hospital quality – The OM Blog by Heizer, Render, & Munson

OM in the News: Hospitals Learn About Safety From Airlines?

Major U.S. passenger airlines have forged a phenomenal safety record largely by relying on pilots, controllers and mechanics to voluntarily report incipient hazards. Analyzing such incident data and then disseminating lessons from it has meant more than a decade without a fatal crash.

Over the same period, the country’s healthcare system has tried to mimic some of these air-safety principles, but it has made scant progress in eliminating deadly treatment errors. Mistakes in hospitals are estimated to cause at least 250,000 unnecessary patient deaths annually in the U.S., reports The Wall Street Journal (Sept. 4-5, 2021).This makes it the fourth leading cause of medical fatalities after cancer, heart disease and Covid-19. Determined to do better, healthcare leaders are now doubling down on aviation’s lead.

The heart of the idea is prodding doctors and hospitals to share more digital data and wholeheartedly embrace self-reporting of their potentially deadly “near misses,” the way that pilots already do without fear of punishment. But as long as hospital equipment isn’t designed to guard against human slip-ups, as jetliner cockpits are, “it will be far too easy to crash the plane in healthcare,” says one hospital Chief Quality Officer.

One obstacle is that financial incentives for hospitals are still not aligned around quality and safety. Typical billing practices track the number and complexity of procedures instead of the outcomes. Information sharing in healthcare is pitiful compared to aviation. When medical errors are reported, it’s usually well after the fact, and information usually stays within the organization.

One element of air safety that has already made big inroads in medicine is reliance on checklists, in large part thanks to Dr. Atul Gawande’s 2009 bestselling book “The Checklist Manifesto.” which we previously noted in this blog.

Classroom discussion questions:

Compare this article to the OM in Action box called “A Hospital Benchmarks Against the Ferrari Racing Team” on page 223 of your Heizer/Render/Munson text.
Now discuss this article in light of the OM box called “Safe Patients, Safe Hospitals” on page 231.

OM in the News: Hospital Checklists and TQM

“Surgery checklists save lives,” reports The Washington Post (April 18, 2017). Hospitals in South Carolina that completed a statewide program to implement the WHO’s Surgical Safety Checklist had a 22% reduction in post-surgical deaths. The study, to appear in the August 2017 issue of Annals of Surgery, is one of the first to show a large-scale impact of the checklist on the general population.

Surgical care requires careful coordination of a variety of skilled health-care providers in a complex infrastructure using specialized tools. “Safety checklists are not a piece of paper that somehow magically protect patients, but rather they are a tool to help change practice, to foster a specific type of behavior in communication, to change implicit communication to explicit in order to create a culture where speaking up is permitted and encouraged and to create an environment where information is shared between all members of the team,” said the Harvard Medical School prof directing the study.

A total of 14 hospitals completed the program, representing 40% of the total inpatient surgery population in the state. Researchers compared the 30-day post-surgery mortality results between the checklist hospitals with those of the rest of the hospitals in the state. The report includes major inpatient surgical procedures from various specialties, such as neurological, cardiac and orthopedic surgery.

The 19-item checklist encourages surgical teams to discuss the surgical plan, risks and concerns. Most of the items are simple, such as “does the patient have a known allergy” or “is essential imaging displayed.” Following surgery, patients are at risk of complications and death from a variety of causes, such as infection and organ failure. The checklist ends with a requirement for a conversation among the surgeon, anesthetist and nurse about the patient’s recovery and management plan. As a whole, the checklist items create an operating room communication culture that improves overall surgical care and safety before, during and after an operation.

Classroom discussion questions:

What other tools described in Chapter 6 could be used in operating rooms to improve quality?
Why are checklists so valuable? What other industries use them regularly?

