Friday, June 10, 2011

"But they are different." Not!

Whenever I talk about the spectacular work Brent James and his colleagues have done with process improvement at Intermountain Health, someone says, "But they are different." These comments are often based on prejudice. It reminds me of the folks in the US automobile industry who initially said of Toyota's use of Lean principles, "It will never work in America. Those Japanese are different. They are so much more compliant than Americans." Then, those competitors discovered that Toyota factories in the US, with American workers, also effectively used Lean. And ate their lunch.

What do they say about IH? They talk about the homogeneity of the population in Utah, meaning that there is a predominantly Mormon population. They subtly suggest that Mormons are somehow more complaint with regard to health care treatment, have fewer health problems, or that the doctors are more likely to follow orders, or something equally foolish. Here's the more accurate description:

The IH network of twenty-three hospitals and 160 clinics provides more than half of all health care delivered in the region. Intermountain’s hospitals range from critical-access facilities in rural areas to large, urban teaching hospitals. Although Intermountain has an employed physician group and a health insurance plan, the majority of its care is performed by independent, community-based physicians and is paid for by government and commercial payers.

We need to recognize that the work done at IH is the result of thoughtful, hard work, and the application of the scientific method to improving patient care. It is documented in this article by Brent C. James and Lucy A. Savitz in Health Affairs: "How Intermountain Trimmed Health Care Costs Through Robust Quality Improvement Efforts." (June 2011, 30:6) Here's part of the abstract:

Since 1988 Intermountain Healthcare has applied to health care delivery the insights of W. Edwards Deming's process management theory, which says that the best way to reduce costs is to improve quality. Intermountain achieved such quality-based savings through measuring, understanding, and managing variation among clinicians in providing care. Intermountain created data systems and management structures that increased accountability, drove improvement, and produced savings.

Since I can't give you a cite to a free copy of the full text -- (Ugh, like JAMA!) -- here are some more excerpts. The whole thing is about reducing variation and conducting experiments to improve key processes. Note the involvement of physicians! This did not come about as a result of payment "reform," financial penalties for "never" events, or Joint Commission surveys.

[In the early days of the effort, we focused] on the processes of care delivery that underlie particular treatments, rather than on the clinicians who executed those processes—the “measurement for improvement” approach.... [T]he system was eventually able to document significant declines in physician variation. Physicians led almost all of the changes themselves. Declines in variation were associated with large declines in costs, while clinical outcomes remained at their original high levels.

Here is an interesting part about how to provide constructive feedback to the doctors, in a manner that persisted in reducing variation:

[T]he clinicians’ experience showed that the guideline was almost never perfectly appropriate for a patient. The clinicians had to adapt the guideline to each patient’s particular needs. Morris’s team recorded all of the adaptations as variances and reported them back to the clinical team treating the patient. The members of the care delivery team sometimes modified the guideline in response to the variances, to reflect the realities of care more accurately. In addition, clinicians often modified their practices to follow the guideline as closely as they could.

But focus matters. You don't change the entire organization at once:

Not all processes are equal in size and effect. Some are the “golden few”—the relative handful of processes that make up the bulk of the care that a clinical organization delivers. . . . Intermountain sought to identify this relatively small subset of key processes.

We divided Intermountain’s work processes into four subgroups: clinical processes associated with specific clinical conditions (clinical programs); clinical processes that are not condition specific (clinical support services, such as pharmacy or imaging); processes related to service quality (patient perceptions of quality); and administrative support processes. We identified and then prioritized the processes within each subgroup.

We found that 104 clinical processes—roughly 7 percent of the 1,400—accounted for 95 percent of all of Intermountain’s care delivery.

And, now look at how this changed the hospital-centric view of care:

Our focus on key clinical processes had a major secondary impact. These processes represent the entire care continuum that patients experience, without concern for the location of the care, such as home-based, clinic-based, or inpatient care delivery. Correctly managed, they lead naturally to patient-centered care. Instead of selling clinic visits, hospitalizations, or technologies to prospective patients, a health system organized around key clinical processes finds its business model driven toward population-level health. This means shifting the focus to modifying the factors that cause disease, with the goal of avoiding future costs for care, instead of responding to health problems only after they appear.

