Tag: hospitals

Good OM Reading: Health Care Kaizen

Paula’s husband had just come out of open-heart surgery. Laying in the recovery room with a breathing tube in his throat, he was clearly agitated. He motioned at his arms to try sign language, but the limbs would not move. Paula (a nurse at the hospital) began to panic along with him. When the anesthesia wore off, he said his hands and arms were numb–they remained so for weeks. It turns out that when surgeons performed the procedure, they had leaned over the  man and put pressure on his arms. With a single, small improvement, a nurse found that arm sled “positioners” could be used to tuck a patient’s limbs in place while removing the pressure.

This story is just one of 100’s in a new book called Health Care Kaizen, by Graban and Swartz, that describes small improvements made by those who do the work.  Kaizens are low-cost, low-risk process changes that can be easily implemented. The idea, say the authors, is to challenge and empower everyone in the organization to use their creative ideas to improve their daily work. And what better a place to see improvements than in our health care systems!

It is often said that “people hate change.” But in this readable book, we see that people actually love change when:  (1) they are fully engaged in the process, (2) they get to make improvements that help patients, and (3)  they don’t fear losing their jobs as a result of the changes. At one hospital, the CEO offered to shave his head if employees generated ideas that saved $3.5 million that year. The staff responded with $7 million in savings (such as $22,000 by switching from paper gowns to cloth ones) and the boss shaved in public.

At another, the neonatal ICU had automated paper towel dispensers. A nurse noticed babies flinching from the ongoing noise and decided to study the impact of what turned out to be a 50 decibel sound. The kaizen result was manual dispensers which allowed babies to get more rest, thereby gaining weight and getting home sooner–saving $2,000/day ICU fees.

Whether you teach health care OM or are looking for great examples of kaizen for class, this is a book worth reading.

OM in the News: Hospital Quality Rising–But 1 in 20 Patients Gets a Dangerous Infection

“Nationwide,” writes The Wall Street Journal  (June 5,2012), ” about one in 20 patients entering a hospital will get a potentially deadly infection, accounting for some $33 billion in preventable costs.” Dangers lurk not only in vulnerable places like operating rooms, but from sink faucets and TV remote controls, which can harbor the most deadly bacteria. (By the way, it is not just hospitals that transmit deadly germs. TV remotes are now being sanitized and plastic-wrapped in 2,200 Best Western Hotels).

For decades, US hospitals have based room cleaning quality on visual checks. These “are no longer sufficient,” says the infection prevention director at New Jersey’s Hunterdon Medical Center.  That hospital conducts random audits of 300 surfaces a month with a new swabbing device (shown in photo). Over 95% of checks get a passing grade, up from only 75% 3 years ago. Hunterdon also cut its rate of C. diff (Clostridium difficile) infections by 79% and reduced MRSA infections by 66% in the past 5 years. A bug called VRE that was on the rise for several years dropped 23% at Hunterdon last year. (C.diff is linked to 14,000 US deaths a year.)

Helping to spur action, the US government has set a goal of reducing hospital infections and other preventable problems by 40% by next year from 2010 levels.  Medicare has stopped paying to treat some infections acquired in the hospital. And facilities with the highest rates of hospital-acquired conditions will face reduced federal payments starting in 2015.

What are hospitals doing?  We now know that C. diff can survive for weeks on a doorknob, alcohol-based sanitizers don’t kill it, and hand washing is not sufficient. Cleaning crews need to use bleach and hydrogen peroxide, rooms have to be scrubbed carefully (even in corners), and “high-touch” surfaces carefully disinfected.

Discussion questions:

1. Why haven’t hospitals mastered quality control of cleaning?

2. How can the tools in Chapter 6 be used in this process?

3. Is 95% cleaning quality sufficient?

OM in the News: Pink Slime and Lean Hospitals

The public is continually subjected to health-related scares, from food packaging to water bottles that contain BPA, a chemical that has been linked to cancer. The media also highlights food additives that are not really harmful, but just sound unappetizing, such as “pink slime” in ground beef and the use of dried insects to color beverages at Starbucks. Yet, according to The Reporter (May 10, 2012), our nation’s hospitals are the one place where people actually have the most reasons to be scared and to demand change.

