Grand Challenges…Here we come!

What comes to your mind when we say “grand challenge”? People think about big issues such as ending world hunger and curing cancer.  These are certainly big problems that takes several thousand people working every minute for the betterment of the society. We all want to be part of these grand challenges, but either have limited capabilities or the time, given our day-to-day schedule. What if we use these grand challenges as learning opportunities? Perhaps this may allow us to make some incremental contributions and also learn at the same time.

This was the main idea when we started our conversations with the Mid-Ohio Food Bank regarding a “learning lab” for our MBOE students. Mid-Ohio Food Bank is one the largest food bank in the United States primarily catering to the 20 counties surrounding the Columbus region. They are an amazing organization with great talent yet have really complex challenges in serving the community. Think about this for a statistic:

“There are over 400,000 people in Franklin community who live under 200% of the poverty line and miss over 15% of their meals. In other words, over 400,000 people are going without food for an entire day each week.”

This is not because Mid-Ohio Food Bank or their agencies have a shortage of food. It is because as Mark Mollenkopf – Strategic Solutions Developer – so eloquently puts – “Our problem is to get the right food to the right people at the right place and the right time”  

This is a perfect learning opportunity for our incoming MBOE students to scope down this larger complex problem into manageable problems in distribution, access, population health, nutrition and consumer behaviors. Our incoming class of students will spend time at the Mid-Ohio Food bank understanding and solving this problem over 5 months beginning November 2019.  They will first learn to break the complexity down to workable “chunks”, where to make impactful changes, how to measure and sustain these changes over 4 different learning sessions. Our students won’t be able to eradicate human hunger in 5 months, but they can certainly make a difference and make substantive improvements in this given time.

Our MBOE and Fisher Management Science team are really excited to use this amazing learning opportunity and help our community along the way!

Come and see what we do in our MBOE program at: https://fisher.osu.edu/graduate/mboe

Skeptics – We have Proof that Operational Excellence Works in Healthcare!

I’ve written a number of times on the skepticism and lack of understanding surrounding operational excellence (Op-ex) deployments in healthcare. Under the op-ex umbrella, there are several change management initiatives such as lean, Six Sigma, Total Quality Management, etc. All of these emphasize the importance of a systemic approach toward the sustainable improvement of key performance metrics.

Although there are several books and research on the benefits from these initiatives in healthcare context, skeptics dismiss them as mostly anecdotal and devoid of the rigor necessary for causal inferences (i.e., the presence of op-ex leads to healthcare improvements). In this regard, the skeptics are right. Many existing inferences in this area come from surveys (i.e., asking healthcare leaders about op-ex and correlating results to performance) or are based on secondary data that may not adequately capture op-ex elements.

Recent research Peter Ward & I conducted with Dr. Susan Moffatt-Bruce and other collaborators at The Ohio State University Wexner Medical Center leaves little room for skepticism about the impact of op-ex deployment in healthcare. Our quasi-experimental investigation permitted us to compare care delivery performance before and after deployment, using a control group from the same setting to account for any variations in the system beyond our experiment. Results show that op-ex deployment reduced 30-day readmissions, decreased monthly operating costs, improved patient satisfaction and also improved the quality of work among caregivers. In short, it works.

The Quasi-Experiment

Our experimental intervention was conducted over a period of three years and used op-ex principles to change the way patients were discharged after a kidney transplant. We specifically looked at a fundamental op-ex element: Standard work during patient discharge. This represents the set of activities standardized in terms of content, sequence, timing and outcome but still able to “flex” based on patient characteristics. An important feature of standard work is that it should be designed and developed by people doing the work and continuously monitored for improvement. In our study, more than 40 nurses, physicians, social workers, IT specialists and nurse managers responsible for discharging the patients designed and developed the new standard work over a nine-month period.

We focused on the kidney transplant discharge process because these recipients require prolonged periods of care after discharge. In fact, one in three U.S. kidney transplant patients  is readmitted within 30 days, resulting in higher hospitalization costs, resource utilization (i.e. longer wait times for other wait-listed recipients), and – more importantly – poor quality of life for the patient post-procedure. When looking closely at the discharge process, we found patients were taking in an overwhelming amount of information in the four days prior to discharge. In this short period, caregivers covered more than 45 topics, including medication, infection prevention, lab compliance, fluid intake, exercise, and dental hygiene, among many others. Some of these instructions – dental hygiene, for one – were not critical to patients’ immediate well-being and could have been given post-discharge. Nurses, we found, also varied their delivery of instructions, adding to confusion and anxiety. Figure 1 represents the current state of discharge process prior to our intervention. As seen from this figure, variability during the discharge process confused the patients and heightened anxiety levels after discharge, triggering readmissions.

