Podcast #127 is a very special conversation with a leader and a hero of mine in the world of patient safety, Richard P. Shannon, MD. Dr. Shannon is a cardiologist and is Chair, Department of Medicine, University of Pennsylvania School of Medicine and the Hospital of the University of Pennsylvania as well as the Senior Vice Chair for Clinical Affairs, Department of Medicine. We'll be talking about his work in using Lean methods to reduce patient infections and other clinical outcomes.
According to data published by the Institute for Healthcare Improvement, the improvements at Allegheny indicated that “the VAP rate dropped by 83 percent and the CLI rate fell by 87 percent.” Savings lives and reducing cost go hand in hand, as his work shows. This work is now being repeated successfully at UPenn.
Leaders at Allegheny General estimate that patients diagnosed with VAP average a 34-day stay, with a net loss to the hospital of $24,435 after reimbursement; patients diagnosed with CLI average a 28-day stay, at an operating loss of $26,839. For an investment of about $35,000 in improvement work, Shannon estimates that the hospital experienced a $2 million improvement
Dr. Shannon was an early pioneer in the use of Lean and Toyota methods to improve outcomes and patient safety, namely the reduction of hospital-acquired central line bloodstream infections when he was at Allegheny General Hospital, near Pittsburgh, as documented in Naida Grunden's book The Pittsburgh Way to Efficient Healthcare: Improving Patient Care Using Toyota Based Methods. You can see inside the book and some of the mentions of Dr. Shannon via Google Books. In Pittsburgh, as part of the PRHI effort, Dr. Shannon learned from Paul O'Neill, read or hear my interview with O'Neill.
For a link to this episode, refer people to www.leanblog.org/127. Scroll down this page for a transcript of this episode.
- Toyota video about Lean at Allegheny
- Interview with Dr. Shannon
- Some Data on Patient Safety and Quality Improvement, including PRHI and Allegheny
- Podcast with Paul O'Neill
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Announcer: [0:12] Welcome to the Lean Blog podcast. Visit our Website at www.leanblog.org. Now, here is your host, Mark Graban.
Mark Graban: [0:42] Hi, this is Mark Graban. Welcome to episode 127 for August 17, 2011. Today's episode is a very special conversation with a world leader and a hero of mine in the realm of patient safety improvement. He is Dr. Richard P. Shannon. He's a cardiologist and is Chair of the Department of Medicine at the University of Pennsylvania School of Medicine and the Hospital of the University of Pennsylvania as well as the Senior Vice Chair for Clinical Affairs in the Department of Medicine.
Now, Dr. Shannon was an early pioneer in the use of Lean and Toyota methods to improve outcomes and patient safety, namely the reduction of hospital-acquired central line bloodstream infections and ventilator-associated pneumonia when he was at Allegheny General Hospital, near Pittsburgh, as was documented in Naida Grunden's outstanding book called The Pittsburgh Way to Efficient Healthcare: Improving Patient Care Using Toyota Based Methods.
[1:45] Now, with the Pittsburgh connections, Dr. Shannon originally learned about Lean and Toyota methods from PRHI, the Pittsburgh Regional Health Initiative and from Paul O'Neill who was my guest back in episode 124. If you want to find that episode, you can go to leanblog.org/124. The blog post and page for this episode is leanblog.org/127. If you want to make sure you catch every episode, you can subscribe real easily in the Apple iTunes store or for more options, go to www.leanpodcast.org.
[2:05] I'm also happy to say that this podcast episode is produced in conjunction with the Healthcare Value Network. To learn more, you can go to www.healthcarevalueleaders.org or you can visit the Website of the ThedaCare Center for Healthcare Value at www.createhealthcarevalue.com.
Dr. Shannon: [2:10], thanks for taking time to talk on the podcast today.
Dr. Richard Shannon: [2:12] It's great to be with you, Mark.