Studies estimate that 100,000 Americans die each year from preventable medical errors and another 100,000 die as the result of hospital-acquired infections. This health-care safety problem can be tackled with the OM tools of lean and TQM. We see this in one of our text’s most popular video case studies, “The Culture of Quality at Arnold Palmer Hospital”– worth showing when teaching Chapter 6.

The good news is that a growing number of hospitals are dramatically reducing different types of preventable errors, including patient falls, bedsores, wrong-site surgeries and medication mistakes, using the principles of lean (Chapter 16).  Dr. Richard Shannon helped his Pittsburgh hospital achieve, in just 90 days, a 95 percent reduction in deaths caused by central-line-associated blood-stream infections–through improved teamwork and making sure the correct supplies are always readily available.  Because these improvements do not rely on expensive technology or years of specialized training, they can be replicated in any hospital.

A 2010 survey, however, shows the bad news–that most hospitals are not devoting time or resources to prevent central-line infections, which claim 30,000 lives annually. And these hospital-acquired infections cost the U.S. about $30 billion a year in unnecessary medical expenses.

Discussion questions:

1. What  OM tools in Chapter 6 can be applied to help prevent infections in hospitals?

2. After watching the video, what does Arnold Palmer Hospital do to maintain quality?

OM in the News: Infection Rates and the Outsourcing of Hospital Cleaning

The Vancouver Sun (May 7,2012) has just reported another outbreak of  infection rates at Canadian hospitals. The article states that  health authorities have been warned for 10 years or more that the outsourcing of hospital cleaners – key personnel in any infection prevention and control program – was a misguided attempt to save money and would put patients at risk.   In  2004,  incidents at Surrey Memorial Hospital concluded that infection prevention had completely broken down. An auditor-general’s 2007 review found that the ministry of health had failed to implement systems for the prevention and control of infection.

Things heated up in 2009 when Vancouver  released reports from its Centre for Disease Control (CDC) on a persistent and lethal  infection  out-break at Nanaimo Regional General Hospital, the third in four years.   The CDC found that: “There were insufficient numbers of cleaning staff to meet the basic daily needs of the facility and they were not adequately trained in appropriate cleaning procedures for a health care facility. They were not able to meet the increased demand for environmental cleaning that is required to control an outbreak.”

Best practices in infection prevention programs highlight the vital role of hospital cleaning: adequate staffing and training, proper equipment and supplies, and real communication and cooperation among hospital personnel at all levels.   None of these factors are included in the government-ordered cleaning audits (which were confined to visual inspections only) that report hospitals passing with flying colors even while infection outbreaks were raging.

Scotland banned the outsourcing of hospital housekeeping in 2008 and brought cleaning back in house. The result? Infection cases have dropped dramatically. Reviews of Ontario’s devastating 2003 SARS outbreak named hospital cleanliness as a critical component in preventing and containing infections, and hospital cleaners’ involvement essential.

Discussion questions:

1. Why are janitorial services successfully outsourced in most organizations, but not here?

2. What OM tools are available to address this quality issue?

OM in the News: Where to Locate the Next McDonalds–in Your Hospital?

We all know that hospitals can be dangerous places to spend a few nights. Here are just a few statistics on annual deaths in US hospitals due to  preventable errors (as cited from a variety of studies): 44,000-98,000 (Institute of Medicine, 1999); 195,000 (Health Grades, 2004); 180,000 Medicare patients (US Department of Health, 2008); and 99,000 (AHRQ, 2009).  But what we would not expect as a reason for our demise to be hospital food. Maybe that is why a group of 1,900 doctors is starting a move to rid  hospitals of our favorite fast food chain, McDonald’s,  that has found a location strategy in a crowded market.

It turns out that 22 hospitals currently have contracts with the fast food industry leader, reports MarketWatch (April 10,2012), including the Cleveland Clinic and Children’s Memorial Hospital of Chicago. “Kids are being treated for diet-related conditions like diabetes on one floor in the hospital and given the wrong message by being offered the world’s most recognized junk food brand on another floor in the hospital,” says the  former president of the American Diabetes Association  “The practice earns McDonald’s an undeserved association with healthfulness among parents and children alike.”

