Health Care Realized

Measurable Progress in Health Care

Using Big Data to Improve Clinical Communication

The DNA of Clinical Communication

Technology

 

 

Last week, I had the opportunity to see two new technologies that incorporated “Big Data” and technology to improve bedside care in the hospital.

 

Translation

 

The first was part of a presentation by Michael Rothman about PeraHealth and the Rothman Index.  The work that he had done reminded me of the power of subtle indications that lie just below our threshold for perception and how, when properly harnessed, these details can help us make better decisions.

Rothman had analyzed a number of variables that appeared consistently in nursing assessments and identified which critical few had the greatest correlation with patient deterioration.   As he found correspondence among these variables, and with the overall health of the patients, he continued to add other measures such as lab values such as creatinine, and discrete parameters such as heart rate.  He pulled together all of this data and through a process called data fusion , mapped the range of each measure in a scalar way.  He then took each value and combined them to produce a number from zero to one hundred where higher values represented better health and outcomes.

The value of this synthesized number was a score that it could be trended over time to provide a graph of patient wellness.  This provided clinicians the ability to assess the condition of the patient instantaneously vs their previous level of health, and identify the velocity of change in their condition by looking at the slope of the curve.

Dr. Rothman has implemented this in a number of hospitals and seems to see consistent improvements in each.  The areas that see the greatest impact were in bolstering nursing communication, and in anticipating patient mortality to increase the utilization of palliative consults.

The other benefit was that this information could be used to improve the ability of attending physicians, or hospitalists to increase efficiency in rounding.  The dashboard that displays each patient’s RI score ranks them by severity and could assist in prioritizing the order in which they were seen.

What was particularly impressive was that his data shows the index to have 96% specificity and 93% sensitivity.  This means that the algorithm fails to accurately identify a patient who is deteriorating only 4% of the time and elicits a false alarm 7% of the time.

One challenge with the index is that it relies on nursing assessments which contain a great deal of data that is non-discrete and subjective.  It seems likely that by including 26 individual measurements, variability within some of the measurements is averaged out, but this could be a potential source of error.  Even more of a concern is the reliability of the data in some assessment measures.  As nurses are inundated with tasks, and “chart by exception”, there is tendency to cut and paste or reproduce data from previous encounters when there is no glaring deficit.  This could mask changes in patient status and decrease reliability of the score.

A confounding result may be an improvement in care associated with increased vigilance by nurses who know they are being measured.  Though the index can be a valuable tool to help nurses to validate their clinical intuition and share a quantifiable measurement with providers to direct care to some of these patients that might have previously fallen through the cracks, it does nothing to alleviate the burden on nurses of managing the overwhelming amount of data that they must manually collect and enter for a patient.

 

Transcription

I had another meeting with folks at a large academic hospital and had an opportunity to learn about research that they were doing with a tool to drive better communication between providers, nurses, and patients and their families.

They had developed a communication platform for critical care that aggregated data and had a user interface that connected caregivers and patients.  The focus was on patient safety and measured patient condition and clinician compliance with protocols in an effort to improve in 7 areas that had been previously been identified as good targets.  The included measures were ventilator associated events, adherence to Mobility/ Ambulation protocols, maintenance of patient respect & dignity, DVT prophylaxis, alignment of goals of care, and ensuring that the team had adequately measured and made accommodations for the patient’s level of consciousness.

One of the unexpected consequences of their pilot was that patients and their families who used the touch screen in their room to communicate their understanding of the goals of care readily adopted the technology, and wanted to continue to using the device after discharge to other units.  Moreover, the researchers felt that these family members were more compliant with discharge instructions and involved in patient support when the patient arrived at home after the hospital stay.

One of the challenges that was identified was that there were discrepancies between what was manually recorded in the tool and checklists for DVT prophylaxis that were used as part of another initiative to ensure that every eligible patient received SCD therapy and heparin if not contraindicated.  The implication was that the clinicians who were measured on whether they had completed the checklist, could complete it inaccurately, to ensure that they met the requirement if time was limited.

 

It appeared that this solution was very effective in improving communication between nurses and providers, giving them real-time updates on how the patient was performing against these metrics and increasing the participation of the patient and family in their care.

 

Replication

 

The contrast that I found between these technologies was that while Rothman works to translate the observations of nurses into a standardized and intuitive measure, the second technology chooses a smaller number of those measurements, but distributes them in an unmodified fashion and prioritizes certain actions over others.

