SHS Roundtable with the Experts: 
Summarizing Health Care Improvement Challenges

Aaron K Kanne and Tom Best

As leaders in health care process improvement, we’re all too familiar with the ailments that plague our health systems. Highly variable and inefficient work processes, misaligned incentives across the spectrum of care, insufficiently optimized technology solutions and  reactive problem solving cause unimaginable amounts of wasted time and effort every day in health care facilities all across the United States.

In an effort to gain some clarity and consensus around the issues, four individuals with over 100 total years in health care and manufacturing improvement discussed these deep-rooted problems and their possible remedies. The panel consisted of the following health care leaders:

• Dwayne Keller, vice president of Healthcare Performance Partners, a lean health care consulting company out of Gallatin, Tenn. Dwayne has two years experience in health care, but 20 years in manufacturing improvement including Alcoa, Michelin and DuPont. 
• David Munch, M.D., chief clinical and quality officer for Exempla Healthcare in Denver, Colo. He has a total of 30 years experience in health care. His first 20 years were spent primarily as a physician, and he has held the positions of chief medical officer, chief operating officer, and various other roles during the last 10 years. In his current role he is implementing lean across three Denver hospitals.
• Ben Sawyer, executive vice president of client services at StatCom, an Atlanta-based health care IT company focused on implementing technology solutions that expedite and hardwire efficient patient care. Ben has a combined 30 years of health care experience ranging from being a hospital change agent to a health care administrator. 
• Pierce Story, managing partner with Jumbee Inc., a health care technology solutions company aimed at creating Web-based tools to model and simulate variable patient demand.  Pierce is the current Society of Health Systems president, and has 20 years of health care experience, nine specifically in process simulation and consulting services.

Stimulated by pointed questions about the future of the U.S. health care system, the group defined the core inefficiencies that plague hospitals and other health care systems in our country. Common themes of underlying causes brought forward included:

• Highly inefficient work processes that exhibit considerable unnecessary variability from one health care worker to the next
• Vastly misaligned incentives across the spectrum of care, which cause complex and frustrating relationships between payors, patients, providers, and health care facilities
• Poorly implemented technology solutions that in many cases have actually caused  more care process problems than they have alleviated
• A lack of urgency from the leaders of health care regarding the need to change from a reactive system of daily fire-fighting to a culture of proactive process improvement

In nearly every health care facility, employee A does the same work in a much different way than employee B. These variations in process and practice cause unimaginable amounts of waste in the daily lives of health care workers. It was estimated by Dwayne Keller that roughly 60 percent of every worker’s day can be classified as some form of waste. That is a staggering number, but for those that have observed frontline staff in their routine activities, it probably is fairly accurate. Variable, waste-ridden processes accompanied with fluctuations in patient demand cause seemingly unpredictable outcomes.

Some facilities have utilized lean philosophies (adapted from Toyota principles) in order to systematically remove the waste that was embedded in their processes. Through the use of kaizen events, A3 thinking, and the application of other lean tools and techniques, the waste has been greatly reduced. According to Dwayne Keller, through his experience of  standardizing work processes from one employee to the next and by creating efficient interactions between workers, cycle time has been drastically improved while patient care has also benefited. The panel agreed, however, that lean is not the sole answer to health care ailments.

Unfortunately, the improvements seen with lean or any other process improvement methodology do not always sustain. Ben Sawyer described it in this way:  Problems arise when the focus is taken off of the particular process or department. People don’t do the process the same way every time; they lose sight of why it was defined that way in the first place, or the manager that was telling them to do it that way moved on to another role.

In the end, practices often slip back to the way they were before the process improvement intervention. If there is not a culture of improvement embedded in the organization, any effort to sustain gains is often futile.

In order to be truly sustainable, improvements in processes must be hardwired into the core of the work. This can be done in a couple of ways. First, a culture of change and proactive improvement can be preached and practiced at all levels of the organization. From the top leaders to the front-line staff, everybody should be speaking and living the same message of value-driven care. This can be difficult to achieve and may take painstaking dedication from top-level administrators in order to break through barriers of cultural stagnancy.