Whether you call it Deming or Lean, it is the same thing. The steps are straightforward and logical and completely consistent with the good intentions and scientific training of physicians: Document process waste and inefficiency using the wisdom of the front-line staff; reduce variation to standardize care as much as possible; conduct scientifically based experiments to improve the standard process; spread the story of effective solutions; repeat. Over and over.

The result is higher quality, lower cost, more patient-driven care and less anecdotal medicine. The government and the payers are not necessary participants in this process. The profession can do it on its own. If it does not, the government and the payers will force upon you an approach that is crude and ineffective and will simply make you resentful.


Barry Carol said...

Paul –

I don’t doubt that Intermountain Health has done a lot of great work in process improvement. Presumably, widespread use of interoperable electronic records is necessary to help with all the needed measurement and evaluation of results.

However, I think it is also relevant to note that Utah has the youngest state population in the country based on median age. Also, due in part to the comparatively healthy Mormon lifestyle, the state’s obesity rate is well below the national average. Moreover, I wonder if patient expectations are any different when it comes to demanding marginally useful tests, especially imaging, and very expensive but probably futile end of life care,

It would be interesting to see if the IH approach could be replicated elsewhere, especially in large cities or more rural areas with above average poverty rates, even with the critical cultural buy-in from physicians. Perhaps IH should consider establishing satellite clinics in other geographies like Mayo has done though even Mayo has not been able to completely replicate the culture at the main facility in MN at its satellite locations.

Paul Levy said...


The obesity rate is lower than the national average but not lower than a lot of other states. See here: Utah - 23.5%; MA - 21.4%; VT 22.8%; Oregon 23%; CT - 20.6%.

True enough on media age.

But the point is that most of what IH did has nothing to do with those demographics. It was pure and simple process improvement.

Having worked on similar things in my former hospital, I can assure you that it is not magic, and it is not patient mix dependent. It is a matter of administrative and clinical leaders choosing to do it -- and boards of trustees supporting and/or insisting on it.

Anonymous said...

I have to agree with Paul; it is the process improvement which is the important thing, and the outcomes follow on as a natural consequence. However, I believe that implementation of this process improvement requires incredible commitment and tenacity on the part of leadership. I have been witness to numerous failed attempts at such at my former hospital system, and it was those 2 leaderhip qualities above which were missing. You just can't give up the first time when the staff and docs try to blow you off. Witness Gary Kaplan's experience at Virginia Mason.
Botom line, this CAN be done, but as of yet there is little will to do the hard work. What will it take? Patients who demand it. Or, someone famous will have to die from a blatant medical error before anyone starts paying attention - your and my relatives aren't enough.

nonlocal MD

Anonymous said...

It reminds me of all the similar arguments about how the Japanese were different, and had unique cultural skill making automobiles.

Marcus hardy said...

I sure wish I knew more about IHC as I've lived in Utah while going to school for a number of years now (boy NYC is humid...I miss the dry).

A good friend of mine shared an anecdote with me after shadowing an IHC supply chain manager. This IHC manager said that when he first started with IHC, he did not take a salary--instead he proposed to receive compensation based on a relatively small percentage of the savings he intended to create by streamlining ("lean-ing") the supply chain.

This fellow apparently made well into seven figures that year.

Now some may scoff a bit, but think of the efficiency and cost savings he created within the organization that could then be devoted to other things, like research, job creation, and most importantly, improved patient care via a number of channels. My take—the gentleman earned his keep.

He did say that they switched him to normal salary the following year.

If there is innovation of that caliber going on there, my thoughts align with Paul's--it's got to be worth taking note of.

Anna said...

The assertion they make seems fairly ignorant. I'm pretty sure that the area that IH serves has large Hispanic and Native American populations in addition to the white Mormon majority.

Nathan said...

From Facebook:

Great article Paul. As former ASQ member, I truly believe that quality and profit do complement each other. However, I realized that this practice is not as widely used in the healthcare industry, as much as in the manufacturing sector.

Furlan said...

Dear Paul,

I am a doctor working in Sao Paulo, Brazil, as a medical director from TotalCor Hospital, a 100 bed's hospital, especialized in cardiology. I'd like to say that I really like your comments every day and they have been a inspirational source for me day by day. You know that problems in the health system are also prevalent throughout the world. But we are seeing every day more people interested in making it safer and trasnparent results. This remains a source of inspiration. Cheers,

Valter Furlan