Mark: [2:17] If you can start. Maybe just introduce yourself and your role and your background for the listeners, please.
Dr. Shannon: [3:15] Sure. I'm the Chairman of the Department of Medicine at the University of Pennsylvania here in Philadelphia and I, for about the last decade I have been engaged in a redefinition of my career. One where I've taken a much more compelling interest in process improvement, particularly toward the elimination of harm to patients in our hospitals. I think our acquaintance is occasioned by the idea of using tools such as Lean methodologies in hospitals, a subject about which you've written and about which I've read from you, as a way to get better and better at everything we do in the delivery of care to patients.
Mark: [3:37] Yeah and the initial redefinition, if you will, started back in Pittsburgh. I wonder if you could talk about some of the origins of how you first got exposed to some of these ideas. Listeners may have heard that I did an interview with Paul O'Neill a couple of weeks back, I was wondering if you could share some of your history in that regard.
Dr. Shannon: [4:16] Sure, well in fact, my redefining my career occurred as a result of a chance meeting with Paul O'Neill at a time when he was still the CEO at Alcoa, and at that particular time, the chairman of the Allegheny Conference, which was a group of the large businesses in Pittsburgh. In his role as the chair, he called together all of the hospital leadership from across the southwestern Pennsylvania area, to ask them to be held accountable for cardiovascular outcomes in the area of cardiac surgeries.
[4:50] At that time Pennsylvania was, with New York, among the earliest to publicly report outcomes in cardiac surgeries. Mr. O'Neill noticed wide variations in outcomes and wide variations in payments attributable to that. He basically challenged leaders to say that businesses were struggling under the weight of double-digit increases in health care costs, and yet weren't seeing value attributed to it. As responsible people within the Pittsburgh community, we had to come together to figure that out. It was indeed a chance occurrence.
[5:17] At that meeting, I was actually asked to defend the honor of my institution at that time, because our results weren't that good. As I began to give the traditional litany of excuses why we didn't quite hit the mark, Paul said that was all very nice, but the job of leaders is to take away excuses by redefining the way in which work was done toward the elimination of waste and harm.
[5:32] A day later, Paul O'Neill and I had lunch and that has created a decade long friendship and a great decade-long mentorship of, I think, someone who, in industry, really applied the ideas of Lean to the extraordinary improvement of Alcoa.
Mark: [5:55] Can you share a little bit of some of the method and approach of looking at reducing hospital-acquired infections? The use of methods or ideas inspired by Toyota, standardized work, looking at different quality methods. Can you talk through some of that process and share some of the results that you had, at least initially, there in Pittsburgh?
Dr. Shannon: [7:00] Sure, I think that the concept was to first be transparent about the problem, and to decode the existing data from what was shrouded in complex epidemiologic metrics such as “infections per 1000 line days,” and rather, tell the individual stories of patients, and their unfortunate outcomes that were occasioned by getting these infections. Decoding the data in order to make it meaningful to people that did the work. On the one hand, “7.6 infections per 1,000 line days” may mean something to an epidemiologist, but it means nothing to a nurse or a physician or a nurses assistant who is working at the point of care with patients who had these things. Yet if you say there are 56 people that had 62 infections, 20% of which died, that creates a very different definition of the problem.
[7:47] The first step that I learned from the industry, and one of the hardest steps still, is the strict definition of the problem based upon intense observations of the current condition. The next thing we did was we decided to break down the process of a central line into placing, maintaining and manipulating the catheter. Then the idea was to have people that did the work, to find the standard processes around those things, test them, create countermeasures based upon the testing and the outcomes, and come to a conclusion about what's the best way we knew we could come up with for placing, maintaining and manipulating the catheter.
[8:11] On the one hand, we have the advantage of some of the work that Peter Pronovost had done with the checklist, all of which pertain to placing the catheter. But we discovered that the majority of central line infections actually occurred long after the catheter was placed, so one not only needed standard workaround placing catheters, but around maintaining catheters and how also those catheters could be manipulated.
