Posts about Health care

Getting Retweeted by Marc Andreessen Generated a Flood of Retweets

On Twitter today I was getting more than 30 times the notifications I normally get. So I took a look to see what is going on. One of my tweets was getting retweeted and liked quite a lot (nearly 100 times each, so far). I figure most likely someone with many more followers than I must have retweeted it.

A bit more investigation and sure enough that is what happened. Marc Andreessen had retweeted it. He has 432,000 followers (a bit more than my 1,600).

image of Marc Andresseen's retweet

This minor internet enabled connection with fame is one of the fun aspects of the internet (to me anyway, I might be a bit odd). I emailed Tim Berners Lee (the creator of the world wide web) a long time ago (probably about 15 years – and I still remember) and received a nice reply. I have written a few posts on my science and engineering blog about his work over the years including a short post on the first web server (Tim’s NeXT computer).

For those that don’t know NeXT is the computer company Steve Jobs headed in between his stints at Apple. In 1999, I was giving a presentation at a conference on Using Quality to Develop an Internet Resource (link to my paper for the talk was based on). I was working for the Office of Secretary of Defense, Quality Management Office at the time. In cutting the time down I eliminated saying that the internet was created by the Department of Defense and giving a few sentences on that history as I figured everyone knew that history. After my presentation, one of the people that came up to talk and somehow I mentioned that history and the 3 people standing there didn’t know it and were surprised. Anyway that NeXT comment reminded me of that story…

The tweet Marc Andreessen retweeted was about research by scientists in London that developed pain-free filling that allows teeth to repair themselves without drilling or injections.

Several people responded that we will never see this in use (based on the idea that announcements of research breakthroughs often fail to deliver). Quite a few people we looking forward to the day when it would be available though. Including some that were sitting in the dentist office while they were reading about it.

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Visual Management and Mistake-Proofing for Prescription Pills

Good ideas often just require some sensible thought to think of an improved approach. Management concepts can help guide such thinking, such as mistake-proofing and visual management.

To apply visual management requires giving a bit of thought to how to make visually obvious what is important for people to know. Mistake proofing is often really mistake-making-more-difficult (for some reason this term of mine hasn’t caught on).

prescription pills packaged together

Image from PillPack, they provide a service to deliver packages based on your prescriptions.

I believe mistake-proofing should put barriers in the process that make a mistake hard. Often what is called mistake-proofing doesn’t really fit that definition. The pill package shown above for example, doesn’t prevent you from continuing past the time on the package (Monday at 8AM) without taking the pills.

To call it mistake-proofing I would like to see something that makes it harder to make the mistake of failing to take the pills: something that blocks progress beyond that time without taking the pills.

Even something as simple as an alert to your smart phone that gets your attention and doesn’t allow the smart phone to be used without indicating you have taken the pills would reach the “mistake-proofing” level in my opinion (for someone that has their phone with them at all times). The Apple Watch could be a good tool to use in this case. Even so those wouldn’t make mistakes impossible (you can say you took the pills even if you didn’t, the phone/watch may lose power…). It would depend on the situation; this smart phone/watch solution is not going to be good for some people.

Another idea is that these pill packages should be tied to the room (in a hospital) and at home if a home care nurse (or even family or others) are responsible for assuring the pills are taken with a big display that perhaps 30 minutes before the pill is due posts a message that says “pills to be taken at 8 AM” and once that time is past it could become more obvious, perhaps after 15 minutes it produces an audio alert. The actual solutions are going to be better from those that know the actual situation than someone like me just thinking up stuff as I type.

But the idea is pretty simple: when you have processes that are important and at risk of failure, design processes with elements to make mistakes hard (and ideas such as mistake-proofing and visual management can help you guide your mind to ways to create better processes).

The entire process needs to be considered. The pill packages are nice, because even in failure modes they provide good feedback: you may still fail to take them at the right time, but you can look at the location where the pill packages are kept and see
if any have a time before right now (in which case you can follow the medical guidance – take the pills right now, contact the doctor, or whatever that advice is). Of course even that isn’t foolproof, you could have put the package into your purse and it is still sitting in their but you forgot.