A  study in the  Pediatrics demonstrated that allowing a McDonald’s  to operate inside a hospital affects hospital guests’ consumption on the day of their visit, and boosts the perception of the “healthfulness” of McDonald’s food. To address this concern, the group just sent a letter to the 22 hospital administrators last week,  noting: “It’s no surprise that McDonald’s sites stores in hospitals. For decades, McDonald’s has attempted to pose itself as part of the solution.”

In 2009, Dallas’ Parkland Health & Hospital System replaced a McDonald’s with a smaller chain offering healthier food. McDonald’s had been the only chain restaurant at the hospital for 20 years.

Discussion questions:

1. Do your students think locating McDonald’s in hospitals is an ethical issue?

2. Into what other types of facilities has the firm expanded?

OM in the News: Hospitals Turn to Lean

 Hospitals, under increased pressure to cut costs and become more efficient as Medicare reduces reimbursement rates, are turning increasingly to lean healthcare, writes MedCity News (March 23, 2012). Quoting Mark Graban, author of Lean Hospitals: Improving Quality, Patient Safety and Employee Engagement, “the lean model is about empowering people to improve and making lots of little savings.”

One of the biggest expenses for hospitals that can be controlled are complications resulting from hospital acquired infections. Graban referenced one hospital that saved $8 million by reducing hospital acquired pressure ulcers. “The goal is to have every employee be a problem solver every day.” Graban added that it’s critical for upper management to create an atmosphere where staff at all levels feel that they can contribute and that their contribution is valued.

Small changes can make a significant difference. Just because something needs to be changed doesn’t necessarily mean it has to be a major undertaking. In many cases improvements that can make a difference are subtle differences. Graban recounts one instance in which a hospital had installed an electronic paper towel dispenser right down the hall from a neonatal intensive care unit and its noise caused some disruption. Some staff spoke with the maintenance team and explained why it was a problem and replaced it with a manual dispenser. “That becomes empowering where a hospital allows changes to be made without treating it as a bureaucratic process,” Graban said.

Ask patients. By taking the time to involve patients in the lean process, hospital staff could get insights that may not have occurred to them or get a better sense of their priorities.

Discussion questions:

1. Suggest some areas in which lean can be applied in a hospital setting?

2. What is the origin of lean production?

OM in the News: R2D2 Enters the Hospital Hallways

Thousands of “service robots” are entering US hospitals. “Picture R2D2 from ‘Star Wars’ carrying a tray of medications or a load of laundry down hospital corridors'” writes The Wall Street Journal  (March 15, 2012).  As America’s elderly population grows, the country’s health care system is facing cost pressures and a shortage of medical personnel. Administrators are planning to foist some of the less glamorous work onto robots. “We are just not going to have enough human hands to do all the work,” says an industry expert.

The new breed of service robots are self-aware, intelligent (using advanced sensors and motion detectors tied to powerful microprocessors and voice activation), and able to navigate changing environments, even in chaotic hospitals.  InTouch Health, in Santa Barbara, has machines that allow doctors to connect to far-flung patients with videoconferencing. The robots enable a doctor to make rounds virtually and check on patients from miles away. More than 400 hospitals are using the InTouch machines.

 Aethon, in Pittsburgh, has sold robots to over 100 hospitals. These machines haul food trays, linens, medical trash, drugs, and medical records around the hospital, all while staying out of the way of rushing doctors and nurses. While the robots are popular with hospital staff, a union spokesperson at El Camino Hospital (which has 20 robots deployed) says: “We will always advocate for good jobs in which community members could be doing the work.”

(There is a short video on the robots embedded in the WSJ article as well.)

Discussion questions:

1. Ask the class to name some other service applications of robots.

2. What are the advantages and limitations of using robots in hospitals?

OM in the News: Iowa Hospitals Saving Millions With Lean Techniques

Though lean has been around for the past 3 decades in manufacturing,  its use in driving health-care performance improvement has been much more recent.  In fact, many of the lean specialists working at hospitals  have been hired from manufacturing companies in the past 6 years. They’re now applying skills once devoted to making factory floors more efficient to health-care challenges such as decreasing patients’ waiting time in ERs.

