Lean thinkers see the waste in healthcare when they are at the hospital “gemba“. I think this is true whether you are a Lean person who is new to healthcare or if you're a long-time hospital person who has learned Lean. Experts (doctors) ranging from John Toussaint to Patricia Gabow to Don Berwick all estimate that between 30 to 50% of healthcare spending is waste.
It seems that, often, when you take this sort of discussion to the general public, people react emotionally as if “reducing waste” equates to not providing people the care they deserve – they think Lean healthcare is about taking away, instead of reducing cost and improving quality. I think this happens even outside of charged political circles. Why is that? I have a theory.
Some of the common waste is described in this article about a new Master's Degree program at Dartmouth:
Disney knows precisely how to gauge the wait for rides at its theme parks.
Major airlines know how to maintain near-perfect safety records on their aircraft.
But hospitals? Most don't know how to avoid making patients wait — some just build bigger waiting rooms.
Medical centers spend increasing amounts of money on patients, but don't necessarily deliver better care.
And estimates suggest that each year in the United States there are 15 million incidents of medical harm, some of which result in injury or death.
Now, a new master's degree program at Dartmouth College is intended to bring more of the business of safety, cost-effectiveness, and efficiency into medicine
My theory is that the general public puts a lot of faith in our healthcare system – blame TV or the movies, I guess. Would they think that a program like Dartmouth's is even needed?
I think people find it hard to believe the 30 to 50% waste estimates because they assume healthcare is fundamentally pretty perfect, or that it should be.
It breaks down into three categories… because we have the following, we should already have perfect waste-free healthcare delivery:
- We have highly trained, motivated people who care a great deal about patients
- We have relatively new, modern hospital buildings
- We have amazing healthcare technology (equipment, software, and medical knowledge)
So what could go wrong, given those three things? Yet, Lean thinkers know the overall system just doesn't work. I think it's hard for the general public to see that 1+2+3 = a lot of waste when they would likely assume 1+2+3 = awesome.
So when errors occur, the general public wants to blame and punish individuals – assuming they must be bad people working in an awesome system. When cost is high, people want to blame the greedy or the incompetent. People don't tend to look at the overall system, they wouldn't expect the problem is bad processes, not bad people. The general public assumes quality is good, when the data show otherwise.
It's safe to say there are indeed a lot of great things about modern healthcare (see 1, 2, and 3, above). But we don't get the high quality and patient safety we deserve and we, in America, certainly spend way more than we have to — and this high spending is partly due to waste, not due to 1, 2, and 3.
Do you think the public shares that perspective that I described above? Does that common (and arguably incorrect) view get in the way of the public calling for real systemic improvement that reduces cost and improves quality/safety? If so, how can we change that perception that 1+2+3 automatically equals awesome?
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I think that you’ve got a useful theory there Mark. I am reminded by what Dr. Deming used to say about the customer (public). “The customer only knows what you and your competitors have led him to believe. The customer never invented anything. The customer didn’t ask for pneumatic tires, incandescent lights, transistors, fuel injection. However, the customer is a fast learner and once they experience something better, they want it and will pay for it.” So, in order to change that perception (1+2+3 = awesome) we have to give the customer new experiences (significantly different from what they’ve had in the past), and once they’ve had it, they’ll demand it again and again.
Mark,
Considering that most of us connect with the health care system through our family doctor’s office and / or numerous specialists–is there any focus on lean healthcare for those connection points? The emphasis seems to be almost exclusively on hospitals. Or, am I missing something?
Mike – It’s generally true that hospitals have embraced lean more than primary care or other healthcare settings, although that’s not always true.
Some of the most impactful lean work is happening within integrated health systems that are looking at the “extended value stream” (lean term) or the “continuum of care” – the handoffs from an inpatient hospital stay to continuing primary care, for example. I think the best lean thinking is happening at the big picture level, for example trying to reduce avoidable readmissions by making sure the handoffs are good to between hospital an primary care.
Mark
Sorry for this rather long post; stay with me.
I have an additional thought. In the 1800’s, our lives were less complex. If a farmer had a broken roof, he fixed it. If the had a broken wagon wheel , he fixed it. Nowadays, you can’t even work on your car if you wanted to without the computer required to analyze what’s wrong. When things are beyond your ability to manage or even understand, you must rely on someone else. And if things go wrong, it cannot be my fault because I couldn’t do anything about it; it’s too complex. It must be someone else’s fault.