Still the pill packages seem like a good mistake-making-more-difficult solution. And it seems to me that process has room to make mistakes even more difficult (using a smartphone addition, for example).

Continual improvement requires a continual focus on the process and the end user for ways to increase reliability and value. Each process in question should have engaged people with the proper skills and freedom to act using their knowledge to address weakness in the current process that are most critical.

Failure to take prescriptions as directed in a common problem in health care. Knowing this should make those involved in the process think of how they can use concepts, such as mistake-proofing, to improve the results of the system.

Too often to much focus is on making better pills compared to the effort is put into how to improve results with simple concepts such as visual management and mistake-proofing.

Each small improvement contributes to creating a more robust and effective process. And engaged people should continually access how the containing systems, new processes and new capabilities may allow more small steps to provide value to those relying on your products and services.

Related: Great Visual Instruction Example for Taking PillsVisual Management with Brown M&MsQuick Mistake Proofing Ideas for Preventing Date Entry Error

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Some Thoughts on Investing from My Recent Interview

In the first few years of this blog I posted occasionally, but still much more than the last few years, on investing and economics. Now I mainly post on those topics on the Curious Cat Investing and Economics blog (see how the name and that practice are in sync with each other?).

I was recently interviewed about investing strategies and thoughts and decided to share that with the readers of this blog. Some excerpts from the interview:

I have maintained a portfolio that I call the sleep well portfolio for 10 years (started April 2005). I hardly have any turnover (under 2% annually I think) and hold stocks I would be comfortable locking in a vault for 10 years. The largest holding there is Apple, followed by Google; I also still really like Google as a long term investment. The stocks in the portfolio for the entire period are: Google, Amazon, Toyota, Intel, Pfizer…

We got out of the “Too Big to Fail” crisis, but have not addressed the core problems – and likely have made them much worse. We didn’t take the opportunity to address the financial system risks created by the actions of “Too Big to Fail” banks. And it seems to me we have left the central banks in a very vulnerable position. They have already played strategies that previously seemed impossible due to the position they were placed in, and if it happens again, what are they going to be able to do? I think the risk of massive economic failure is large enough to consider in an investment portfolio.

How would you suggest an investor guard against the potential for a massive economic disaster?

John Hunter: My main thoughts on that are to greatly value companies that are likely to weather economic calamity greater than any since the great depression. Having tons of cash obviously helps (Apple, Google…). Having a business model that puts a company in a position to make money (even if it is a lot less than they are making today) if the economy does extremely poorly, is also good (Apple, Google, AbbVie…).

It is possible for the economy to be hit so hard Apple, Google, etc. lose money. But if that happens, I believe huge numbers of other companies are going to be out of business, and the economy will be in shambles…

The sleep well portfolio has beaten the S&P 500 by about 220 basis points (on an annual rate of return basis) (see details on how marketocracy calculates returns – they reduce returns by 200 basis points to simulate investment adviser fees). The interview includes much more details as well as links to posts on my investing blog going into more detail.
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Management Blog Review 2012: Gemba Walkabout

This is my second, of two, 2012 management blog review posts. In this post I look back at the last year on Mike Stoecklein’s Gemba Walkabout blog. Mike is the Director of Network Operations at Thedacare Center for Healthcare Value.

photo of Mike Stoecklein
  • In a very long post, Some thoughts on guiding principles, values & behaviors, he provides a sensibly explanation for one the real difficulties organization have making progress beyond a certain point (project success but failure to succeed in transforming the management system). “I’m not saying this approach (focus on tools, teams, events) is wrong, but I do think it is incomplete. I think we also need to work from right to left – to help people understand the guiding principles, to think about the kinds of systems they want and to use tools to design and redesign those systems. Dr. Shigeo Shingo said, ‘people need to know more than how, they need to know why’.

