A Lean Guy Watches CBC’s “Rate My Hospital”
“Approximately 8 to 10% of the individuals who walk through our doors are being hurt by us,” says David Musyj, CEO of Windsor Regional Hospital. That's one of the first things you hear in this CBC program “Rate My Hospital,” which aired earlier this month in Canada. See also this page on the investigative report.
The patient safety challenges are pretty universal across modern Western countries. This isn't just a Canada problem. You see similar estimates of patient harm in Canada, the U.S., England, Germany, the Netherlands, etc.
From the CBC text:
Unlike the United States and the U.K., Canada remains one of the few developed countries that has kept basic information on how well hospitals care for you largely hidden from public view.
The data and information are “largely hidden from public view” in the U.S., generally speaking. The grass always seems greener…
The story talks about the “thousands” of Canadians who die each year from hospital acquired infections. There's one particular story about a woman who died just weeks after contracting a c. diff infection through getting routine surgery at a Vancouver hospital. The widower says people at the hospital were “compassionate” but “nobody took any responsibility.” The hospital didn't publish infection rates (something that's not common here either) and, while some provinces share data, it's not always expressed in equal terms. The UK's NHS has a national website that can be searched to view infection rates allowing people to see where mortality rates are highest.
Dr. Dick Zoutman (who I have met in my travels through Ontario) says hospital acquired infections could be the FOURTH leading cause of death in Canada. 220,000 will get infected each year. They expect between 8,000 to 12,000 dying each year from this “preventable” disease.
About seven minutes in, the story goes to Saskatchewan, where they are “using methods perfected by the automaker Toyota” to fight these super bugs. Maura Davies, the CEO of the Saskatoon Health Region, says “This is like nothing we've ever experienced. We used to report our results and make excuses… and now we have to have a corrective action plan that says here's how we're going to turn it around.”
The hospital uses DAILY data (discussed in management huddles) to drive improvement. “Are people washing their hands? Do we know if they are washing them the right way?” asks Davies.
You can hear a person being taught to wash hands using the Training Within Industry methodology, as they reference “key points” and “important steps.” Read more in this book Getting to Standard Work in Health Care: Using TWI to Create a Foundation for Quality Care. They actually have people observing to see if it's being done the right way. Hand hygiene reports are posted online… transparency leads to pressure to get better.
In the third segment, they talk about an iPhone app for emergency departments in Alberta. A woman chose to go to a hospital that had posted an 18 minute waiting time to see a doctor, choosing that over their preferred hospital that posted nearly a three hour time. At the “18 minute” hospital (supposedly a real time piece of data), they actually waited three hours to be seen and then waited hours more to be admitted… but, in the mean time, bled to death due to an aneurysm.
“Is the app an improvement or a distraction?” The daughter of the woman who died says she thinks the app seems more like an effort to look good or to be “fake.” The app won't tell you if patients are “parked” in the hallways. A doctor says the most dangerous thing in Alberta hospitals is the waiting times.
From a survey of nurses across Canada, ”
- 40% feel burnt out” and they feel “stretched to the limits” and “it's impossible to provide safe care when you're so tired.” 62% feel like they are understaffed. “Our equipment is falling apart” and attempts to fix things are met with “punitive measures” and the government only cares about “cutting costs and saving money.”
“To speak up is to risk being bullied and being threatened with job loss.”
Those are all very serious cultural problems that get in the way of improvement… again, not just Canada. Randomly running a bunch of improvement events or using just some Lean tools won't fix these problems if we don't address the culture and eliminate the culture of fear.
The CBC host says that provincial governments in many cases, encouraged hospital CEOs to NOT respond to questions about what they are doing to prevent surgical errors or infections. But, the CEOs of “132 hospitals responded to us anyway.” 75% of the CEOs didn't respond.
The last piece shows CEO David Musyj in scrubs in the workplace, “not an Undercover Boss per se” (as we had an misunderstanding about before). I give him credit for being “embarrassed” by low hand hygiene numbers and for working to improve things rather than hiding the problem, bringing rates up from 40% to 90% (and they are still working to get to 100%).
Musyj says meaningful change will happen once Canadians start demanding answers.
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Canadians have been demanding answers for the state of their system for eons. What’s missing is that the demand is without recourse: There’s no way to impact the system meaningfully beyond political pressure, and that often has it sent to various places in the priority chain. Decision-making is often glacial.
Because our healthcare is tied directly to the public purse, it is impacted by the budgetary constraints of the host province. In Ontario, we now have a $270B debt – TWICE that of California, yet we have a fraction of the population (~13M vs. ~37M). Any improvements need to be made within a budget continually under constraint to ever-increasing salary demands and the relaxation of billing caps for doctors.
Hopefully, the application of lean concepts can begin to improve the system we have. Because it is certainly not sustainable in its present condition.
In business you get held accountable, by consumers, if you supply poor service, or products sooner or later your sales decline for it. Unfortunately in healthcare most people have no real idea if what is happening to them is a result of something that took them to the hospital or something that happened at it. So unless healthcare as a profession starts share the truthful information with us, there is no real way to hold them accountable. Once they start to disclose the truth about themselves they will be taking steps to being accountable, and that will be the start of fixing the problmes healthcare faces very where.
In Canada and other publicly owned systems, getting information out will be harder, as politicians are ultimately to blame for the mess they control. Unfortunately we do not elect people base upon their skills, instead we choose them on popularity, until that changes no one can honestly hope to fix the whole system, yet as Windsor Regional shows you can still show success in your area if you hold yourself accountable. David has a lot more courage that most administrators do, but that simple show of courage has allowed him and those he works with to improve.