[8:47] Workers made observations of how catheters were maintained and manipulated and defined standard work. Then how to eliminate the variation and the consequence was new practices and new procedures that dramatically reduced the central line infection rates among our patients. In Pittsburgh, that occurred over a three-year period where we went from 49 infections down to four, in those early days.
[9:13] Then, doing similar work here at University of Pennsylvania, over a similar sort of thousand-day journey, roughly three years. We've gone from 361 infections down to 11. In the last fiscal year, three years after we began this standardized approach to placing, maintaining and manipulating catheters, we've reduced the number of central line infections by close to 97%.
Mark: [9:47] That's great, to see that it's repeatable across the organizations. It's great to see. Before you move forward on that, I just want to go back, maybe one thing you said in emphasizing the idea of the people who did the work, doing the observation and the creating of standardized work which is what you're going back even to Pty Ichino and Toyota. What was thought was that there's a misperception that it seems sometimes standardized work or checklist that this is something just being dictated to people.
[9:54] There might be a comment on that, or misperceptions or discussions that you've had with others in the industry about these ideas.
Dr. Shannon: [10:22] I think the key to the application of the principles of Toyota, to health care, is first, the idea of bringing discipline and structure to problem solving. Using the “Four whys,” using techniques such as “Five S.” Those are disciplined ways to think about problems.
[10:50] The second challenge is to take those tools and put them in the hands of people that actually do the work. I think, importantly, and one of the real aha moments we've had is, that really requires pulling people off the line and training them in these ideas and then mentored Kaizen-like events around rapid cycle improvement as they redefine the work.
[11:09] You need both skilled mentorship along the line, but you also need to train people in observations, in the creation of countermeasures, in deep disciplined problem solving around Kaizen events, in order to really engage the workforce.
[11:23] I think some of the mistakes that are often made is that you could have a one-day seminar on Lean thinking and people sit in a room and somehow, as if manna from heaven, receive this inspiration.
[12:00] I think you really need to do this training on the line, at the point of care, in a very structured way, so that workers can see the power of these tools. I think that's perhaps the biggest innovation that we have been able to achieve here at Penn is that we do a lot of structured disciplined problem solving exercises, or Kaizens, on the units, at the point of care, around problems identified by workers, and then mentor workers in solving those problems using the tools that Lean provides.
Mark: [12:15] Because, like you said, this isn't a quite fix, it seems like it creates a challenge of where is the time. Everyone says well that sounds great, but we don't have time. Are there some things that you've done? Is it just a leadership commitment to say we need to make the time available?
Dr. Shannon: [12:49] Well, I think you do need that leadership commitment. Let me say it the way we've done this. As we embarked on our effort here at Penn, we trained 220 nurses on our oncology units, in the skills of observation, problem identification, by that I mean background, current condition, target condition, countermeasures, anticipated outcomes, measured outcomes, and then a gap analysis around those things, really structured problem solving approaches.
[13:19] 220 nurses, and to do that, we actually had to take them away from their daily patient care routine, to work with a mentor, to develop these skills. To accomplish that, we actually brought in one extra nurse each day shift and each night shift, for a period of about six weeks, in order that we could pull people off the line and engage them in this problem-solving capability.
[13:45] Once you teach people the power of these things and allow them the freedom to identify and solve problems in a structured way, you never go back, you never, ever go back. You never, ever lose that capability. The initial upfront investment is really modest compared to the longstanding and sustainable power of developing those disciplined problem solving capabilities.
[14:15] Now, Mark, if I may, by analogy, or the analogy that we built to support this is, nurses and doctors and social workers and case managers, spend their day rounding on sick patients. Rounding on sick patients involves collecting history, doing a physical examination, creating therapeutic interventions. Each of those clinical tools has a systems counterpart.
