In this episode, we talk about lean healthcare and quality. We'll be back to the regular show next week.
For a link to this episode, refer people to www.leanblog.org/128.
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Welcome to the Lean Blog podcast. Visit our firstname.lastname@example.org. Now, here's your host, Mark Graban.
Mark Graban (12s):
Hi, this is Mark Graban. Welcome to episode 128 of the podcast for August 24th, 2011. Get a different kind of podcast for you today. Normally I enjoy playing the role of host and interviewer, but today we're turning the tables. We're using some audio with permission from our good friends at Quality Digest from a video broadcast, a program called Quality Digest Live, where I was the guest about two weeks back where they were interviewing me about lean healthcare. So here you'll hear their editor-in-chief and host Dirk Duscharm, along with co-host Ryan Day talking to me. So I hope you enjoy the, the change of pace. Come back in the next couple of weeks, we'll have our usual mix of guests, as we always do for all episodes.
Mark Graban (56s):
Go to leanpodcast.org.
Dirk Duscharme (59s):
We're gonna move on to quality in healthcare. And with us today, we have Mark Graban, the, the Skype. If I can get my Skype window up here and Hold on one second. There we go. Mark, do we have
Mark Graban (1m 12s):
You? I think so. Hi,
Dirk Duscharme (1m 14s):
Dirk. Awesome. Mark Graban is the author of Shingo Award-winning book Lean Hospitals, and he's agreed to join us here today on the show to talk about quality in healthcare and what is going on with healthcare quality today, and how quality consultants and quality professionals, such as Mark, what they're doing behind the scenes in healthcare to make the process work better. Not only, mark, correct me if I'm wrong, this isn't not only administratively, but also the actual patient care itself. Is that right?
Mark Graban (1m 46s):
Yeah, that's true. Lean as a improvement methodology is being embraced by people in administrative departments. I mean, a lot of times people might think at looking at materials management within a hospital, applying lean methods there. A lot of hospitals started off looking at their revenue management cycle and saying, if we can send billing out in a less batchy way, we get paid faster. That's worth a lot of money to the hospital. But you'll also see a lot of improvement in clinical areas. I think lean started to take root in healthcare and hospital laboratories, which to some, you know, some people's perspective, sort of like a factory. And then it's spread to areas of direct patient care, improving processes in emergency rooms and in ICUs and, and having impact on things like waiting time and also preventing infections and reducing mortality.
Dirk Duscharme (2m 38s):
Now, in your, in, in a recent article that you, that you wrote, putting the continuous, putting the continuous back into healthcare improvement that you wrote with Dr. Gregory Jacobson, and by doctor we actually mean medical doctor. Right. Tell us a little bit about what you covered in that story. You were talking about the use of Kaizen and Kaikaku, I believe.
Mark Graban (2m 60s):
Right. So as, as, as if the word kaizen wasn't intimidating enough to some people, we throw another word in there. Sometimes Kaikaku.
Dirk Duscharme (3m 8s):
Mark Graban (3m 10s):
Continuous improvement. Kaizen is the word that means continuous improvement in, in most translations, kaikaku is a word that means radical improvement. And what, what Greg, what what Dr. Jacobson and I wrote about, he's an emergency room physician where they were practicing kaizen, where he worked at Vanderbilt University Medical Center, you know, small daily, low risk, low cost, local improvements. These were not week long inve events. And, and a lot of organizations will call these rapid improvement events, which I think is actually a fairly apt and descriptive term in a lot of places back in manufacturing. These are called Kaizen events, which is, as we've discussed, it's kind of an oxymoron.
Mark Graban (3m 50s):
It's an episodic improvement project with the start and endpoint. It's really not at all continuous. And then, so we were writing about not that events are bad, but let's keep them in perspective and let's make sure that we're not only trying to do projects and events, that we also have continuous improvement going on on a, a daily basis. Well,
Dirk Duscharme (4m 9s):
I, I suppose there's kind of good news, bad news. I mean, I, I, I suppose the, the, the good news is that healthcare organizations, hospitals and whatnot, are actually trying to embrace these quality techniques, quality methodologies that have been around actually for quite a while and that we're most familiar with in manufacturing. I guess the, the, the downside of it is there's still a lot to learn in terms of, of how to use them properly within that environment.