    Most managers view their organization like an org chart, managed vertically. They assume that the organization can be divided into parts and the parts can be managed separately

    It’s what they believe, and what they don’t know is that is is wrong – especially for a complex organization.
    If their thinking was based on the guiding principles (for instance “think systemically”) they would manage their organization differently. They would see their organization as as set up interdependent components working together toward a common aim.”
  • Reflections on My (Brief) Time with Dr. Deming – “The executives thought he was pleased. When they were done with their ‘show’ he thanked them for their time, but he wanted to know what ‘top management’ was doing. He pointed out that they were talking about improvements on the shop floor, which accounted for only about 3 percent of what was important.” When executives start to radical change what they work on the organization is starting to practice what Dr. Deming taught. Mike recorded a podcast with Mark Graban on working with Dr. Deming.
  • Standard Work and PDSA – “What I have noticed is that sometimes people insert another wedge (shown as black) in the diagram below. So, progress gets stopped because some seem to believe that standard work doesn’t get adjusted as you make improvement.” This is a brilliant graphic including the text standard work misued. The 2 biggest problem with “standard work” in practice is ignoring the standards and treating them as barriers to improvement. Standard work should be practiced and if that is a problem the standard work guidance should be changed.
image showing how failure to adjust standard work can block progress

During the year stay current with great posts twice a month via the Curious Cat Management Improvement Carnival.

Related: Management Blog Review 2012: Not Running a Hospital2011 Management Blog Roundup: Stats Made EasyStandardized Work InstructionsAnnual Management Blog Review: Software, Manufacturing and Leadership

Management Blog Review 2012: Not Running a Hospital

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.”

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USA Spent $2.6 Trillion, $8,402 per person,17.9% of GDP on Medical Expenses in 2010

Total health expenditures in the USA in 2010 reached $2.6 trillion, $8,402 per person or 17.9% percent of GDP. All these are all time highs. Every year, for decades, health care costs have taken a larger and larger portion of the economic value created in the USA.

In 2009 the USA Spent Record $2.5 Trillion, $8,086 per person 17.6% of GDP on Medical Care.

USA health care spending grew 3.9% in 2010 following an increase of 3.8% in 2009. While those are the two slowest rates of growth in the 51 year history of the National Health Expenditure Accounts, they still outpaced both inflation and GDP growth. So yet again the health system expenses are taking a bigger portion of overall spending. This has been going on so long that the USA spends double what many other rich countries do on healthcare with no better results.

As a result of failing to address this issue for decades the problem is huge and will likely take decades to bring back just to a level where the burden on those in the USA, due to their broken health care system, is equal to the burden of other rich countries. Over 2 decades ago the failure in the health care system reached epidemic proportions but little has been done to deal with the systemic failures. Dr. Deming pointed to excessive health care cost, back then, as one of 7 deadly diseases facing American business. The fact that every year costs have increased more than GDP growth and outcome measures are no better than other rich countries shows the performance has been very poor. The disease is doing even more harm today.

Some good things have been done over the years, most notably by Don Berwick while at the Institute for Healthcare Improvement. He was effectively thrown out of office by the politicians recently. The same politicians that have through decades of such foolish acts contributed more than any other group to the broken health care system that burdens the USA today. In the last 10 years a significant amount of good work has also been done in “lean healthcare”: applying lean thinking to healthcare. But it is similar to the quote that a “bad system will beat a good person.” With all the bad systemic issues the efforts, good as they are, in lean healthcare are mainly improving around the edges. Of course, “around the edges” of a $2.6 Trillion dollar system can still be extremely valuable and important.

Related: USA Heath Care System Needs ReformUSA Spends Record $2.3 trillion ($7,681 Per Person) on Health Care in 2008Systemic Health Care Failure: Small Business CoverageMeasuring the Health of NationsHow to improve the health care system performanceManagement Improvement in HealthcareUSA Spent $2.2 Trillion, 16.2% of GDP, on Health Care in 2007

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Management Improvement Blog Carnival #150

Mark Graban is hosting Management Improvement Blog Carnival #150 on the Lean Blog, highlights include:

  • Watching Waste in the ER! – As part of his relatively new blog, Anthony Scott (Frontline Lean) writes about his experiences with waste in an emergency department. The waste isn’t surprising to those who have been a patient or those who have worked in the E.D. Scott is a supervisor in a lean manufacturing setting and he applies lean thinking to this unfamiliar environment.
  • Case Study: The Nordstrom Innovation Lab – Eric Ries (Startup Lessons Learned), author of the excellent book The Lean Startup, has a post with video featuring the use of “Lean Startup” methods and mindsets within a Fortune 500 company. Eric writes, “It’s one thing to talk about “rapid experimentation” and “validated learning” as abstract concepts. It’s quite another to see them in action, in a real-world setting.”
  • Top 3 Things I’ve Learned After 18 Months in Healthcare – My friend and DFW-area neighbor Mike Lombard (Hospital Kaizen) reflects on his first 18 months after transitioning from manufacturing into healthcare. In addition to his main points, Mike ends the post with an invitation for others to Move to Healthcare, writing, “Like I said earlier, I’ve learned a lot (a lot more than is shown here) and I continue to learn everyday. If you’re an engineer, project manager, quality professional, operations manager, or any other type of business professional, you can make the move to healthcare. Just be ready to focus on people, deal with complexity, and be proud of your work. Most of all, be ready to continuously learn and improve.”

I know we are all busy but, Mark, has done a great job highlighting some excellent posts. Take a look at the full carnival post and each of the posts. It is very nice to see how many great posts we are able to find for every carnival. A decade ago finding this kind of content was nearly impossible.

Related: Management Improvement Carnival #50Management Improvement Carnival #100

Management Improvement Carnival #111

Mark Graban hosts the Management Improvement Carnival #111 on the lean blog, highlights include:

Hospital Providing Better Health Care While Reducing Costs

Business Week has a good article on the strides one hospital has been able to make at reducing costs and improving quality. Hospitals: Radical Cost Surgery

Walk into Providence Regional Medical Center, in Everett, Wash., and you will see a hospital trying something different: It brings the equipment to the patient. In 2003, Providence opened one of the few “single stay” wards in the nation. After heart surgery, cardiac patients remain in one room throughout their recovery; only the gear and staff are in motion. As the patient’s condition stabilizes, the beeping machines of intensive care are removed and physical therapy equipment is added. Testing gear is wheeled to the patient, not the other way around. Patient satisfaction with the “single stay” ward has soared, and the average length of a hospital stay has dropped by a day or more.

High quality at a low price. Every other industry strives for that combination, but a hospital that does both is all too rare. Providence and its cost-efficient brethren demonstrate that quality care can be delivered at an affordable price, provided hospitals can be persuaded to rethink decades-old practices.

The crazy world of hospital economics does not offer a lot of incentives to change. Both Medicare and private insurers reimburse on a piecework basis – known as fee-for-service – that encourages hospitals to treat more, prescribe more, and test more.

Providence has also published data showing that infections, lengths of stay, and surgical complications have dropped since starting its own program.

But hospitalists are still controversial in many communities, because primary care physicians are wary of giving up control of their patients, along with their share of inpatient fees. Dr. Joanne C. Roberts, one of the first hospitalists at Providence, has not seen this conflict in Everett, possibly because most of the hospitalists and primary care doctors are associates at one large medical practice, Everett Clinic. That’s not true everywhere, she says. “In another community where I worked, independent doctors were pretty hostile. Everyone was trying to grab part of the money. That just doesn’t happen here.”

In a study of 2,531 operations at Providence, Brevig reported that the incidence of transfusions was reduced to just 18% in 2007, from 43% in 2003, while the average patient stay was reduced by half a day. The changes have saved Providence an estimated $4.5 million.

Brevig has been proselytizing for his plasma practices at medical meetings, but to little avail. Only some 200 U.S. hospitals have a blood conservation program. Since patients are billed the cost of the plasma, doctors aren’t motivated to change their habits.

There are many more great examples of positive actions being taken in health care. But all you have to do is look at the overwhelming evidence of how amazingly poorly the health care system in the United States is doing to know that it is, overall, an enormous failure. For decades the enormous cost of supporting special interest groups that benefit from the current broken system have forced the rest of society to pay for their unwillingness to improve. We can no longer afford to accept the poor performance. We need to adopt the new ideas much more quickly and eliminate the taxes on the rest of society to support those that want to take an every increasing amount from society to support their outdated, failed policies.

