In Pursuit of Preventive Medicine

December 2, 2011 by 1 Comment

By Matthew Kopetsky

During grad school, I benefitted from the mentorship of one of healthcare’s masters of change, David Gustafson.  During his more than 40 years as a professor in the University of Wisconsin’s Industrial and Systems Engineering Department, he has directed the NIATx, CHESS, been the principal investigator of the TECC project, chaired the department, and found time to mentor, in addition to myself, two of my relatives.  I remember, during one of Gustafson’s guest lectures in a change management course, his account of the inspiration for the Network for the Improvement of Addiction Treatment (NIATx).  Instead of reading about addiction, he actually posed as an addict and actively pursued recovery, eventually checking himself in to rehab for several weeks.  The broken processes and unsupportive rehabilitation environment that he observed shocked him enough that he has dedicated decades of his life to improving them.

A few months ago, I accidently had my own Gustafson-esque inspirational experience as a consumer of healthcare.  It had been several years since my last physical and, as a healthcare consultant, I began to feel hypocritical not maintaining my own personal long-term health plan.  My intentions were noble – pursuing preventive medicine – however, the experience left me wondering why, despite my good health, that I even bothered.

Finding a PCP

A family friend Physician suggested that I pursue a Primary Care Physician (PCP) in my area who is known for being “great with young, healthy males.”  Unfortunately, due to my travel schedule, I’m only available for appointments on Fridays and he only saw patients Monday through Thursday.  So, since the Physician practiced within the network of a large medical teaching facility, the receptionist suggested that I see a Resident.  My appointment was made for the following Friday and I assumed that the all-important “referral” had just taken place.

Getting to the Appointment

Since I hadn’t received driving directions after making my appointment, I arrived (early) at the address listed on all of the pre-appointment paperwork that I had received in the mail and already filled out.  After many blank stares from the business office personnel who had sent me snail mail, I finally obtained the Resident’s number and learned that he was at an office on the other side of town.

The Appointment

Two hours after my appointment was supposed to occur, I was in an exam room with a Resident (and my boss was wondering why I still wasn’t back from my appointment).  The Resident asked me why I was there and, after I explained my desire to get a physical so that I could have peace-of-mind for another several years, he was shocked that I would get a physical in perfectly good health.  In response to being asked what I would like him to do, I suggested several things which I thought to be normal male physical protocol.

The Bill

Several months later, while enjoying my healthy peace-of-mind, I received my hospital bill for the charges which my insurance company deemed Patient Responsibility (~$200).  Then, a couple weeks later, I received the entire Physician Bill because my insurance company had denied the entire Physician balance, deeming the visit out of network (~$400).  So, after an inconvenient visit to a Physician for preventive reasons, I was left with a $600 bill and the quality of my health was exactly the same.  Unfortunately, most consumers don’t understand their insurance plan’s detailed Explanation of Benefits (EOB) well enough to know when charges are denied in error (in defense of consumers, I have had to review EOBs professionally and they can be very confusing).  Since I knew the referral for my care was legitimately from the office of my PCP, I pursued an appeal of the denied Physician charges.  After several phone calls, I was informed that I could either fax or mail a formal appeal of the denial decision to my insurance company (no e-mail since the process needed to be as difficult as possible).  After the fax number that I was provided didn’t work, I sent an old-fashioned letter and hoped that (in 4-6 weeks) my appeal would be honored (and my credit score wouldn’t be affected by my delinquent Physician balance).  Fortunately, the insurance company approved my appeal and paid nearly the entire ~$400 Physician balance.

 

What would Gustafson do?

“…hopefully by the time my loved ones need complex critical care, I will have solved enough of the simple issues that their healthcare experience will be more positive.”

Unfortunately, the healthcare industry hasn’t evolved into the most user friendly experience.  Even when consumers try to be proactive about their care, it is at the very least an inconvenience.  However, in my non-urgent care experience, there are many simple things that could have been handled differently which would have left me with a more positive experience.  The biggest positive outcome from my experience was a revitalizing reminder of what inspired me to enter the healthcare field – hopefully by the time my loved ones need complex critical care, I will have solved enough of the simple issues that their healthcare experience will be more positive.

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What’s Your Improvement Mantra?

November 18, 2011 by Leave a comment

By Tom Best

Even if you’re not a football fan, you’ve probably heard phrases like these before:

  • Our team just needs to “get a win”, and we’ll turn this program around!
  • Let’s prepare for “one game at a time”, and in the long-run we’ll end up on top!

Successful coaches have used such phrases to make seemingly impossible goals feasible.  I’ve also found these two phrases helpful in guiding healthcare improvement efforts.

“Get a win”

While many projects require long-term effort to achieve sustained improvements, we sometimes undervalue the benefits of a short-term “win.”

I once worked with a hospital to increase the reliability of their med and lab specimen transportation system.  The bulk of items were transported via pneumatic tubes.  To the frustration of many, tubes were often unavailable.  Hoarding tubes at each care unit only seemed to make matters worse.  As a result, many had deemed this problem too difficult to fix. 

To start the project, our team decided that I set aside an afternoon to walk from unit to unit, releasing any stockpile of extra tubes back into the system (with help from unit management). 

