Right Care - Right Patient, Not Just About Improved Clinical Outcomes

Nearly everyone in the field of health care by now has read or seen a reference of the report "To Err is Human", which in 1999 brought to light the high amount of medical errors that lead to death in this country.  Stemming from that was an onslaught of quality improvement initiatives, root cause analyses, and overall shift in how we as a society went about providing health care.  That study is probably the main reason the four of us blog contributors got to where we are today, trying to continue improving our health care system from as many facets as possible.

Providing the right care to the right patient, which seems simple enough at a high level, was not being followed on a patient level and it was costing United States health care facilities millions in malpractice suits and worse costing lives. Over a decade later, right care to the right patient is still something health care facilities may struggle with or even worse may not even realize an error is happening.  My first official project as an Operations Improvement Specialist was at a small town hospital in southern Wisconsin that was experiencing decreasing patient volumes and was struggling to meet the budget set last fall.  Having only one inpatient unit spread on two floors, with roughly 30 inpatient beds total, improvement options from the outset appeared minimal.  The goal of the project was to cut cost of operations in any way possible in order to secure the viability of the hospital in the future.

Patient satisfaction and clinical outcomes were never an issue at this location, but they were important to the project in that any recommendations made would need to ensure those high marks still were met.  However, being in a rural area, patient volumes were a real problem and a cause of poor labor efficiency.  To help minimize the effects of high staffing, patients were in many cases allowed to be roomed on the intensive care unit to give them the patient volume they needed.  After examining the acuity of these patients that were housed on the ICU, it was very apparent this was a case of over treatment, and it was costing the hospital double what was needed in wages alone.  Couple the wage discrepancy with nurse to patient ratios being much higher in the ICU and the total cost was nearly $250,000 to the organization.  The care being given in this case was not worse in terms of nursing care, but from an operations standpoint the cost to provide this service outweighed the benefits.

Since our look at the hospital, a move has been made to absorb the excess capacity that was treated in the ICU on the med/surg floor.  In order to accomplish this other initiatives were needed to reduce their patient volumes such as discharging patients earlier in the day and holding their observation patients in a different location.  Work is being done to better understand the data through our electronic medical record and provide weekly data updates to track progress on discharging earlier and better patient assignments.  The goal is by budgeting process of 2013 to accurately forecast volumes with changes in place.

To Err is Human

Case Against Benchmarking an Organization Nationally

A major part of the work being done, for the health care system I work in, to improve operationally relies heavily on benchmarking.  I am not going to try and explain the detailed process but it definitely consumes a lot of the time I spend at work in some fashion.  Dating back a decade or so, the organization decided that in order to compete with other hospitals across the country it would be necessary to compare operating statistics, focusing primarily on productivity.  The goal was simple enough:  improve your productivity numbers and your costs would decrease.  Productivity in this case referred to worked hours per unit of service, which was a ratio that determined in essence the amount of work that was paid for to complete a volume of service that represented roughly 80% of the value added work they did. For example on nursing units the service is patient days.

This system has been in place for at least a better part of the last decade and has evolved over time to accommodate more departments and different services.  However, as health care is changing at an ever rapid pace, is benchmarking to a national database the best way to continually improve an organization to keep up with the changing landscape?  I will go on record as to say it is not the best practice and improvements can be made without comparing nationally.  There are several issues that I would like to address.

Issue Number 1.  Substantial Time Involved in Creating Benchmarks.
  -  Without going into details into what benchmarking entails where I work, it involves substantial man hours to update and maintain the benchmarks.  It at a high level requires obtaining data, submitting it, finding the appropriate compare groups in the database, and then setting targets for hundreds of hospital departments.  The targets are then used to drive improvement, however the sheer volume of time for the task of creating and maintaining these benchmarks puts limits on the time that can be spent actually improving a department.

Human Computer Interaction

I am currently taking a course titled Human Computer Interaction. It is a very interesting class and it brings up a lot of useful discussion.  The following is a quote from Wickens highlighted in the course book titled "Display and Interface Design: Subtle Science, Exact Art" by Kevin M. Bennett and John M. Flach:

"Many aspects of decision making are not as accurate as they could be. The limitations of information processing and memory, previously discussed, restrict the accuracy of diagnosis and choice. In addition, limits of attention and cognitive resources lead people to adopt decision-making heuristics, or "mental shortcuts," which produce decisions that are often adequate but not usually as precise as they could be ... Finally, we will sometimes refer to general biases in the decision-making process. These biases are either described as risky -- leading to a course of action based on insufficient information -- or conservative -- leading to the use of less information or less confidence in a decision than is warranted."

