Cleaning out the Backlog: 3P in the NHS, “Secret” HAI Weapons, MRI $$$, and Fines for Medical Harm


As I sometimes do, I'm going to close out a bunch of browser tabs (which makes my Mac run faster) and I'll do that by sharing some articles that caught my eye but maybe don't merit full blog posts of their own.

I'm cleaning out the LeanBlog backlog and trying to reduce inventory… so here we go:

Healthcare of tomorrow? Using 3P lean design to build better hospital wards

In this article posted at, Gary Prior, the “Lean Design of Space Programme Manager” for the NHS's North East Transformation System shares details and photos of the “3P” (aka “Lean Design”) methodology that is increasingly used to design and build hospitals and clinics.

“Just like product design, which can account for up to 80% of the final costs, the design of a hospital can lock in significant costs too. Poor visual management, which often isn't easily identified from blueprints, can have an immediate impact on staffing levels – especially in high acuity settings.”

One “silly design” mistake is (sorry if you're eating breakfast or lunch) “issues like [only having] one toilet between six patients recovering from a colonoscopy, a procedure that is most likely going to result in a patient needing to use a toilet.”

3P is a worthy solution that draws on the input and active participation of all stakeholders, including patients and staff. Costs are reduced, walking distances are lessened, and visual management and efficiency are improved.

As Prior says in the conclusion, “Hospitals are already scary places for many people – we don't need to make matters worse.”

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A secret weapon for preventing HAIs

What's the “secret weapon” for reducing hospital acquired infections (HAIs)? We shouldn't be keeping secrets since I saw a stat yesterday (one that was new to me) that said one in 25 hospital patients are fighting an HAI at any given time.

That “secret”? Better training and utilization of….wait for it…. the housekeeping staff!

We need more than better hand hygiene compliance (and that could still stand to be much better than it is today in most hospitals).

“All the hand washing in the world won't do a bit of good if clean hands then immediately come in contact with contaminated surfaces like the ones in the studies above.”

Since “clean does not necessarily mean microbially clean,” as Rodney E. Rhode, PhD writes, hospitals need to do better job with housekeeping.

Dr. Rhode laments that:

“My fear is that environmental services staff rarely appear on the radar of hospital administrators except when there's a need for budget cuts.”

Let's invest in people and processes instead of treating them as an expense to fire or outsource to the cheapest bidder (or allowing hospitals to be, on average “short by five to nine full-time [housekeeping] employees.”

We have to do better. HAIs cost the U.S. between $35.7 billion to $45 billion a year. Being cheap or skimping on housekeeping reminds me of the old expression that I heard 20 years ago at GM: “We'll save money no matter how much it costs us!”

As the article cites:

In another instance reported in USA Today, Jewish Hospital-Mercy Health in Cincinnati was experiencing an unusually high incidence ofClostridium difficile (C. difficile), a potentially fatal form of diarrhea. The hospital managed to half the rate within six months, with hospital officials crediting new environmental cleaning practices as a significant factor in reducing these infections.

Hospital housekeepers aren't just cleaning rooms, their mission and purpose is saving lives. Are you breaking rocks or building a cathedral?

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In California, That MRI Will Cost You $255 — Or Maybe $6,221

Last November (I have a big backlog here), NPR had a story about cost variation in California.

“Prices for common medical tests like mammograms and MRIs are notoriously opaque. Negotiated rates between insurance companies and doctors or hospitals are sealed tight by contract. We know there's price variation, but comparing what one insurance company pays versus another is virtually impossible.”

NPR station KQED in San Francisco set up a web form that asked patients in the public what their insurance company paid for care. And people responded!

Variation in the price of common procedures included:

  • $128 to $694 for a screening mammogram
  • $467 to $1,567 for a lower back MRI (and Medicare paid only $255 while the self-pay full price was $6221)

It's really hard for people to make good health decisions when cost data (and quality/safety data) is so hard to get in most states. As we've learned in Wisconsin, better data has allowed employers like Serigraph to lower costs and improve quality for covered employees and family members (listen to my podcast with Serigraph's chairman John Torinus).

Then there's this craziness reported by a patient:

“I was told the procedure was $1,850. I have a $7,500 deductible. So I talked to (an employee) who said if I paid up front and agreed not to report the procedure to Blue Cross that it would be $580.”

As NPR points out, a higher price doesn't mean better quality in healthcare.

“People are starting to wonder why they're paying dramatically more if that extra money isn't buying better health.”

Ya think?

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8 local [California] hospitals fined for errors

If fines really helped improve quality and patient safety, maybe we need more fines and bigger fines?? I guess that's a tongue in cheek suggestion.

While the federal government says “avoidable medical mistakes” fell 17% between 2010 and 2013, many hospitals are being fined up to 1% of Medicare payments for poor quality.

“The renowned Cleveland Clinic and the highly rated UCLA Medical Center were among those that are losing 1 percent of their total Medicare reimbursements from last Oct. 1 through September of this year.”

How does that program work?

That program scored more than 3,000 hospitals across the country on a 10-point scale, with 10 being worst. It measured infection rates associated with three common medical procedures and looked at preventable complications such as falls, bed sores and collapsed lungs. Hospitals with a score of 7 or greater received a penalty.

A “10-point scale” – what is this, an annual employee performance appraisal? I'm getting off topic, but check out this WSJ article, if you have access, on “The Trouble With Grading Employees.” The first reader comment is from Kevin Cahill, a grandson of W. Edwards Deming.

So, back to infections… if HAIs cost us “between $35.7 billion to $45 billion a year” maybe the feds should threaten hospitals with $50 billion in fines if they don't improve infection rates?

Going back to the second article, some hospitals have reduced infection rates by half. OK, let's have the feds threaten $20 billions in fines unless all hospitals cut rates by half… if they achieve that goal, we'll all be better off?

If only life were that simple… life and medical harm goes on… and the beatings will continue until quality improves.

Enough of my snarky-ness. Why are some hospitals performing better than others? Why do we have some pockets of excellence?

So why are some hospitals excelling while others are getting penalized? There's no definitive answer, but those with the best scores basically say the same thing: It's the culture.

Dr. David Buccigrossi, director of quality at Kaiser San Diego, said preventing errors is about much more than following the best protocols or using the latest equipment. He said the most important thing is getting all workers to feel comfortable calling each other out when they see an unsafe practice.

“What gets you to the next level is to inculcate a culture where you empower your people at every level to do the right thing,” Buccigrossi said.

Culture, culture, culture. Processes, systems, and culture. It starts with leadership at the top (or the lack thereof).

This isn't rocket science. Everybody can do this. Let's get to it.

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Mark Graban
Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.


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