The headlines sing the message to the high heavens almost every day: our healthcare delivery system is unaffordable, inefficient, and sometimes downright dangerous. It is in need of true transformation. At the heart of transforming care we need to tap into the wisdom of those delivering care and equip them with the means to propagate the kind of change necessary to yield a new healthcare delivery system that works for the provider and the patient.
Change is never easy, and healthcare is undergoing the most significant change most of us have ever experienced. Patients have growing treatment options, and the tide of change in how healthcare is financed may well improve access and affordability. For those who provide care—physicians, nurses, and other health professionals—there are new pressures for not only improving the quality and safety of care delivery, but the efficiency as well. Likewise, those who lead healthcare organizations, those that pay for healthcare, employers, insurers, and the government all have to reimagine how to organize, pay for, and provide care.
Much hope is placed on the use of technology to address any number of woes in healthcare, from improving efficiency to patient safety. This is not surprising, as technology has been a significant part of advances in medicine. Though current and emerging technological breakthroughs may turn the tide in the transformation of healthcare, changes in beliefs and behaviors will be at the root of lasting transformation.
Dr. Avedis Donabedian, the father of quality improvement in healthcare, gave us a model to use when confronting how to improve care delivery. He suggested that we think about care in terms of structure, process, and outcomes. This framework allows us to apply science to make change. But applying science alone does not yield sustainable change.
Any of us leading change initiatives find some individuals ripe for change and laggards that fight us all the way. The majority between those two wait to see if what we’re proposing is a real improvement or simply a fad. Their inaction—fearing change or new ways or fearing the loss of what they know—is most often driven by behaviors and beliefs (culture).
A fundamental part of our current culture is tied to how we have isolated, encapsulated, and segregated the How, What, Who, When, and Where of patient care. Everyone is keenly aware of the silos and there are white papers and conversations and seminars about how best to break them down. One thing is sure: applying science alone will not overcome these barriers. It will take a combination of applying science and addressing culture in order to make truly sustainable change.
As we look ahead to the needed transformation of how we deliver healthcare, 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. Yet in other instances either there is not an evidence base or the changes are not clinical in nature. So while we set forth to change culture and enact change, we also must gather evidence and continue to rely on structure, process, and outcome.
Over the past decade, we at The Lean Transformations Group have applied both science and culture change to produce an environment that looks for prevention of harm and engages clinicians, administrators, and other members of the healthcare team. We have achieved encouraging results, such as driving infection rates to zero among participating hospitals. We have helped healthcare organizations learn how to make real and sustainable change using the value-stream improvement method and have helped healthcare providers develop an adaptive, problem-solving culture—one that focuses on preventing fires rather than constantly fighting them.
The outcomes we are seeing make us believe that we are on the right track, including:
- Reduced the average length of stay (LOS) in a large emergency department by 30%,
- Reduced the number of patients who left without being seen (LWOBS) by 60% in the same hospital,
- Increased independently gathered customer (patient) satisfaction scores by 73%,
- Reduced operating-room changeover time, which increased the number of surgical procedures performed by 20%,
- Reduced annual staff turnover by as much as 67%.
Plan, Do, Check, Act
Value-stream improvement (VSI) served as the basis for our many hospital improvement efforts. The method—value-stream improvement—is based on lean thinking, which has been around for decades and had its origins in manufacturing in Japan. Lean thinking has spread worldwide and throughout virtually every product and service business, including healthcare. 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 scientific method, which provides the foundation for many approaches to problem solving. Throughout this guide you will see this problem-solving method referred to in the form of the plan-do-check-act (PDCA) cycle, also known as plan-do-study-act or -adjust (PDSA). PDCA corresponds with VSI project phases and the actions that are taken to address specific problems and improve performance.
As a healthcare professional you are already familiar with the PDCA method even though you may not recognize the terminology. PDCA forms the basis for all clinical care provided to patients who come to you with some type of problem.
- Clinical care begins with assessment of the patient’s condition leading to a diagnosis and plan of care (grasp the situation and plan). The treatment plan is a hypothesis about what is wrong with the patient and what will make the patient better.
- The next step is treatment for the diagnosed problem (do). Treatment is the experiment 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 you whether the experiment 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 value-stream improvement steps occur as you and team:
- 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 experiments;
- Implement change and measure the results;
- Take appropriate follow-up action.
Many in healthcare are new to lean and this concept of “value streams.” Others have become keenly aware in the past five to 10 years of its applicability to the challenges that confront healthcare organizations and providers today. Patient journeys travel through many health-care value streams, and the quality and efficiency of these journeys in most organizations is insufficient. Improving patient journeys requires intervention at the value-stream level.
Examining and working to improve healthcare value streams addresses problems affecting your organization now, and it also develops the skill sets and mindsets for a new way to work, manage, and lead. The effective leaders of transformational change will be tasked with sorting through the maze of problems within your function, unit, department, facility, or organization; establishing priorities; and focusing as a group on solving the right problems together. And this exercise is undertaken by everyone involved: managers, staff, specialists, and doctors on the frontlines of healthcare.
And, the transformation is just beginning. Going forward will require identifying and selecting a problem in the performance of a specific value stream, defining a project scope, creating a shared understanding of what’s occurring in the value stream, developing a shared vision of an improved future, and working together to make that vision a reality. And anything you determine to be “best practice” should be qualified with the recognition that it is only “best practice” for now. There will be a new “best practice” in the future as you continue to solve problems and improve. In addition any “best practice” you borrow from elsewhere must be qualified with the knowledge that although this best practice worked for the organization where it originated, it may not automatically work in your own. You will need to ask, “What does it take to make it work in my culture?” and figure out how to apply it in the culture of your organization. Keep in mind that sometimes it won’t work in your setting no matter what adjustments you make. Sometimes that best practice solved a different problem than exists in your organization. In summary, you will need to look at best practices and apply them only when appropriate to your value stream and the specific problems that you need to address and to your organizational culture.
Keep looking and keep thinking. By continuing the search for better practices and experimenting in how to apply them to your problems, you will develop a culture of true continuous improvement.
Judy Worth and Tom Shuker are authors of Perfecting Patient Journeys, along with Beau Keyte, Karl Ohaus, Jim Luckman, David Verble, Kirl Paluska, and Todd Nickel. To learn more about the book and their work, please go to: http://www.lean-transform.com/.