Performance Excellence Summit Welcome Address

Photo by razihusin/iStock / Getty Images
Photo by razihusin/iStock / Getty Images

Last week Hospital IQ was invited to chair the Healthcare Focus day of the 2016 Performance Excellence Summit in San Francisco.  We were honored to present in front of so many quality improvement and business process leaders.  Below is the speech given by Ben Resner, VP Solutions of Hospital IQ to open the day.

We’re here today to talk about making healthcare better through improved processes that create efficiencies and reduce errors.  I’m really looking forward to this conference because it’s a group of like-minded people where I don’t have to explain myself.  Part of my job at Hospital IQ is demoing our product, and for a lot of hospitals, we’ll spend the first 20 minutes just giving a background on operations research and process improvement.  Yes, it’s a “thing” and yes it can help your hospital.  And yes, I’m flattered that you think I invented this but I really can’t take credit.  Today you will meet a group of innovative people who have all drunk the kool-aid and are fully committed to using data to improve healthcare.

And I use the word “innovative” deliberately because for many in the healthcare landscape, “innovation” simply means new ways of extracting payment from insurers.  What we’re talking about today is true innovation through operational efficiency and process improvement – doing more healing and wellness with less waste, fewer resources, and fewer mistakes.  We’re not simply sloshing cost from one bucket to another bucket with shenanigans that don’t actually improve quality.

For those of us here today, "innovation" means developing tools and culture to identify and execute on opportunities for care coordination that removes bottlenecks.  It means doing more surgeries with fewer complications, using less staff overtime and less patient waiting.  It means getting patients to the right bed at the right time with a distraction-free handoff.  It means looking at the hospital holistically so the effect of resource allocations in one part of the hospital can be understood to impact other parts of the hospital.

This type of true innovation is much more challenging than revenue cycle management.  It's not an invisible back-room process that can be plugged into an existing patient flow with no change to the clinical staff.  The change we’re talking about requires leadership that can cross departmental boundaries and supervise cultural change in how hospitals operate.   For operational efficiency to be realized, hospital staff from surgeons to CNAs need to adapt their behavior.

While true operational efficiency is hard to achieve in practice, it’s fundamentally a collaborative endeavor.  It doesn’t pit healthcare stakeholders against each other.  There’s no intrinsic us versus them.  It’s not payers versus providers or industry consolidation versus regional competition.  Nobody is rooting for more hospital acquired infections or greater ED wait times.  We don’t need to give one story to the CFO and a different story to the CMO. 

This is not to say process improvement is a hand-holding kumbaya moment – people certainly disagree about whether a program helps or hurts patients or, as one client put it, “is the juice worth the squeeze”?  But everyone wants the same outcome; we’re just arguing about how to get there.  As programs are demonstrated to work and are cost-effective, there’s rarely credible non-political pushback against widespread implementation.  (Political pushback is another story and nobody denies it exists.)

Many of us come from industry and look to companies like Toyota and Amazon to inspire models of efficiency.  How many of us have read an article or blog talking about how hospitals would be better if run more like a hotel, theme park, air traffic control tower, aircraft carrier, automotive factory, etc?  How many of us have written one?  At a minimum, we all come from hospitals that give lip service to moving in this direction.  At best, there are true leaders who are pushing hospitals to be run efficiently.

Any quality improvement project must show a return on investment in order to move out of the trial phase.  This is the only way to get the sustained attention of hospital leadership.  Our job is to not just socialize these changes but to show hard ROI.  Until that happens, we might be more correctly classified as part of a hospital’s marketing and outreach than the core infrastructure.  It’s a great challenge but every other modern industry has been totally transformed by operation science.  Now it is healthcare’s turn.