Mark Graban (4m 37s):
I, I think that's, I think that's fair to say. Healthcare has gone through its waves of improvement programs as other industries have. TQM was quite popular and it was often quite a big failure in healthcare. People were frustrated that TQM didn't really have the, the transformational kind of impact you might have hoped. I'm, I'm a, a big fan. Even before I learned about Lean, I, I learned about Dr. Deming's philosophies. People in healthcare know who Dr. Deming is, and they know his teachings. It just wasn't really, it, it, it's just, it didn't take root. And that's not Dr. Deming's fault. I think there's leadership issues there. Hospitals have tried Six Sigma, and I think the thing that's different with Lean some of the, the leading hospitals out there are, are really embracing Lean as a management system, as a daily culture from the CEO down to frontline managers, engaging everybody in, in improvement.
Mark Graban (5m 31s):
I, I think that's the difference with Lean is that it provides a little bit more of a, a framework for managing, not just doing improvement.
Dirk Duscharme (5m 37s):
Well, is is there, is there anything that's unique about implementing these type of changes within a healthcare environment? And I, and I gotta tell you upfront, my wife has been a nurse for a long time. She's been, you know, she's been a floor nurse. She's been a a, a home healthcare, she's now a hospice nurse. And I mean, I know from her, I mean, I hear her come home that sometimes different agencies she's worked for and not good words about, you know, the quality. Most of these guys have some sort of quality manager or quality, quality person. And it seems to me like this is, seems like a, a more than unusually rough environment to try to, to make changes in, in quality using the methodologies that we we're familiar with.
Dirk Duscharme (6m 24s):
I mean, is is that your Yeah. Is that your understanding?
Mark Graban (6m 27s):
Yeah, and I, I don't mean to paint too broad of a brush, but healthcare has, is traditionally focused on what you might call the technical aspects of work. The clinical elements, you know, your physician training, your nurse training. The problems with quality and patient safety and healthcare are, are more often due to problems on the process and systems side of things. And that, I think that's where healthcare has just traditionally underinvested in terms of time and resources. You know, a a a very non-line factory will still have industrial engineers and process engineers and people are working on the process. It may be built off of very non-line assumptions, if you will. Hospitals just have a lot of, you know, traditionally had a lot of very talented, hardworking, caring people all trying their best.
Mark Graban (7m 13s):
And, and I think, you know, quality professionals would realize that, that that just, that doesn't work. So when, you know, healthcare professionals get frustrated when they're lectured to do better without being given the time or the methodology or the leadership to try to do so. And, you know, I think that's what we're trying to address with Lean. That's what we're trying to do. What Greg and I are working on together with our company, Conexus, trying to help bring tools and, and coaching and methods to, you know, not have this just be, you know, God forbid any sort of slogans. Again, that's something Dr. Deming would've told us not to do, not just to have the CEO screaming, we need zero infections. You know, we need to have a method and we need to have a process for getting there.
Dirk Duscharme (7m 51s):
Now, you know, in our previous segment, Ryan talked about, you know, 10,000 deaths over the past 10 years attributable to, to prescription prescription drugs. And I'm going to assume that these are probably, I mean, without looking into it, I'm going to make an assumption here based on a bit of experience that some of these are do doing due to probably improper administration of drugs, the wrong patient, getting the wrong drug, that kind of stuff. When, when you're working in a hospital environment, do do these methodologies like, like lean and so forth, help address those types of issues that directly affect patient care?
Mark Graban (8m 35s):
Absolutely. And if you look at, you know, instances, for example, where patients in the hospital are giving the wrong medication or the wrong dosage, this, this can certainly be harmful or fatal. If you look at, for example, the actor, Dennis Quaid, his twins were given an adult dose of a blood thinner. His, his kids were in the neonatal icu. And what happens is you have just a chain of, of, of progression of errors from the pharmacy. And, and the check and the double check didn't happen or didn't work properly, medications got delivered. Now you've got nurses that are often being put under the gun for saying, well, why didn't you double check the medication? Well, the adult dose was never supposed to have been there because it was a neonatal, you know, ICU and multiple nurses across the span of 24 hours all administered that same dose, the wrong dose.
Mark Graban (9m 25s):
And, and, and quad's, twins thankfully survived. There've been other cases where, where children have have died because of this. And a lot of it comes down to process. If you look at the organization of a pharmacy, a lot of times when we start teaching about error proofing in systems, and instead of just saying to everybody, be careful, they start looking and say, well, maybe we shouldn't alphabetize our drugs because that really increases the risk of grabbing the wrong dose of the wrong medication. Let's, let's put things in a more random order. I saw people do this in factory stockrooms 10 years ago to help prevent grabbing the wrong part.
