Can those people be successful without a clinical background?
Absolutely. Those people are trained to do process improvement in any environment. They’re trained to be successful in any environment.
One of the problems in that regard may be the medieval-like system of professional guilds among clinicians in healthcare, as well as the issue of credibility with clinicians, correct?
Well, but that’s basically the chicken-or-egg problem. Just this May, the President’s Council of Advisors on Science and Technology, or PCAST, issued a report that included recommendations for the hiring of professional process engineers in healthcare, and it was the third or fourth paper in several years to do so. And it said, we need to reengineer healthcare. And you’re right, per the medieval-guild aspects of clinician training and development in healthcare. The existing medical residency programs are nothing more than apprenticeships that focus entirely on patient care, but without systems education. So there needs to be education in the healthcare professional schools, as well as the healthcare management schools, around all of this. In fact, a friend of mine, the dean of the Central Michigan University Medical School, has made Lean training mandatory for medical students. And other medical and nursing schools are starting to do this. When a doctor is trained, they come out with some knowledge about MRI functions, even though they don’t run MRIs. Doctors and nurses should get basic training in [quality improvement and process engineering]. We don’t ask doctors and nurses to learn how to build EMRs [electronic medical records]; why should we ask them to fix EMRs? It’s a cultural bias in healthcare, that we didn’t do it that way. And in terms of EMRs, they’re a completely different way of doing the same thing they’re doing now.
Process improvement isn’t necessarily seen as a different way of doing things. I don’t know if you’re aware, but the incidence of claims denials in Medicare is god-awful, it costs us many billions of dollars a year, and we’ve done some work with hospitals, and the reason for many of those denials is because of the lack of a valid signature on a claim; that’s a process issue, and it costs money.
When it comes to adopting Lean management and other principles in patient care organizations and really embedding them into patient care organizations’ culture, are we talking about a CEO-level issue?
Yes, it’s a CEO issue, and it’s a board issue. It’s a fiduciary issue. They’re losing tons and tons of money. And very little of it is clinical waste. I recently talked with a hospital medical director; his organization had done a lot of Lean projects. But it wasn’t accepted and built into the culture. So then they visited Virginia Mason Medical Center in Seattle [Virginia Mason Medical Center has strongly adopted the Toyota Production System as part of its core operating strategy: see this HCI article for more]. And then they saw what churches and street gangs had done successfully forever, and that is to drum into their adherents exactly what to do, over and over. And we don’t have that kind of mandatory culture except in a few places in healthcare, such as Virginia Mason.
So it does have to come from the top, and does it have to be mandatory?
Yes, absolutely, and it also has to be something where the people at the practice level are involved. One of the biggest “aha” moments I had at General Motors, when I worked there, was the revelation that you can’t get anything done without the participation of the people putting the bolts on the cars. I was recently a patient in the hospital; I was pretty sick, actually, and there were a whole bunch of different specialties involved. And the nurses, who were wonderful, told me, these people—the specialist physicians—don’t communicate with each other. And here’s another example: I was lying in bed in the hospital at 2 AM one morning, and a nurse came in and said, I’m here to draw blood. And I said, I’m sure that’s wrong. And another nurse came in and got it clarified; the first nurse was supposed to draw blood from the patient next door! Think about airlines—they have what’s called a 5S process.
So in that regard, we’re talking about the extensive use of checklists, as advocated by Dr. Atul Gawande, correct?
Yes, and Peter Provonost before him, who actually got checklists going. It’s a pure industrial technique. And one of the problems is that people have gone in and started using Japanese names like Kaizen and stuff; well, that’ll turn people off! I’ve taken dozens of process engineers into healthcare. They have to spend a little time learning the vocabulary and cultural issues before they jump right in. But then they absolutely can do it.
In order for patient care organizations to really change, it will take a cultural revolution around the adoption of continuous quality work, correct?
Yes, but at the same time, you’re now starting to see some incentive changes, particularly coming out of healthcare reform, at the federal level, and also coming from private payers. And because of that shift, you’re starting to see some incentive changes. This whole pay-for-performance thing has woken people up.
In the context of all of this, what do hospital and health system leaders need to do right now?
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