Health Care Outcomes—The Rotator Cuff

“As you might expect, Julie, as a senior citizen many of my friends are also senior citizens.  And as a volunteer in health care, my senior citizen friends tend to share with me their poor health care outcomes.”

“Curmudge, I recall that some of those outcomes have occurred pretty close to home, like your college roommate in Stan’s Story and Ms. Curmudgeon in A Day in a Hospital in Prague. “    

“As it turned out, my wife’s problems weren’t over when she returned home.  The fall in Prague had torn her rotator cuff, which now needed surgical repair.”

“Clear the track!  I think another medical anecdote is headed our way.”

“After waiting several weeks to get on the doc’s schedule, my wife went in for arthroscopic surgery on her right shoulder.  Regrettably, the screws (or whatever) were observed to pull out, so the doc had to finish the job via open surgery.  After several weeks of therapy, an MRI revealed that the results of the open surgery hadn’t held, either.”

“What a bummer!  So Ms. Curmudgeon couldn’t raise her right arm all the way.  That’s quite a disability for a professional organist and choir director.”

“I found it interesting, Julie, that the Medicare Summary Notice showed two CPT (Current Procedure Terminology) codes for my wife’s rotator cuff surgery.  One was for the arthroscopic surgery and one for the open surgery, neither of which was successful.  If it weren’t for the two CPT codes, it wouldn’t have caught my eye.  It would appear that the doc was paid the same, irrespective of the outcome.”

“That’s the system, Curmudge.  Outcomes are not factored into reimbursements.  And because Ms. Curmudgeon was covered by Medicare, the citizens of the United States paid for two unsuccessful surgeries.  As we quoted Dr. Groopman in an earlier posting, ‘No one can guarantee the right outcome from a treatment for an individual patient.’ ”

“I guess that’s one reason why reimbursement systems based on outcomes are problematic.  One would think that qualifiers might at least be added to the bill…perhaps an ‘attaboy’ for a success and ‘oops’ for an obvious failure.”

“No physician can afford too many ‘oopses,’ Curmudge.  As you said earlier, patients—especially senior citizens—don’t hesitate to talk about their health care experiences.”

“The surgeon put in a full morning’s work and was paid for his efforts, but he was probably as frustrated as we were.  Perhaps the shoulder was truly beyond repair.  This was a story with no happy ending for anyone.”

“Paying for procedures and not outcomes is one of those ongoing problems in today’s health care.  My guess, Curmudge, is that we will discuss this further.”

Kaizen Curmudgeon    

Spring Cleaning--The Bright Side

“Do you remember, Curmudge, that our most recent “Spring Cleaning” posting sounded as if health care was burdened by a host of intractable problems?” 

“Of course I recall, Julie.  That was the one that ended with aircraft carriers being run by 19-year olds.  Then I became distracted and talked about L.A.M.E., LEO, and Lean pretenders.  Sorry about that, but perhaps a senior citizen’s thought processes are sequential distractions separated by momentary profound insights.”

“If you say so, Curmudge.  So now let’s talk about the bright side of Lean in health care.  Books have been written about the Lean success stories in Seattle, Pittsburgh, and the other side of Appleton (1-3).  These show the value of being an early adopter and demonstrate that substantial improvements are feasible.  And there’s also the new book by Bisognano and Kenney, Pursuing the Triple Aim, which describes progress in seeking the best care for the whole population at the lowest price (4).”

  

“To stay on top of progress in the health care universe, one must be an avid reader of blogs and then follow your inquisitive mouse through inviting links.  Sometimes it’s like opening a closed door to reveal a Shangri-La on the other side.”

“So all the time I thought you were sitting at your desk, your head was actually in a mythical Himalayan paradise.  Please tell me some of what you have found on your electronic journeys.”

“I started on the IHI (Institute for Healthcare Improvement) website and ended at a New York Times editorial.  It mentioned improvements at Virginia Mason Medical Center such as using a checklist to justify (and reduce) CTs and MRIs.  Cincinnati Children’s Hospital uses computer models to predict the number of ICU beds needed by patients having surgery.  Other institutions have eliminated inefficient processes such as multiple re-entries of the same patient data for scheduling, admitting, discharge and billing.  It’s interesting to read this in everyday English, but the Times never mentioned Lean by name.  Incidentally, as part of the same wander through the Web, I learned that Virginia Mason has its own blog, http://virginiamasonblog.org.”

