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Lean thinkers see the waste in health care when they are at the hospital gemba. I think this is true whether you are a lean person who is new to health care or if you’re a long-time hospital person who has learned lean. Experts (doctors) ranging from John Toussaint to Patricia Gabow to Don Berwick all estimate that between 30 to 50 percent of health care spending is waste.
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It seems that, often, when you take this sort of discussion to the general public, people react emotionally as if “reducing waste” equates to not providing people the care they deserve—they think lean health care is about taking away, instead of reducing cost and improving quality. I think this happens even outside of charged political circles. Why is that?
I have a theory.
Some of the common waste is described in this article about a new Master’s Degree program at Dartmouth:
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The Healthcare System is really fragmented sub-systems...
Trained, motivated people in new facilities with new technology are also working in the fast food industry. That's another industry that doesn't have a stellar reputation with customers. The problem in healthcare - just ask anyone who recently sat in an emergency room or waiting room - is a problem with incentives. There is no one who really believes they gain by improving the customer's experience or retaining the customer. Instead, doctors battle insurance companies. The insurance companies battle back. Hospitals, labs, drug companies, doctors and insurance companies don't treat people like customers. Large employers are seen as the "customers" for group health insurance plans. Employees at those companies have little control over the cost of their insurance plans or the relationship those insurance companies have with the doctors and hospitals. Insurance plans for small companies and individuals do not allow a reduction in coverage (and premium) if the insured agrees to waive certain types of claims. For example, an insurance company won't offer a policy that excludes maternity, drug treatment and diabetes coverage, even if I say I'm willing to exclude those things from my policy. Similarly, I cannot get a quote for health insurance that covers only cancer and heart disease, even if I agree to pay for sore throats, broken arms and annual physicals.
Improving some work processes to drive out waste and variation is possible in healthcare. Expecting those improvements to accrue to the financial and customer service experiences is flawed because the "customer" hasn't been identified correctly within the "system." Worse, the customer isn't the one paying the bills! Think lunch insurance!
Everyone Knows Healthcare is Slow and Error-prone
Anyone who has sat in a doctor's office or an emergency department waiting room knows healthcare is slow. Everyone knows someone who has had some sort of complication from treatment or surgery. Or they've read an article about wrong site brain surgeries (three times in the same hospital) or some other atrocity.
The public knows, but they don't think they have the power to change it.
Healthcare has to want to change. It's happening at some forward thinking hospitals like Virginia-Mason, Mayo Clinic, Cleveland Clinic and others, but it's not happening fast enough.
ED wait times, according to Press Ganey are still four hours, unchanged over the last decade. 10 years after To Err is Human found healthcare to be the eighth leading cause of accidental death, a Joint Commission article asked: "Is it better?" The physician's answer: "We don't know, because we don't really measure it." The public should ask: "Why not?" What get's measured, gets better, but healthcare isn't measuring as well as it could. There are measures, but most clinicians tell me that these numbers are underreported by a wide margin.
A few states now require hospitals to publicly report their errors, mistakes and mortalities. Every state needs to require it. And the public needs to demand it.
Healthcare has to want to get far faster, better and cheaper if it's going to pick up its part of the additional costs of universal healthcare. There's an estimated trillion dollars in waste, rework and unnecessary treatments that are waiting to be eliminated. Hospitals have to save $112 Billion ($2.5 million/hospital/year).
The methods and tools of Lean Six Sigma are easy, getting people motivated to use them to serve patients is much more difficult.
Jay Arthur is the author of Lean Six Sigma for Hospitals, McGraw-Hill, 2011. To find out more attend one of my free Lean Six Sigma for Healthcare webinars: www.qimacros.com/webinars/webinar-dates.html.
Quality
I think the public has heard of major healthcare errors (like Dennis Quaid's twins), but my impression is that people think it's always an anomaly (a bad person) as opposed to continual systemic risk. We all too easily and quickly blame a bad person and don't clamor for the process to be improved.
If the public is aware of bad quality, they certainly are clamoring loudly for healthcare quality to improve.
