Cross-industry perspective touted as care solution
It beats 'best practice,' consultants say
Hospitals and other health care providers could benefit greatly from incorporating the concepts and strategies prevalent in other industries, say two senior consultants with the Dallas-based Thomas Group, and they're not just talking about Six Sigma and Lean manufacturing.
While those manufacturing techniques are certainly useful — and have become health care buzz words — something else is needed, adds Gary Morrison, the consulting firm's senior vice president for health care and former executive vice president and chief operating officer at the 1,000-bed Parkland Health and Hospital System in Dallas.
"If you look at the agendas of most health care conferences, you see Lean and Six Sigma," he points out. "[Those concepts] are interesting, but it's kind of like talking about total quality management 15 years ago. It's not a singular solution to the complex issues facing health care."
Hospitals can also learn a great deal from, for example, credit card companies, Morrison says. "They process an extraordinary amount of information and they have to get it accurate to appropriately charge you. There is a lot of learning that can happen if you look at retail."
The difference is that in health care, at least in the emergency department, you're required to provide care regardless of ability to pay or whether the person is known to you, he adds. "But most care is not [urgent]. There are procedures that can be captured from other industries in terms of data accuracy and identification of the person.
"How many times are you asked for a [photo ID] when outside your normal shopping area, and how many hospitals require a photo ID to verify a Medicaid card? [Hospitals] don't require the same documents that are required in a retail setting."
Compare a hospital to the U.S. Navy — with which the Thomas Group has worked — and its training of naval aviators, suggests Eric Labe, senior vice president for the consulting firm.
The crew on a naval aircraft carrier is made up of young men and women whose average length of duty is 18 months, he says, and they're handling more takeoffs and landings than the San Francisco airport. Complicating the situation is a landing strip that can pitch at a 30-degree angle, Labe says, and yet time after time the process takes place without a problem.
"I just read a Massachusetts Institute of Technology study, based on data from 1990 to the present, which shows that an airline passenger stands a one in 8 million chance of dying in a crash," he adds. "That means [the odds are] you'd have to fly every day for 21,000 years before a plane you're in goes down. Compare that to the health care system and ask why it is not at the same level."
"If we required physicians to go through the same level of training that we require of airline pilots," notes Morrison, "what would happen to the [hospital] error rate?"
One of the factors working against process improvement in health care is the insular nature of the industry, he contends. For that reason, Morrison says, "what other industries bring to us is limited. I would suggest that this insular position is an excuse not to change behavior, and because [health care] doesn't understand outside industries."
Instead of discussing best practices in an industry with huge problems, he notes, "we bring in people from other industries who are not encumbered with, 'I've seen this 15 times at other hospitals and it worked pretty well.'"
"Instead of driving new 'best practice,'" he says, "we take the cross-industry perspective."
Identify 'cultural barriers'
Looking at, for example, the length of time it takes to get a patient through the various phases of an emergency department visit, Labe adds, "We might say, 'What's keeping this from happening in half the time?' Then we get the participants to give all the reasons it can't be done."
What happens, he says, is that cultural barriers begin to be identified: "It's always taken this long," or "It can't be reduced by that much, but maybe we can shave one hour."
If there is a lag in the process because of something the laboratory has to provide, Labe says, one might pose the question, "What if we can get a lab result in a shorter time?"
Using a term from the manufacturing industry, he suggests doing a "hot lot."
"If I took a patient as he entered the door, walked him through from stage to stage, and made every resource available, how long would it take? Probably 10% or 20% of the time it takes currently."
If it takes one hour to do a hot lot, Labe says, experience has shown that a realistic goal for ED throughput is probably one-and-a-half to two times that. "Work backward from that and say, 'What is stopping me from doing that?' Some barriers are real and some are perceived."
Another example of a cultural barrier to change, Morrison says, is a comment health care executives frequently hear from physicians: "If you change that, patients will die."
"Ninety percent of the time it's not accurate, but the executive is not a physician," he says, and so isn't prepared to challenge the statement. "We really need to get providers in rooms and see where these cultural barriers to change are."
Tending the IT 'web'
Computer systems chosen for front-end processes are another source of inefficiency, he points out. "How often does a patient have to give demographic information when receiving care in an integrated system that isn't really integrated?"
There are many examples of disparate software, Morrison says, because most hospitals follow the philosophy that "'best of breed' is the way they should go, rather than 'best for the whole.' The lab buys its own system, the pharmacy has its own system, and they're all by different manufacturers."
As a result, the information technology department spends a lot of time playing "web master," he adds, making a reference not to the Internet, but to "a spider web, where [technicians] are constantly repairing the connections."
"We treat packages that we ship better than patients in the health care system," Labe says. "What can we learn from FedEx and UPS and apply back to the hospital? All their systems speak to each other."
The first step to a solution, Morrison says, is to suggest that the whole is more important than the sum of the parts. "Everybody wants the best widget they've seen. Using a car analogy — which is actually quite material to the hospital IT issue — the best thing is to make the vehicle function well, with everything in tandem, not to have the best engine."
At most hospitals, he says, the needs of the inpatient department drive the software choice. When he was at Parkland, however, and a decision was being made on a number of platforms, Morrison recalls, "we said that the software selection would not sub-optimize another department or another function."
"People have to sit back and say, for example, that the best registration system for ambulatory services may not be the best for inpatient," he says. "Parkland had 45,000 admissions a year and 1 million outpatient encounters. Which has the greatest accuracy need?"
One response to that question is that there may be more outpatient encounters, but there is much less revenue per encounter than with inpatient admissions, Morrison acknowledges. "So oftentimes the revenue capture issue drives it, rather than whether [the system] is convenient, accurate, or better for the patient. At Parkland, we chose a balanced approach that we felt addressed both sides.
"The point is, look in the marketplace for the best you can do for the whole, rather than the best you can do for each individual function in the whole," he notes.
Solutions across the health care spectrum, Morrison continues, need to lie in optimizing the whole enterprise, as opposed to individual silos.
Going back to the earlier example, Labe adds, things might be running efficiently within the walls of the ED, but the problem is that it doesn't run independently of the rest of the organization.
"I have a friend on the senior faculty of a medical school who says that a medical school is basically a fiefdom of academic departments tied together by air conditioning, hallways, and parking," says Morrison. "That description also applies pretty well to many hospitals."
(Editor's note: Gary Morrison, who is based at the Dallas headquarters of the Thomas Group, can be reached at [email protected]. Eric Labe, who works out of the firm's Detroit office, can be reached at [email protected].)
Hospitals and other health care providers could benefit greatly from incorporating the concepts and strategies prevalent in other industries, ...You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content