Accountability only works when there is open access to information.
The use of the lean model to help fight hospital based infections is a clear example of operations management tools being used in a healthcare delivery system.
It is concerning to me that the status quo up until this point was to hide the reports and problems in the hospital. It’s one thing to hide the errors and problems from the public, but within the hospital, the hospital made excuses to themselves and never tried to address these issues.
Using lean management, they will hopefully identify the value adding processes that help prevent infections and can identify the waste steps that are not helping the problem. I would hope that streamlining process will help them identify a unified set of procedures that will help prevent infections and also identify procedures to help diagnose and treat infections if they do arise
One of the most crucial aspects surrounding this issue is that in order to improve the quality of care being provided to patients, the hospitals have to be more transparent with the community and their staff. How the hospital is performing should be public knowledge because they are providing services to consumers.
In this case, lean management would be an appropriate tool to use for improvement here because the focus should be on patient satisfaction. In Canada, the government is only concerned with reducing costs and saving money, not the quality of care being provided. Therefore, using the steps to create a lean enterprise, Canadian hospitals should first ask the consumers (patients) what they view and define as “quality care” and then identify the value stream and eliminate processes that occur in the process which hinder the quality of care being provided. The hospitals should also consider how the employees feel about the care that they are given; are they feeling pressured due to large influx of patients which then leads to sometimes making mistakes? One of the key aspects of lean management is to create a value stream map, which will help to understand and recognize in which processes the quality of care is not being provided based on explicit expectations made by the patients. Creating a value stream map helps to clearly define a problem in order develop appropriate and specific solutions to the problem. Hopefully by utilizing lean management techniques, this will improve the ratings of hospitals in Canada.
I definitely agree that transparency in health care is an issue. There is a large gap between the knowledge of health care providers and their patients, making complete reliability on patient satisfaction difficult. Although consumer satisfaction is important, I think provider motivations must first be addressed, as it is a common practice to for providers to hide medical errors. A balanced scorecard approach could be used to help managers change the culture of their organization with the interests of the consumer in mind. In conjunction with culture change, identifying consumer value streams while analyzing process flow could help identify inefficiencies in the hospitals’ systems and help promoted the use of standardized provider practices.
I think you probably don’t work directly in patient care as cited by the above comment you made regarding making errors. Some hospitals have zero tolerance for errors and they’re serial incidents with follow up action of the employee. These errors as you call them are being addressed within the organization. The problem is employees feel they are being punished especially in this climate of employee job insecurity. How satisfied do you think professionals feel when they work under these kind of daily pressures. The bottom line is happy employees make for happy patients!!
I agree that employees shouldn’t be put under that unfair pressure of being punished or fired (or jailed!) due to systemic errors. That fear is what leads to things being covered up.
Having a “zero tolerance” policy, unfortunately, sounds like a lot of management bluster that’s not helpful unless management is also working together to help prevent and solve errors.
In looking at the rate of infections from an operations management perspective, it is evident that the lack of transparency prevents a push for change. If we were to apply lean principles to this conundrum, creating more transparency regarding these infection numbers would specify the value of creating a system in which higher hand-washing rates are encouraged, as a lack of hand-washing is thought to lead to these infections. A value stream should be created in order to better understand the system in its entirety, and identify steps in the system of value and steps that are not valuable. Some sort of implementation must be used used in order to achieve these higher hand-washing rates and establish a better flow in the process. Eventually, the lower infection rates will produce higher standards, and this will create a “pull” for the continuation of this improved quality measure. The implementation should amended as necessary moving forward in order to try to achieve the highest hand-washing rates possible.
While it is unlikely that this system will produce perfect compliance with hand-washing requirements, any improvement in the current infection rates will be worthwhile. These patients deserve the best care possible, and that these infections can be so easily prevented is a sign that an intervention must be used as soon as possible.
An unhealthy work environment cannot possibly work to help unhealthy patients. Hospitals filled with disgruntled employees with over-the-top utilization rates will inevitably commit many errors and preform lower quality work. A commitment to quality on behalf of such hospitals is frankly hypocritical. The health of patients and employees needs to be jointly concerning. Running projects like increasing hand-washing need buy-in from employees and this environment does not facilitate that. A culture that holds greater respect for employees and empowers them to propose ways to improve care quality and safety will be a start, but overworking them needs to be addressed first. Improving care coordination will be another way to help decrease medical errors. I wonder if the hospital has done a value stream map to seriously investigate these medical errors?
Ammar – I agree that culture and respect are critical.
I’m not sure how a value stream map would help investigate errors. Can you elaborate on that?
[…] Last Monday, I blogged about a Canadian hospital CEO who stated they were hurting “8 to 10%… […]
Mark, good summary of CBC’s “rate my hospital”. Too bad the Fifth Estate didn’t look further under the covers at the ongoing antics and arrogance of local hospital administrations, hospital boards, and hospital foundations. With the exception of the 132 hospitals that responded to the survey, the Fifth Estate missed the real story behind the remaining hospitals that refused to respond to the survey. If they dug a little deeper they would have uncovered more serious physical infrastructure health and safety issues, misleading ads and communications by hospital officials, hospital foundation fundraising concerns, disturbing personal and political agenda’s by hospital officials and politicians that were not in the publics best interest etc.