Related: Community Medical Care SuccessesCEOs Want Health-Care ReformUSA Spends Record $2.3 trillion ($7,681 Per Person) on Health Care in 2008Health Care: Lessons for the USA from Switzerland

Video Overview of the PDSA Cycle

Robert Lloyd, PhD From the IHI Open School‘s, presents a nice overview of the PDSA Cycle (plan-do-study-act). The webcast includes an example of using PDSA to improve the discharge process for a hospital.

As I have said many times the keys to success are to turn the PDSA cycle rapidly, predict the results in advance, and analyze the results to continually improve. the Improvement Handbook is an excellent resource.

The IHI Open School is a great resource and exactly the type of thing organizations with a mission to improve performance should be doing. Provide resources online that are easy for people to access and then apply in their organization. See more management webcasts.

Related: Tom Nolan on PDSASaving Lives: US Health Care Improvement5 Million Lives Campaign

Management Improvement Carnival #79

Mark Graban is hosting Management Improvement Carnival #79 on the lean blog, highlights include:

  • A Natural Match (Deborah Dolezal, Lean Healthcare Grand Rounds): “As a healthcare worker and an implementer of lean, I am often struck by the similarity of the human body and the lean methodologies.”
  • Kaizen Corner — for lack of a battery (Paul Levy, Running a Hospital): “The idea is to keep asking why (the 5 why’s) until they discover the root cause, which is defined as that level of understanding that will permit development of a countermeasure that will prevent the problem from occurring again.”
  • Put Down That Tool (Jamie Flinchbaugh): “Use the simplest tool possible. When you start to use tools that are more complicated than they need to be, we add unnecessary waste and bureaucracy to the process of improvement.”
  • How NUMMI Changed Its Culture (John Shook, “What I learned was most powerful at NUMMI was to start with the behaviors, with what we do.”

Related: Management Improvement Carnival #62Management Improvement Carnival #40Management Improvement Carnival #29

Blame the Road – Not the Person

The system is responsible for 90, 92, 94, 97% of problems – W. Edwards Deming. Fix the system, don’t blame the people. When you seek system fixes you approach situations differently than if you search for people to blame.

By the way, I am often asked about the data supporting Deming’s contention that the system was responsible for 97% of the problems. This statement was not based on a set of data but on Dr. Deming’s decades of experience. And he increased the percentage over time – as he learned more.

Roads that are designed to kill

Half blamed the runner, saying she should not have been running in the street at that hour. Half blamed the driver, for not paying close enough attention. Not a single writer blamed the road.

Your streets are designed to kill people.

Vision Zero started about 30 years ago, when traffic safety researcher Claes Tingvall got the idea that we didn’t have to accept road traffic deaths as a fact of life. Tingvall and his colleagues said that these deaths were not “accidents’’ but were predictable and preventable. And they set out to prove it.

One of the ways they began to protect people was to put barriers down the center of two-lane roads. They showed that this could be done cheaply. When Mylar – a strong polyester film – is supported by closely spaced plastic poles, it can keep cars from crossing the median. When the Swedes used this type of center barrier to separate the traffic going in opposite directions, they effectively prevented head-on collisions and the death rate on these roads fell by 70 percent to 80 percent.

Global health research shows more improvements can save lives. For example, Ghana put in rumble strips – small bumps spaced closely together – across all the roads leading into the capital city of Accra, reducing fatalities by 35 percent. Research has shown that speed bumps on roads are one of the “best buys” in all of global health.

Most people think we are doing all that can be done to keep our roads safe. They are wrong. Road traffic injuries kill more than a million people a year worldwide, including 40,000 a year in the United States.

Is a situation killing 40,000 people in the USA a year a health care issue? It sure seems to me it would be. It probably isn’t a disease management issue though (some might try to say bad roads are a disease but I wouldn’t say that). I think this is one, of many examples, that shows that we have a disease and injury management system not a health care system (in addition to illustrating systems thinking, effective root cause analysis, PDSA, innovation, respect for people…).