A cornerstone of ROI-driven cultural change is a robust data operation.  The good news on this front is that data has gone from non-existent paper records to awful electronic ones.  We’ve finally gotten to awful.  Yeah!  But we can work with awful.  We’ve been able to find signal in this noise.  And I believe that as we demonstrate the value of this data the quality will improve.  As clinicians feeding electronic health records see the utility and impact of accurate data, these clinicians will become more engaged.  Clinicians will be more diligent about raw data entry and leadership will be more demanding of tools that support accuracy over box-checking.

What has taken healthcare so long?  Is it just because of how we consume and pay for healthcare?  Or is there something else?  Is healthcare somehow different than a factory or hotel?  When I’ve done a good job describing what I do to people outside healthcare, their reaction is almost universally “you mean hospitals don’t already do that?”  Most people are surprised to learn that future inpatient elective admissions are not routinely reconciled against anticipated census to make sure there’s a bed for the patient after surgery is completed.  If an inpatient case can fit into the surgical schedule, it gets booked – no questions asked.  In all fairness, airlines and hotels also overbook but they use historical data to specifically calculate how many overbooks to accept in order to achieve a targeted rate of actual bumped customers.  Most hospitals treat bumped cases and overcrowding as a random external event totally out of their control – kinda like the weather. 

I don't think anyone can deny that healthcare is different.  For example, unlike cars and iPhones, humans were not designed for serviceability.  Healthcare is more like expecting Toyota to build a facility for repairing iPhones but not having any access to the people who actually built the iPhone.  A key part of factory process improvement is feedback and unless I’m mistaken, there’s no process where front-line clinicians can impact the fundamental design of humans.  We all see failure-prone plumbing and infected vestigial appendages and there’s nothing we can do about it.  Hospitals are basically tasked with servicing a product they did not design or build and had to reverse-engineer all the operating parameters.

That said, much of healthcare is like a factory.  Research consistently shows correlations between procedural volume and outcome.  Aggregating similar patients to high volume shops produces better results at lower cost.  Results improve even more when throughput is steady and predictable.  Nobody would expect iPhones to maintain their quality if managers forced workers to produce twice as many on Monday than Friday.  But somehow we expect this with hospitals and act surprised when variability impacts quality.

We need to take the right lessons from factory automation and logistics.  When the Wright brothers were developing the airplane, like so many other inventors, they looked to birds for inspiration.  But unlike previous attempts at controlled flight, the Wright brothers correctly understood flapping of wings to be about propulsion and not lift.  Flapping made birds go forward but it didn’t make them fly.  The lesson they took from birds was the airfoil -- the wing's cross section.  And they wisely kept the airfoil but replaced flapping with a propeller.  In healthcare, we need to apply the same thoughtful diligence and sensitivity to our work.  We need to know what is flapping and what is geometry.  Blindly copying every lesson from factory logistics will wind up looking like those black & white movies of failed frantically flapping flying machines we saw in junior high that are supposed to illustrate the irrepressible scrappy spirit of innovation based on a deeply flawed premise.  I don’t think any of us want to be that.

There is so much opportunity for hospitals to catch up to every other modern data-driven professionally managed industry.  How many of you are six-sigma black belts?  Six sigma means 3.4 defect per million.  For so many aspects of hospital operations, just getting to two or three sigmas is an accomplishment.  Wait time in the ED under 4 hours?  Discharge boarding under 8 hours?  Where do we start?

Healthcare is also unique because for so many – I think most –  of its participants, it is a mission-driven industry.  By this I mean doctors and nurses go into healthcare for a genuine desire to provide healing and care.  Yes, the salaries and status are appealing but I believe that fundamentally the majority of clinicians are in it to help people. By contrast, if I were to assert that investment bankers are truly motivated by a genuine desire to help humanity by efficiently allocating capital to the most worth enterprise, most would laugh.  Investment bankers are about the money and there’s absolutely nothing wrong with that.  But here healthcare is also different and our programs and products need to reflect that core value.  The goal of data-driven operational efficiency and quality improvement is to make it easier for hard-working and well-meaning clinicians to practice their craft with the best infrastructure and processes to lead to the best possible outcomes.