Headlines shout the message almost every day: The U.S. healthcare delivery system is unaffordable, inefficient, and sometimes downright dangerous. It is in need of true transformation. To do this, we must tap into the wisdom of those delivering care and equip them with the means to create a new system that works for both providers and patients.
Change is never easy, and U.S. healthcare is undergoing one of the most significant overhauls in its history. Patients must decide about multiple treatment options, which may soon be more accessible and affordable. Health professionals face new pressures for not only improving the quality and safety of care delivery, but also its efficiency. Likewise, those who pay for healthcare—employers, insurers, and the government—must reimagine how to organize, pay for, and provide care.
The expectation is that technology will address a number of healthcare delivery woes, among them improving efficiency and patient safety. This isn’t surprising, as technology has played a significant part in advancing medicine. However, sustainable healthcare transformation must come from changes in beliefs and behaviors.
Dr. Avedis Donabedian, considered by many to be the father of quality improvement in healthcare, gave us a model to use when tackling the task of improving care delivery. He suggests that we think about care in terms of structure, process, and outcomes, a framework that allows us to apply science to effect change. But this technique alone won’t yield sustainable change. As anyone who has led a change initiative knows, some individuals are ripe for change, and others resist all the way along. In between are the people waiting to see if the change will be a real improvement or simply a fad.
A fundamental part of healthcare’s current culture is tied to how we have isolated, encapsulated, and segregated the how, what, who, when, and where of patient care.
How do patients want to receive care?
There are difficult questions to ask about how we care for patients and how patients wish to receive their care. In some cases we have clinical evidence that supports changes in how we deliver care, but in other instances either there is no evidence base, or the changes are not clinical in nature. As we address healthcare reform, we must continue to gather evidence and rely on structure, process, and outcome.
During the past decade, the Lean Transformations Group has worked to apply both science and culture change to healthcare. Encouraging results have been achieved, such as driving infection rates to zero among participating hospitals. The group has helped healthcare organizations learn how to use the value-stream improvement method to create an adaptive, problem-solving culture, one that focuses on preventing fires rather than constantly fighting them.
The outcomes we are seeing, including the ones below, make us believe that we are on the right track:
- Reduced the average length of stay (LOS) in a large emergency department by 30 percent
- Reduced the number of patients who left without being seen (LWOBS) by 60 percent in the same hospital
- Increased (independently gathered) patient satisfaction scores by 73 percent
- Reduced operating-room changeover time, which increased the number of surgical procedures performed by 20 percent
- Reduced annual staff turnover by as much as 67 percent
Plan, do, check, act
Value stream improvement served as the basis for many of the Lean Transformations Group’s hospital improvement efforts. The method is based on lean thinking, which has been around for decades and has its origins in manufacturing in Japan. Lean thinking looks at the delivery of services or goods as a stream of activities in which, ideally, all participants along that stream are creating value that meets customer (e.g., patient) needs and minimizes activities that do not create or add value.
Value stream improvement is based on the plan-do-check-act (PDCA) cycle to address specific problems and improve performance. Healthcare professionals are already familiar with the PDCA method even though they may not recognize the terminology. PDCA underlies all clinical care provided to patients:
- Clinical care begins with assessment of the patient’s condition, leading to a diagnosis and plan of care (plan). The treatment plan is a hypothesis about what is wrong with the patient and what will make the person better.
- The next step is treatment for the diagnosed problem (do). Treatment is the process or action performed to see if the hypothesis is correct.
- Follow-up with the patient determines if the treatment is working (check). The patient’s improvement, or lack thereof as observed in follow-up, tells us whether the process succeeded or failed.
- Additional action (act) is taken as needed.
Just as PDCA in a clinical setting is applicable even though every patient is different, PDCA in an improvement setting is applicable even though every value stream is different. Changes are driven by conditions in the value stream, and improvements occur as teams:
- Make a detailed assessment of the current state and the need for change.
- Create a shared vision of the future state.
- Develop a plan to implement change through a series of actions.
- Implement change and measure the results.
- Take appropriate follow-up action.
Although some healthcare providers are new to lean and the concept of value streams, others have become aware of the methodology and its applicability to healthcare challenges. A patient’s journey through the healthcare system involves many value streams whose quality and efficiency in most organizations is insufficient. Improving patient journeys requires intervention at the value-stream level.
Working to improve healthcare value streams helps develop skills for a new way to work, manage, and lead. The effective leaders of transformational change in healthcare are tasked with sorting through the maze of problems within their function, unit, department, facility, or organization; establishing priorities; and focusing as a group on solving the right problems together. As they do this, they must also realize that anything they determine to be a “best practice” will be just one of many. There will be new best practices in the future as other problems are solved and improvements are made.
In addition, any best practice implemented from benchmarking other organizations might not automatically work for another organization. We must ask, “What does it take to make the process work in our culture?” Sometimes it won’t work no matter what adjustments we make.
In summary, we need to examine a best practice and apply it only when appropriate to the value stream, the specific problem that needs solving, and the organizational culture. Keep looking and keep thinking. By continuing the search for better practices and experimenting with how to apply them, we can transform healthcare into an industry of true continuous improvement.