“Curmudge, had you ever heard of Hunterdon Medical Center in New Jersey?”

“Not before a few weeks ago.  The Wall Street Journal on 6/05/12 ran this article, ‘Behind One Hospital’s Fight Against Deadly Infection.’  Here are some of the things Hunterdon Medical Center did to reduce the incidence of Clostridium difficile and MRSA among patients: sanitizing rooms with ultraviolet light, scrubbing surfaces with bleach and hydrogen peroxide, washing hands with soap containing chlorhexidine, equipping nursing station computers with washable keyboards, and purchasing new equipment to more rapidly identify contaminated surfaces.  As a result, Hunterdon cut its rate of C. diff infections by 79%.”

“Did it ever occur to you, Old Guy, that some of these great accomplishments in health care quality and patient safety might not have been the product of an organized Lean program?”

“Julie, if one is doing the right thing, the name given to the program doesn’t matter.  Quality and safety go hand-in-hand, and they are outcomes of Lean—as are efficiency, waste reduction, and respect for people.  Now, shall we proceed in our search for the bright side of health care?”

“Lead on, Professor.  By the way, I’m surprised that you were not aware of the great things going on at Denver Health until some of our colleagues went there for a visit.”

“The explanation is simple, Julie.  The older one gets, the more he misses.  I understand that Denver Health’s CEO is a Lean zealot, and they focus their rapid improvement events on 16 value streams.  That clearly shows their inspiration by the Toyota Production System.”  

“I suspect that great things that we don’t know about—Lean and other programs—are occurring all across the country.  ‘Lean (June) is busting out all over,’ probably even in Oklahoma.”

“Julie, I find it hard to imagine any hospital’s not embarking on some program to improve their efficiency, safety, and patient experience.  So the good news might be that there are lots of hospitals out there practicing Lean sub rosa, i.e., hiding under the bushes.  The bad news could be that I am totally wrong.”

“It wouldn’t be the first time, Curmudge.”   

“There’s more good news.  In our April 15 posting we mentioned that med students and residents are learning about quality, safety, and patient-centered care in extracurricular instruction.  Paul Levy’s June 14 posting suggests that programs on those themes are proliferating.  Here’s a quote from another posting on June 14: ‘No organization can succeed at continuous improvement without a mechanism for recognizing where it is not doing well or well enough.  Only those hospitals that cherish the opportunity to learn not only from adverse events, but also from near misses, work-arounds, and plain old inefficiencies in the delivery of clinical care will rise to a level of high quality and will maintain that level.’  Although these links don’t describe recent accomplishments, they inform the listeners/readers of what must be done in the near future.”

“So that’s our story; some good news plus a stimulus to keep up the good work.” 

Kaizen Curmudgeon

(1)  Kenney, Charles.  Transforming Health Care: Virginia Mason’s Pursuit of the Perfect Patient Experience. (2010)

(2)  Grunden, Naida.  The Pittsburgh Way to Efficient Healthcare. (2007)

(3)   Toussaint, John and Gerard, Roger.  On the Mend: Revolutionizing Healthcare to Save Lives and Transform the Industry.(2010)

(4)  Bisognano, Maureen, and Kenney, Charles.  Pursuing the Triple Aim: Seven Innovators Show the Way to Better Care, Better Health, and Lower Costs. (2012)

Nothing New

“You are aware, Julie, that when I sell my house and move to an apartment I won’t have much room for my personal library.”

“That will be especially true if your apartment is just a room in what we used to call The Old Folks Home.”

“That’s not what I am planning, but in any case, I’m sorting my books and discarding those that are out of date.  One leadership book published in 1989—a twinkling of an eye ago on my time scale—contained the same advice one would read in a book published yesterday.  It seems that in leadership, there’s (almost) nothing new under the sun.”

“Curmudge, I anticipate that you are going to tell me that ‘everything one needs to know he learns in kindergarten.’ “

“That comes later, Julie.  Before we leave the old book, I must share this note that I found in it.  A survey in the 1970’s revealed that 7% of one’s success is determined by his knowledge, 12% by his skills, and 81% by his attitude.”