The Business Record (Feb. 24, 2012)  just  reported that in my home  State of Iowa (I was born in Dubuque), more than 70% of the 118 hospitals say they are now using lean techniques. This is up from 50% just 3 years ago. The Iowa Medical Society provides 73 separate detailed, and on-line, monthly quality measures based on reports from all of the state’s hospitals.

Iowa’s 2 major quality goals are to reduce hospital-acquired infections by 40% and reduce preventable readmissions by 20%. If these two goals were achieved nationwide, health care costs in the US would be reduced by $35 billion. Since the Congressional Budget Office (CBO) expects health-care spending to increase at a rate of 8%  per year between now and 2022, Medicare/Medicaid programs will double in the next decade to $1.8 trillion, or 7.3% of our nation’s total economic output.

Under the Patient Protection Act, hospitals’  medical reimbursement payments will be linked to their performance on such procedures as cardiac, surgical, and pneumonia care. “Health care is turning to lean to continue to stay in business,” says the CEO of  the Iowa Healthcare Collaborative. Currently, one of its biggest projects is an initiative to ensure operating room supplies are delivered to the right place at the right time, to minimize unnecessary movements of supplies.

You might want to show the Arnold Palmer Hospital video on JIT (see Ch.16) if you discuss this article with your class. It illustrates the many ways OM and lean are  critical to the future of hospitals.

Discussion questions:

1. Why is lean so important in the health-care system?

2. Name several areas in which lean can be applied in a hospital.

Video Tip: Supply Chain Management at Arnold Palmer Hospital

We think our video case studies on the Arnold  Palmer Hospital for Children and Women have been very popular for 2 reasons. First, they cover seven different OM topics–from quality to layout to process design to JIT to capacity to project management to  SCM–which means you can follow one organization from start to finish during the semester. And second, hospitals are a great example of a service application of OM that students can relate to. So if you are looking for a video to spice up your supply chain (Chapter 11) lecture, this is a good choice.

Arnold Palmer Hospital (APH) used to belong to a 900 member national group purchasing organization (GPO), through which it saved money on virtually every staple it needed.  But not everyone was pleased. Doctors, for example, were given only limited brand choices of certain surgical implants, like pacemakers, through the GPO. And it was difficult to take advantage of local vendors who might provide better service and prices. By creating its own, much smaller GPO, with only 7 local hospital members, APH realized it could save 7%, around $7 million annually, on its $100 million in purchases. This savings came despite the increased overhead of starting one’s own purchasing department.

In this 8-minute video, you will see the power of an interesting group, a Medical Economics Evaluation Committee. The committee allowed hospital staff to have  input into the approved products list, picking the medical tools they preferred, but only after agreeing to stick with a few choices at the best prices–truly a combination of medicine and economics.

The video also shows the 3 tiers of suppliers and how they are effectively integrated into the supply chain to drive down costs, reduce inventory, and improve quality.

OM in the News: Hospital ERs Turn to Lean Management

The Wall Street Journal (Aug.2, 2011) writes: “To speed patients through the system, emergency rooms are adopting lean-management principles pioneered by Toyota to increase efficiency, cut costs, and provide better service”. It’s certainly about time. Waiting times in ERs that can run into several hours have become a fact of life in the US. And while the number of ER  departments has dropped by 1/3 over the past 2 decades, the number of patients seeking care has gone up by 40%. To boot, there are fewer doctors doing primary-care even as more uninsured patients show up (who must, by law, be treated).

The lean production changes (see Ch.16) include: (1) streamlining the traditional methods of triaging, which means no longer providing a bed for non-critical patients,(2) staffing with less-costly nurse practitioners and PAs so ER doctors can avoid paperwork and focus on care, and (3) posting ER waiting times on-line , in waiting rooms, and even on highway billboards.

The 2 metrics ERs use to judge their efficiency are: LWBS (“leave without being seen”) and AWT (“average wait time”). The latest national LWBS number is 2.7%, up from 1.7% in the prior decade. (California is closer to 20%).  “We don’t want them to walk out the door for their own health, but it’s also not a good business model”, says one ER director. Revenue drops about $450,000 if even 1% of patients walk in a typical ER.

