Comments on: Medical Errors in Hospitals Still Occur at Alarming Rate http://www.leanblog.org/2009/07/medical-errors-in-hospitals-still-occur/ Mark Graban's leanblog.org - Lean Healthcare, Lean Thinking, Lean Manufacturing, Toyota Production System Fri, 10 Feb 2012 10:01:31 +0000 hourly 1 http://wordpress.org/?v=3.3.1 By: Mark Jaben http://www.leanblog.org/2009/07/medical-errors-in-hospitals-still-occur/#comment-5212 Mark Jaben Fri, 17 Jul 2009 10:12:40 +0000 http://leanblog.bigbigdesign.net/2009/07/medical-errors-in-hospitals-still-occur-at-alarming-rate/#comment-5212 Mark<br />The recent US News and World hospital ratings are a perfect example. Look at their initial screening parameters, which are based on being a teaching hospital, number of beds and number of nurses, none of which have any relationship to quality. Where is their methodology to justify these criteria? And yet, most people will not even note this. They will just accept that there is merit to these ratings. Mark
The recent US News and World hospital ratings are a perfect example. Look at their initial screening parameters, which are based on being a teaching hospital, number of beds and number of nurses, none of which have any relationship to quality. Where is their methodology to justify these criteria? And yet, most people will not even note this. They will just accept that there is merit to these ratings.

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]]> By: Mark Jaben http://www.leanblog.org/2009/07/medical-errors-in-hospitals-still-occur/#comment-5200 Mark Jaben Wed, 15 Jul 2009 10:56:45 +0000 http://leanblog.bigbigdesign.net/2009/07/medical-errors-in-hospitals-still-occur-at-alarming-rate/#comment-5200 I don't blame Healthgrades or Leapfrog or Medicare or any of a number of other groups trying to begin an effort to rate healthcare. We must, however, be very mindful of their limitations before we quote them as being definitive. They, too, must practice continuous improvement to someday zero in on what really matters.<br /><br />Doctors get bashed over not having done this work, but it just reflects how difficult and complex it is. Doctors know that the history of medicine contains too many examples of a great idea that just didn't work out when tested against reality. <br /><br />Therein lies the potential for Lean I don't blame Healthgrades or Leapfrog or Medicare or any of a number of other groups trying to begin an effort to rate healthcare. We must, however, be very mindful of their limitations before we quote them as being definitive. They, too, must practice continuous improvement to someday zero in on what really matters.

Doctors get bashed over not having done this work, but it just reflects how difficult and complex it is. Doctors know that the history of medicine contains too many examples of a great idea that just didn't work out when tested against reality.

Therein lies the potential for Lean

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]]> By: Mark Graban http://www.leanblog.org/2009/07/medical-errors-in-hospitals-still-occur/#comment-5190 Mark Graban Tue, 14 Jul 2009 11:04:01 +0000 http://leanblog.bigbigdesign.net/2009/07/medical-errors-in-hospitals-still-occur-at-alarming-rate/#comment-5190 Mark - I heard similar criticism of HealthGrades last week. That seems very shady when it's "pay for play" or "pay for rate."<br /><br />It's interesting to see how efforts like the Wisconsin Collaborative for Healthcare Quality play out:<br /><br />http://www.wchq.org/index.php Mark – I heard similar criticism of HealthGrades last week. That seems very shady when it's "pay for play" or "pay for rate."

