Sunday, November 06, 2011

Bravo to Brent James

Dr. Brent James last week was awarded Columbia Business School’s W. Edwards Deming Center for Quality, Productivity and Competitiveness. As described in the press release:

The Deming Cup grew from the center’s drive to highlight the achievements of business practitioners who adhere to and promote excellence in operations – the Deming Center’s area of focus. This award is given annually to an individual who has made outstanding contributions in the area of operations and has established a culture of continuous improvement within their respective organization.

Dr. James was recognized for his pioneering work in applying quality improvement techniques that were originally developed by W. Edwards Deming and others, in order to help create and implement a “system” model at Intermountain, in which physicians study process and outcomes data to determine the types of care that are most effective.

Imagine that, improving clinical care is consistent with efficiency in the health care system.  This has to be another lie, just like that stuff about Pronovost saving lives and reducing costs by reducing the rate of central line associated bloodstream infections.  Or assertions by that trio of fraud, Spear, Toussaint, and Kaplan.

This stuff can't be true.  If it were everybody would be doing it.  Right?

Back on January 15, 2009, I published a post entitled "What does it take?", in which I expressed frustration with the slow pace of process improvement in hospitals.  What followed in the comments was a virtual seminar by some of the country's leaders in the field.  They are still worth checking out.  Brent offered his point of view:

Paul, you have put your finger on what I regard as THE core task of the present generation of the healing professions. It is very clear that we are in the midst of a transition. The term of art that is usually used to describe the present state – and which Don Berwick so eloquently explained (at least, at the level that an individual physician would experience it) – is “the craft of medicine.” It’s the idea that every physician (or nurse, or technician, or administrator, etc.) is a personal expert, relying primarily on their personal commitment to excellence. In a very real sense, every physician occupies his/her own universe, with its own reality, truths, physical constants. As a physician I might say to a colleague, “What works for you, works for you. What works for me, works for me. Let’s both stay focused on the patient – our core fiduciary commitment to put the patient first in all things – and that will guarantee the best possible results.”

David Eddy said it most eloquently: This core assumption of the craft of medicine is scientifically untenable.

As a direct result of some solid research around this fact, the healing professions are in the midst of a major sea-change, a once-in-a-century shift: We’re moving from “medicine practiced as individual heroism” to “medicine as a team sport.” The kinds of tools you’re talking about make perfect sense in a team setting, but almost no sense within the craft of medicine.

Don is right in calling it culture change. However, we are well past the tipping point. There is strong evidence that the professions have committed to a new course and are actively moving. It’s the difference between 5% of the profession “getting it” (where we are now), and moving to a point where it is standard, accepted, background business essentially all of the time.

The key change concept was perhaps best expressed by Winston Churchill: “People like to change; they just don’t like to be changed.”

I am also deeply impressed by Roger’s classic text on change: Diffusion of Innovation. He describes bottom-up change, by sharing results (both data and word of mouth) from initial thought leaders (his “early adopters”). That has worked very well for us, and makes the change fun – rather than something that a bunch of external “know nothings” are trying to do to you. 

11 comments:

Anonymous said...

Congratulations to Dr. James; another giant in the field. It would be difficult to quantify, but I wonder if there is any data on exactly what progress has been made since your Jan 15, 2009 post. My impression is a little, but not a lot.

nonlocal

Barry Carol said...

Streamlining processes and following evidence based medical guidelines should improve both healthcare quality and outcomes. Moving the hospital and physician culture in that direction is certainly the right thing to do for patients. However, if it also reduces revenue for hospitals and income for doctors, there will be significant countervailing pressure against positive change. We need to move away from fee for service reimbursement in favor of some combination of capitation and global payments to ensure that the financial incentives will help to push the healthcare system in the direction it should go. Right now fee for service payment has the opposite effect.

Paul Levy said...

Ah, Barry, you fell into that trap. The truth of the matter is that the kind of process improvement advocated by Brent has a positive impact on the bottom line of the hospital, as we demonstrated at my place.

Don't confuse reducing the amount of unnecessary MRIs and the like, which does reduce revenue, with process improvement that reduces total costs of providing service. As we and others have shown, even with fee-for-service payment regimes, you can do better financially by employing his methods and similar ones like Lean.

Think of it this way. If your unit payments are fixed by an insurer or Medicare, reducing your unit costs increases the bottom line. Going further, if you expect unit costs not to rise at the old levels, if you can shave costs faster than your rates are shaved, you come out ahead.

e-Patient Dave said...

BOY are you right about the comments on that 2009 post. Everyone, go read it! It's a time trip, but as you say, there's a TON of teaching there: Don Berwick (then at IHI), Jim Conway, Gary Kaplan of the legendarily-good Virginia Mason Medical Center, Atul Gawande, Brent James himself, and numerous patients.

Seriously, go read it. Man, that was 34 months ago! Compare to today. NOT much change - in fact the Cleveland Clinic of all people just said they'll no longer publicly report their infection rates!

Thirty years ago I took a weekend course on structural thinking, "Leadership and Mastery," co-led by the then-young Peter Senge, with Charlie Kiefer. We learned that when complex systems resist change (as if a strong gyroscope were attached), it's a sure sign there are powerful feedback loops in place. All efforts to change it will fail until those loops are identified and undone.

What will it take? Go read it.

Paul Levy said...

A friend kindly writes privately, and not as a post:

'I have to say, I'm puzzled by your sarcastic notes about liars and "trio of fraud." I know you've done it before, but it always puzzles me. I personally never get inspired by it, and in fact for newcomers it's completely confusing because there's no teaching in it - to the contrary, getting the sarcasm requires knowledge of the history. In contrast, it was actually world-changing for me when you asked "What does it take?" and laid out the facts.'