Figure 1

 

The new standardized discharge work sought to resolve these inconsistencies. The caregiving team developed specific instructions on the content, sequence, timing, and delivery outcome for each element of discharge, drawing from data on 15 former transplant patients. The team also decided to adopt a two-part instructional approach, with inpatient nurses giving the most essential discharge instructions during the hospital stay (Part I Instructions), while outpatient nurses gave other instructions (Part II Instructions) 48 hours after discharge. This resulted in a formal handoff process between the inpatient and outpatient caregiving teams. After implementing this new process, the team also adopted 10-minute “huddles,” or standing meetings, to continuously monitor and improve communication at inpatient (bi-weekly) and outpatient (weekly) units by focusing on problem solving and best practice-sharing. These huddles have been going on for more than a year, with full participation from the caregiving teams. The entire op-ex implementation, launched in May 2015, took about a year. Figure 2 represents the process after the op-ex implementation.

Figure 2

To validate the benefits of the Op-Ex implementation, we tracked the discharge process outcomes for more than 700 kidney transplant patients for four years (two years prior to, and one year after, implementation). To ensure our data weren’t skewed by factors such as discharge procedure changes or electronic medical record implementation, we collected patient discharge process data from 180 heart and liver transplants, using them as a control group. Patients undergoing heart and liver transplants experience similar outpatient issues as kidney transplant recipients and have very similar discharge instructions (as seen in Figure 1). We also controlled for patient factors such as age, preexisting conditions, length of stay, functioning of transplanted organ at the time of discharge, ethnicity, 30-day mortality rates, etc. In addition, we adjusted for any other changes to the process that were not a part of our experiment (e.g. adding new technologies)

After accounting for all these effects, we used a difference-in-difference (DID) approach to estimate the causal effects of our implementation on readmission outcomes. Our analyses suggest that the likelihood of getting readmitted to the hospital was about 35% lower for the treatment group (kidney transplant process after Op-Ex implementation) compared to the control group and pre-implementation group (See Figure 3).  On average, this accounted to a 25% reduction in the overall readmission rates after the intervention for the treatment group, resulting in a conservative savings estimate of $85,000 due to hospitalization expenses for the unit. This doesn’t capture savings from the overall patient well- being after the surgery.

We also found a 10% increase in the overall patient experience quality score, measured using the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. Interestingly, the control group unit experienced an 11% decline in these scores during the same time period (see Figure 4). Improving the scores from this survey has been a key objective for hospital administrators as Medicare/Medicaid reimbursements are now tied to them.

 

Figure 3

Figure 4

Our study shows that Op-Ex transformation indeed can result in improvement across multiple outcomes. The real challenge is how to initiate and sustain this journey. All these results were possible due to the hard work of all the front-line nurses in this unit. They truly are the miracle workers who continue to sustain this journey and innovate as they move along.

 

Five Star Treatment – Moving the Needle on Patient Safety and Experience

Moving the needle

Whether they like it or not, hospitals today can’t solely measure success by properly treating patients according to established standards of care. Moving a patient through surgery to recovery with no complications or hospital-borne bugs, for example, is only part of the equation in the eyes of the government agencies holding the purse strings for critical Medicare and Medicaid reimbursement dollars. Now, patience experience also matters – and hospitals must wrangle with age-old cultural tensions to avoid getting hit where it hurts.

To avoid penalties and bring in maximum federal reimbursement funds, hospitals since 2013 have had to show high marks in evidence-based standards of clinical care and the Hospital Consumer of Healthcare Providers and Systems, or HCAHPS, survey. This survey measures patients’ experience, driven largely by how they grade their interaction with physicians and nurses. Pressure is mounting, as reimbursement penalties are set to potentially double next year if hospitals don’t show improvement on clinical care and patient experience under terms of Obamacare, the Patient Protection and Affordable Care Act passed in 2010. In addition to these penalties, we also find that improving both these dimensions can actually reduce the occurrence of 30-day readmission rates1.

Physicians greet this newfound emphasis on patient experience with skepticism at best and outright resentment at worse, largely due to the subjective nature of the HCAHPS survey. This, however, perfectly illustrates the challenge therein: It’s difficult to simultaneously improve these two measures in a notoriously hierarchical culture where doctors focus relentlessly on disease and nurses fear challenging them, even while carrying the torch as the patient advocate. Luckily, it’s possible, and our forthcoming research2 points to key measures that can drive the culture change needed to make it happen.

