose: If the costs of this procedure and hospitalization had not been covered by Medicare, would the man’s children have proceeded along the chosen path? I am guessing not…. In the US, we don’t have a good societal process for making these decisions. In the United Kingdom, though, they do…”
  • You don’t “do Lean” – “The lesson, though, is that Jim was at gemba, heard the (unintentional) call-out, responded respectfully, and analyzed and solved the problem while it was fresh.”
  • How to stop a future cancer epidemic – “The theory of preventative care, including inoculations, is that we spend a little money now to offset big expenses later in life. But sometimes behavioral friction keeps this from happening, even when the technologies and approaches are proven. We are witnessing such a failure right now with regard to Human Papilloma Virus (HPV).” This same problem, a lack of long term and systems thinking, confounds improvement efforts everywhere. Tackling the problem is mainly a matter of psychology; if you are lucky it can be addressed also by building the capacity of people to appreciate systems and long term consequences.

Related: 2011 Management Blog Roundup: Gemba Panta Rei2011 Management Blog Roundup: Lean Six Sigma Blog2010 Annual Management Blog Review: Software, Manufacturing and Leadership

4 Responses to “Management Blog Review 2012: Not Running a Hospital”

  1. Mitch Mitchell
    January 4th, 2013 @ 12:19 am

    Interesting stuff. As a health care consultant as well, though more financial, he says some things that are good and some things that he knows can’t really be addressed fairly and why. After all, there are sick people in hospitals, not enough staff, not enough money, and medicine, when all is said and done, really is more practice than science. The numbers are unavoidable, even if horrid, because there’s just not enough ______; take your pick. lol

    Still, it’s an industry that has its way of beating up its C-level people, and that’s problematic. Health care is moving towards the same problems that school systems have in this country; too much government, too much regulation, not enough money or support.

    I’ll have to check out the book… after I finish the other 5 I’m on right now. :-)

  2. John Hunter
    January 4th, 2013 @ 1:08 am

    I think we spend far far too much on health care already. It has taken an ever increasing portion of GDP (now 18% of GDP). Health care has taken an increasing percentage of GDP every year for decades. A very poor performance.

    The USA spends twice as much as other rich countries on health care for no better results http://investing.curiouscatblog.net/2012/01/26/usa-spends-7960-compared-to-around-3800-for-other-rich-countries-on-health-care-with-no-better-health-results/ If government intervention makes things worse that means the performance of the USA is even worse (because they are twice as bad with the “advantage” of less government involvement than any other rich country). Still the amount of government pay for USA health care is huge – it is the myth that the health care system is not supported mainly by government already (and has been for decades).

    The challenges are large. The huge cost issue is not one that can be addressed by leaving the extremely bad health care policies the USA has pursued for decades while just cutting budgets. The system has to be fixed which will reduce costs. There are a few countries doing well, but overall those that are getting the same results as the USA at a fraction of the cost are not really doing that well. So the USA is greatly underperforming, not exceptional great performers but performers that themselves need to improve a great deal. That is how bad the USA health system is now.

    The fixes for the decades of USA health system failure range from large macro economic fixes all the way to applying lots of process improvement tools to optimize performance of specific processes in each location.

    At the very worst the USA should just accept we are horrible at health care and just try to reach mediocre performance. We already have mediocre results. But at the highest cost, by far, of any rich country. Just by moving our costs to be in the same middle of the pack performance (where our results already are) would mean at least $500 billion less a year spent on health care.

    This is before even getting into the huge macro economic problems caused by the USA system of tying benefits to employment and huge numbers of people without coverage and forced into bankruptcy (which just make the USA performance even worse). The harm done by the current health care system in enormous.

    Dr. Deming, decades ago, included it on the 7 deadly diseases of western management and it has only become a worse problem since then. Thankfully hundred of people are doing good things (like Paul Levy, Don Berwick, Mark Graban, Dr. John Toussaint…) but the scope of the problem is enormous and decades of continuing the special interest driven system we have now has been disastrous.

  3. Mitch Mitchell
    January 5th, 2013 @ 2:13 am

    You wouldn’t think we spent too much if you were in the industry; then again, every industry probably says the same thing. I will say however that comparing the costs of health care in the U.S. to other countries is unfair, almost like comparing salaries in the U.S. to salaries in China and saying we’re overpaid.

    By the way, your blog doesn’t send out notifications that you’ve responded to a comment; I just happened to come back because I was curious.

  4. John Hunter
    January 5th, 2013 @ 4:26 am

    I would definitely think we were spending too much on health care if I was in the industry – but I understand many would not. It is entirely fair to compare health care costs across countries, the USA has some disadvantages but plenty of advantages. That other rich countries get as good results for half the price is exactly the kind of thing those of us paying for the system should look at. Mainly the pricing differences are do to horrible policy decision in the USA for decades (that are basically just favors to special interests that cost the society at large greatly).

    The differences in say nursing and other pay is close to insignificant. Administration and specialist pay in the USA is multiple times was it is in other rich countries. While this is a significant cost it is just one of many huge problems with the USA system – even if you wanted to continue to say the USA people should be paid multiple times the comparative rates for other countries that would only leave a small part of the problem in place (I would imagine that can’t tax the users by more than 10% additional health system cost, over all the other rich countries).

    For other fields, rich country comparisons are not that much different (other than executive pay, in every field, and medical specialist pay – in both the USA has vastly inflated pay in comparison to rich country peers).

    We might decide it is worth it to make sure the intrenched interests in the USA health care system can continue to sap the economy – that has been our decision the last few decades. I disagree with that choice.

    I don’t know of many things the USA compares extremely poorly economically to our peers (and I don’t think there is anything nearly as bad for the USA as the health care comparisons). Very expensive and poor internet connectivity and mobile phone plans would be 2 areas in which the USA does a very poor job. But they are tiny issues compared to health care (which 18% of our economy). Maybe we are substantially more expensive for education.

    I believe we are cheaper compared to other rich countries for food prices, energy prices, housing, cars (though often pricing is pretty similar some countries have high car taxes)…

    I have been looking for enhanced commenting wordpress plugins but have failed to find ones worth using yet (I know they exist, I just can’t find them).

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