I found that the first technology is dependent upon a continuing and sustained effort by the nursing team, if not an improvement in their diligence around these tasks. Though I’m certain that the Rothman team does a great job with engaging nursing leadership and driving the adoption of the technology, I can imagine scenarios where implementation would place an increased burden on nurses who are already at capacity for what they can effectively accomplish.

What was illuminating about the second technology is that it actually highlighted this point.  By showing the checklists that were used successfully and led to better outcomes could still introduce errors in the record, this technology provided an insight into the fact that there can be an equal and opposite force opposing the adoption of new technology.  The second technology, to my way of thinking created a way to distribute some of the inertia of care back to the patient and their families therefore potentially reducing the workload on the clinical team.

Ultimately, both technologies show a lot of promise and have the potential to improve outcomes and drive lower costs of care.  Before considering either or similar technologies, a thorough needs assessment should be performed to determine the impact of addressing these specific aspects of clinical communication, and to ensure a thorough understanding of the saturation level of nurses’ workload.

Embracing failure

One of the things that I think often gets lost in sales and consulting both as the vendor and the customer is that there is no “perfect” solution.  There certainly is a problem—this is the reason that the hospital is soliciting bids or advice from outside vendors—but usually the solution is only an approximation and may, in fact, only address a small part of the problem.  The real value of choosing and implementing a solution is the that it allows the opportunity to get a better understanding of the problem, and the of the capabilities of the team implementing the solution.  As I had discussed in previous posts, culture plays a huge role in how successful implementations are, and how they will position the organization for future improvement.

 

In sales and business, I have many times seen people rest the entirety of their success for a quarter or a year on one big deal.  Amazingly, mid-level managers, executives and others in the organization fall into the trap of thinking this way and throw all their resources at these deals.  Often the most predictable thing happens—the deal is pushed until the next quarter.  When this happens, one has a great opportunity to see the true culture of the organization.

 

The alternative to this approach is to make sure that there are always multiple ways to meet quarterly projections and annual quotas.  It is human nature—and I am often guilty myself of it—to be swayed by the dream of a big payout.  Buying a lottery ticket for a dollar with an infinitesimally small chance of winning a fortune, taking supplements based on “ancient lost secrets” that promise eternal youth (but haven’t been around long enough to be evaluated by the FDA or any peer-reviewed scientist), or following the latest fad in your business because everyone is doing it.

 

Relying on people is always a much safer bet.  They will surprise you and achieve, often spectacularly, in areas no one else had imagined.  Cultivating an environment where failure is not punished allows an organization to get a true understanding of the capabilities of their people, and where the infrastructure needs improvement to better respond to inevitable challenges.

 

Hospitals can’t cure everyone, or deliver immortality, at least not in the foreseeable future.  All human endeavors rely on limited information and are subject to constraints which necessarily deliver less than perfect results.  The goal therefore needs to be to optimize outcomes aligned to capabilities and create an environment where resources flow dynamically, almost organically to the areas where they can be best utilized.

Speaking With One Accord

Visibility

Working with many hospitals as I have, I realize that I am in a unique position to be able to see the inner workings of the hospital, as well as its relation to the greater market of hospitals without the pressures of having to compete, manage or work there.

 

I was recently speaking to a nurse  who explained to me that, most days, she was overwhelmed with tasks during her shift and could not get them all accomplished.  For every clinical intervention, there  was a flow sheet, and a checklist, and a report, and some need to document on the commodore 64 that resided on a desk with wheels that was supposed to be rolled into each room as part of every patient interaction.

 

Leadership would always emphasize that all these things were important to complete so that during handoff the next nurse would be informed about the patient and the outgoing nurse would not look foolish and have nothing to say.  There was even public shaming associated with random reports generated by the charge nurse and posted showing who had initiated an MAR request for acetaminophen, but failed to do a pain assessment 20 minutes later.

 

It has always been this way

The context of this story includes technology that is not adequately mapped to the work at hand.  Nurses carry handheld phones that lack caller ID so that when they are interrupted by a call, they  struggle to decide whether they should walk away from a patient to take a call or wait for the caller to call back.  There still is a mix of paper and electronic charting.  Some devices automatically report information to the EMR while some do not.

