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

In Hospitals, a trade-off between patient safety and patient experience

Balance

Hospitals that adopt strategies to reduce errors and meet government requirements face an initial tradeoff between improved patient safety and a decline in the quality of individual patients’ experiences, according to new research.  Quality process management, a practice associated with the private sector, is becoming more common in hospitals as they set up operating systems in response to federal and state mandates to reduce medical errors and improve patient safety, the researchers say. It is not surprising to find that the implementation of these techniques led to improved safety outcomes. But finding that these improvements sometimes came at the expense of the quality of the patient experience was unexpected. Also referred to as experiential quality, the quality of the patient experience is gauged by how patients perceive their personal interactions with health-care providers.  “Patient Safety is about doing things correctly – strict guidelines, standardization and checklists, for example – so when you consider experiential quality is about customizing health-care delivery to an individual patient’s needs, there is a tension there,” said Aravind Chandrasekaran, associate professor of management sciences at Ohio State and lead author of the study.

“When leaders were more patient-centric, our analysis showed that they were able to overcome that tension between patient safety and the quality of the patient experience,” Chandrasekaran said. “Leaders have to be thinking about patients when they design their operations. That way they can cater many of their design principles to individual patients.”

How might this tension play out? Consider a patient  safety guideline of giving a beta blocker prescription for patients who have had a heart attack, but offer no suggestions for how to effectively relay that information to a patient. So the hospital gets a good mark for prescribing the drug, but a patient may not understand the instructions and possibly won’t even fill the prescription.

Chandrasekaran and colleagues assert that setting up standardized quality management systems is the most effective way for hospitals to meet state and federal mandates geared toward patient safety. Quality process management entails a systematic approach to map, improve and adhere to given sets of guidelines with a goal to minimize an organization’s variation in its processes.  Federal and state regulations in health care have become more stringent since 1999, when the Institute of Medicine released a milestone report stating that almost 100,000 people died every year as a result of preventable medical errors in U.S. hospitals.

In a move toward standardization, the U.S. Centers for Medicare and Medicaid Services (CMS) in 2003 issued hospital care guidelines related to four health conditions: heart attack, heart failure, pneumonia and surgical care. CMS requires hospitals to report their care practices with these types of cases, and has provided financial incentives to hospitals that are best at adhering to the standards of care outlined in these guidelines. In addition, many states have passed patient-safety legislation calling for reductions in hospital-acquired infections, also beginning in 2003. In the study, the researchers used this legislation as an example of state leadership focused on improving patient safety.

These regulations have led many hospitals to adopt quality process management practices to improve their safety outcomes as quickly as possible. But the researchers also wanted to examine what happened to the patient experience as hospitals focused on new techniques to improve their clinical quality. To determine these relationships, they analyzed four sources of data: a survey of 284 acute care hospitals in 44 states; CMS patient safety scores publicly reported between April 2009 and March 2010; state legislative mandates for reduced hospital-acquired infections passed between 2003 and 2008 in a portion of those 44 surveyed states; and April 2009-March 2010 reports from the Hospital Consumer Assessment of Healthcare Providers and Systems survey as a measure of patient experience quality. Directors of quality or chief nursing officers at 284 hospitals in 44 states were surveyed to determine how extensively respondents were using a data-driven, quality management system to design operations and train staff with the goal of adhering to CMS guidelines. Additional questions examined the leadership style and culture of each hospital.

The analysis showed that a focus on quality process management was simultaneously associated with an increase in patient safety as reported by hospitals and a decrease in the quality of the patient experience as reported by patients. State legislative mandates to improve patient safety initially reinforced this tradeoff. However, the earlier these laws were passed, the sooner hospital environments adjusted to operational changes so they could improve the patient experience as well.  When analyzing the  survey data about hospital leaders’ traits, we found that patient-focused leadership could soften the negative association between quality process management and experiential quality, allowing hospitals to excel in both areas.

Hospitals also commonly survey patients after their stays to gauge their satisfaction with their care. These surveys collect information about patients’ overall impression of their care and whether they would return to the hospital or recommend its services to friends and family. This suggests that patients are able to understand and appreciate the standardization in hospitals if they experience better levels of communication during their care. In other words, treating patients well enables them to better perceive when they are getting the ‘correct’ clinical care.

Do we understand Lean Deployment in Healthcare?

Patient Safety                                             Lean

Anyone who has taught lean principles grounded in the famous Toyota Production System (TPS) to organizations outside the manufacturing industry has – at least once – heard this common refrain: “(Insert industry here) isn’t cars on an assembly line. This doesn’t apply to my work.”

Leading lean thinkers, of course, have learned how to work with individuals and teams to move past this roadblock and garner buy-in – that’s why the practices and tools intrinsic to TPS have made their way into countless industries. Lean still can be a target for criticism, though, and one need look no further for proof than an article published earlier this year in the New England Journal of Medicine – and the debate it ignited.

