The Case for Lean-3

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The Quality Myth:
Complying with best practices or standards, national or international, is a good start to build a foundation for a safe and standardized care. However, this is not how it’s being handled or at least viewed in many healthcare organizations, let alone that meeting standards does NOT guarantee positive results or outcomes of care, according to many experts.

Many organization mistake complying with “accreditation” standards with the notion of achieving the right level of quality and safe care. In fact, doing that may actually jeopardize safety and quality of care by settling with minimum requirements, adopting a very rigid view point, or focusing on documentation rather than sustainable changes in actual practices. And because of that, no rooms is left for creative problem solving or daily continuous improvement. Staff in such organizations, using their own words, have become robots memorizing and following a set of external standards, often without even knowing the rationale behind them. And when a situation arises that call for innovative solutions or new ideas, they seldom step up, much like a linear school system based on fixed subjects evaluated by final exam results only. So, instead of investing on people to lead and improve quality and safety, those hospitals have created disengaged and uninterested work force that get real hype only by signing the final box on a piece of paper.

Decision makers in healthcare organization need to understand clearly that writing a policy or adding a checklist does not guarantee good results in real patient care. They need to ask the questions: what is a “good” outcome of care they aspire to provide to their patients, and how does complying with the same standard over and over again achieve that?.

I recall looking at one Linkedin post by a very famous hospital group in India. The post advertises the attainment of accreditation by the JCI, and states that it has achieved the most prestigious excellence award in healthcare in the world. I’m not sure if JCI accreditation (or any accreditation for that matter) can be considered an excellence award, and I can’t recall JCI referring to that itself!
The problem with many healthcare organizations seeking international or even national accreditation is that their main goal, is to market their services and acquire more patients, and hence more business, or to satisfy regulatory requirements. This is well known among those close to the decision making and strategic planning (assuming there is proper strategic planning).

One of the private hospitals I know which somehow succeeded in achieving multiple international accreditation, mentions in its documents that they support a continuous improvement culture through complying with accreditation standards. Not only this is a flawed understanding of what continuous improvement is, but when you ask the concerned staff about the standards they were accredited for, and are expected to apply in their daily work, you only get blank faces!

I’ve had the chance to come across a number of healthcare organizations, both governmental and private, that have obtained different accreditation status, and yet are notorious among their own staff, let alone the consumers of their services, as providers of poor quality and less compassionate care. This alone indicates without much doubt that obtaining accreditation is in most cases merely a certificate on the wall that has no real impact on the system of care.
The accrediting and regulatory bodies do also play a role in this misconception and malpractice. They need to revisit their strategies, and the criteria used in the evaluation of quality and safety in any healthcare organization, and how big is the value of granting accreditation for the communities served.

The IOM landmark report “Crossing the Quality Chasm” 15 years ago showed that healthcare systems were broken, misaligned, and fragmented. Sadly, the same problems still exist today, and the number of patients suffering from medical errors and poor quality of care are on the rise despite all the advances on the medical field and the efforts to improve quality and safety.
On the brighter side, there are some great examples around the world of healthcare organizations who succeeded somehow in pinpointing reasons of many common issues, whether it’s lack of vision and leadership, rising costs, miscommunication, medical errors, wasted time and energy on things that adds no value, patient dissatisfaction, demotivated or burnt-out workforce, to mention a few. Also, many countermeasures were put in place to overcome those issues with surprising results.
Some organizations adopted lean healthcare and continuous improvement as their everyday philosophy with a great deal of success, setting an example and paving the way for other healthcare organizations to follow or at least look critically at how they view quality and safety of care, and what they really need to change.