Maybe people tolerate the waiting because they assume quality would suffer if the doctor went faster, although we know (with lean) that efficiency and quality (and cost) go hand in hand.
Health Care Cost -- Key Issues Must Begin to be addressed
David McGan
I'll share my recent experience this summer. I'm becoming extremely frustrated that nobody seems to be addressing the significant issues below in my letter published in my local newspaper.
True Health Care Reform Essential
The subject of Health Care Reform over the past 18 months appears to be largely focused only on a system that will provide availability of Health Care insurance to everyone. The cost to taxpayers of such a system will be high. Most agree that current health care insurance premiums will continue to rise. One of the barriers to business expansion repeatedly expressed by business leaders is the unknown associated with future health care cost.
I’m concerned that the discussion seems to be centered only on providing health care insurance to everyone. In reality, it is the rapidly escalating cost of Health Care itself which is the elephant in the room. Without radical, targeted efforts to reduce the real costs of Health Care, and major improvement in the efficiency of Health Care delivery, current attempts to “make Health Care available to everyone” could ultimately bankrupt the United States.
Case in point: I experienced a kidney stone attack on Saturday of the Memorial Day weekend. After attempting without much success to deal with the pain for the entire day, I ultimately sought treatment that night at the emergency room, being unaware of any other alternative treatment options available at that time. After an approximate 2-hour visit, I was sent home with a prescription for pain control (which is all I really wanted in the first place) and referred to an urologist.
The bill for that 2-hour visit? Over $6500. The follow-up to the urologist? $500. Total cost (not including medications): $7000 plus. While I’m grateful that I am somewhat covered by insurance, my out of pocket share still came to about $2000. After seeing that bill, I really needed pain medication.
Why so high a cost? I requested and received a detailed billing from the hospital. The ER visit included two CT scans to determine if my problem was a kidney stone and where it might be. CT Scans: $3700, plus approximately $500 to interpret the CT Scan. Why a CT scan instead of a much less costly X-Ray? While in ER, the initial reason offered was that the hospital had no radiologist on duty on the weekend to read the x-ray, so a CT scan was ordered, and the file transmitted to a radiologist in Australia.
After further questioning whether such an expensive test as CT Scans was appropriate treatment, I was told that CT Scans have become the “Gold Standard,” replacing X-Ray for diagnosis of kidney stones. It was also suggested to me that concern for possible malpractice suits is a partial reason that CT Scans are ordered to help minimize the chance of being sued later on. How many other “common,” less expensive tests have been replaced by similarly expensive “Gold Standards?” Is it realistic to think that the nation’s health care system can afford these types of “Gold Standards” for common, easily diagnosed medical issues and at the same time expect to pay for all these expensive diagnostic tests for everyone in the US?
What will it take? Tort reform is a good place to start. Re-examining current treatment protocols should be undertaken. Availability of 24-hour walk-in clinics would be less expensive to operate than Emergency Rooms. Readily available cost information of treatment options would help the consumer make more informed decisions concerning treatment.
The health care industry MUST begin to truly focus on identifying and eliminating Waste and Non-Value Added activities in the current health care system, then aggressively target many of them for reduction or elimination. Industries in the Manufacturing sector have made great strides in these types of continuous improvement activities. These methods are also beginning to be utilized in the Health Care industry, with some pretty amazing results. However, much of the current Health Care activity is focused on Patient Safety. However, all this activity is but a blip in the current national health care debate.
The current focus on Health Care Reform must shift from its costly “insurance for everyone” focus to one of attacking and eliminating the root causes of health care costs – inefficient delivery of services, waste and non-value-added activities in the current system, and the ever-present tort litigation elephant in the room. Perhaps Mr. Obama’s recently appointed “Lean Health Care Czar” will begin to look at a truly coordinated health care COST control effort across the nation. “If we can send a man to the moon……”
P.S. The stone passed the following Tuesday. The follow-up x-ray ($250 vs $4200 for CT Scans) indicated additional stones in both kidneys. How much will it cost the next time?
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