The January issue of NEJM featured an article called “Medical Taylorism” where authors and physicians Pamela Hartzband and Jerome Groopman assert that lean principles “cannot be applied to many vital aspects of medicine. If patients were cars, we would all be used cars of different years and models …” This tipped off a flurry of rebuttals, including one from Lean Enterprise Institute CEO John Shook boldly titled “Malpractice in the New England Journal of Medicine.” In his piece, which itself attracted widespread attention, Shook writes that the foundational lean principles of continuous improvement and respect for people are critically important in the health-care system.

Shook is right, but I’d like to approach this discussion from a different angle, namely that this line of criticism has emerged elsewhere – and it’s rooted in a lack of understanding of lean deployment.

One of my initial research areas sought to understand how standardization and “smart application” of Design for Six Sigma (DFSS) principles can aid R&D and innovation efforts. I pursued this as a number of business press publications and industry practitioner blogs lamented the damage Six Sigma does to creativity and praised the need for variation for innovation. Several years of research1,2 at Fortune 500 companies with my colleagues in Fortune 500 companies made us realize such sentiments don’t hold much water. We found ambidex, in fact, that principles of Six Sigma/DFSS – when applied to the innovation process correctly (hence the “smart” in “smart application’) – can help reduce unnecessary variation and stop worthless innovation activities that consume R&D funding (shift).

I’ve more recently collaborated with researchers and physicians to tackle similar questions in health care. Once again, the findings – published in several academic and practitioner outlets – are very similar: The smart application of lean and continuous improvement principles can help develop a safe and patient-centric healthcare system.

In arguing that patients aren’t cars, the NEJM’s authors are absolutely right – but they’re dead-wrong in concluding there’s no place for lean in “many vital aspects of medicine.” As with our R&D research, we’ve found that lean deployment in hospital settings minimizes unnecessary variation that comes from care providers, not patients. In fact, it frees up time and effort to cater to the necessary variability in a population diverse in its illnesses, economic backgrounds, languages and more.

 

Huddle2

As an example, in a recent study, my fellow researchers that include physician leaders and I spent years looking at Ohio State University’s Wexner Medical Center, specifically a lean deployment effort in its kidney transplant discharge process (see right picture). Transplant recipients after discharge must drink at least three liters of fluid a day – failure to do so can spike creatine levels, elevating blood pressure and increasing the likelihood of readmission. This is an evidenced based fact well-grounded in the medical literature7. During our roundings, we found variations in how these instructions were delivered to the patients: One nurse, for example, nonspecifically recommended drinking “a lot of fluids” while another suggested 100 ounces. Interestingly, we found nurses varying instructions between patients and patients who received different instructions from more than one nurse. These nurses weren’t being intentionally deceptive but their inconsistencies confused patients as they took in a tremendous overload of instructions.

Overhauled through the lean deployment via standard work design, nurses in our medical center now clearly explain the specific volume of fluid, use a jug to visually illustrate, and discuss the consequences of not following the instructions. Preliminary findings show this approach soothes patients’ anxiety levels and has reduced the chances of readmissions in the first month after transplant.

This isn’t just a lean approach to a problem – it’s a smart lean approach. And in an environment that, yes, isn’t cars on an assembly line that matters more than ever.

References:

  • Chandrasekaran, A., Linderman, K., Sting, F., Benner, M. 2016, Managing R&D Project Shifts in High-Tech Organizations: Multi-Method Study. Forthcoming at Production and Operations Management
  •  Chandrasekaran, A., Linderman, K., and Schroeder, R.G. 2012. Antecedents to Ambidexterity Competency in High Technology Organizations. Journal of Operations Management, 30(1-2) 134-151.
  •  Chandrasekaran, A., Senot, C., Boyer, K. 2012. Process Management Impact on Clinical and Experiential Quality: Managing Tensions between Safe and Patient-Centered Healthcare. Manufacturing and Service Operations Management, 14(4) 548-566
  •  Senot, C., Chandrasekaran. A. 2015. What has the highest impact on Readmissions Rates? Harvard Business Review (A joint collaboration between HBR-NEJM)
  •  Senot, C., Chandrasekaran, A., Ward, P., Tucker, A., Moffat-Bruce, S (2016) The Impact of Combining Conformance Quality and Experiential Quality on Readmissions and Cost Performance. Forthcoming Management Science
  •  Chandrasekaran, A., Anand. G., Sharma L., Ward, P., Henry M., Pesavento T., Moffatt-Bruce. The relationship between Patient Anxiety, Quality of Discharge Instructions and 30-day Readmission Rates for Kidney Transplant Recipients. (Findings presented at the American Surgical Congress, Feb 2016)
  • Gordon, E.J., Prohaska, T., Gallant, M., Siminoff, L., (2009). Self-care strategies and barriers among kidney transplant recipients: a qualitative study. Chronic Illness. 5(2) 75-91.