Related: Find the Root Cause Instead of the Person to BlameTraffic Congestion and a Non-SolutionChecklists Save LivesSaving Lives: US Health Care ImprovementThe Economic Benefits of Walkable CommunitiesSWAT Raid Signs of Systemic FailuresSystem Improvement to Respond to the Dynamics of Crowd DisastersThe Leading Causes of Death

Don’t Hide Problems in Computers

Making things visible is a key to effective management. And data in computers can be easy to ignore. Don’t forget to make data visible. Paul Levy, CEO of Beth Israel Deaconess Medical Center in Boston recently hosted Hideshi Yokoi, president of the Toyota Production System Support Center and wrote this blog post:

Together, we visited gemba and observed several hospital processes in action, looking for ways to reduce waste and reorganize work. It was fascinating to have such experts here and see things through their eyes. Mr. Yokoi’s thoughts and observations are very, very clear, notwithstanding a command of English that is still a work in progress.

The highlight? At one point, we pointed out a new information system that we were thinking of putting into place to monitor and control the flow of certain inventory. Mr. Yokoi’s wise response, suggesting otherwise, was:

“When you put problem in computer, box hide answer. Problem must be visible!”

The mission of the Toyota Production System Support Center to share Toyota Production System know-how with North American organizations that have a true desire to learn and adopt TPS.

Related: The Importance of Making Problems VisibleGreat Visual Instruction ExampleHealth Care the Toyota Way

Community Medical Care Successes

The Cost Conundrum by Atul Gawande, New Yorker (The Power of a Checklist was published there in 2007 by the same author)

For example, Rochester, Minnesota, where the Mayo Clinic dominates the scene, has fantastically high levels of technological capability and quality, but its Medicare spending is in the lowest fifteen per cent of the country—$6,688 per enrollee in 2006, which is eight thousand dollars less than the figure for McAllen. Two economists working at Dartmouth, Katherine Baicker and Amitabh Chandra, found that the more money Medicare spent per person in a given state the lower that state’s quality ranking tended to be. In fact, the four states with the highest levels of spending—Louisiana, Texas, California, and Florida—were near the bottom of the national rankings on the quality of patient care.

I talked to Denis Cortese, the C.E.O. of the Mayo Clinic, which is among the highest-quality, lowest-cost health-care systems in the country. A couple of years ago, I spent several days there as a visiting surgeon. Among the things that stand out from that visit was how much time the doctors spent with patients. There was no churn—no shuttling patients in and out of rooms while the doctor bounces from one to the other. I accompanied a colleague while he saw patients. Most of the patients, like those in my clinic, required about twenty minutes. But one patient had colon cancer and a number of other complex issues, including heart disease. The physician spent an hour with her, sorting things out. He phoned a cardiologist with a question.

“I’ll be there,” the cardiologist said. Fifteen minutes later, he was. They mulled over everything together. The cardiologist adjusted a medication, and said that no further testing was needed. He cleared the patient for surgery, and the operating room gave her a slot the next day.

The whole interaction was astonishing to me. Just having the cardiologist pop down to see the patient with the surgeon would be unimaginable at my hospital. The time required wouldn’t pay. The time required just to organize the system wouldn’t pay.

The core tenet of the Mayo Clinic is “The needs of the patient come first”—not the convenience of the doctors, not their revenues. The doctors and nurses, and even the janitors, sat in meetings almost weekly, working on ideas to make the service and the care better, not to get more money out of patients. I asked Cortese how the Mayo Clinic made this possible.

“It’s not easy,” he said. But decades ago Mayo recognized that the first thing it needed to do was eliminate the financial barriers. It pooled all the money the doctors and the hospital system received and began paying everyone a salary, so that the doctors’ goal in patient care couldn’t be increasing their income. Mayo promoted leaders who focussed first on what was best for patients, and then on how to make this financially possible.

No one there actually intends to do fewer expensive scans and procedures than is done elsewhere in the country. The aim is to raise quality and to help doctors and other staff members work as a team. But, almost by happenstance, the result has been lower costs. [actually the Deming Chain Reaction] Continue reading

CEOs Want Health-Care Reform

Decades ago Dr. Deming emphasized the deadly disease of excessive health care costs in the USA. Since then, year after year, the situation has become worse (reaching $2.2 trillion in spending in 2007 – 16.2% of GDP). During that time senior executives has put forth very little serious effort (in comparison to the huge cost) to fix this problem. Finally, in the last few years, more and more senior executives are actively moving to address the ever worsening crisis (including, Howard Schultz, CEO at Starbucks).