It's interesting to see how efforts like the Wisconsin Collaborative for Healthcare Quality play out:

http://www.wchq.org/index.php

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]]> By: Mark Jaben http://www.leanblog.org/2009/07/medical-errors-in-hospitals-still-occur/#comment-5181 Mark Jaben Mon, 13 Jul 2009 05:22:49 +0000 http://leanblog.bigbigdesign.net/2009/07/medical-errors-in-hospitals-still-occur-at-alarming-rate/#comment-5181 Mark,<br />There is no doubt error and unexpected or undesired outcomes happen in healthcare. A very real problem in healthcare is knowing what constitutes quality. <br /><br />For instance, many of the Medicare quality indicators do not really reflect on quality. Moreover, rating services, like Healthgrades, are far too crude to provide helpful measurement, and don't really contribute to understanding what quality actually is. <br /><br /> Healthgrades gets its data from the individual hospital. Its revenue is derived from the hospital paying Healthgrades if the hospital wants to use their ratings for marketing.<br /><br />In one instance I am intimately familiar with, Healthgrades presented a hospital with one of its few 5 star ratings in a particular state, only to have the hospital lose its Medicare and Medicaid funding one month later for serious and unresolved quality problems!<br /><br />How can this be? It's hard to responsibly and effectively measure what we don't truly understand. In lieu of this, we create measurements that do more harm than good by misleading us into thinking we are doing quality, creating rather than reducing waste. Metrics must be clear and relevant. So far, medicine has neither. And this is a real problem Mark,
There is no doubt error and unexpected or undesired outcomes happen in healthcare. A very real problem in healthcare is knowing what constitutes quality.

For instance, many of the Medicare quality indicators do not really reflect on quality. Moreover, rating services, like Healthgrades, are far too crude to provide helpful measurement, and don't really contribute to understanding what quality actually is.

Healthgrades gets its data from the individual hospital. Its revenue is derived from the hospital paying Healthgrades if the hospital wants to use their ratings for marketing.

In one instance I am intimately familiar with, Healthgrades presented a hospital with one of its few 5 star ratings in a particular state, only to have the hospital lose its Medicare and Medicaid funding one month later for serious and unresolved quality problems!

How can this be? It's hard to responsibly and effectively measure what we don't truly understand. In lieu of this, we create measurements that do more harm than good by misleading us into thinking we are doing quality, creating rather than reducing waste. Metrics must be clear and relevant. So far, medicine has neither. And this is a real problem

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]]> By: Anonymous http://www.leanblog.org/2009/07/medical-errors-in-hospitals-still-occur/#comment-5163 Anonymous Wed, 08 Jul 2009 19:56:10 +0000 http://leanblog.bigbigdesign.net/2009/07/medical-errors-in-hospitals-still-occur-at-alarming-rate/#comment-5163 Mark:<br /><br />Sitting here waiting for a family member to come back from the operating room (minor surgery = surgery on somebody else!) your topic of the day naturally led me to try to divine where this particular hospital stands. It is not easy at the "HealthGrades" website! Not only do they require you to chase down one rabbit trail at a time, by procedure and region, to see how an individual hospital is rated, but the ratings are for complications and other outcomes - NOT explicitly "errors" - so they are only really useful as relative measures. You can't really expect a "zero complication" environment - this (hospital care) is rework, after all, fixing problems! A complication in (or after) the O.R. is not necessarily an error - some people are really very sick! It would be great to see comprehensive error reporting. Maybe I just missed it.<br /><br />Any how, that said, the "BEST" results (relative or not) I found on "HealthGrades" web site for this hospital in almost all the categories I tracked down reflected my observations in the gemba here: visual cues, standardized communications at the pre-op level (with patients and with family), and flexible scheduling as opportunities for accelerated movement arose. Checklists in use! White boards (that weren't here last time I passed through) with obviously prototyped labelings, speak of an environment of continuous improvment (and reminded me of what I see and strive for in my own plant). <br /><br />So, my shallow investigation into a totally unscientific sample of ONE, says: This stuff works. Who is surprised? It is said that when you walk into a lean plant, you can tell - you can see what is supposed to be happening, and where the problems are even if you don't know the business or the industry. My experience in health care gemba is the same.<br /><br />-Anonymouse today, due to reference to family member in hospital! Mark:

Sitting here waiting for a family member to come back from the operating room (minor surgery = surgery on somebody else!) your topic of the day naturally led me to try to divine where this particular hospital stands. It is not easy at the "HealthGrades" website! Not only do they require you to chase down one rabbit trail at a time, by procedure and region, to see how an individual hospital is rated, but the ratings are for complications and other outcomes – NOT explicitly "errors" – so they are only really useful as relative measures. You can't really expect a "zero complication" environment – this (hospital care) is rework, after all, fixing problems! A complication in (or after) the O.R. is not necessarily an error – some people are really very sick! It would be great to see comprehensive error reporting. Maybe I just missed it.