OM in the News: A New View of TQM in Hospitals

The atrium of the Henry Ford West Bloomfield Hospital

At the Henry Ford West Bloomfield Hospital outside Detroit, patients arrive to uniformed valets and professional greeters. Wi-Fi is free and patient meals are served on demand 24 hours a day. Members of the spa staff give in-room massages and other treatments.

While clinical care is the focus of any medical center, hospitals have many incentives to move toward hotel-inspired features, services and staff training. And competing on the amenities is all the more important because there is so little reliable comparative data on hospitals’ medical outcomes. “In the absence of hard data on cancer treatment or surgery success, patients may look to the quality of the hospital’s environment,” writes The New York Times (Aug.2, 2016).

In 2009, a 24-hour room service at Henry Ford West Bloomfield was introduced instead of set meal schedules. Similarly, patients at the more than 50 Henry Ford Medical outpatient centers in the region can choose the time and location of many tests, procedures and appointments using an online system modeled on airline reservation portals. When it was introduced in 2014, cancellation and no-show rates dropped immediately.

At Henry Ford West Bloomfield, scores from federally mandated surveys show that the evolving features at the hospital have helped to improve its customer satisfaction ratings and make patients more likely to recommend the hospital to others. Length of stay and readmission rates have also decreased, which allows more beds to open up and the hospital to treat more patients. Indeed, a study by Deloitte found that hospitals with higher patient experience ratings were generally more profitable than those with lower scores. “Hospitals want to create a loyal customer base,” says an industry expert.

Classroom discussion questions:

Referring to the Global Company Profile featuring Arnold Palmer Hospital (see Ch. 6), what techniques does Arnold Palmer use that are not noted in the Henry Ford article?
Why is it hard to measure hospital quality?

Good OM Reading: An MIT Case Study of Hospital Efficiency

American health care is undergoing a data-driven transformation. This MIT Sloan Management Review (June 25, 2015) case study examines the data and operations analysis culture at Intermountain Healthcare, a Utah-based company that runs 22 hospitals and 185 clinics. Data-driven decision making has improved patient outcomes in Intermountain’s cardiovascular medicine, endocrinology, surgery, obstetrics and care processes — while saving millions of dollars in its supply chain. Here are just two examples from this lengthy, but very readable study, one worth sharing with your class.

SURGERY: When data showed Intermountain’s chief of surgery that surgical infection rates at the hospital were in line with national norms, he presented the findings to the surgeons there. He said, “You think you’re great, but compared to other hospitals in the country, you’re not above average.” So a committee of clinicians spent a year developing a list of 30 possible causes, then whittled it down to 5 and made recommendations of changes. Doctors hated some, like having to give up bringing personal items into the operating room, including fleece jackets they would wear to keep warm. But in fact, after a 6 month trial, infection rates fell to half the national standard.

SUPPLY CHAIN: Supply costs will exceed hospitals’ top expense–labor–by 2020. The challenge is that a lack of price transparency and no system for sharing cost information with unaware doctors. So Intermountain started a supply chain organization–facing 12,000 vendors, $1.3 billion in expenses, and a culture that ceded much purchasing authority to doctors. One challenge was finding a way to reduce expenses for physician preference items (PPIs)–the devices that doctors request because they prefer them to comparable products. PPIs consume as much as 40% of a hospital’s supply budget. Intermountain launched a system designed to reduce costs by tracking its 50 highest-volume procedures and presenting information to surgeons on their supply options. One thing it found was that some coronary surgeons used sutures that cost $750, while others used sutures that cost $250. The analytics revealed no appreciable difference in patient outcomes. Doctors had no idea that the things they were using cost so much.

OM in the News: The Dangers in Measuring Hospital Quality

One of our definitions of quality in Chapter 6 is user based: “quality lies in the eyes of the beholder.” The Atlantic’s article (April 17, 2015), titled “The Problem With Satisfied Patients,” states though, that a misguided attempt to improve healthcare has led some hospitals to focus on making people happy, rather than making them well. When healthcare is at its best, hospitals are 4-star hotels, and nurses, personal butlers at the ready—at least, that’s how many hospitals seem to interpret the government mandate by the Department of Health and Human Services. DHHS announced that 30% of hospitals’ Medicare reimbursement would be based on patient satisfaction survey scores. The goal: transparency and accountability, which would improve healthcare.

