Posts Tagged with process

posted by adgrooms on June 19, 2019

On March 27, 1977, two Boeing 747s collided killing 583 on a runway in Tenerife, in the Canary Islands, off the coast of Morocco. This accident led to a new era of standardization and safety in aviation. Aviation studied its vulnerabilities and innovated to be a much safer form of transportation with .07 deaths per billion passenger miles, reducing the number of commercial fatalities from the thousands at the time of the Tenerife accident to a few hundred in recent years.

Medical errors and injuries are an ongoing problem for healthcare. Are there systemic gains that aviation has accomplished that healthcare can use to improve outcomes?

In comparison, both professions require years of rigorous training. One difference is that aviation includes extensive leadership, decision making, teamwork, and other non-technical skills where physicians receive little, if any, of this line of training. Physicians are required to interact with patients and staff as a leader while making numerous difficult decisions. Why wouldn't this type of training and support be provided in healthcare?

The safety initiative in aviation discovered that lack of communication was the root cause of many accidents. One response was a move to flatten hierarchies. The captain is in charge and has the last say in decision making, but if a co-pilot sees a problem, they are encouraged to speak up, not shut up. Collaborative approaches like team-based care have a positive impact in the clinical setting, but it only works if every team member feels valued and each voice is welcome. A culture of mutual respect for every role is needed for a cohesive, well-functioning medical environment.

The healthcare industry needs to provide an avenue for physicians to report a mistake without fear of repercussion. Aviation has cultivated a culture of reporting mistakes through the Aviation Safety Reporting System run by NASA. It is a place where pilots, air traffic controllers, flight crew, and maintenance can report errors voluntarily. The reporting is then used to improve whole systems, not to punish individuals. This allows for constant improvement in safety processes that benefit the whole industry. Healthcare already suffers from too much bureaucracy but a similar, industry-wide reporting system could simplify and standardize reporting while creating a culture of safety and a shared resource for improvement.

Aircraft have systems that collect a massive amount of information. This information is used to refine workflows. Much of the process has been automated such as controlling the plane in level flight. Healthcare has gone in the opposite direction with the implementation of EHRs. Doctors are burdened by required manual input in clunky interfaces. Modern aircraft interfaces offer inspiration to the development of more robust clinical software.

Airlines invest heavily in the wellbeing of their staff. There are strict guidelines on how much pilots can work, and psychological staff are readily available for support. This is not necessarily the case for physicians. With ongoing shortages, physicians are working longer hours, and burnout has become a heavily discussed problem. The safety improvements of the airline industry provide good justification to healthcare for making similar investments in the wellbeing of their team.

There is an effort in health care to learn from aviation. Captain Chelsea "Sully" Sullenberger, famous for the miracle on the Hudson emergency landing, speaks to doctors on improving systematic processes in the pursuit of patient safety. Although there are differences between the two disciplines, safety and the outcomes of patients/passengers are a shared objective.

posted by adgrooms on June 13, 2019

Healthcare and auto manufacturing may not appear to have a lot in common, but healthcare is experimenting with Lean, an organizational methodology that comes from the auto industry. Since patients aren't cars and doctors aren't robots, how is this going to work in healthcare? Does it belong in healthcare? Why consider it at all?

Changes to regulations in the last decade, such as HIPAA and HITEC, have led to increased administrative oversight and increasing waste. This costs the organization, staff, and patients time and money. The basic principles of Lean include mastering simplicity, eliminating waste, and constantly improving. The Lean model is thus an appealing countermeasure that could provide positive results. Well implemented Lean processes locate and eliminate inefficiencies and redundancies to create a smoother workflow.

Another basic tenant that is particularly relevant to healthcare is respect for the workforce. It is supposed to give employees more say in how things are done. Employees are encouraged to find processes to improve and increase quality. Giving employees the latitude to find and use software that makes their job more efficient, within secure parameters, could also reduce some of the waste.

Lean practices narrow the scope of work and eliminate administrative obstacles. EHRs have shifted providers' daily work away from caring for patients. They are now overwhelmed with data entry. Asking providers to give care and code for billing goes against the Lean ideal of each job having a specific purpose. Although capturing reimbursement is a very important function, according to Lean principles, a physician should be focused on the care of the patient. Another role, or ideally automation, should be responsible for coding and reimbursement.

As Lean is tried in healthcare, it is getting mixed reviews. It shows promise but is not yet proven. In future posts, we will look at the successes and failures to try to determine whether and how Lean benefits healthcare.

posted by adgrooms on June 11, 2019

Is organizational transparency possible in healthcare? The very nature of healthcare includes private, personal information. Does this prevent healthcare organizations from having a culture of transparency? What are the benefits of being transparent and why don't more institutions strive for transparency?

Medicine is based on trust. Patients trust that a doctor is going to take care of them. Doctors trust that their organization will support them. In a healthy institution, you see trust reflected in every interaction. But no person or place is perfect. People make mistakes, and when that happens, trust is reduced and needs to be restored. Fostering trust is one of the major benefits of transparency. It is impossible to learn from a mistake without first acknowledging it. When there is an event, there is a choice to be made. The organization that acknowledges and addresses a mistake retains the community’s trust. Versus the organization that denies the problem and withholds, hides, or misrepresents information. On the inside, a culture of blame and shame breeds a toxic environment. On the outside, this behavior erodes the community's trust. Transparency is a conversation that banishes blame and cultivates constructive thought.

