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. 

 

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.