With lean changes, one Phoenix hospital chain (Banner Health) saw its LWBS drop from 8% in 2007 to 0.5%  this year, while volume increased 4%. At Ochsner Medical Center (New Orleans), AWT went from several hours down to 33 minutes, while the LWBS rate dropped from 15% to 1%. The process analysis tools we discuss in OM can indeed make a major difference in the quality of health care.

Discussion questions:

1. What tools in Ch.7 (Process Strategy) can be useful in reengineering in the ER?

2. What other JIT/Lean/TPS approaches discussed in Ch.16 can be employed in the ER?

OM in the News: Disney Service Quality Spreads to Medicine

Disney has been long respected for excellent customer service and for treating its “guests” with the personal touch that improves the theme park visit. Disney’s “on-stage” and “off-stage” approach to separating public and private areas is well-known, with “cast members” (employees) always maintaining a magic image to the public. The Orlando Sentinel (July 16, 2011) now reports that Disney has designed a program for health-care professionals to assure that patients are as satisfied with a trip to the hospital or doctor’s office as they are with a trip to the theme park.

For $3,500 each, health-care workers spend  3 1/2 days at Disney, learning to pay closer attention to the patient experience. “Oftentimes in health care, the patient in the bed is almost secondary”, says a consultant. “Everyone comes in looking at their task instead of the patient”.

When Disney worked with Florida Hospital to open a new children’s pavilion a few months ago, the plan includes simplified name tags, new uniforms, a ban on cell phones, greeting patients with a smile, and kneeling down to talk to children at eye level. (Our Table 6.5 in the Managing Quality chapter relates to these “determinants of service quality”).

“By exceeding expectations, doctors can attract new clients through referrals from satisfied patients”, says Dr. Chris Smith, a S. Carolina family doctor who attended the Disney program. At Smith’s office, the receptionist is now a “greeter”. And he has established off-stage private break rooms for staff to relax, vent, or do things a patient should not see. Just like other industries, doctors are learning that every service activity matters.

Discussion questions:

1. Ask students to describe a positive and a negative medical service experience.

2.  What other quality tools can medical professionals employ from non-medical fields?

OM in the News: The Pressure on Hospitals to Improve Efficiency and Curb Waste

As the White House and Congress debate how to contain runaway medical costs, equipment maker GE is embarking on its own quest to help hospitals reduce wasteful spending and treatment errors. As much as $500 billion out of the $2.2 trillion spent on health care is wasted on duplicate processes, bad coordination, and out-of-date scheduling, says GE, in the latest Businessweek (April  18-24, 2011). “It’s generally accepted that for every $100 spent on health care, $20 or more is waste”, adds the CEO of GE’s health-care/IT unit.

GE’s plan takes two approaches. The first is to cut costs of medical imaging, with 80 new products coming on-line in the next 2 years, including an MRI that scans only extremities. This frees up whole-body machines for more complex scans, which both cuts a hospital’s costs and raises its revenues.

Although improving molecular imaging , which helps catch diseases earlier, is the most glamorous way to save money, the US health-care overhaul is also looking at a second source. For GE, that means branching into information technology and consulting. The 2010 law signed by Obama  requires hospitals to use more IT to reduce costs and medical errors. As a result, hospitals are looking for outside expertise. GE  Healthcare plans to do $1 billion annually with its new consulting unit, analyzing patient data and digitizing medical records.

OM is again at the center of these changes, leading the way with new technology (Ch.7), process improvements, and quality tools. Many profs have asked us to keep an eye out for health-related examples such as this one.

Discussion questions:

1.Why are so many expensive devices used in hospitals?

2. How can OM help make hospitals more efficient?

3. How can medical records increase the quality of healthcare?

Good OM Reading: Safe Patients, Smart Hospitals

After reviewing The Checklist Manifesto for our blog a few months ago, I wondered how Dr. Peter Pronovost’s  book, Safe Patients, Smart Hospitals would add to the important role  OM plays in hospital quality. Simple and avoidable errors in hospitals around the world are made each day that cost the lives of patients. Inspired by 2 tragic medical mistakes —  his father’s misdiagnosed cancer and  sloppiness that killed  an 18-month old child at Johns Hopkins– Pronovost has made it his mission, often swimming upstream against the medical culture, to improve patient safety and prevent deaths.