Medicine is the same. We have created this perception. Part of this is our medical training which emphasizes that we must make the difficult decisions even in the face of uncertainty to plow ahead; our patients rely on this. Much of the time we are correct and our patients benefit. And so we learn that mostly this works. In the absence of being able to judge any other way, patients also learn that mostly this works, which is why they like their doctor so much even in the face of evidence that our system has some deficiencies.
We then confuse this with believing we know how best to run the delivery system, which is, by many estimates, the most complex organism on the planet.
There are plenty of people displeased with their medical care delivery, which they can judge. But, we in medicine , have confused the two. We need to better understand the interrellationships between how the delivery system and the care provided impact each other, counter each other, support each other and affect each other. What’s the best way to coordinate these? A Lean thinker knows- continuous improvement and kaizen, for both the people working in medicine and those who rely on what medicine does for them.
Sorry to digress, but the woman in that picture above has undoubtedly the most beautiful blue eyes I have ever seen.
Changing the public perspective will be pretty scary and difficult because it means that the people who represent the system will have to stand up and say “we have problems” and then expose and enumerate them. Obviously, consistent with lean thinking (problems are treasures…), but pretty darn difficult to do, especially when you are accustomed to being on top in a command-and-control system. It is obviously happening within the medical community, but I don’t here many people shouting from the rooftops to the public at large.
Chugachmiut is using lean tools (root cause analysis) to try and determine how we can move good health further back into the life process. Our analysis is that many of our adaptive behaviors, such as smoking, alcohol and drug abuse, domestic violence, obesity, all have links to Adverse Childhood Experiences (and the infliction of childhood traumas). These adaptive behaviors have direct links to negative health consequences. If we can help adults understand the improvement tools, and motivate them to use them, we end up with healthier adults who are more productive in the work place. I am blogging about our Restoration to Health Strategy at http://knightbird.wordpress.com. If this works, then we will not need as much healthcare.
@Patrick – better example of the full continuum of care!
General comment to all, check out this article:
http://healthaffairs.org/blog/2010/09/14/berwick-brings-the-triple-aim-to-cms/
It talks about Dr. Don Berwick in his new role at CMS, looking to reduce waste in healthcare. He knows we can reduce cost while improving quality. He said:
Now there’s a partisan politics element to this, but part of the reason the “Death panels” demagoguery works with some is the widespread belief, as I wrote about here, that healthcare is naturally pretty efficient and that the only ways to improve quality or reduce waiting times is to spend MORE money, when Lean clearly shows us we can accomplish all of those goals while spending LESS.
Hi Mark,
I just wanted to add on some of the points you listed about the perception of healthcare and quality in the public domain. During my recent MBA experience in healthcare management, we often had discussions similar to this, and I remember that one of the take home points was that healthcare is fundamentally a treatment of people business. Patients that come into the hospital are often admitted during emergency periods (lack of preventative medicine practice, lack of insurance), etc. and since healthcare facilities continue to advertise their successes in patients. This often creates a false sense of security during a family members ill health, and sadly, medical practitioners become targets of frustration (and lawsuits).
I agree with the need for Lean/Six Sigma processes (I even focus on them and wish to make a career out of it in healthcare) but sadly with the millions that are spent, dramatic improvements in healthcare outcomes will not be immediately realized unless the underlying health concerns are investigated and the access and use of the system is improved. All medical regulatory and quality bodies have gone in the right direction, and for example mistakes are no longer tolerated. Awareness in desired healthcare process outcomes is just a slow and steady process and it will take some time before the objectives are realized.
I have to disagree slightly with the above comments. I completely agree the reality is that there is tremendous waste within the health care systems. But in all Western societies, the most significant predictor of the health of the population is income and education level… the actual amount of money that is thrown at health care and the manner it is managed (I’m writing from that “single-payer” country up north) has little to do with it.
On the other hand, the direct impact of a health care system that is dysfunctional and has a culture that reinforces the systematic waste of resources and tolerates errors can be catastrophic on a personal level. I recently watched the Discovery Channel’s documentary “Chasing Zero” that highlighted the direct impact on a number of individuals including the narrator, Dennis Quaid (his newborn twins were overdosed on a blood thinner medication). One thing that struck me was an observation that when the 50 US hospitals with the worst quality performance had a member of their board of directors interviewed, not a single one of those under-performing hospital board members realized how poor their performance was compared to the national benchmarks… all of them were blissfully ignorant and thought they were above average or average.