Dirk Duscharme (10m 1s):
So let me, let me understand the logic of that. That's, I've never heard of that. So the idea was that if they're alphabetical, you might accidentally grab the one beside or, you know, in front of or behind rather than if it, if they were random. You, if you're looking for something that starts with an A and it's surrounded by a C and a Z, you're probably more likely to pick the right one. Is that the, the idea? Right.
Mark Graban (10m 21s):
And, and that would be an aspect of it. And then, I mean, you know, you see cases where, you know, pills have fallen into the wrong bin, so you might be grabbing from the right bin. Yeah. And kind of doing a check-in, you know, this is a human factors issue. When you're not expecting the find a mistake, our brain plays tricks on us. So you may be looking at the med and expecting it to say five milligrams when it really says two milligrams. And so just trying to help establish the, the process in a way that makes it harder for errors to occur. And, and healthcare has relied far too long on, on asking highly trained people to just be perfectly careful. Okay. And the modern patient safety movement, and I think this is where it lines up very well with lean thinking, teaches the simple, I, I think obvious point that, look, we're human regardless of how much education we have, we, we make mistakes, we get tired.
Mark Graban (11m 12s):
It might be dark, there might be other human factors involved. We need to have good system design to help prevent those errors.
Ryan Day (11m 18s):
Gosh, okay. If, if, if any industry really needs to get past the slogan phase of lean, root, cause analysis,
Dirk Duscharme (11m 33s):
All those other things that
Ryan Day (11m 34s):
Error proofing Yeah. You know,
Dirk Duscharme (11m 36s):
Get past the slogans and down to it
Ryan Day (11m 38s):
Yeah. And really applied it would be the, the healthcare industry. Right.
Mark Graban (11m 43s):
Right. And tying it back to your first story, I, I don't recall the government ever coming in with guns drawn to take action against a hospital that was harming patients. I mean, well,
Ryan Day (11m 52s):
You don't have raw milk there.
Mark Graban (11m 53s):
You may have a hospital get shut down, but when you look at the numbers and, and often these are unknowable numbers, but they're on the scale of 100 to 200,000 people dying in the United States due to preventable medical errors in hospitals, preventable hospital acquired infections. This is, this is the scale of this problem really is huge, really a really big
Dirk Duscharme (12m 16s):
Problem. Well, and, and act actually leads me to my, to to my last question before we let you go. So I, I don't know, you know, what's been happening in the last 15 years? I mean, have we, have we gotten, have we gotten better? Do you, do you think healthcare has improved or is it status quo? Wh which way are we moving
Mark Graban (12m 34s):
It? It depends. I mean, right now there are such pockets of excellence within healthcare. It becomes really hard to generalize. You know, some of these estimates in terms of number of people who were harmed and killed in healthcare were published in 1999 by the Institute of Medicine. They took very conservative estimates and very conservative. Extrapolations Health Affairs published an article a couple of months ago that indicated new data is showing that that number may have been underestimated by a factor of two or three. Oops. So a lot of people are arguing that on the whole things are not getting better. Now, the good news part of the story is, if you look at hospitals like ThedaCare and Virginia Mason Allegheny Medical Center in Pittsburgh, they've done amazing things in terms of reducing mortality after cardiac surgery, reducing, in Allegheny Medical Center in Pittsburgh, they reduced central line bloodstream infections by 95% using leans.
Mark Graban (13m 32s):
Wow. And they, they cut mortality 100% because that, that is a very severe type of infection. You, you have hospitals doing just great work. But I think the, the question a lot of us in the quality and, and lean and patient safety movements ask, you know, why isn't this spreading more quickly? There, there are, you know, this is not anecdotal data. This is peer reviewed medical journal, published really hard, proven data as much as anything you're ever gonna find in the lean improvement world. And it's, it is just kinda a historical pattern. People in healthcare will say, A new proven best practice traditionally takes about 20 years to become accepted throughout the industry. And that, that's a trend in a pattern that goes back a hundred years.
Mark Graban (14m 15s):
Dirk Duscharme (14m 16s):
Well, mark, hey, thanks for, thanks for joining us. Sure. And sharing all that information. Again, this is, this has been Mark Graven with us via Skype. Mark is the author of the Shingo Prize-winning book Lean Hospitals. Well, once again, thank you for joining us for another Friday and with my, my buddy here, Ryan Day, while Mike is on vacation. Thanks for joining us for Quality Digest Live, and we will come back to you next Friday. Same time. That's 11:11 AM Pacific for another great show. Thanks for joining us.
Announcer (14m 48s):
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 email@example.com.
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