 

Since information is collected in an asynchronous manner and by multiple sources—nurse, tech, integrated device, phone, provider, imaging or other department etc…–there is no timely way for anyone to see a holistic view of the patient.  Ultimately, this environment ensures that information will not be assimilated into the record, that interventions are tied to outdated results, and that clinicians are unable to communicate effectively.

 

The challenge I see at every hospital that I visit is that the folks who really care are swamped by those who have just accepted that everything is broken and resign themselves to putting in 8 to 12 hours of misery to get their paycheck.

Call to Action!

No matter your role in healthcare, we owe it to ourselves to cultivate good leaders.  If you see someone with ideas, encourage them to speak up.  Develop a clear mechanism to bubble these ideas up so that in your workspace they are considered, can be implemented where it makes sense, and their effectiveness evaluated.

 

Ensure that there is a clear list of priorities for the institution that everyone understands.  Since on many occasions, if not consistently, things will be left undone, determine which will have a lesser impact so that they can be skipped.

 

Have an ongoing evaluation strategy to review these tasks and determine, if they are frequently not being done, if they are truly critical to the mission and should remain priorities.

Speaking Truth to Power?

Optimal Decision Making

I saw an interesting Ted talk today called “Dare to Disagree”.  It was not exactly what I had expected–it was not a primer on how to disagree without being disagreeable–but was still thought-provoking.  In her presentation, Margaret Heffernan shares a few stories about how a competing perspective can identify gaps in a leader’s thinking, or confirm the accuracy of it.  Uncertainty is a given in Healthcare these days, but as a leader it is critical that we eliminate as much of it as possible in our decision making.

Where we fall short

In the past, I have worked with executives who are not completely comfortable in their role.  One symptom of this affliction is a tendency to dissemble and undermine transparency.  I remember working with a senior leader at GE who explained to me the benefit of invoking the term “The Business” as a way to minimize accountability and give yourself “wiggle room” in negotiations.  By making statements such as “the direction for the timing for the fix for this product issue is under review by ‘the Business'”, or “the actual products for which you are compensated is being evaluated by ‘the Business'”, he insisted, one could create a miasma of jargon around the outcome of any situation, while still sounding authoritative.  At one time when he was brought into a negotiation with executive leadership for a large deal that was predicated on addressing some ongoing product issues he employed this tactic in an attempt to minimize the challenges the hospital was experiencing and focus them on the benefit of the solution we were proposing. Though he was very eloquent when he spoke, as we walked out of the meeting, the hospital’s COO pulled me aside and asked that I not bring him to any future meetings.  I felt as though sharing this feedback with him would not be appreciated, especially after seeing him get very angry when my peers would try to pin him down for answers.  Unfortunately, his leadership style led his direct reports to leave him out of serious decisions and go around him for support when higher level approval was required.

In Practice

You cannot hope to keep your team engaged unless they see the big picture or the overall vision of the organization, and understand how their role contributes to it.  When you must choose between being open with your team, or keeping them in the dark, trust them to understand, and hear their perspective.

It is critical to team unity that everyone is engaged and it is critical to the success of the organization that they are doing their best work. This can be accomplished to a great extent when the contribution of each person in the organization is valued and they are encouraged to speak up when their opinion differs from the consensus.

The least among us?

In hospitals today, it is easy to forget that folks without letters at the end of their name may have valuable insight to provide.  I came across an interesting article called SELF-ORGANIZATION AND POLITICS: HAYEK AND “HEALTH” ECONOMICS that refers to economist Friedrick Hayek and his thinking around predicting behavior.  Though Hayek is specifically describing public policy and its ability to drive political outcomes, I find one element of this thinking particularly relevant here.  Hayek believed that central planning structures were destined to fail because administrators could never fully understand the constituent parts of the system.  More specifically, there was knowledge that was inherent in the work done at one level that was not available at other levels.  According to his research, the prices of goods were determined at the level of the transaction and were not amenable to fiat control.  The takeaway is that there is sustained value at each level of organization that is not evident to other levels of organization.  Sometimes our culture falsely assumes that the amount of education, or authority that someone has is proportional to the value of their perspective.  Leaders can handicap themselves by adopting this view.

Bottom Line

It is important to leverage each of our employees and team members and create synergy by encouraging them to feel good about their role in the organization, and do the same with their peers, supervisors, and direct reports.

In my next post, I will talk more about some of the ways to do this.