They seem to be realizing that hoping the problem will just fix itself is not a great strategy. Finally senior executives are realizing they need to have the government address the systemic failures. Those executives need to keep up their efforts because those seeking to retain the system that doesn’t work, because they personally benefit from it, have been doing a great job of preventing progress for decades. Until a critical mass of senior executives demand change from Washington the chance of improving the relative performance of the USA health system in comparison to other countries is very bleak (we have just been getting more expensive and less effective [relative to other countries] over time).

CEOs Secretly Want Health-Care Reform

Carl T. Camden, CEO of Kelly Services (KELYA). Managing insurance for his vast, geographically dispersed workforce of temporary workers is horrendously expensive, he complains: “My health-care costs total more than my profits.”

But in private, “CEOs overwhelmingly want out of this business,” says Benjamin Sasse, an Assistant Secretary of Health & Human Services under President George W. Bush who’s now an assistant professor at the University of Texas at Austin. “They just do not want to be seen as more willing to dump [benefits] than their competitors are.” Sasse says many CEOs he has talked with would even pay a new tax if it got them out of the insurance business.

Related: Many Experts Say Health-Care System Inefficient, WastefulArticles on Improving the Healthcare systemApplying Disruptive Thinking to the Healthcare CrisisOur Failed Health-care System
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Management Improvement Carnival #62

Mark Graban is hosting the Management Improvement Carnival #62 on the Lean blog, highlights include:

  • Why Quality is Dangerous (Dr. John Toussaint – ThedaCare Center Blog): “If we are going to have carrots and sticks it should be centered on what improvements healthcare organizations and providers are making every day, month, and year. Measuring and improving is how we are going to create better performance in healthcare not dictating and punishing.”
  • Beth Israel Deaconess: Systems, safety, and (avoided) severance… (Steven J. Spear – Chasing the Rabbit): “… BIDMC’s efforts to achieve perfect safety by being transparent when systems fail, using that transparency to see problems so they can be solved.
  • Going to Gemba (Paul Levy – Running a Hospital): “By witnessing problems and work-arounds in real time, the team can have a better idea of how to solve problems to root cause and make incremental improvements in work flows.”
  • Managing the Burning Platform (Mark Rosenthal – Lean Thinker Blog): “It is really easy to say that, in these emergencies, long term thinking doesn’t matter. But I contend that it is even more important right now. This is a time for action. It is not a time for panic.”
  • LeanBlog Video Podcast #2 – Kevin Frieswick, Error Proofing Handwashing (Mark Graban – Lean Blog): “I’m still experimenting with video podcasting, after my first attempt with Jamie Finchbaugh. LeanBlog Video Podcast #2 is… the video from Kevin Frieswick and MetroWest Medical Center with the device for error proofing hand washing on the way into patient rooms”

Overview of the management improvement carnival.

USA Spent $2.2 Trillion or $7,421 Per Person on Health Care in 2007

Health spending in the United States grew 6.1 percent in 2007, to $2.2 trillion or $7,421 per person.
For comparison the total GDP per person in China is $6,100. This continues the trend of health care spending taking an every increasing portion of the economic output (the economy grew by 4.8 percent in 2007). This brings health care spending to 16.2% of GDP (which is yet another, in a string of record high percentages of GDP spent on health care). In 2003 the total health care spending was 15.3 of GDP.

With the exception of prescription drugs (which grew at 1.4% in 2007, compared to the 3.5% in 2006), spending for most other health care services grew at about the same rate or faster than in 2006. Hospital spending, which accounts for about 30 percent of total health care spending, grew 7.3 percent in 2007, compared to 6.9 percent in 2006.

Spending growth for both nursing home and home health services accelerated in 2007 (4.8% v. 4.0%). Spending growth for freestanding home health care services increased to 11.3 percent. Total health care spending by public programs, such as Medicare and Medicaid, grew 6.4% in 2007 v. 8.2% in 2006. In comparison, health care spending by private sources grew 5.8% compared to 5.4%.

