We focused on how Vancouver Coastal Health (VCH) improved patient safety and throughput in a time of increased governmental control and decreased reimbursement.

We provided a perspective of not focusing on the differences between the Canadian and U.S. systems, but how a Canadian organization adapted and succeeded under changing legislative imperatives. 

David presented how VCH improved patient throughput. With occupancy rates over 100%, VCH requires quick bed turnaround times. Through a process of using call centers, patient service cards, and enhanced bed management processes in housekeeping, VCH was able to bring turnaround times down to 48 minutes, despite increased volumes and complexity of care.

David then went on to describe VCH’s focus on patient safety measures. Using a standardized visual provincial cleaning audit tool, and observational audits enhanced with technologies such as glo-germ, thoroughness of the physical cleaning practice was ensured. Staff training, standardized cleaning practices, resulted in improved predictability of results. 98% of all sites passed a quality audit score, up from 29% in 2004.

Click here to see a copy of the presentation.

I thought of this “new normal” as Peter Kaprielyan, Vice President of Organizational Improvement and Philanthropy, took me on a tour of Underwood-Memorial Hospital (NJ). I saw cross-functional employee teams sticking post-it notes on fishbone diagrams, discussing processes, and coming up with new more efficient ways of improving care.  There was a high level of energy, as employees were not focused solely on cutting costs, but on improving processes using a combination of Lean, Six Sigma, and “Theory of Constraints” to create efficiencies, eliminate waste, and remove limiting factors.

Peter then walked me through the renovated Emergency Department. I saw how Underwood increased the ED footprint, access points, and available rooms. The goal was to expand resources to allow more patients to come in through the ED…to improve patient throughput, and to create satisfied patients in a very competitive market. Peter shared with me satisfaction scores that increased significantly in the facility. 

Gulati reviewed companies responses to prior recessions based on the moves that they made. In terms of promotion-focused moves, companies could engage in “market development” and/or “asset investment”. In terms of prevention focused moves, they could reduce their employee head count, and/or engage in operational efficiency.

Underwood’s response would be categorized as one of hybrid approaches that Gulati saw as most efficient. In Gulati’s analysis, the companies that performed the best focused on operational efficiency (as a prevention-focused strategy), and market development and asset investment as promotion focused moves. Following a recession, Gulati saw companies that approached their market this way as having a 13% CAGR for sales and 12.2% for EBITDA over a three year period following the recession.  For comparison, companies that focused more on employee reduction (and not operational efficiency), with both market development and asset investment saw sales increase only 3.3% and EBITDA drop 5.2% over the same three year post-recession period.

Gulati simply explains that companies that respond to a slow down by reexamining aspects of their business model are poised to have their profits grow faster than those of competitors when demand returns. From my view, Underwood looks poised to be prepared for the “new normal.”

Following his career, Clarke became a General Manager and changed his first name to just Bob.  He held a variety of executive positions with the Flyers and, for a brief period, other NHL clubs.  Just this past week, Clarke was honored for his management success.  

One team Clarke managed was the (now defunct) Minnesota North Stars – which made a Cinderella run to the Stanley Cup in Clarke’s first year as a GM with the team.

Bob Ganey, North Stars coach, recalled Clarke’s management approach: “He’d pull out a pad of paper and he’d say, ‘What are our needs? Where are we weak?’ And then once that was established, it was, ‘How do we answer those needs? How do we attempt to solve those things?’ That’s a method of work that I still use, not only in my work capacity as a manager, but in other places. What’s the problem? Where are we weak? What do we need and how do we solve that problem?”

A simple approach…but an approach worth featuring as an example of excellence in operations.   To read more about Clarke’s management approach, go to the Flyers web site at:

http://flyers.nhl.com/club/news.htm?id=520693&navid=DL

HFMA has made available the full write-ups of the session in Philadelphia and in Houston.  You can access them by visiting the HFMA web site at either:

http://www.hfma.org/NR/rdonlyres/11530D88-40C8-45BE-9BF7-C383BEEFCCE8/0/400686ValueCareDeliveryRoundtable.pdf

Or

http://www.hfma.org/NR/rdonlyres/CABA400B-1F87-4C5C-B181-CCC497396E53/0/1075_Roundtable200910Aramark_w2.pdf

In the 2005 book, The John Deere Way, David Magee reports on Deere’s commitment to quality and customer service.  Quality extends far beyond the John Deere product lines and dealerships.  The total quality effort is what employees see…that quality in their daily work ultimately results in quality that the customer sees when they “get behind the wheel of a new yellow Deere 710 backhoe loader.”