But a recent study revealed that patients who reported being most satisfied with their doctors actually had higher healthcare and prescription costs and were more likely to be hospitalized than patients who were not as satisfied. Worse, the most satisfied patients were significantly more likely to die in the next 4 years. As one MD said: “Patients can be very satisfied and dead an hour later.”

The concept of “patient experience” has characterized patients as customers and nurses as automatons. Some hospital job postings advertise that they are looking for nurses with “good customer-service skills” as their first qualification. By treating patients like customers, hospitals accept the cultural notion that the customer is always right. But hospitals, too, can offer poor care and still get high patient-satisfaction ratings. A study of poor performing hospitals found that 2/3 of them scored higher than the national average on the key patient question; “YES, they would definitely recommend the hospital.”

Research has shown that hiring more nurses is the true key to patient satisfaction. Higher staffing of nurses has been linked to fewer patient deaths and improved quality of health. Failure-to-rescue rates drop. Patients are less likely to die or to get readmitted to the hospital. Their hospital stay is shorter and their likelihood of being the victim of a fatigue-related error is lower.

Classroom discussion questions:
1. What are the definitions of quality (see Chapter 6) and how do they relate to hospitals?

2. What are the flaws, if any, in surveying patients to measure hospital quality?

OM in the News: Safer Surgery Through Operations Management

“Hospitals are trying to make it safer for patients to go under the knife,” writes The Wall Street Journal (Feb. 17, 2015). Surgery can be risky by its very nature, and 46% to 65% of adverse events in hospitals are related to surgery. Despite years of prevention efforts, procedures are still performed on the wrong body part and surgical tools are sewn up in patients. The consequences of surgical error are huge, both for patient health and hospital finances. Johns Hopkins estimates that there are 4,082 malpractice claims each year for “never events”—the type of shocking mistakes that should never occur. There are also 600 reported operating-room fires in the U.S. each year, though there may be many more that aren’t reported.

Many hospitals don’t collect reliable data on their own adverse events, and as industry experts say, “you can’t improve a hospital’s surgical quality if you can’t measure it.” In Tennessee, 10 hospitals participating in a data analysis program from 2009 to 2012 reported that they reduced complications by nearly 20% since 2009, saving at least 533 lives and $75.2 million in costs. Data analysis can also help prevent foreign bodies from being left in patients when they do undergo surgery. With new OM processes in place, if a count at the end of a procedure indicates sponges or instruments are missing, hospital policy requires an X-ray before the patient leaves the OR, which can’t be overruled by a surgeon.

Surgeons are also expected to follow strict infection-prevention processes, such as sterile procedures that include fully draping patients on the operating table and wearing caps and masks before putting in a central line, a tube inserted in the chest to administer IV fluids, drugs and blood. As briefings and checklists become part of the hospital culture, new doctors coming out of training know this is the expectation. Older doctors are often hard to convert.

Classroom discussion questions:

1. Why is it important to measure hospital quality?

2. What do checklists do in this setting?

OM in the News: Checklists as a TQM Tool in Hospitals

How can we use the TQM tools in Chapter 6 to reduce deaths in surgery? One tool is a kind of poka-yoke called a checklist (see p. 223). The Wall Street Journal (Dec. 13-14, 2014) quotes Dr. Atul Gawande describing how he worked with a team from the airline industry to design what emerged as just a checklist. Surgical blunders, says Gawande, are “most often basically failures of communications. The checklist had some dumb things—do you have the right patient ? But the most powerful components are: Does everybody on the team know each other’s name and role? Has the anesthesia team described the medical issues the patient has? Has the surgeon briefed the team on the goals of the operation, how long the case will take, how much blood they should be prepared to give? Has the nurse been able to outline what equipment is prepared? Are all questions answered? And only then do you begin.”