5 Ways to Create a Toxic Culture in Your Hospital

l am often enticed to click on advertisements in articles that I am reading with titles similar to the title of this post.  Since the Holidays and end of the year responsibilities find me short on time, I’d like to tease my next post with the following list of things that many organizations do to undermine their culture and condemn their efforts to drive improvement to failure.  One of the most important(and least considered!) steps in implementing strategies to improve performance is getting buy in from staff.  Take a look at the list below and reflect on whether you or your organization has committed the following sins this Christmas Season:

  • Ignore Staff Satisfaction
  •  Experience Frequent Executive Turnover
  •  Fail to Articulate a Clear Vision
  •  Fail to Prioritize Patient Satisfaction
  •  Accept Mediocrity, Institute a Non-merit Based System for Advancement, Nepotism

What’s not Waste?

 

As a follow up on my last post  identifying waste as described by Lean methodology, I’d like to emphasize what is not waste.

 

As anyone with experience in Lean workouts knows, there can be quite a feeling of exuberance in identifying areas for improvement and seeing cost savings materialize as a result. The challenge is to ensure that we don’t get carried away.

Waste in Real Life

I work with a hospital who had spent millions of dollars to have a team of Lean consultants identify cost out opportunities.  As part of a Kaizen workout, they identified supply closets as poorly organized, with some supplies overflowing from a shelf and empty bins labeled with supplies that were MIA.

In what seemed like a logical exercise, they polled the staff about the frequency with which they used each of these items and correlated their responses to the ordering and par levels that had been established in purchasing.

After this exercise was complete, they found an old Arctic Sun device, buried under half opened packages and covered in dust.  Since no one could remember using it, and Biomed had never performed annual maintenance on it, the consultants recommended throwing it out to make space for items that would be more “valuable”.

Unfortunately, when a few months later a patient with a spinal injury was admitted to the ICU and required core cooling for the therapy prescribed by the medical team, there was no equipment available to support this protocol. Fortunately for the patient, they had this system in the ED, but this situation resulted in the hospital purchasing a new fleet of warming/cooling systems at a tremendous cost because the cost of stocking multiple types of blankets was prohibitive.

 

Is this optimization?

Just because an airplane can fly faster and more efficiently when 10% of its fuel is discarded in response to certain flying conditions, it doesn’t follow that eliminating the other 90% will yield proportional gains in efficiency.

The danger in utilizing Lean and other programs in the hospital setting is that the observations that support making the changes are snapshots in time.  It is nearly impossible to know whether the baseline for operations over the last year will be at all representative of the conditions in the next 12 months.  The inclination to create a totally “Lean” efficient system is very compelling, but without leaving slack to accommodate an ever changing environment, you can hyper-engineer your processes.  This can create competing incentives within your processes, and leave the hospital unable to be flexible.

Where are the trade-offs?

Operational leverage—by which I mean leveraging the efficiency of the organization against the risk of perturbations to the system.  An example of this in everyday life is road construction.

When planning for a road is done, the plan is to make it completely efficient based on the number of cars that will use it. Once the road is completed, the initial conditions may change dramatically.  For instance, because the road provides access to previously unoccupied land, businesses may come in and line the road causing backups at exits, and increased traffic between exits.  In a very short period of time the road that was sufficient to support this route as it was at the time of planning is woefully inadequate.

Bottom Line

The point here is that there are likely a great number of things that are done well at your hospital.  Moreover, it is human nature to hedge—by putting a few extra dressings in a special drawer for emergencies for instance.  Make sure that by streamlining your processes, you are not eliminating the human element.  With a holistic understanding of your hospital, you can marry process to expertise to culture and create a truly optimized organization.

Labor Costs in Healthcare and Lean Methodology

lean-labor-pictureIs Labor Waste?

Over the last 10 years it has become increasingly fashionable to incorporate Lean principles into hospital operations.  As many readers are likely aware, Lean Methodology is derived from the manufacturing processes developed by Toyota to improve quality and reduce cost that continues to be used effectively.

As part of operational excellence initiatives by companies such as Motorola, GE, and others, Lean, 6Sigma, as well as iterations of Total Quality Management developed by W. Edwards Deming were instituted through the 80’s and 90’s and have become mainstays from business school to the boardroom.  In recent years, hospitals have joined the fray.