Hospitals and tractors are certainly different animals, but the importance of quality processes is shared. In a recent blog (2/8/2010), Bob Wachter reviews Atul Gawande’s Checklist Manifesto. The insightful point that Wachter makes is that “the public is so unsettled by our patient safety and quality flaws… (because) they assume that we do know the right thing to do, but simply screwed it up.”  Wachter quotes Gawande: “… under conditions of true complexity – where the knowledge required exceeds that of any individual and unpredictability reigns – efforts to dictate everything from the center will fail.  People need room to act and adapt.” 

Says Gawande: “In a world in which success now requires large enterprises, teams of clinicians, high-risk technologies, and knowledge that outstrips any one person’s abilities, individual autonomy hardly seems the ideal we should aim for. ..what is needed, however is discipline…discipline is hard – harder than trustworthiness and skill and perhaps even than selflessness. We are by nature flawed and inconstant creatures. We can’t even keep from snacking between meals. We are built for novelty and excitement, not for careful attention to detail. Discipline is something we have to work at.”

Despite demonstrating that checklists produce results, there is resistance to their use because of the (1) Master of Universe mentality (Rock Star; Fighter Pilot; Hero), (2) our jobs are too complex to reduce to a checklist, (3) checklists are too rigid and don’t force us to look up and see and think ahead of what’s in front of us.

Gawande finds two pitfalls in our resistance – the fallibility of human memory when it comes to mundane, routine matters that are easily overlooked under the strain of more pressing events and secondly, people can lull themselves into skipping steps even when they remember them – after all certain steps don’t always matter…until one day they do.

The similarity to a manufacture of a tractor is startling – Gawande is stating that the people need to see the quality that they are producing, and be aware that it is quality based on an established process (like through a check list).  Gawande gave a great example of a cleanliness checklist used in intensive care units in all Michigan hospitals in 2003 to eliminate infections. Said Gawande (in his New Yorker article that inspired the book):  “ In December, 2006, the Keystone Initiative published its findings in a landmark article in The New England Journal of Medicine. Within the first three months of the project, the infection rate in Michigan’s I.C.U.s decreased by sixty-six per cent. The typical I.C.U.—including the ones at Sinai-Grace Hospital—cut its quarterly infection rate to zero. Michigan’s infection rates fell so low that its average I.C.U. outperformed ninety per cent of I.C.U.s nationwide. In the Keystone Initiative’s first eighteen months, the hospitals saved an estimated hundred and seventy-five million dollars in costs and more than fifteen hundred lives. The successes have been sustained for almost four years—all because of a stupid little checklist.”

Within hospital operations, I’ve seen how the successful application of a process called AIDET (Acknowledge, Introduce, Duration, Explanation and Thank You) when applied to support service workers creates a positive reaction within patients and leads to higher patient satisfaction scores. AIDET is a mnemonic device which really does serves as a checklist to support service workers when interfacing with patients. Click here to read Quint Studer’s application of AIDET. 

Like Deere, quality impacts the cost structure at hospitals in every area of the business. Successful hospitals see quality as all pervasive, and instill the camaraderie, discipline and processes in place to create a culture of quality. “The promise of quality always comes first” is from Magee’s work about Deere. Gawande would add that in hospitals, the process that ensures quality (a checklist) is part of that promise.

• Total number of scheduled maintenance work orders completed in a year as a function of the total number of capital equipment owned by the hospital
• Percentage of CE departments that have administrative support as a function of the number of FTEs
• Total number of FTEs in the CE department as a function of adjusted discharges
• The total number of pieces of capital equipment and unscheduled repairs completed in a year as a function of the hospital’s total patient occupancy percentage
• CE labor expense versus total CE expense
• Parts and supplies expense versus total CE expense
• Service contract expense versus total CE expense
• Total cost of management and maintenance of medical equipment (total CE expense) versus the total capital acquisition costs
• Total CE expense versus the total number of beds that are staffed and operated by each hospital
• Total CE expense versus adjusted patient discharges
• Total CE expense versus the total number of capital equipment it maintains
• Total CE expense versus the hospital’s total operating expense.