The result, after he tested in 8 cities around the world, was that in every hospital that used the checklist, complication rates fell. The average reduction in complications was 35%. The average reduction in deaths was 47%. The system has since been replicated in multiple places. Scotland has implemented it and taught it at the frontlines –and has now demonstrated that 9,000 people’s lives have been saved over the last 4 years.

“The hardest part,” says Gawande, “is to bring the culture that has the humility to recognize that even the most experienced people, even the most expert fail.” Doctors fear these kinds of checklist systems. When he surveyed surgeons 3 months after they adopted it and asked, “What do you think about this approach?” he found that about 20% really dislike it—“It’s paperwork, it’s a pain in the butt, I don’t want to do this.” But when he asked, “If you’re having an operation, would you want the team to use the checklist?” 94% did.

Classroom discussion questions:

1. How else can checklists be used in hospitals?

2. What other TQM tools can be employed in a surgery process?

OM in the News: How Operations Management Improves Hospital Procedures

Swamped with tasks such as hunting for supplies, tracking down medications, filling out paperwork at the nursing station and looking for missing test results, nurses may spend less than two hours of a 12-hour shift in direct patient care, says The Wall Street Journal (July 22, 2014). But research has also found that the more time nurses spend at the bedside, the less likely patients are to suffer falls, infections and medication errors, and the more likely they will be satisfied with their care.

Now hospitals are changing traditional work practices, shifting more routine tasks to certified nurse assistants and other less highly skilled staffers. They are eliminating inefficient processes that make nurses walk as many as 5 miles around the hospital in a single shift. Some hospitals are aiming to triple the amount of time nurses spend with patients. That means locating supplies inside patient rooms and having pharmacists deliver medications to patient floors. As more hospitals adopt electronic medical records and place computers in patient rooms, they are enabling nurses to access information quickly and fill out medical charts while keeping close to patients.

Presbyterian Medical Center, in Winston-Salem, N.C., found in a 2010 internal audit that nurses were involved in direct patient care at the bedside for only 2.5 hours every 12-hour shift. “Not only was that eye-opening, it was also completely unacceptable,” says its chief clinical officer. With a shift to a team-based model, the hospital hit 6.5 hours per shift at the end of 2013, with a goal to hit 8.5 hours by the end of 2015. Process changes helped save $20 million last year at Presbyterian, and the transfer to electronic records also reduced by 42 minutes the amount of time spent paging doctors, copying and faxing, and tracking down tests.

This is a good article to link to the video case studies on Arnold Palmer Hospital in Chapters 6 (Quality), 7 (Process Analysis), and 9 (Layout).

Classroom discussion questions:

1. What tools of TQM could be used to help improve hospital processes (see pages 218-222)?

2. Why is it important for nurses to spend more time with patients, and less time at their stations?

OM in the News: Best Practices at the Sanford Health System

In 2012, waste in the national health care system was measured at $750 billion annually. Driven by tightening margins and increased pressure for positive outcomes, health systems nationwide are looking for ways to maximize resources and trim costs, writes Argus Leader (May 7, 2014).

“It’s not just about cutting costs,” said the CEO of Sanford Clinic in South Dakota. “We do have to cut per-unit costs, but we have to look at standardization, best practices. We have a very fragmented health care system, and that’s where integration and coordination of care is so critical. It’s not just for efficiencies. It’s for best outcomes and eliminating errors and waste.” The clinic’s approach to becoming more efficient involves the approaches of Kaizen and Six Sigma, tools used in business for process improvement, but the greater goal is to integrate continuous performance improvement into the culture.