Any how, that said, the "BEST" results (relative or not) I found on "HealthGrades" web site for this hospital in almost all the categories I tracked down reflected my observations in the gemba here: visual cues, standardized communications at the pre-op level (with patients and with family), and flexible scheduling as opportunities for accelerated movement arose. Checklists in use! White boards (that weren't here last time I passed through) with obviously prototyped labelings, speak of an environment of continuous improvment (and reminded me of what I see and strive for in my own plant).

So, my shallow investigation into a totally unscientific sample of ONE, says: This stuff works. Who is surprised? It is said that when you walk into a lean plant, you can tell – you can see what is supposed to be happening, and where the problems are even if you don't know the business or the industry. My experience in health care gemba is the same.

-Anonymouse today, due to reference to family member in hospital!

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]]> By: Mark Welch http://www.leanblog.org/2009/07/medical-errors-in-hospitals-still-occur/#comment-5162 Mark Welch Wed, 08 Jul 2009 19:40:51 +0000 http://leanblog.bigbigdesign.net/2009/07/medical-errors-in-hospitals-still-occur-at-alarming-rate/#comment-5162 The same principles apply in Healthcare, Tim, only they are often a little more difficult to see, but with training and experience there is no reason improvement shouldn't happen. Marks's article, with reference to John Shook, illustrates the cultural issues very clearly, and this only supports the notion that using only lean tools without cultural change will fail (the "counting" is just level 2 error-proofing at best). So they know they are supposed to count... This is effective inasmuch as they know why, what is at stake, and to the extent the Director audits the process, reinforces it, and removes barriers to it being omitted. The same principles apply in Healthcare, Tim, only they are often a little more difficult to see, but with training and experience there is no reason improvement shouldn't happen. Marks's article, with reference to John Shook, illustrates the cultural issues very clearly, and this only supports the notion that using only lean tools without cultural change will fail (the "counting" is just level 2 error-proofing at best). So they know they are supposed to count… This is effective inasmuch as they know why, what is at stake, and to the extent the Director audits the process, reinforces it, and removes barriers to it being omitted.

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]]> By: Tim McMahon http://www.leanblog.org/2009/07/medical-errors-in-hospitals-still-occur/#comment-5160 Tim McMahon Wed, 08 Jul 2009 17:13:07 +0000 http://leanblog.bigbigdesign.net/2009/07/medical-errors-in-hospitals-still-occur-at-alarming-rate/#comment-5160 I am not too familiar with this subject (healthcare errors) but in manufacutring this would be related to compliants and risk management. The obvious risk of death being signficant. Wouldn't FMEA be a tool you would use to evaluate proces or euqipment design potential opportunities for mistakes, errors, failures and the associates risk. Then I guess the harder part of improving those weakneses to reduce the risk.<br /><br />Where humans are involved you can not elminate human error but improvements can and certainly have been made. The hardest part in lean or continuous improvement is learning to "see" the waste. I guess I wonder if the can and what tools are they using to do that. I am not too familiar with this subject (healthcare errors) but in manufacutring this would be related to compliants and risk management. The obvious risk of death being signficant. Wouldn't FMEA be a tool you would use to evaluate proces or euqipment design potential opportunities for mistakes, errors, failures and the associates risk. Then I guess the harder part of improving those weakneses to reduce the risk.

Where humans are involved you can not elminate human error but improvements can and certainly have been made. The hardest part in lean or continuous improvement is learning to "see" the waste. I guess I wonder if the can and what tools are they using to do that.

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