From this study, Dr. Wang concluded that using multiple comparisons (both financial and operational) one can gain valuable insights into the current performance of a CE department and find areas that deserve further scrutiny to reveal unique characteristics and/or opportunities for improvement.

For a briefer commentary on clinical technology benchmarking, Dr. Wang authored an article in the October 2009 issue of 24×7 magazine that focuses on technology and service solutions for biomed. Here is a link: http://www.24x7mag.com/issues/articles/2009-10_10.asp.

Initially created as a way for MedLine to raise awareness for its new line of pink gloves, it was done to increase Breast Cancer Awareness. However, it is also obvious that it involved staff at all levels at Providence St. Vincent Medical Center in Portland, Oregon, along with their supplier Medline. I especially enjoyed the environmental service workers dance with their high dusters, and food service people with their plates! What a great way to energize an organization, and have employees be front and center.

I guess it is not surprising that this hospital has been a Thomson Reuters 100 Top Hospital a phenomenal 10 times, last named in April 2009. Their focus on their employees is manifested by this quote on their web site from Janice Burger, chief executive of Providence St. Vincent. “Our highly skilled physicians, nurses and staff are dedicated to delivering outstanding, compassionate care to our patients and their families.”

With an administrative staff that puts their employees first, their patients benefit.

Great job, Providence St. Vincent.

Highlights:

• Press Ganey calls “Response to concerns/complaints” the “Number 1 priority” for our nation’s hospitals.
• Highest correlated item between HCAHPS “Likelihood to recommend” was “staff worked together to care for you.”
• In April 2008, CMS began requiring all hospitals to publicly report HCAHPS data. Only seven months later (October), Press Ganey data showed inpatient satisfaction scores climbed more significantly than at any other point in the 24 year history of Press Ganey (see chart on page 2 of report). The study reports (p. 14), “In October 2008 alone, Press Ganey found a 1.53 percent jump in the overall rating of a hospital and a 1.96 percent increase in the likelihood to recommend a hospital to family and friends, both unprecedented increases in the more than two decades that such data has been collected. Typically, satisfaction follows seasonal ups and downs, with a modest upward trend being found in the past decade.”

What gets measured (and reported)…improves! Thoughts?

According to Barbara Blundi Manaka PhD RN, Associate Director, Programs in Healthcare Management at Temple University, Philadelphia, PA, the concept in structuring the Management Grand Rounds program is to offer students opportunities to visit organizations that are outside the traditional student mindset of a healthcare provider.

In addition to myself, a number of ARAMARK Healthcare senior leaders spent some time talking to and advising the students in the areas of marketing, operations and human resources. There were some good lessons for the students including:

1. Healthcare is a process where care is delivered by more than the doctor and nurse.  Support service workers (food, environmental services and clinical technology management staff) play a significant role in patient satisfaction and clinical quality.
2. For a hospital to truly excel, everyone in the organization must focus on satisfaction, service excellence and operational efficiency.
3. With the difficult job market, five “quick tips” were reinforced for students who are interviewing. Those being:
   1. Be aggressive – finding a job is hard work; network!!!
   2. Stay Positive – don’t panic
   3. Compromise if necessary – pay expectations and further commute
   4. Do not give up – devote part of the day to job hunting and the rest to doing something positive
   5. Train for a new field – outsourcing may require a career field change

Temple graduate student Vicki Freedman frames her point.

ARAMARK Healthcare Vice President of Operations, Sebastian Mitchell, explains to Temple students the importance of staff motivation in meeting a hospital's goals.

From left, Barbara Blundi Manaka PhD RN, Associate Director, Programs in Healthcare Management at Temple University, Philadelphia, PA, discusses the practicum with Cheryl Camuso, Vice President of Marketing, and myself.