Rumit – I’m on the same page with you, but I disagree with the statement: “…and for example mistakes are no longer tolerated.”
There’s still an awful lot of “well, mistakes will happen” mindset in healthcare. Organizations don’t pay attention to near misses, so problems fester until the same situation leads to an injury… I think we might be moving in the right direction, but we have a long way to go still.
Mark,
I am not sure the public’s opinion about items 1, 2 and 3 but I think that most customers (patients) do not see the vast amounts of waste due to the fact that in healthcare, unlike manufacturing and many other service industries, the customer is shielded from the waste since they only pay a deductible, which represents a small fraction of the total costs for the product/service provided. Eliminate health insurance and I guarantee you that people will immediately feel the pain of the waste in the system and have a strong interest in reducing it.
There is an article by David Goldhill whose father died in a hospital due to a hospital-acquired infection (HAI). The name of the article is “How American Health Care Killed My Father”.
http://www.globalresearch.ca/index.php?context=va&aid=14904.
He spent over a year trying to understand what went wrong. He concluded that it was not bad people but rather a bad system. He also talks about the large amount of costs in healthcare and he explores the impact of eliminating health insurance along with other fundamental changes that are needed to truly transform healthcare.
[…] is a companion post to yesterday’s “3 Reasons the General Public Thinks Hospitals Can’t Improve.” Lean zealots often take for granted that, not only does Lean work, but that people want to […]
To all, (and not to step on anyone’s toes)
The first step is to understand the problem. Doing this requires understanding the perspectives of everyone involved in the process.
From the comments above, I wonder if we have truly understood all the perspectives, patient and doctor, administrator and nurse, board member and staff; individual and community, rich and poor and in the middle.
Everyone is involved in healthcare as a patient, family member, worker in the field. There are great many ‘ideas’ about what is wrong, but a paucity of understanding all the perspectives to begin to truly understand the problems from everyone’s perspective.
Establishing a means to do this would be a worthwhile endeavor
Thanks,
Mark Jaben
Mark – anytime anything involves politics or government (as healthcare does), we run into the U.S. culture that loves to jump to conclusions and/or jump to blame. I think my usual readers don’t quite have that tendency as bad (and I try not to) but we’re not perfect.
Looking forward to seeing you at Cindy Jimmerson’s lean healthcare event next week.
[…] there’s a communication gap where some automatically hear that as rationing and denying care, for reasons I wrote about last week. A lot of people don’t see how there’s 30 to 50% waste in healthcare from inefficiency […]
Mark –
You make several good points here. I think people generally regard the health care delivery system in the U.S. as one of the most “educated” and professional industries with which they regularly interact. Rightly so.
Historically, hospitals and health systems have regarded doctors, nurses, therapists, etc., as professionals who should be able to “plug ‘n play” [i.e., verify their training, hire them and turn them loose].
Again, historically policies and procedures were the kinds of things you only heard about when a “problem” arose. In short…there was no formal “system” in which providers were expected to participate. You were considered professional, your background checked out….now go do your job. This is what professionals did. It was, and still is, haphazard, random, inefficient and, in a word, dangerous. We have as many “holes” as we have “cheese” in our health care system today.
Mark,
I agree that there are plenty of opportunities for Lean in Healthcare, however I also believe there are some fundamental issues that go beyond Lean. I believe there are some opportunities that cross organizational boundaries that will have to be addressed in order to create an environment where creating waste is not rewarded. Let me explain:
If you can imagine a world where there was no cost for any course of treatment, doctors were not paid anything, (no lawsuits either) and doctors had complete data regarding outcomes of treatments for the conditions they are seeing in their patients, you could get to the idea of utilizing the most effective course of treatment based on outcomes. After the most effective treatments are identified, then we can work to make them as efficient as possible. Obviously we don’t operate in this kind of an environment, but we can use it to help decide how to fix the current system.
We need to find a way to put better data in our doctor’s hands.
We need to find a way to eliminate the incentives for prescribing one course of treatment or medication over another.
The same condition exists regarding the integration of medical care when necessary.
If you can imagine a world where the doctors with the best knowledge of a patients medical condition worked together as a team to apply the most effective treatments you could see how we might eliminate redundancy and mistakes regarding patient care. Our healthcare system today does not adequately support these concepts. The question is, why not?
We need to find a way to allow the doctors with the best knowledge of a patient’s medical condition to work together as a team to apply the most effective treatment.