The Sanford Health System, of which the clinic is a part, set a goal of finding $100 million in efficiencies this year, with much of the savings coming through better supply chain management. “We looked at cost transformation opportunities, which is tying it back to product standardization; maybe some miscellaneous contracts we have from one region to another that we could consolidate,” added the President of Sanford USD Medical Center. As the system has grown, it has commanded better pricing options from vendors. Various Sanford locations have worked together to identify best practices and streamline products and pharmaceuticals to achieve more savings through buying in bigger quantities.

Agreeing to use a common spine hardware, for example, saved $2.5 million annually. Working with cardiologists to determine the pacemaker of choice across the system saved another $2.4 million. Further, a new asset management system is designed to further optimize staffing and supplies. It will monitor where patients and care providers are to manage patient flow and track equipment.

Classroom discussion questions:

1. Why is OM so important in hospitals?

2. What tools in Chapter 6 can be used to improve hospital quality?

OM in the News: Robots in Surgery Don’t Always Work

Robotic surgery has grown dramatically, increasing more than 400% in the US between 2007 and 2011, reports The New York Times (Sept. 10, 2013). About 1,400 da Vinci systems, made by Intuitive Surgical Inc. of Sunnyvale, Calif. and costing $1.5- $2.5 million each, have been purchased by hospitals. On the market for more than a decade, more than a million procedures have been performed with the da Vinci.

But a new study follows a series of reports critical of robotically assisted surgery. Documents against Intuitive have outlined the aggressive tactics used to market the equipment and raised questions about the quality of training provided to surgeons, as well as the pressure on doctors and hospitals to use it–even in cases where it is not the physician’s first choice and he or she has little hands-on experience.

Almost 57% of surgeons surveyed anonymously said they had experienced irrecoverable operative malfunctions while using the da Vinci system. And between 2000 and 2012, thousands of da Vinci mishaps were reported to the F.D.A., including 174 injuries and 71 deaths, according to The Journal for Healthcare Quality (Aug. 27, 2013). Yet by combing news reports and court records, researchers at Johns Hopkins were able to find examples of botched operations that were not reported to the agency. They concluded that adverse events associated with the da Vinci were “vastly underreported.”

Reports made to the F.D.A. represent only “the tip of the iceberg” of surgical complications and adverse drug reactions, says the president of the National Research Center for Women and Families. “The consequence,” she states, “is that little is known of the real disadvantages of the equipment, and the injuries and deaths it may cause, even as robotic surgery is widely marketed to consumers.”

Discussion questions:

1. Is the da Vinci a successful product?

2. Are robots always useful in increasing productivity and accuracy?

OM in the News: Quality Control in Intensive Care Units

If you want an example of how the tools of OM can result in major improvements in the field of health care, read The Wall Street Journal (Sept. 11, 2012) article on the use of checklists in hospital intensive care units. A national patient-safety program, sparked by the death a decade ago of an 18-month-old child, reduced the rate of a deadly bloodstream infection by 40% in hospital ICUs.

The initiative, led by Johns Hopkins’ VP-Quality, Dr. Peter Pronovost, was implemented in more than 1,100 ICUs in 44 states. It took aim at bloodstream infections associated with catheters used to deliver drugs directly into patients’ major veins. The result of the effort was a reduction in the rate of infections to 1.137 per 1,000 days of catheter use, from 1.903, over the first 18 months that hospitals implemented the program. This cut represented at least 2,000 infections avoided, more than 500 lives saved and $34 million in health-care cost savings.

One professor who helped with the rollout of the program in Rhode Island, said the results are “dramatic.” Though the ideas in the program weren’t new, its developers “figured out how to bundle those best practices and insert them into the daily practice of nurses, physicians and other health-care professionals.”

Mortality for central-line infections in the U.S. is 12% to 25%. The CDC estimated there were around 18,000 of the infections in ICUs in 2009, down from 43,000 in 2001. The entire program is built on checklists like pilots use. Key practices on the checklist include hand washing, properly covering up care givers and patients when a catheter is inserted, and using the right disinfectant at the site of insertion. But equally important, according to Dr. Pronovost, were cultural changes, such as authorizing nurses to ensure that doctors adhere to the lists.

