The headline is my modification of a Deming expression, that management's job is prediction. Statistical process control was one way of predicting future outcomes of a process (if you have a statistically stable process, you can predict that tomorrow will be like today). Management also has to be proactive in terms of anticipating potential quality or safety problems. That's one reason management must go to the “gemba” (or “actual place”) and it's a reason why they must audit standard work and safety practices on a regular basis.
The blog I've linked to above is an interesting one, written by Paul Levy, the CEO of a major Boston Hospital (Beth Israel Deaconess Medical Center). He's very open in his discussion of hospital management issues, which is very admirable and unique. In the linked post, he writes about the hospital's recent “Joint Commission” inspection and links to the full report. Again, very admirable. I'm not sure if any other hospitals are doing this. Levy and BIDMC obviously mean well and want to improve their quality and their accountability to the public. Again, hooray for that.
Since many of you reading this are from the manufacturing world, I think the best parallel to the Joint Commission is to think about ISO9000, a quality “certification” of sorts that's been mocked in the Dilbert cartoon. The problem with ISO9000 is that getting certified is often NOT a predictor of good quality. That's not just me saying that, although my own personal experience bears that out. ‘A factory can document poor processes and still get certified if they follow those processes and still have poor quality. Expected future LeanBlog Podcast guest John Seddon wrote a whole book debunking ISO9000.
The Joint Commission has its critics also, as this story about Mass General Hospital (also in Boston) shows. Inspectors found numerous quality and safety problems, yet the hospital was still going to have its certification renewed. Quality and procedural problems included:
“…staff neglecting to wash their hands before and after caring for patients; medical records lacking dates and times; and patients on pain medication for whom caregivers had not recorded whether their pain had improved.
Why beat up on MGH for a problem that plagues most hospitals (poor handwashing, something I've written about before and something David Mann commented on)? Ok, sorry, that was sarcasm. What does the Joint Commission prize guarantee to you, the patient? It's not a guarantee that caregivers are going to wash their hands!!! Maybe it's a certification that says they're trying hard or that they care, but that's not enough.
There's more criticism of the Joint Commission in the August 6 issue of “Modern Healthcare” magazine. John Toussaint, CEO of ThedaCare, a leading example of Lean healthcare, criticized them by saying:
“… the Joint Commission's hospital accreditation criteria falls short of what's needed to ensure safe, quality healthcare.”
So back to BIDMC, what problems were found in their Joint Commission report?
Doctors were not following standard work (my term, not theirs) and irregularly used the hospital's “medication reconciliation” system. That system helps avoid drug interaction and allergy problems. Levy said, “Over the coming weeks and months, we will make use of the system mandatory.” You might think, why not now, this week, today? Why not before? I'm sure people at BIDMC knew the system wasn't be used, why wasn't this fixed? As Levy pointed out in the comments, it is a complication that physicians are not employees, but that's no excuse — it's just an additional difficult leadership challenge, not being able to rely on “being the boss.” Toyota's Gary Convis was always quoted as being taught you should “lead as if you have no authority.” Maybe Convis can run a hospital now that he's retired from Toyota?
“Code carts” in the patient units didn't have proper security for certain medication. “We are fixing this,” Levy says. Again, did this require outside inspectors to discover? It seems reasonable that a hospital would consider drug security to be an important issue. Why was it not proactively addressed? Levy commented that they did have audits and “hold managers accountable,” but that's not the same as actually fixing it, is it?
In another safety problem, Levy reported, “…some gas canisters were not properly secured. This is a true public safety hazard. If an unsecured gas canister falls and the regulator breaks off, the heavy tube can be an uncontrolled projectile.” To those of you working in factories — how often is this unsafe condition allowed to exist? Hospital administrators and managers need to be in the “gemba” auditing for situations like that. Oh, and the gaps in the fire doors were too wide. Oops, they'll fix that too, now that it was pointed out. Levy said that it's hard to find a large factory that wouldn't have that problem. Really? If so, is that an excuse?
Levy says this:
“The upshot is this. We did very, very well. On average, the Joint Commission finds 10 or more requirements for improvement in their hospital surveys. We had eight. Our re-accreditation is secure. The areas in which they found us wanting were legitimate and proper, and it is our job to fix them. The good news is that we were not surprised. Most of the areas they pointed out were on our agenda to fix over the coming months as part of our continuous improvement efforts.”
Being “on the agenda” is not the same is being fixed! I know that we can't magically fix all problems at the drop of a hat, but all organizations need to prioritize safety and quality issues, be proactive, and prioritize things. Is it complacency that thinks, “these things have been a problem for a long time, so we can take our time in fixing them?” Maybe it's a pat on the back to the employees to say “we did very, very well” but I'd rather see the Toyota mindset of striving for perfection and not being satisfied with passing marks from the Joint Commission.
I know I'm beating up on them, and I'm sure the hospital and its leadership have the best intentions. But, given the state of healthcare quality and safety, intentions aren't enough. We need improvement! Again, I do admire the hospital and Levy opening themselves open to criticism from yahoos like me.
I did submit a question to Levy on his blog (if you haven't figured that out already) and we had some discussion, you can read it yourself in his comments section or see Kevin's post about it on Evolving Excellence. I won't rehash it all here, but it's too bad that Paul started using the “tired excuse” (as another commenter said) that patients are complex. Of course they are, but let's discuss how to fix these problems faster rather than debating whose environment is more complicated. 600,000 unique patients don't require 600,000 unique processes to support their care. I'm not talking about standardizing how doctors diagnosis and cure. I'm talking about standardizing the truly repeatable support processes (lab, pharmacy, radiology, etc.). There aren't 600,000 femurs so different as to require 600,000 different ways to x-ray or MRI them.
Please do visit Paul's blog and read his full post and all of the comments. Thoughts?
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