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The Case for Lean-2

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The Documentation Era:
This has a lot to do with miscommunication, but it deserves a category of its own due to its magnitude and the dysfunctional way it was built into daily clinical practices. Everyone knows how important eye contact when communicating, and we have been taught in Med School how important it’s to talk to your patient without putting barriers between you and them, not even a desk. Nowadays, doctors do exchange good and constant eye contact, but the computer screen, busy typing and clicking while asking the patient for very important and sensitive information, and the poor patient gets only the side profile of the doctor’s face. This shows how much respect there is nowadays between doctors on one side, and patients and their families on another side, and the tiny if any amount of trust and rapport being built. The first step of the healing process!
It’s commonly said that if something was not documented, it’s not done. The reason behind pushing vigorously   towards it by many is an attempt to make sure that necessary information are available and accessible anytime, for better continuum of care, safety, and for medico-legal purposes. It’s clear that healthcare systems have taken the wrong turn on this and lost the essence of the whole value of documentation, to the point that it has become one of the main reasons for broken systems and unsafe practices.
Studies have shown that the national average of nursing time spend at the bedside providing direct care to the patients in the US is less than 50%. Most of the time is spent doing things that adds no direct value to the patient, including documentation. If you have the chance to observe a nurse in an inpatient unit for an extended length of time (the time you are waiting for your doctor, maybe!), you could see the huge amount of time wasted, not in delivering medications, not in assessing patients, not discussing cases or responding to patient and family needs, but in handwriting, typing, punching and stapling, filing and shelving , and getting papers signed or stamped. Nurses who are supposed to be closer to patients more than any healthcare professional have turned into secretaries who are overwhelmed with a great deal of paper or computer work, and the only touch time with patients in one day can be as much as 30 minutes in total!
Documentation is necessary, but over, redundant, and disorganized documentation has become an issue that everyone complains of, and takes providers away from their most important job they signed up for. What went wrong?
One of the clear factors is the requirement of some regulatory and accrediting bodies requiring all sorts of information to be documented in a certain way or format, and in the absence of creative and versatile care systems, or well-educated and smart health informatics professionals,  providers have no choice but to comply in the exact way. If you had to choose, provide better care (not medicine) with less documentation, or complete documentation but less care and compassion, which one would you opt for?
Another major issue is in the design and management of popular information systems in the market, many of which are not co-developed with healthcare professionals, never looked at actual care process, and only focused on what the doctor or nurse need to document or view. Even after incorporating all the requirements on a nice looking system, it turns out to be unfriendly and hard to navigate. On the other side, IT professionals managing those systems in a healthcare organization have no clue about the impact of adding one module after another on the care process, and don’t really bother to rethink and integrate documentation requirements when they arise, causing inflation of data in an already broken system..

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The Case for Lean-1

During this year I had  unusual several encounters with a number of healthcare providers, sometimes as a patient, and others as a companion or caregiver, both in inpatient and ambulatory settings. This experience has lead me to personally reach a conclusion that  I’ve realized deeply: today’s healthcare is very dysfunctional and full of waste! This is not news for many of providers and consumers of healthcare, and definitely has been the case for decades, but perhaps the blessing (or curse in this care) of learning more about lean, system thinking, continuous improvement..etc, has made the picture so crystal clear and easy to spot, compared to the untrained eye.
The irony lies in that everyone claims they are providing the best quality, most compassionate and patient-centered. You could hardly find a healthcare facility without these as strategic goals, values, and slogans everywhere, while in the bitter fact, most of them are merely average. Another irony is that many for-profit organization assume they are making a lot of profit based on the financial reports, but if you look deeper, they are wasting as much money down the drain. Then we wonder why healthcare costs keep rising, and why quality and safety are not getting any better, at least in the patient’s eye.

Miscommunication:
No two people disagree that communication is one of the most important requirements of safe and good healthcare, and everyone preaches about that during meetings and conferences. So, we try to standardize it in a very restrictive manner, or  purchase high-end automated information systems. However, when it comes to real daily work, miscommunication is very common, and at many instances, highly risky.
One can easily notice the number of repeatedly asked questions by different healthcare professionals at any care setting, whether outpatient, inpatient or in between. It makes one wonder if there is any dialogue actually going on between receptionists and nurses, nurses and doctors, doctors and other doctors, you name it, and whether they really do work as a team like all the nice group photos posted on the walls or websites. This gap will eventually lead to waste in time, effort, and the cost of  sophisticated system, or at least paperwork, let alone patient dissatisfaction. Working in silos is an issue in healthcare that improvement experts talk about all the time, but is still very common and evident.
There are several factors that play part in this. The first in my opinion has nothing to do with the intentions or even the awareness of the providers about the importance of good communication, but with how the clinical care processes are designed in the first place. Most of the care planning is individualized, the information gathered about a patient condition are documented, sometimes overly, but not shared in real-time, and everyone know hot to navigate and fill fields on the computer, but not actually reads.  The other factor is more cultural.
The hierarchical relationship between healthcare professionals where the physician is still an authoritative figure that don’t communicate with others readily and openly, and by that I mean 2-way communication.  I’ve seen many cases where this disconnect lead to patient harm and sometimes death.

                                                                                                                          to be continued...