[14:37] What's the background to the problem? What's the current condition based upon observations of the problem? Just as doctors and nurses, house staff and others round on sick patients, we as leaders have to round on sick systems within our hospitals, and apply the same kind of clinical reasoning. It's remarkable to me, the analogy.
[15:12] Clinical reasoning that we do to sick patients for our sick systems. We've used that analogy to take nurse managers and our unit-based clinical leadership team which is the structure we used here in Penn to apply these ideas, to have them focus on systems illnesses, using Lean kinds of methodology. The final point about that is actually beginning next week, we're taking 12 of our medical residents to a three day intensive deep dive into Lean methodologies.
[15:38] Then for 32 weeks, are going to use these residents engaged on our medical units to create what we're calling the Persian, the perfect patient discharge. That is to say using Lean tools, what does the patient want and need to make a successful transition from the hospital, back to a level of health that is greater than that in which they came in.
Mark: [15:45] That sounds reminiscent of some of the work from PRHI in the goal of perfect patient care.
Dr. Shannon: [16:11] Exactly. I'd like to avoid what I consider to be the rhetoric or pejorative around readmissions, right? Which is the sort of the bellwether cause these days. Say that for any given patient, the goal is to get what they want and need to transition back to health at the time of discharge, and that if we do that, the consequence will be no one needs to be readmitted.
[16:32] But rather than focus on re-admissions, many organizations are doing perfecting the process of transition of patients out of the hospital using Lean tools as really the work that we're going to have these residents in our unit-based clinical leadership teams engaged in, all speaking the common language of Lean methodologies.
Mark: [17:01] OK, Dr. Shannon, maybe one last question here, you talked about sick systems, we have them everywhere whether it's Pittsburgh or Dallas or Boston or England, can you share some thoughts on the spread and diffusion of the ideas that you've been sharing, things that Dr. Pronovost and Dr. Gawande have been sharing? What are your thoughts on the acceptance and adoption by leaders in other organizations?
Dr. Shannon: [17:57] I would say that these ideas continue to gain momentum so there has clearly been progress, greater acceptance of the idea of dealing with our sick delivery system, and to perhaps use tools borrowed from high performing industries to address those illnesses. But I think, Mark, it continues to be too slow. Where I think you see really great progress is in organizations such as Virginia Mason where the CEO Gary Kaplan believes deeply in these ideas or the ThedaCare system where a CEO physician such as John Toussaint takes these ideas throughout an organization.
[18:30] I think folks like Peter Pronovost, Atul Gawande and myself are in the field working within those organizations and trying to demonstrate to other elements of our organization the powers of these ideas. But until the leaders at healthcare organizations themselves adopt these strategies, I think we won't get the kind of transformational change that the system needs. Now, I'm encouraged by some of the efforts emanating from CMS.
[19:08] I think Don Berwick is beginning to really articulate the idea of the elimination of wastes through process redesign as the way to solve the CMS dilemma, as opposed to just across-the-board cuts. Whether in the timing given the crisis in debt restructuring in the nation, he'll have time to do that, I don't know. But I think we're beginning to see these ideas permeate into healthcare in a deeper way, but it's not fast enough.
[19:24] The system really needs to begin to transform very quickly. Until leaders of healthcare organizations, academic medical centers adopt these strategies and implement them throughout their organizations, we'll have great islands of excellence, but we won't have cured the system.
Mark: [19:49] Well, Dr. Shannon, I want to really thank you for taking time to continue sharing your story and helping to inspire others to continue improving their own systems and improving patient care and their organizations. I wish you'll continue. Best wishes for you there at University of Pennsylvania and hopefully, we can talk again soon.
Dr. Shannon: [19:52] Great. Thanks, Mark, always nice to be with you.
Announcer: [20:12] Thanks for listening. This has been the Lean blog podcast. For Lean news and commentary updated daily, visit www.leanblog.org. If you have any questions or comments about this podcast, email Mark at leanpodcast@Gmail.com.
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