Discussion questions:

1. How else can operations management tools be used in ICUs?

2. Ask students to report on Dr. Pronovost’s book, Safe Patients, Smart Hospitals, which we described in this blog last year.

Good OM Reading: Big Medicine vs. The Cheesecake Factory

It was back in January, 2011 that we blogged about Dr. Atul Gawande’s excellent book on health care quality called The Checklist Manifesto . Gawande’s newest piece, “Big Med,”‘ which appears in the New Yorker (August 13, 2012) is an amazing read as you prepare to teach quality management in Chapter 6. He argues that healthcare can must learn from all high-reliable industries, from aviation, to pit crews, to construction, to the Cheesecake Factory.

Gawande writes: “In medicine, we are trying to deliver a range of services to millions of people at a reasonable cost and with a consistent level of quality. Unlike the Cheesecake Factory, we haven’t figured out how. Our costs are soaring, the service is typically mediocre, and the quality is unreliable. Every clinician has his or her own way of doing things, and the rates of failure and complication (not to mention the costs) for a given service routinely vary by a factor of 2 or 3, even within the same hospital. Big chains thrive because they provide goods and services of greater variety, better quality, and lower cost than would otherwise be available. Size is the key. It gives them buying power, lets them centralize common functions, and allows them to adopt and diffuse innovations faster than they could if they were a bunch of small, independent operations. Such advantages have made Wal-Mart the most successful retailer on earth.”

Physicians, though, have been mostly self-employed, working alone or in small private-practice groups. But that’s changing. Hospitals and clinics have been forming into large conglomerates. And physicians—facing escalating demands to lower costs, adopt expensive information technology, and account for performance—have been flocking to join them. Only 1/4 of U.S. doctors are now self-employed—an extraordinary turnabout from a decade ago, when over 50% were independent.

Enjoy Gawande’s description of his tour of The Cheesecake Factory’s kitchen and the disheartening comparison to a hospital’s medical operations. It’s a good 15 minute investment of your time.

Good OM Reading: RX for the Emergency Room

If you want to read an excellent article about issues of quality, capacity, and bottlenecks in hospitals, see OR/MS Today (Oct., 2011), for “RX for the ER”. The authors (one of whom is head of the ER at New Orleans’ Ochsner Hospital), write: “As an industry, hospitals exhibit technologic excellence in terms of diagnostic and therapeutic innovations. However, service delivery has been absent. The economic incentives to develop and sustain service delivery models that are viewed by the patient as efficient, useful, and valuable have been to a large degree nonexistent in a hospital environment”.

But things may be changing. Patients are demanding relevant information, more choice and better services. As a result, healthcare in the US is beginning to embrace the OM techniques that have made other sectors of American industry competitive. ERs are the perfect place to begin. And Ocshner Hospital had no choice but to reengineer its ER after Hurricane Katrina wiped out 70% of New Orleans’ healthcare services in 2005. ER volumes ramped up overnight to 180% of pre-hurricane averages and wait times tripled. Annual revenue loss, estimated to be $500,000 for every 1% of patients who leave prior to examination, is one factor in hospitals wishing to invest in a more efficient system.

Some of the highlights of the article: (1) ER arrivals tend to follow a known demand curve at different hours (contrary to what many administrators think), making staffing much more efficient; (2) the ER bed is the major resource in the department and it runs at more than 100% capacity a large part of the day– but 75% of patients do not need a bed and are discharged that day; (3) low risk patients do not need the services of a highly trained ER physician, and physician assistants can provide good care at 25% of the cost; and (4) registration and triage time can be reduced by 80% with lean workflow models.

This article is full of excellent graphics (10 of them) that you can use in class to make points about lean, waiting line costs and distributions, workflow, and metrics.