Second, technology solutions must be customized to each implementation context. For some who see pre-packaged technology as the sole answer to the financial woes that face health care, it may seem unnecessary to approach health care IT in this manner. Many feel that if the health care industry would simply implement a fully electronic health record, the majority of the problems would fade away.  Each panel member could attest to the reality that a number of health care IT implementations have done more harm than good. Staff attest that they spend more time documenting on the computer than they ever did on paper and grumble that computers slow them down rather than speed them up. How can technologies that are supposed to improve the quality of care end up hurting it?  The answer lies not in the technology, but in the way the technology has been developed and inadequately applied.

Many systems were developed with little end-user input, which has resulted in aesthetically pleasing user interfaces with less than ideal functionality. These applications typically focus on a few areas or departments in the hospital, which can make for numerous systems in one facility that do not work well together. Furthermore, once those systems are developed and sold to a health care facility, the implementation typically consists of installation of the product, training on its features, and a subsequent long struggle on the workers’ part to adapt their daily processes to the new system. Many “improvements” that were developed in the system just do not make practical sense in the real world of health care. Every panel member could agree that underdeveloped connections between systems can cause inefficient workarounds to become a part of everyday processes. Eventually, frustrations mount and employees end up feeling like they do not have a direct say in their daily roles. They become adverse to the latest and greatest development, and they see technology as a hindrance rather than a help.

Thankfully, there are technology implementations that do go well. There are systems being developed that encompass the entire process of care, from scheduling to discharge, that help to automate many processes that bog down health care workers. For example, information technology companies are starting to incorporate customer feedback on the front-end of development rather than post-implementation. In addition, patient tracking systems are being developed to “bolt-on” to the various systems that have been implanted in hospitals.  These systems not only let the users know where the patient is in their stay and phase of care, but what needs to happen next. They automate transport requests, allowing these team members to see their next job in an automatically prioritized queue. They eliminate phone calls and improve the visibility around traditionally open-loop tasks, such as inpatient radiology exams and medication administrations.

Unfortunately, even these systems, if not correctly developed and implemented, will cause negative interruptions and inefficient operations in employees’ daily lives. So what is the answer? How can we get past these setbacks? The panel of experts came to the conclusion that the answer lies in the theory that technology itself cannot create efficiency in care processes, but it can help to automate and hardwire already efficient work. Through a strong collaboration and partnership between health care systems and IT companies, efficient technology solutions can be developed, work processes can be defined and planned together, and implementations can improve the care process. If this collaboration is thorough and effective, health care facilities will end up with newly designed processes that match up with their custom-designed systems and the transitions will be as natural and painless as possible.  Once the mindset of technology being the accelerator rather than the ignition of improvement is turned into practice, the possibilities for improvement become almost limitless.

In terms of an accelerator for health care improvement, the experts also recognized the place of technologies that support an organization’s operational decision making. Pierce Story described the use of dependable simulation applications to more accurately predict the outcomes of potential decisions. Dynamic capacity management solutions can be developed to break the mindset of “midnight census” staffing ingrained in current practice. With these tools, health care leaders could make real-time decisions on how to deploy their resources to match current workload and future demand. Dwayne Keller and others in the group have seen these tools used in manufacturing. Overall, the experts agree that these tools are invaluable when applied to health care, but the group advocates for the combination of such techniques with rapid-cycle improvements that quickly address front-line waste.

Dr. David Munch stated that the solutions to the ailments of health care will not come completely from outside influences. Real waste reduction and work flow effectiveness are created internally. Without them, external influences will be as effective as "rearranging the chairs on the Titanic." Others agree that outside influences such as changes in payment structure will exert pressure for improvement, but they will not in and of themselves address the underlying problems. Whether government were to take complete control of the entire spectrum of health care, or if they left the scene entirely and made it a completely free market system, that external policy change would not address the waste and inefficiency that is built in to our work processes.

Overall, the group concluded that the change will not happen overnight. It will take systematic, consistent and diligent process improvement. Through collaboration such as this roundtable discussion, and consistently applied methods, waste in health care can be reduced and, thus, the quality and cost of care can be improved.