“Obviously the survey didn’t include physicians in cognitive or procedural specialties.”

“Let’s focus on attitude.  One can be a command-and-control manager who lives by ‘meeting the numbers’ or ‘getting the product out the door,’ or he can be a leader who adheres to the Lean principle of ‘respect for people’ or the teachings of Servant Leadership.    It’s the person’s decision, as in our posting on Choices.”

“So Curmudge, what about all of those books on management and leadership that don’t seem to change much over the years?  A lot of people have established businesses and had successful careers writing and teaching how to lead and manage.”

“That’s second order stuff, Julie.  Their teachings are full of how-to-do-it details and reminders that aren’t very helpful unless one has made the essential choice of respecting people.”

“You mean details like time management, goal setting, motivation, delegation, and using Lean tools without a Lean culture?”

“That’s the idea.  Simply going through the motions takes one’s Lean journey nowhere.”                      

“I think I’ve got it, Curmudge.  But where does one obtain guidance in making the all-important choices?”

“At your mother’s knee, in church, at kindergarten…”

“…or by an epiphany later in life.  How do you like that word, Curmudge?”

Kaizen Curmudgeon

"Everybody's tryin' to get into the act."

“That’s a famous quotation, Jaded Julie.  Who said it?”

“I haven’t the foggiest idea, Curmudge.  But since you never turn on your TV, it must be someone from long, long ago.”

“It was Jimmy Durante, star of radio in the ‘40’s and TV in the ‘50’s and ‘60’s.  Definitely before your time.”

“Okay, you’ve proven that your memory is not totally kaput, so why are we talking about a Jimmy Durante quotation?  Wait…I’ve got it!  It’s because ‘the act’ in the quotation can easily be replaced by ‘Lean.’  ‘Everybody’s tryin’ to get into Lean.’ “

“You are indeed correct, Julie.  There is a Lean consultant on almost every street corner, and they often give Lean another name to make it sound like their own invention.  Others take the name ‘Lean’ and give it to their ‘idiosyncratic collections of practices and procedures intended to cut costs, improve efficiency, and sometimes to improve effectiveness.’ (1) That’s okay if they are teaching real Lean and not L.A.M.E. (Lean As Misguidedly Executed).  In a recent posting, Graban has reiterated some of the principles of the Toyota Production System to help us distinguish true Lean from L.A.M.E.”

“I guess you are saying that it doesn’t matter what they call it as long as they do it correctly.  That’s the exact opposite of what Henry Higgins said in My Fair Lady, ‘The French don’t care what they do, really, as long as they pronounce it correctly.’ “

“I believe we’ve used that line before, but I don’t recall when.  Anyway, the reason for this discussion is a book I’ve been reading.  It’s The Power of LEO, The Revolutionary Process for Achieving Extraordinary Results by Subir Chowdhury.  As I read it, I couldn’t help thinking how it parallels Lean.”

“My anticipation, Curmudge, is that you are going to tell us what those parallels are.  I already know one difference; LEO is an acronym and Lean isn’t.”

“Right as usual.  L—Listen.  Observe and understand; seek input from all stakeholders.  E—Enrich.  Explore and discover; create new ideas for improvement and solutions for problems.  O—Optimize.  Improve and perfect; select and test the best improvement ideas and problem solutions.  LEO is ‘an encompassing strategy that can be embraced by everyone in an organization.’  The author also states that, ‘Quality methodologies like Six Sigma and Lean can be highly effective but are used narrowly and by limited personnel within an organization.’ “

“Hey, Curmudge!  What he says might be true about Six Sigma, but that’s not been my experience with Lean.”

“Here’s another subtle difference.  The author often refers to quality in the manufacturing sense, meaning products that meet customer needs and processes that are performed right the first time every time.  In health care, quality often refers to meeting defined quality measures; denoting quality in terms of patient outcomes is elusive.  In Lean, quality is implicit in implementing standard work and reducing waste and inefficiency.”