Magnet

The Magnet matters

These findings come five distinct case studies that involve more than 50 interviews we conducted at five large acute-care hospitals. This was paired with data drawn from more than 3,000 hospitals from 2006-12, before and after Obamacare kicked in. Strikingly obvious is the sheer difficulty of improving clinical care and patient experience without trade-offs (also evidenced in a different study3 conducted in 2012). Clinical care is comparably easier to operationalize and roll out through top-down directives: keep quality consistent, keep patients safe, and keep variation during care delivery minimal. The problem? These directives can make little room for the customized patient care in nurses’ hands. At the same time, providing a patient with a Ritz Carlton-quality experience means nothing if it interferes with doctors working to keep them alive and well.

A winning strategy a number of hospitals are beginning to adopt, we found, starts with clinching “Magnet” hospital status through the American Nurses Credentialing Center (ANCC). Its Magnet Recognition Program® is the stamp of a high-quality program, denoting they are involved in decision making from the highest strategic levels to the patient’s bedside. The presence of this “bottom-up” decision making, we found, is a crucial factor in hospitals’ ability to improve on “hard,” evidence-based patient care and the “soft” patient experience side. In fact, we found hospitals with ANCC Magnet status were 24 percent more likely than their peers to show improvement in both of these measures, according to federal data from the Centers for Medicare and Medicaid (CMS).

Flattening this hierarchy doesn’t mean the end of administrative oversight, but it does require a newly measured approach to it. What emerged in our research was a “sweet spot” of administrative duties for nurses. Hospitals whose nurses average more than 25 percent of their shifts completing checklists and managing electronical medical records instead of patient are more likely to show weaker trends in improving on both dimensions. But so are hospitals whose nurses spend scarcely more than 10 percent of their time on the same tasks. Administrative oversight and an empowering culture for nurses can peacefully exist, but only if both are carefully balanced.

Playing matchmaker

To maintain the culture needed to treat patients and treat them well, providers can learn much from the physician-nurse interaction in the five hospitals we closely studied. Collaboration between doctors and nurses at the same rung on the ladder – Chief Nursing Officers and Chief Medical Officers or Medical Director – Nursing Director – is a longstanding best practice, but it’s not enough. In another forthcoming research4 on collaboration, we found that the best hospitals took this a step further, routinely pairing experienced, high-level nursing staff with low-level doctors, aiming to instill the importance of patient experience early in their careers. The reverse happens, too: One hospital, for example, paired a chief medical officer with an entry-level nurse and noted success in breaking down the hierarchy that can prevent nurses from speaking up. Taken together, these cross-level collaborations can drive major gains in the improving both the clinical and patient experience measures that matter most.

These crucial collaborations can take many forms. Hospitals we studied reported placing nursing leaders on physician-hiring committees or sending medical directors to work with nurses on day-to-day tasks. One even borrowed from iconic General Electric CEO Jack Welch, issuing a “get on board or get out” policy for its new collaborative culture. These surely move the needle, but they’re also formal measures that “force” physician-nurse interactions. The most successful hospitals see these collaborations form and grow organically, whether it’s nurses inviting physicians to their meetings or informal touch-base discussions in hallways. These connections might not be in the service of scratching another item off a checklist, but their impact can be just as powerful.

 

Articles

  1. C. Senot, A. Chandrasekaran, P. Ward, A. Tucker, and S. Moffat-Bruce, “The Impact of Combining Conformance Quality and Experiential Quality on Readmissions and Cost Performance,” Management Science (2016).
  2. Senot, C., Chandrasekaran, A., Ward, P. 2016. “Role of Bottom-Up Decision Process in Improving the Quality of Health Care Delivery: A Contingency Perspective“. Forthcoming at Production and Operations Management
  3. A. Chandrasekaran, C. Senot, K. Boyer, “Process Management Impact on Clinical and Experiential Quality: Managing Tensions Between Safe and Patient-Centered Healthcare,” Manufacturing and Service Operations Management 14, no. 4 (2012): 548-566.
  4. C. Senot, A. Chandrasekaran, P. Ward. 2016. Collaboration between Service Professionals during the Delivery of Health Care: Evidence from a Multiple- Case Study in U.S. HospitalsForthcoming in Journal of Operations Management.