He began by developing a basic 5-step checklist (see Ch.6) to reduce catheter infections. Inserted into veins in the groin, neck, or chest to administer fluids and medicines, catheters can save lives. But every year, 80,000 Americans get infections from the central lines and 30,000-60,000 of these patients die.  Pronovost’s checklist has dropped infection rates at hospitals that use it down to zero, saving 1,000’s of lives and tens of millions of dollars.

His steps for doctors and nurses are simple: (1) wash your hands, (2) use sterile gloves, masks, and drapes, (3) use antiseptic on the area being opened for the catheter, (4) avoid veins in the arms and legs, and (5) take the catheter out as soon as possible. He also created a “central line cart”, where all supplies needed for the procedure are stored.

Provonost believes many hospital errors are due to lack of standardization, poor communications, and a non-collaborative culture that is “antiquated and toxic”. Whereas safety in the airline industry is a science, and where every crew member works as part of the team, he writes: “doctors think they are infallible”.

This is an inspiring book which shows how one person, with small changes, can make a huge difference in patient care. Your students in the health care areas will appreciate the OM insights provided. An interview with Dr. Pronovost appears in The Wall Street Journal (March 28,2011).

OM in the News: Hospitals Fear Outsourcing Records to India

Whenever I blog on the subject of outsourcing  (see Chapter 2), I find myself using the word “controversial” (as on 10/12/10). And, indeed, this week’s Wall Street Journal article (Nov.2,2010) describes the contentious issue of outsourcing digitizing of hospital medical records to India. Overseas providers, it is commonly feared,  do not have the security and privacy controls that US hospitals require. “As soon as it leaves the confines of the US, its not subject to the same rigorous laws as we are”, says the CIO of a Texas chain of 40 hospitals.

Every company in IT wants to cash in on the lucrative $50 billion US health care market fueled by a federal mandate for hospitals to convert to electronic records by 2017.  Amazingly, only 20% of US hospitals currently have electronic health records. Its a carrot and stick approach, with $6 million grants to an average sized hospital (I wonder where all this money comes from!) and penalties for missing the deadline. Its “like another Y2K opportunity” for software firms, says the head of New Delhi’s HCL Technologies.

So the real question is, who should get the contracts? Its not so simple. HCL has about 2,400 American employees in N.C. Then again, Cognizant Technology Solutions is a US firm in N.J., but has most of its staff in India. Indian tech giants Infosys, Wipro, and  Tata are all lined up with bids. But so are IBM, Xerox, and Dell in the US.

Discussion questions:

1. How do students feel about sending medical records abroad for automation?

2. Can this impact relations with India, which sees this as protectionist? (President Obama visits India in 2 days).

3. Why was Y2K such a boon to the IT industry? (Some of your students may not remember the drama that year).

Good OM Reading:Lean Hospitals

If there was ever a field in need of our knowledge, consulting, and experience as teachers in OM, it is our hospitals. If you have had the unfortunate experience of spending time in an ER, an OR, or an overnight stay, you will really appreciate this book.

Or if you are just  looking for great examples of OM and TQM in the health care field, I highly recommend it. Lean Hospitals, by Mark Graban (Productivity Press, 2009, 252 pages) is simply excellent. Each chapter is full of stories and data you can use in class. Graban describes, in real hospitals, how lean improves patient outcomes, increases employee and physician satisfaction, all while saving money.

Lean is not new in hospitals, as Graban traces auto production methods back to a Michigan hospital in 1922.

Chapters 1 and 2 are introductory, Chapter 3 deals with Value and Waste, Chapter 4 with Value Streams , Chapter 5 with Standardized Work, Chapter 6 with Visual Management, 5S and Kanban, Chapter 7 with Root Causes, Chapter 8 with Error Proofing, Chapter 9 with Improving Flows, and Chapter 10 with Engaging Employees.

I found myself taking notes in every chapter. Graban’s writing style makes this a very readable book. Mark also keeps a  useful web site  that is worth visiting.