As you might guess, I wasn’t too excited to build a reputation as the tube police.  But, you know what?  The effort served its purpose.  Although the improvements to tube availability were short-lived, a primary goal of our project became crystal clear to unit management after only one afternoon’s work. 

To sustain improvement, we implemented an annual education competency for all clinical staff on the proper usage of the tube system.  But the initial walkabout was just the “win” we needed to get improvement started.  It effectively communicated our long-term improvement goals, and demonstrated that we were going to address this problem directly.

“One game at a time”

Another project aimed to reduce the frequency of mislabeled lab specimens.  While the definition of a properly-labeled specimen was practically universal, each care unit had a different set of challenges impeding proper labeling.  It was next to impossible to recommend one solution for all units; previous efforts along these lines had not fixed the problems.

Our team decided that labeling procedures throughout the hospital should be addressed sequentially, group by group.  We first analyzed data to identify departments with a high percentage of mislabeled specimens.  We then started working with one department at a time.  We used a standard framework to guide our efforts (i.e. the SEIPS Model) but the details of the approach were dependent on the situational factors, such as the initial level of leadership engagement and the current state of the unit’s labeling process.  During these efforts, we shared our progress with the rest of the organization, highlighting the improvements that resulted in the areas we had visited.

There is a word of caution when applying the “one game at a time” mantra.  If misinterpreted, it can produce unsustainable improvements.  In our context, after moving to the next unit’s specimen labeling procedures, the team still needed to periodically circle-back with previously-visited units to ensure the problems were permanently fixed.  Revisiting an area can be done efficiently if standardized data collection and reporting mechanisms are in place.

In closing, “get a win” and “one game at a time” are just two mantras that apply across multiple industries. 

What other phrases guide your healthcare improvement work?

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The power of a question

November 10, 2011 by 1 Comment

By Todd Schneider

Often in improvement work, we rely on Lean tools, Six Sigma methodologies, classic Industrial Engineering methods, etc.   However, perhaps we often overlook one of the most valuable skills of a change agent – Asking questions. 

Most often, improvement professionals are not the subject matter experts in the clinical or operational area in which they are improving.  This provides the perfect excuse to ask questions.  Sure, some questions are part of other tools or methodologies.  Obviously we ask questions when we apply the 5 Whys.  And it’s common to ask “what happens next?” when constructing a flowchart.  But do we ask the questions of “what if” or “why not” enough?  When done correctly, the questions asked are not so much for your learning, but instead to stimulate the group’s creativity and awareness.

 Several years ago, I was working with an organization that had been awarded a grant from the Robert Wood Johnson Foundation.  As part of the grant, the organization was provided technical assistance from the Institute for Healthcare Improvement (IHI).  One of the project teams was working to improve the care of the Acute Myocardial Infarction (AMI) patients, which typically present to the ER with chest pain.  At that time, there were two main goals the team was working to achieve: 1) Obtain an EKG within 5 minutes of arrival, and 2) Go to the Cath Lab and open the vessel within 90 minutes of arrival (commonly referred to as “Door to Balloon”).  We were reviewing this project with staff from IHI during a site visit.  During the discussion, Don Berwick, then President/CEO of IHI, asked a simple, yet important question.   “If I told you that a chest pain patient would arrive to the ER at 5:00 p.m. today, would you be able to meet the goals for Door to EKG and Door to Balloon?”  Almost immediately the team leader responded, “Yes, of course.”  Berwick responded, “Then go do it.  Get ready.  And if the patient doesn’t come at 5:00, keep waiting.  We know the patient will come.”

 The team did just that.  They figured out how to get the process right for that next patient.  That conversation was a pivotal turning point for this project team.  It helped them focus on how they could do it right once, and then figure out how to do that every time for every patient.  This organization went on to become an early leader in the care of the cardiac patient and several years later still referred to that moment as an important stimulus for their work.  It didn’t change their overall goal or even their general focus.  But it did re-frame the project, which allowed the team to look at the project from a different perspective.

By all means, we need to continue to use all the tools we have available, but we must not forget about the power of asking questions.  The questions may be simple; they don’t need to be complex or technical.  However, the questions should stimulate new ideas and help the team see the potential for new solutions. 

 Speaking of questions, have you asked a few today?

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Field Note: Infection Prevention in Outpatient Settings

July 26, 2011 by Leave a comment

By Alina Hsu

The CDC recently published a new infection prevention guide and checklist specifically for health care providers in outpatient care settings such as endoscopy clinics, surgery centers, primary care offices, and pain management clinics.”

According to the CDC, more than three-quarters of all the operations in the United States are performed at outpatient facilities.  “Patients deserve the same basic levels of protection in a hospital or any other healthcare setting,” said Michael Bell, M.D., deputy director of CDC’s Division of Healthcare Quality Promotion.  “Failure to follow standard precautions … cannot be tolerated.”

The guidelines recommend specific procedures or practices in the following areas:  administrative, educational, HAI surveillance/reporting, hand hygiene, use of personal protective equipment, injection safety, environmental cleaning, sterilization of medical equipment, respiratory hygiene, and triage of potentially infectious patients.

In hospitals, implementation of infection control programs lags far behind our knowledge of best practices.  The missing element appears to be the sustained will or commitment of organizational leaders.   Certainly, if the commitment is there, Industrial Engineers and other process improvement professionals can help with the execution.

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