Is There "Standard Work" for Clinical Care?
This commentator points out some shocking waste in the healthcare system:
Although cancer doctors work long hours, they still fail, frequently, to provide therapies the medical evidence says the patient needs.
Sometimes the problem is occupational blinders. For instance, radiation oncologists think prostate cancer should be treated with radiation, while urological surgeons favor surgery.
Sometimes, it's communication. The doctor thought a treatment had been considered, but it hadn't. Sometimes, it's human limitations. The doctor thought he was doing what's best, but his memory of the medical literature was flawed.
What's scary is that getting treatment for any disease based on the medical evidence happens on average about 55 percent of the time â€” essentially, you're flipping a coin.
We waste 30 cents of every health-care dollar providing treatments we don't need, not providing treatments we do, and fixing preventable medical mistakes.
That adds up to a $700 billion problem.
I've traded emails with one doctor (after I've written about standard work in medicine before) who claimed that the profession is full of the ultimate scientists, who believe evidence and always follow the best practices (although there might be disagreement on the best practices).
Over my vacation last week, I read an excellent book, Better: A Surgeon's Notes on Performance, written by Dr. Atul Gawande that further delves into this topic. I'll write more about the book sometime soon. Dr. Gawande brings up some examples where the treatment for a disease, such as Cystic Fybrosis, varies widely across the specialized centers that are set up to treat exactly that disease. You can read more about that in his New Yorker magazine essay that ultimately became a chapter in his new book. Why aren't the best known treatments found more consistently?
I experienced this first hand last year when I had surgery to remove some bad varicose veins in both legs (I would blame Mom and heredity, but it's Mother's Day after all). The first surgeon I saw seemed knowledgeable and credible, he suggested one type of surgical procedure. I called a friend who happened to be a nurse at a vascular clinic in another state. I told her what had been suggested and she screamed, “No! That's an old, invasive, extremely painful procedure. Run away from that doctor!” I found a local vascular specialist who knew the latest, less invasive procedure.
So here were two professionals, both certified and pedigreed…. why did I get two totally different procedures suggested? My nurse friend said, “The first surgeon suggested the procedure he knew how to do,” rather than the one that was best.
I don't know all of the answers, but this is a type of waste that we need the real experts, the MD's (like Dr. Gawande) and the medical schools, to figure out — how do we create a culture where the best known “clinical pathways” (aka “standard work”) are followed as often as possible? How does my first surgeon pass me on to a specialist without taking money out of his own pocket? What are the ethical standards there? Lean guys, like me, can only ask the question. If “standard work” can provide benefits in other industries, it sure can in medicine, right?
I'm not trying to dump on doctors. They are human and mistakes get made. That's where Lean methods, like error proofing and standard work, can help support MD's in doing a better job. Standardizing doesn't mean the MD's have to be like robots, anymore than standard work turns other types of workers into robots. It's important to standardize the methods that are known to improve safe and high-quality outcomes. It's great that doctors are often amazingly creative in fixing our widely-varying human bodies. But maybe we should save that creativity for when it's really needed??
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