“From our earlier discussion, here is an important feature that Lean and LEO have in common.  As we know so well, Lean is a culture to be implemented throughout an organization.  In LEO, quality is the responsibility of all of the people all of the time.  The author quotes Aristotle, ‘Quality is not an act, it is a habit.’ “

“Julie, as I read about LEO I was impressed by its similarities with parts of an A3 form.  The Listen phase of LEO resembles the left side of an A3.  They seek an understanding of the current condition; they observe and understand by going to gemba just like in Lean.  ‘The quality that LEO can deliver is directly proportional to the quality of the information gathered in the Listen phase of deployment.’ “

“As I understand it, Listen concludes and the Enrich phase begins when the LEO team makes a map of the current operational situation (the familiar current state map).  ‘In the Enrich phase, the search is on for the best solution.’  They seek to develop alternate ways to solve the problem.  Their efforts under Enrich resemble root cause analysis and use of other Lean tools under Current Condition and Problem Analysis on an A3 form.”

“ ‘In the LEO Optimize phase, the solutions selected during the Enrich phase are torn down to their details.  That’s where their weaknesses can be found.’  This seems more appropriate in the development of an industrial process.  The counterparts of this section in an A3 would be the Target Condition and Countermeasures.”

“If you haven’t forgotten it, Curmudge, what’s the bottom line?”

“A major LEO deployment appears to start with a team of LEO consultants rather than a single sensei as in Lean.  From there on, much is familiar.  A certified LEO trainer trains a cadre of local people to take over after the initial deployment.  LEO overview classes are taught to the employees where they learn that LEO is focused on rooting out waste, not employees.  Active involvement of the CEO and top management is essential, and they are urged to integrate LEO into their everyday work lives.  Overall, LEO appears to be another way of describing and implementing the kinds of changes that are becoming essential in every business.”

“So I suppose that Jimmy Durante would approve of everybody’s tryin’ to get into the act, or Lean, or LEO, or whatever.”

“Of course, but only if it’s true Lean and not L.A.M.E.”

Kaizen Curmudgeon

(1) Chambers, David.  Efficient Healthcare (2009, Rice University Building Institute).                    

Happy Fifth Birthday

“Happy fifth birthday, Julie.”

“On our second birthday, in May of 2009, you sang ‘Happy Birthday’ to me in Italian.  Last year, only four months after Ms. Curmudgeon’s passing, you were somewhat upbeat.  Today you sound almost morose.  What’s up, Curmudge?”

“The loss of our sponsors last winter, as we explained on March 1, was pretty traumatic.  However, I should be grateful that the Old Man who writes our scripts can still do it in his spare time.”

“I’m puzzled, Curmudge.  How does a retired person like the Old Man define ‘spare time’?”

“It’s time spent doing what you want to do.”

“So when a working person has spare time, he does what he wants to do.  But retired people can reverse the expression.  When they are doing what they want to do, they call it spare time.”

“You’ve got it, Julie, as usual.”

“I really appreciate your clarifying what is meant by spare time, Curmudge.  But are you certain that you didn’t just make all that up?”

“It’s really a matter of the Old Man’s finding any time—no matter how you define it—to write stuff for us.  I know that he has plenty of material.” 

“You’re right.  There are bulging files at work and a stack of unread books here at home.  As he says, ‘There’s so much to learn and so much to teach.’  Nevertheless, I’m worried that his literary flame has sputtered occasionally and might be extinguished.”

“It won’t be self-snuffed, Julie. He remains an inveterate teacher and intends to ‘keep on a-keepin’ on’.”

“Is that a foreign language, Curmudge?”

“Not foreign, just regional from Southwestern Virginia.  It can be translated as ‘hang in  there.'“

“I have one final question.  The Old Man himself has said that everyone needs an editor.  Who is doing that?”

“You’ve already met Doc Mack.  There is also Liz, who once earned her living by writing.  And finally there is Al, who knows the bad side as well as the good side of the business world.  They are a diverse, yet incomparable, team.”

“I’m relieved, Curmudge.  I didn’t want the Old Man to be flying solo.  Happy fifth birthday.”

“Keep on a-keepin' on, Julie.”

Kaizen Curmudgeon   

Spring Cleaning—This Isn’t “Happy Talk”

“Curmudge, I googled it.  ‘Happy Talk’ is a song that was sung by Bloody Mary in the musical, South Pacific.  But I was hoping that as you cleaned out your files this spring you’d find quotations that were cheerful and encouraging.”