Ultimately, the question that needs to be answered as we consider using these tools in our hospitals is: what outcome can we reasonably expect from implementation?

There are two areas that are targeted as part of any workout and subsequent project.  Lean focuses at the most basic level on maximizing “Value Added” activities, and minimizing waste.  Hospitals, by their very nature provide a great deal of value which is underpinned by research and EBM initiatives.  Though we can always train better, and adopt best practices faster, the medical community has always been effective at developing new cures and procedures to improve outcomes.

In today’s post, I would like to focus on waste.

Where is the waste?

  • Waste associated with reimbursements
  • Uncompensated care
  • Waste associated with data that is acquired, but not used
  • Waste in the form of expertise that goes unused because collaboration is hindered by incompatibility in technology, poor process management, lack of vision.

How do we manage waste?

One of the principles that is integral to the success of the Toyota Production System is that everyone has  a stake in the process. Everyone is considered a respected member of the team, and their work is valued. If there are defects in their work, it is considered a problem with the process rather than with the individual.

The story that often is told to illustrate this is of the janitor who is cleaning around the production line. When he notices that the lighting is inadequate to ensure that the floor is clean, he stops the line knowing that if he can’t see well, other workers on the line may miss something and pass an error along through the manufacturing process.

To ensure the buy in of all employees, few if any employees are ever fired, and budget cuts result in executives reducing their pay. Some say this is more applicable in Japan, but similar productivity has been seen in Toyota factories in the US.

So how does this relate to hospitals?

 

Frequently, I see hospitals institute layoffs, then several months later hire staff to fill the same positions. This creates resentment in the folks who stay, and cynicism in those who are forced to look for work. While a snapshot of the balance sheet for the few weeks following the layoffs shows reductions in labor costs, the added expense of cross training and rework can cancel out these gains.  More importantly, productivity can be dramatically reduced.

According to work done by Tom Muha, PHD referenced in his article Medical Errors Why don’t nurses speak up? hospital productivity in the US is in a lot of trouble:

“Surveys show that over 50% of the staff in a typical hospital are disengaged, only performing their jobs and doing the minimum required to collect their paycheck.

Even more startling is that up to 20% of hospital workers are “actively disengaged.”

What proportion of the staff at your hospital falls into these categories?

The bottom line

As Medicare continues to emphasize bundled care reimbursement, it is critical that expenses are reduced to achieve margin targets.  Labor is traditionally one of the largest costs on a balance sheet and may appear to be an easy target for cuts.  The impact on operations is such that any short term gain is vastly outweighed by significant losses.  Driving more efficient operations will likely require more rather than fewer personnel, though they should be better tailored to their roles.  The greatest source of waste  is likely found in preventable complications which can result in huge costs and for which there is no reimbursement.

Ultimately the greatest form of waste is poor patient outcomes.  Better managing this type of waste will drastically reduce costs and support revenue generating opportunities.

Working Together to improve Medical Device Connectivity

What a remarkable time to be in healthcare!clock
Regardless of your stance on the elections last month, it is clear that we are on the verge of significant changes to the way that we treat patients and do business.  Healthcare IT and Medical Device companies have all seen an uptick in valuations, and the market is screaming for innovations like those that we see outside of the hospital every day.

One of the things that I find remarkable is the difference in the velocity of technology between the consumer and healthcare space.  While I can appreciate the effect that additional regulation and research requirements have on the ability of companies to bring medical solutions to market, I am frequently disappointed in the unwillingness of companies to work together to solve problems.

When I was working at GE, it was hardly unusual to hear that peripheral technologies that could potentially enhance our core products were not “validated”, or not compliant with the company’s standards.  I always found this odd considering that other companies faced the same regulatory burdens to receive FDA approval as we did, as well as the fact that many of the smaller companies had much more to lose if there were issues with their tech as their reputation was dependent on a very small number of implementations.

Over time, in an effort to add value for my customers, I became a believer in the need for collaboration between companies, and an advocate for bringing vendors together to solve the issues that the hospital was facing.  Ultimately, this led to synergies between technologies that allowed each to exceed its individual capabilities.  Working with companies like Voalte, Extension, Verizon and others supported better workflows and led to improved outcomes.

We all have a vested interest in improving care delivery, and making it more accessible and less expensive. I have always valued my role as a leader in this area and would encourage you to realize the impact that you have as well.

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