NY Times on Standardization, Deming, and Lean Principles in Healthcare
About 10 people sent me this article via the blog or Twitter, so thanks for that. Don't worry about duplication if you see stuff you think I'd be interested in reading or blogging about.
The cover story in today's NYT features Dr. Brent James from Intermountain Health (located primarily in Utah). I've visited one Intermountain facility and I know they have a very active Lean improvement effort. The NYT article was fascinating because it pulls together themes including:
- Standardization vs. intuition
- Standardization vs. unthinking commonality
- Standardization and kaizen
- Dr. Deming and Lean / Toyota principles
The important results — better patient care, better outcomes, lower mortality — yes, saving lives as a result of systematic process improvement work.
I'm going to start with some items that appear near the very end of the article, starting with references to Dr. Deming. The article states:
“Most industries have incorporated Deming's big ideas and are now making only incremental progress. “However, there is one big exception,” Lewis adds. “You guessed it: health care.”
What? Everyone but healthcare is DONE implementing Dr. Deming's ideas? Who is the reporter listening to? Is he listening to the people who are always asking things like “what's next after lean?” as if we're done? It reminds me of this other article that was sent to me by a friend, where the Gallup CEO says the ridiculous:
“Jim Clifton, Gallup's chairman and CEO, says businesses have, in most cases, maximized every possible benefit from practices based on neoclassical economics, such as Six Sigma, reengineering, and total quality management. The significant competitive advantages from these practices have hit a point of diminishing returns, he adds. Most well-run companies have wrung almost every efficiency they can from their operations — and their competitors have too.”
I'd argue that hardly anybody has truly implemented Dr. Deming's ideas, just as no company has wrung all of their waste out of their system. Look at Dr. Deming's famous “14 Points” and see if that really sounds like any organization you know. Healthcare isn't THAT far behind others in implementation of Deming's ideas. At least healthcare people have typically heard of “PDSA“. Anyway, enough of that rant and let's get back to healthcare and the NYT article's better points, including citing Dr. Deming's idea that better quality costs LESS.
The NYT rightfully points out a perversity of the piecework “fee for service” system that much of American healthcare works under. Intermountain has been punished, financially, for providing lower cost, better quality care, much as Virginia Mason and ThedaCare have found in their Lean improvement efforts.
“When Intermountain standardized lung care for premature babies, it not only cut the number who went on a ventilator by more than 75 percent; it also reduced costs by hundreds of thousands of dollars a year. Perversely, Intermountain's revenues were reduced by even more. Altogether, Intermountain lost $329,000. Thanks to the fee-for-service system, the hospital had been making money off substandard care. And by improving care — by reducing the number of babies on ventilators — it lost money. As James tartly said, “We got screwed pretty badly on that.” The story is not all that unusual at Intermountain, either. That is why a hospital cannot do as Toyota did and squeeze its rivals by offering better, less-expensive care.”
Is anything in the health insurance reform debate working on that problem?
The article talks about following the scientific method in medicine — looking at data and results to see which methods work best with patients. There's a theme in Dr. James' work: reducing variation in treatment improves outcomes for many conditions and diseases.
Some of the results improvements cited in the piece:
- ARDS survival rates went up to 40%, compared to a standard rate of 10%
- Death rate for coronary-bypass surgery fell to 1.5% (half the national average)
- Lower-than-average readmission rates for heart-failure and pneumonia patients
- Reducing pre-term C-sections from 30% to less than 2% (leading to fewer newborns with respiratory problems)
Dr. James estimates:
“… the changes have saved thousands of lives a year across Intermountain's network. Outside experts consider that estimate to be fair.”
There is, not surprisingly, debate about the role of standardization in healthcare — does it help more than it hurts? Are there cases there standardization isn't the best approach? Sure, there are cases where a physician's intuition and experience count for more than a standardized approach.
Dr. James argued:
“Guys, it's more important that you do it the same way than what you think is the right way.”
But, he knows you can't standardize everything:
“You cannot write a protocol that perfectly fits any patient. Humans that come to us for care are just too variable.” James likes to say that the trained, expert mind of a physician is the most valuable resource in medicine.
It sounds safer to err on the side of standardizing too much instead of the current state of not standardizing nearly enough.
Yes, it is possible to rely too heavily on numbers and patterns when treating patients. But the bigger risk â€” the one we are now taking â€” is relying too heavily on intuition. “There is too much evidence â€” good evidence â€” that the [current] care many patients receive isn't up to snuff,” says Dr. Alan Garber of Stanford University.
The key themes in the work of Dr. James that remind me of Lean:
- Using data (“Show me your mortality rates, and then I'll believe you.”)
- Not punishing physicians who don't get the best results (you ask them to review their own methods) — “well-done quality improvement is not punitive, it's educational.”
- Altering guidelines over time (what Lean thinkers would call “kaizen”)
- Allowing physicians to override or ignore a protocol IF they can justify it
- You can't force people, you have to sell them on the standardized approach.
A final idea is that using standardized methods as much as possible is a way of freeing the mind up to think about the truly important things (which Toyota preaches, by the way, for assembly workers):
“[James] adds that he is simply trying to focus that resource [physician's thinking abilities] on the problems where it is most needed: those for which data does not have an answer.”
I've heard Toyota people say you want to eliminate the hundreds of LITTLE repetitive decisions so that the person involved can focus on the FEW major decisions with a fresh mind that's not fatigued from constant decision making.
I know I've used a lot of excerpts, but I hope you'll read the whole article on the NY Times site. I also hope it inspires you to take action to improve quality at your own hospital or organization. Dr.
Brent James and Intermountain set a great example.