Of course, this person is exactly correct, and I offer apologies. If I have any defense, it is that I still remember the scorn and skepticism I was occasionally shown by peers in the academic medical community when I would discuss these issues and otherwise advocate for process improvement and transparency on this blog. But, s/he is right. It's time to get over that and focus on more positive messages and leave the bad vibes from these recalcitrant doctors and administrators behind.

As Brent suggests, there IS a transition underway. I just wish that it could move a lot faster, as there are people's lives at stake. By people, I mean actual mothers, fathers, brothers, and sister. We need to keep this very personal. It is not about statistics.

In light of this imperative, I plan to keep my impatience at the fore, but drop the sarcasm. So thanks to my friend for the helpful suggestion.

Barry Carol said...

Paul –

I hear you on how improving processes can reduce the cost of providing a specific service or bundle of services. My reference to lower revenue was about what can happen when you do the job right the first time and, under fee for service, will no longer be paid for treating infections that didn’t occur or treating a patient following a readmission that was prevented.

Or, in the case of end of life care, if you have a process that draws the patient and family out on their values and priorities and wind up providing less care than a default “do everything” protocol would call for, you will generate less revenue that you would have by providing low value or futile care that the patient and family didn’t want but there was no living will or advance directive and the patient could no longer communicate.

The Gundersen Lutheran Health System based in LaCrosse, WI has an excellent “process” to deal with this issue which could be replicated by others but, at the end of the day, revenue will likely decline. Indeed, Gundersen’s average cost of and revenue from end of life care is about 30% below the national average according to a recent broadcast by PBS TV’s “Religion and Ethics News Weekly.”

Paul Levy said...

Yes, but . . . and it is a big "but" . . . there are offsets. For example, by reducing ventilator associated pneumonia and other infections in our ICUs -- see here: http://runningahospital.blogspot.com/2010/01/progress-in-icus.html -- we were able to dramatically reduce length of stays. This enabled us to see more patients, with offsetting revenue growth. Also, we were able to avoid building a new ICU, which we had faced because of capacity limits. This avoided a large capital outlay, plus avoid incurring a whole new set of fixed costs for nurses, other staff, equipment, and supplies. (The name of the game for tertiary hospitals for the future must be to avoid unnecessary new capital outlays and other fixed costs.) Overall, we had a real contribution to an improved bottom line.

Finally, our lower cost of providing care made us attractive to insurance companies creating limited network products, as well as PCP and multispecialty groups. Result, dramatic increase in patient volumes.

e-Patient Dave said...

I've been looking at healthcare now for almost four years (late Jan 2008), and from my perspective now, Brent's comment on your Jan 2009 post stands as one of the most important I've seen. (Emphasis added)
_______

Paul, you have put your finger on what I regard as THE core task of the present generation of the healing professions. It is very clear that we are in the midst of a transition. The term of art that is usually used to describe the present state – and which Don Berwick so eloquently explained (at least, at the level that an individual physician would experience it) – is “the craft of medicine.” It’s the idea that every physician (or nurse, or technician, or administrator, etc.) is a personal expert, relying primarily on their personal commitment to excellence. In a very real sense, every physician occupies his/her own universe, with its own reality, truths, physical constants. As a physician I might say to a colleague, “What works for you, works for you. What works for me, works for me. Let’s both stay focused on the patient – our core fiduciary commitment to put the patient first in all things – and that will guarantee the best possible results.”

David Eddy said it most eloquently: This core assumption of the craft of medicine is scientifically untenable.
__________

Thanks for revisiting this. It's vitally important, and now I've got to figure out how to work this into my appeals for a better world. How do we turn this into an agenda for action??

Barry Carol said...

Paul –

I agree about the offsets that BIDMC was able to capture while you were CEO there. However, if every institution pursued that strategy, the fallacy of composition would set in and the hospital sector would contract as not everyone will be able to attract more patients or make its cost structure attractive to insurers developing limited network or tiered network products. Don’t get me wrong. A smaller, less expensive, more cost-effective, high quality healthcare system is exactly what I would like to see evolve. I just think that we need to move away from the fee for service payment model in favor of capitation or bundled payments to ensure that the financial incentives are aligned to help that process along instead of penalizing doctors and hospitals trying to do the right thing for patients. Improving the patient risk scoring state of the art would also be helpful.

dsblanchard said...

I think one of the key reasons medicine has a chance of changing from my practice - your practice to our practice is the fact that new residents are becoming female in greater percentages. Females make decisions democratically (considering the views of others). Males make decisions in isolation and when they've made their decision in their own mind, they then dictate to others. Perhaps Brent's ideas have been simmering for such a time as this.

Dawn Blanchard, PhD, RN

Anonymous said...

"..... it's a sure sign there are powerful feedback loops in place. All efforts to change it will fail until those loops are identified and undone."

Powerful quote, Dave - and I think those feedback loops, in the context of the 'craft' of medicine, lie within the medical education system. Although there are early efforts there to promote teams, these are primarily directed, I suspect, to changing docs' hierarchical attitudes, i.e., I am the Captain of the ship. The idea of the craft, I am sure, persists in the diagnostic and therapeutic arenas. There are good reasons for it, but they are largely outdated now.

So I think your action agenda should start with residents, medical students, and the AMC physicians who teach them. Paul will no doubt attest that it will be an uphill slog.

nonlocal