Just some food for thought.. I felt the quote contained some concepts that should be more heavily considered  in the design of both Electronic Health Records and Clinical Decision Support tools. The project I will be working on for this class will be a prototype of a 'Diabetes Provider Decision Support' tool. We will be using the concepts discussed in the class to create our version of the ideal interface design to aid providers in understanding their patients' diabetes risk in a simple, easy-to-interpret display. Stay tuned for updates from class and/or the finished product of the project.

Article: "Can Hospital Chains Improve the Medical Industry?"

I was recently able to go visit my good friend who moved to New York City in June.  As we walked by one of the many newsstands on the streets I noticed a cover story featured on The New Yorker, ‘Health care’s new recipe: Chain restaurants have long delivered good, cheap, standardized service to millions. Why can’t hospitals do the same? Atul Gawande on a coming revolution in medicine.’ Undoubtedly I was drawn to purchase it, so I followed my natural instinct and did. I will brief over a couple major points I found interesting throughout the article.

In the article, Gawande studies operations at the Cheesecake Factory. He does so by working with Dave Luz, the regional manager for eight Cheesecake Factories in the Boston area. Throughout his observations he learned the Cheesecake Factory was able to work out an optimal staff-to-customer ratio and solve the problem of wasted food. They have managed to do so by producing a field of computer analytics known as “guest forecasting”.  By looking at past trends pulled from historical data they can forecast what to expect; the result is the ability to order the correct amount of food from suppliers and staff an accurate amount of employees.  We then ask the question, can this be done in Healthcare? Can we forecast what types of patients to expect? How much supplies will be needed? It is clear that the complexity of preparing food does not go hand-in-hand with diagnosing a patient, however there has to be a level to which forecasting can (and hopefully will) be achieved in health care.

Gawande also offers insight to a personal experience of his own where his mother received a knee replacement surgery. Prior to choosing a particular place where his mother would do the surgery, he did some research.  The man for the job turned out to be a surgeon named Jon Wright. A quote stated in the article by Wright was “Customization should be five percent, not ninety-five percent, of what we do.” Wright actually made this a reality by standardizing the way in which knee replacements would be done where he practiced.  Gawande’s mother had a successful surgery and better than anticipated recovery as a result. Other overall outcomes of this standardization included (as quoted by the article):

·          Distance patients could walk two days after surgery increased from fifty-three to eighty-five feet

·          Nine out of ten patients could stand, walk, and climb at least a few stairs independently before discharge

·          The amount of narcotic pain medications required fell by a third

·          Patients could leave the hospital nearly a full day earlier on average (saving some two thousand dollars per patient) 

It is evident that the standardization of this surgery was successful, however it is mentioned in the article that not all were exactly friendly about what Wright was trying to do. The role that he took on was not an easy one. It is human nature to do things in a way that one sees fit and it is also human nature to be liked by others. A major challenge being faced now and in the future will be to find the people that are willing to be advocates such as John Wright. To take on such a role one must be able to see the bigger picture and the benefits that such changes can bring as highlighted above.           

It is promising to see the visibility of such articles in major publications, public knowledge and awareness of what is currently being faced in the health care industry is definitely needed. The link to this article is provided below, I highly recommend reading it.

Gawande, A. (August 13 & 20, 2012). Annals of Health Care. Big Med. The New Yorker. Retrieved from: http://www.newyorker.com/reporting/2012/08/13/120813fa_fact_gawande?currentPage=all

Cost of Technology

My primary care physician shared this wonderful drawing with me recently.  It shows a girl visiting the doctors office, she is on an examination table surrounded by her happy family.

Aside from the wonderful colours the most striking aspect of the drawing is how the physician is depicted - he is hunched over a computer facing away from the smiling family.  Now I know that this isn't the case for all clinicians using EHRs - but it does remind us there can be unintended costs to their adoption.  

These costs can often be avoided by diligently analyzing clinical needs.  Rooms layouts should be tailored to facilitate discussion between the family and the physician often using the EHR as a discussion tool.  Similarly the task of documenting visits in the EHR should be optimized so as to be as un-intrusive as possible.

Welcome to Healthie

Howdy folks, and welcome to healthie. Healthie is a blog about industrial engineers improving the field of health care.

We plan to use this site to share what we're learned and discuss mistakes we've made as we work to improve the nations health care systems. We'll also likely discuss some industrial engineering techniques, share links that are interesting to us, and talk about pertinent literature.

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Stay tuned.