“For the most part, it didn’t turn out that way, Julie.  And most of these quotes are fairly recent.  They suggest that health care should still be in intensive care.”

“Well I hope that our readers realize that these are quotations from notable authors and not original with you and me.”

“Julie, after 200 postings our readers should realize that nothing is original with you and me.  So sit back and shudder at what you are hearing.”

“Health care remains fundamentally unsafe.”  (L. Leape, runningahospital.com, 3/20/12)

“Too often, doctors think they are infallible, communication between doctors and nurses is poor, and accountability is virtually non-existent.”  “There is difficulty admitting that well-meaning, highly trained, competent doctors predictably and continuously make mistakes.”  (Peter Pronovost, Wall St. Journal, 2/17/10)

“We (physicians) can’t know it all.  We can’t do it all by ourselves.”  “Holding on to that old culture (complete autonomy) has been a disaster.”  “We need pit crews, not cowboys.”  (A. Gawande, TED talk, April 2012)

“You can’t practice medicine by committee.”  “Uniformity of practice is a nonsensical goal that fails to allow for differing expression of disease states.”  (S. Greenfield, Wall St. Journal, 9/07/10)

“It sounds, Curmudge, as if Dr. Greenfield doesn’t favor standardized work, algorithms, and checklists.”

“That’s why a goal of evidence-based medicine is to accommodate variation between patients while minimizing variation between clinicians.”   

“Most clinicians and nurses believe quality improvement is done to them rather than something they do.”  “Without physician leadership, quality improvement efforts are unlikely to succeed.”  (P. Pronovost, beckershospitalreview.com 2/28/12)

“The average Medicare patient sees two physicians and five specialists a year.”  “You (patient) have to be the central communicator…there is no little Tinkerbell picking up your medical records and automatically delivering them to the physicians in your life who should know what is happening with you.”  (B. Gray, kevinmd.com 4/09/12)

“We don’t often talk about money, Julie, but here are some ways to achieve big savings:”

“Decrease the practice of routinely administering untargeted chemotherapeutic false hope and real suffering to patients with widespread metastatic cancer.  Recognize death to be normal, and endeavor to make it as dignified and free from pain as possible.  Do not prolong dying to keep the revenue flowing.”  (George Lundberg)  “Stop overtreatment with unneeded antibiotics, surgery, and intensive care, especially at the end of life.”  (Donald Berwick)  (Both found in kevinmd.com 5/07/12)  

“Whether happy or not, physicians set the tone at their places of work.”  (G. Hood, Survey of physician happiness.)

“L.A.M.E. = Lean as mistakenly executed.”  (M. Graban, LeanBlog 4/10/12)

“No one can guarantee the right outcome from a treatment for an individual patient.”  (P. Hartzband & J. Groopman, Wall St. Journal, 3/31/12)

“Creating a culture of safety includes: Admitting our own errors and mistakes when they occur, and feeling empowered and supported to speak up when we see another’s. (and)  Learning from errors so that we don’t repeat them.”  (O. Peskovitz, runningahospital.com 3/16/12)

“Julie, you should find this example of precise performance to be encouraging:”

“An aircraft carrier is an airport on top of a nuclear power plant (run by) a bunch of 19-year olds.”  (S. Patterson, runningahospital.com 4/18/12)

“That’s an oversimplification, Curmudge.  You know that those 19-year olds are led by the best of the best and that all critical functions—especially on the flight deck—are exquisitely choreographed and perfected by repetition.”

“Our local hospitals will never go to sea, Julie, but I’ll bet that those kids could teach them a thing or two about the value of standard work.”

Kaizen Curmudgeon

Spring Cleaning--Safety and Quality

“Hey, Julie, I’ve been doing some spring cleaning.”

“Your messy office or your cluttered basement?”

“My office is not messy, but my files are overloaded.  I’ve been sorting them to discard the junk and retain the classics.  Although this stuff goes back to 2006, the gems shine as brightly as they did originally.”

“Then, Curmudge, let’s share some of them with our readers.  They are all quotations, but we won’t have room for complete references.  Perhaps we can just state the name of the author or the blog or publication in which the quote appeared.”

