Tuesday, December 14, 2010

The value of standard work

"The most important thing we can teach our residents and trainees is the value of standard work."

Imagine if that were the philosophy in every academic medical center. It is the philosophy at the Mayo Clinic, according to Dr. Stephen Swensen, Director for Quality. Dr. Swensen commented on these matters during last week's IHI Annual Forum. I was not able to attend his session, but a colleague did go and reported back to me.

For years, I have been hearing about the quality of care given at Mayo and was having trouble learning what distinguishes the place. I should have figured it out. The simple summary of process improvement is that you cannot design and implement improvement if there is too much variability in your process. Why? First, you cannot design an experiment for change unless you are confident that your change is being applied to a relatively uniform "prior." Second,
you cannot measure improvement compared to a base case if there is not base case.

Dr. Swensen talks a lot about the "cottage industry" and "farmers' market" approaches to medicine, as opposed to the Mayo way of standard work, decision support, and forced protocolization. Mayo has a Clinic Clinical Practice Committee that has the authority to set practice standards and methods across the organization. When improvements are discovered, there is rapid diffusion of learning.

When it comes to residents, they must be bronze-certified through Mayo Quality Academy before treating patients. This includes training on simulators before being allowed to practice procedures (like central lines) on patients.

Dr. Swensen also discussed four
conflicts in academic medical centers that prevent truly patient centered care:
  • Physician Autonomy - As mentioned, a high variation environment is inherently unsafe.
  • Financial conflicts - Some care receives higher payments; there are financial conflicts between the doctors and the hospital; and fee-for-service creates conflicts of interest.
  • Research - The well-intentioned focus on the mission that "we're here to advance knowledge" can interfere with care.
  • Education - The well-intentioned view that "we're here to provide training opportunities" lets trainees practice on patients and causes care to be organized around the training program, rather than vice versa.
As I heard this, I thought about our place. While we have instituted some standard practices, it is clear that we have not gone as far as we might. On the financial front, we have started to move away from fee-for-service, but there is not a uniform payment system across all of our payors. And his comments about research and teaching are often likely to be valid.

I will state immodestly that we are viewed as one of the leaders among academic medical centers with regard to quality, safety, and process improvement. If we still have so far to go, after several years of concerted effort, the academic medical sector as a whole has miles to travel.


Engineer on Medicare said...

A very large part of what is now primary care could be standardized and done by a computer-driven operation where most of the contact was done by technicians and others trained to take histories, draw blood for tests, record blood pressure and other vital signs and spit out reports BEFORE the client sees the physician.

Imagine a clinic where the computer schedules well-baby visits, mammograms, screening tests, and regular tests for those on maintenance drugs for diabetes, hypertension, and lipids; and whatever else applies. All of those results would be in the computer record and available BEFORE the physician sees the client rather than after as is now the case.

Turn a lot of the decision and treatment decisions over to the patient. I had a tick bite of unknown type. Since Lyme disease is prevalent in my area, I was concerned. A quick search told me that 500 mg of doxycycline is an effective preventive for Lyme, but it took an hour of my time and 20 min of physician time to go through a long conversation until I said to him; what would you do? He said. "I'd take the doxycycline," and finally prescribed it. Bill to Medicare over $100. Cost of doxycycline about 50 cents if I could have picked it up at my local pharmacy.

We won't get costs under control until we standardize and get the health care equivalent of WalMart and Home Depot in the business.

Anonymous said...

It is heartening to see such a post from the CEO of an AMC, because AMC's are often the worst offenders of the non-standard approach, with independent departmental fiefdoms both perpetuating the inter-specialty 'tribalism' cited in your previous post; and contributing to the startling fact that an AMC may offer cutting edge care in one department and be perfectly awful in another.

I am curious however, without sarcasm, about this sentence:

"When improvements are discovered, there is rapid diffusion of learning."

Many physicians fear that such standardization will kill the ability to discover such improvements, because it is the variation in practice which can lead to improvement. How is this potential obstacle overcome at Mayo, I wonder?

nonlocal MD

Barry Carol said...

I could be wrong on this but my understanding is that some of the factors that differentiate Mayo from other AMC’s include the following: (1) The doctors are all employees of the institution. (2) Physician salaries fall in a tight range across departments. (3) Mayo only hires people who are comfortable working in a team oriented, collaborative and collegial culture. There are no cowboys or lone rangers. (4) The doctor is usually unaware of the patient’s insurance status – Medicare, Medicaid, commercially insured, uninsured.

I think #1 and #3 are particularly important in achieving a standardized approach to care and improving processes from there.

Anonymous said...

As a patient who has received care at Mayo Clinic, I can attest to the quality of care being vastly different than any other institution. It is truly AMAZING!! I do not believe that the providers are necessarily brighter or better but they way in which they are allowed and directed to provide care is vastly different.

A friend of mine that has worked as a physician in Boston is now working at Mayo Clinic. When I asked why the quality of care is different, she informed me of several reasons. What I found most striking is the difference in which they oversee their interns, residents and fellows. Everyone employed at Mayo Clinic, no matter their function or status is held to a very strict standard and any deviation has consequences.

Mr. Levy, if there is a way for you to spend time at their institution learning what they do and how they do it, it will serve your institution well. I do believe you have the best of intentions at BIDMC and have made wonderful strides in infection control, safety and the like but if you want to truly stand out from your neighbors, emulate Mayo Clinic. I have every confidence BIDMC can provide the same quality of care as Mayo Clinic; which in turn will cut costs and boost patient and employee satisfaction.

Peter said...

I believe that Inter Mountain may be one of the leaders in this standardization. What is BIDMC going to be doing in the ED to improve outcomes?

76 Degrees in San Diego said...

Resident education is based on the progressive assumption of responsibility in medical decision-making, based on an individual's progress and under the supervision of a member of the medical staff. When something "goes wrong", the "captain of the ship" is the attending physician. "Practicing on patients" does not adequately describe this complex process.
Most all residencies begin with a set-aside time to teach incoming residents the many processes of the hospital.
w/r/t to data entry by less trained personnel, sure, but..."GIGO"! GIGO* is rapidly diseminated now in our EHRs. (*garbage in, garbage out)