Private health insurance premiums grew 6.0 percent in 2007, the same rate as in 2006. Out-of-pocket spending grew 5.3 percent in 2007, an acceleration from 3.3 percent growth in 2006. Out-of-pocket spending accounted for 12.0 percent of national health spending in 2007. This share has been steadily declining both recently and over the long-run; in 1998, it accounted for 14.7 percent of health spending and, in 1968, out-of-pocket spending accounted for 34.8 percent of all health spending.

The costs for health services and supplies for 2007 were distributed among businesses (25%), households (31%), other private sponsors (4%), and governments (40%).

Decades ago Dr. Deming included excessive health care costs as one of the seven deadly diseases of western management. We have only seen the problem get worse. Finally it seems that a significant number of people are in agreement that the system is broken. Still, admitting the system is broken is not the same as agreeing on how to fix it. The way forward to workable solutions still seems very difficult.

Full press release from the United States Department of Health and Human Services.

Related: Many Experts Say Health-Care System Inefficient, WastefulInternational Health Care System PerformanceUSA Paying More for Health CareHealth Insurance Premiums Soar AgainPBS Documentary on Improving Hospitals

ER Checklist

The popular ER TV show highlighted the importance of using checklists in surgery yesterday.

Such powerful quality tools, like the checklist, are just waiting to be used. But far too many fail to use these simple improvement tools. And in health care those failures are potentially critical.

Related: Checklists Save LivesThe Power of a Checklistmanagement improvement dictionaryArticles on Improving the Health Care System

Applying Disruptive Thinking to the Healthcare Crisis

Update: Sadly MIT delete the video. It is a shame educational institutions lose interest in knowledge just a couple years later. Thankfully we didn’t have to rely on the people deleting web content at universities to keep all the historical content we have in books from hundreds of years ago. I think it is a huge lose to what the mission of these schools should be but that attitude doesn’t seem to be shared by the schools.

The Innovator’s Prescription: A Disruptive Solution to the Healthcare Crisis:

Christensen spies symptoms of such disruptions bubbling up in the healthcare industry, such as molecular diagnostics, imaging technologies and high bandwidth telecom, and business model innovations. Integrated health systems like Kaiser Permanente have a leg up in deploying and optimizing these disruptive technologies.

The push for widespread healthcare reform must come from employers, who in spite of their declared intent to cut healthcare costs also know “they profit when their employees are healthy and productive.” Affordable healthcare, he concludes, “doesn’t come by expecting high end, expensive institutions or expensive caregivers to become cheap, but by bringing technology to lower cost providers and venues of care, so they can become more capable.”

Clayton Christensen is the rare management thinker that I feel real provides profound insights into thinking about management. There are many other good management thinkers that offer valuable idea, just most of them (in my opinion) really are presenting material in ways that offer managers a good way to take action on all the long known good management ideas that we fail to adopt successful for decades.
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The Ergonomics of Innovation

The Ergonomics of Innovation by Hayagreeva Rao and Robert Sutton

the IHI case teaches us that innovations spread quickly when organizations focus relentlessly on selecting and spreading ideas in ways that ease the burden of thought and action for everyone involved. This mind-set differs from the one that burdens most organizations, where innovation
is seen as difficult, expensive, and protracted. The IHI staff’s ergonomics-of-innovation mind-set focused on making things easier and cheaper for everyone, including the staff itself.

IHI focused on small things that had a big impact without placing a big load on hospital staffs (reducing the number of infections, for example, hinged on frequent and thorough hand washing). In this way, the organization adopted what Karl Weick calls a “small wins” strategy.

Berwick and his team believed that simply asking hospital staffs to “try harder” to save lives wasn’t enough; people need concrete, easily learned and implemented tools.

Related: Saving Lives: US Health Care Improvement5 Million Lives CampaignPBS Documentary: Improving HospitalsHospital Reform – IHI on CBSArticles on Improving Health Care PerformanceDrug Prices in the USAposts on innovation

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