“Okay, Tonto, you type while the Lone Ranger shuffles papers:”

“99,000 patients die each year as the result of hospital-acquired infections and errors.  That’s the equivalent of one fully-loaded 747 crashing each day for 200 days out of a year.  About 7,000 people per year are estimated to die from medication errors alone with three-fourths of the adverse drug events due to failures at the system level.”  (Graban 8/09/09)      

“Curmudge, I find these numbers astonishing, yet the original sources of these values are quite believable.”

“The only way to crack down on error is to admit its inevitability.  Being aware of the mistakes we make that lead to error is the only way to curb it.”  (K. Schultz in ‘Being Wrong’)

“After surgical technique, most surgical error was caused by human factors: judgment, inattention to detail, and incomplete understanding, and not to organizational/system errors or breaks in communication.” (pubmed/18847639)

“In the arena of skill- and experience-based errors, the research is clear.  Nothing can take the place of repetition.”  (emsresponder.com)

“Checklists seem able to defend everyone, even the experienced, against failure in many more tasks than we realized.  They provide a kind of cognitive net.  They catch mental flaws.” (A. Gawande)

“About 15 percent of patients are misdiagnosed.  In fact most cases are due to mistakes in the mind of the doctor.”  (Jerome Groopman)

“Studies have demonstrated that geographical location strongly determines specialty care access and procedural decision making.”  (Harrington, Quality Digest, 2006)

“In Pennsylvania alone, the mortality rate during a hospital stay for heart surgery varies from zero in the best-performing hospitals to nearly 10% at the worst performer.”  (NY Times, 5/17/07)   

“There’s also a very complex social and organizational hierarchy that makes it difficult for people lower on the hierarchy to critique or speak up when they see a problem with someone higher up.”  (WebM&M, Nov. 2006)

  

“All health care providers performing invasive procedures must adopt the Joint Commission Universal Protocol, including performance of a time out immediately prior to the procedure.”  (medscape.com/17053)

“Out-of-hospital sudden cardiac arrest survival to discharge generally reported at less than 10%, and survival from in-hospital sudden cardiac arrest estimated at 18%.”  (WebM&M, July/August 2007)  “A 2010 study of more than 95,000 cases of CPR found that only 8% of patients survived beyond one month.”  (G. Hood, 4/16/12 Medscape)

“Please note, Julie, that if one ‘codes’ in a hospital and somehow manages to survive, he still has his original ailment, and in addition, a crushed chest.”

“Wow, Curmudge, I can see why old guys like you in a hospital want their chart to indicate ‘Do not resuscitate.’ ”

“(A patient safety officer’s) job ethically is to transparently promote a reliable and safe environment.  To do that, you need transparency.”  (A. Frankel, MD, WebM&M, Dec. 2006)

“The single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes.”  (L. Leape, 2008)

“Environmental cleaning is so important that when it is not done regularly and rigorously, placing a patient in a room previously occupied by a patient with Clostridium difficile can be a fatal mistake.  Cleaning hands with soap and water is essential, because alcohol sanitizers are often ineffective against C. diff.”  (hospitalinfection.org, Jan. 2009)

“There is compelling evidence that performance measurement leads to performance improvement.” (However) “Good performance is not necessarily good care, and pressure to improve performance can come at the sacrifice of good care.”  (R. Werner, Medscape 555953)

“For employees, it is the culture of the organization that is the reality, not the mission statement that hangs on the wall.”  (A. Yelton, GE Healthcare)

“Lean Thinkers now have the tools to reform healthcare delivery.”  (Jim Womack)

“It takes 18 years for proven best practice to become the industry standard in healthcare.”  (Brent James, 2009)

“I was hoping, Curmudge, that we would find quotations that would cheer me up.  If these are ‘up,’ I’d hate to see what ‘down’ is.  As we continue to rummage through your files, will we find material that is more encouraging?”

“No guarantee, Julie.  I suspect we’ll find lots of suggestions of the right things to do, but examples of resounding successes are apt to be rare.  It will take a lot more work before every hospital is as safe and efficient as a nuclear-powered submarine and as customer-friendly as a Ritz-Carleton Hotel.”

Kaizen Curmudgeon