Transparency improves safety. In line with learning from mistakes, maintaining awareness of performance is the only way to learn and improve. As Peter Drucker said, "If you can't measure it, you can't improve it". This extends further in a healthcare organization. If you track outcomes and measure results but keep the numbers hidden from team members, they can not contribute to improvement. You are relying on the few that know to provide the solutions and they may not be the right people with the right knowledge. It is a substandard use of the team's abilities. When tracking is implemented and all team members are brought to bear, the best achievements can be reached.

Culture change is not easy. Moving from no or low transparency to full visibility requires a plan and time for adaptation. It requires buy-in from everyone in the organization and a leap of faith in each other. Increasing internal visibility in low-risk areas will give team members time to adjust and become advocates. A good place to start is increasing internal access to measures of performance and outcomes. When the organization has reached a good level of comfort with internal transparency, it will be ready to work on external visibility, eventually becoming a resilient culture that constructively incorporates all feedback.

Clearly, there is a benefit to healthcare in transparency, even though enacting and maintaining transparency is difficult. Egos must be checked at the door; none of us want to reveal our faults. But, intentionally acknowledging our faults leads to positive change. Ultimately it is conversation through all levels that will lead to long term success.

posted by adgrooms on June 6, 2019

Healthcare providers need great tools that facilitate their work and empower them. IT teams need to stay ahead of risk to their organizations; this includes all forms of system resilience, especially security risk. Leadership needs cost-effective solutions and reliable systems. To this end, healthcare IT departments have oversight of all software used in their institutions. They are charged with protecting patient data, efficient use of resources, and the overall security of computer systems; therefore, they review and approve every piece of software used. Sometimes employees find the approved software to be inadequate or prefer using solutions not provided by the institution. The use of unauthorized software without disclosure is known as "shadow IT". What are effective ways of addressing shadow IT?

Some healthcare employees may not know what a security risk shadow IT is or the HIPAA policies they are violating. For example, one common use of shadow IT is communication. Providers looking for a more efficient way to share patient health information amongst themselves could be using their personal device for messaging. It seems like a pragmatic and reasonable solution, but in reality, this is an insecure method and highly vulnerable to a data breach. How can these instances be addressed?

Many times it is the lack of a good clear process towards getting a better solution implemented. Any large organization has many rules and processes, and it is hard to be aware of the relevant steps. A solution-seeking provider may not know where to go to get the software approved. Is it an IT committee? The IT department itself? The CTO? Having a defined and published process with a clear entry point gives the progress-oriented people on the front lines a path to work within the institution's guidelines. A step beyond this is to develop an innovation committee. All approaches should show appreciation for the inclination toward improvement and steer creative souls into constructive, informed steps in partnership with IT.

Maybe you are an IT team member reading this thinking "We have a process. We still have this problem." This is an indication that a process audit would be helpful. Can you view the steps from the perspective of a healthcare provider in your organization? What are the steps to discovery? How do they become learn how to work with you? Is the process time-consuming or confusing? Can it be more clear or streamlined? Are innovators encouraged? Discouraged? Punished, even?

Shadow IT may not be any single department’s fault. Conflicting interests between leadership, IT, and the providers can cause the adoption process to be slow and painful, leading to more shadow IT. Creating and refining a collaborative and encouraging process will go a long way to reducing shadow IT, increasing security, and encouraging innovation.

posted by adgrooms on June 4, 2019

A recent report in the Annals of Medicine provided an estimate of the institutional cost of physician burnout. The researchers used mathematical data from other recent studies to come up with the conservatively estimated total annual cost of $4.6 billion or $7600 per physician. The study notes that it focused on the cost of replacing physicians and lost income from unfilled positions. When we consider other organizational costs of overburdening physicians, the amount is much higher.

Inefficient systems, which contribute to burn out, are a cost unto themselves. When Physicians are required to spend more than half of their (12 hour) workday in the EHR, their training is not put to best use. The amount of available time for patient care is unnecessarily limited. What would the impact be of reclaiming just one hour for each person? Spent on patient care or spent on self-care, either would lead to a greater benefit to the individual and the organization.

Beyond this, a 12-hour workday is wearing people out to the point of error. Mistakes due to decision fatigue are another hidden cost. At the end of a long day, of course, decisions are not going to be the same quality as those at the start. Minor mistakes lead to costs in unnecessary tests and prescriptions. Major mistakes, in the case of injury, add large costs of lawsuit settlements and legal bills.

Cost-effective solutions to this include:

  • Proper delegation of tasks. e.g. If another staff member can do the task, move it to their queue.
  • Streamlined interfaces.
  • Effective automation.
  • Communication triage.

This study and others have found that a moderate investment per physician can reduce burnout. Considering the extra costs not included in the study, the potential for a large return on investment is very high. Do you see a downside?