6) Making Healthcare Waste Reduction and Patient Safety Actionable

Session #6 – Making Healthcare Waste Reduction and Patient Safety Actionable

[Female Facilitator]

I am pleased this afternoon to introduce our speakers and analysts for session 6 – Making Healthcare Waste Reduction and Patient Safety Actionable.  First, we have Dr. David A. Burton.  Dr. Burton is the former executive chairman and CEO of Health Catalyst and he currently serves as a vice president, future product strategy.  Before his first retirement, Dr. Burton served in a variety of executive positions in his 23-year career at Intermountain Healthcare, including founding Intermountain’s managed care plans and serving as a Senior Vice President and member of the Executive Committee.  He holds an MD from Columbia University, did residency training in the internal medicine at Massachusetts General, and was board certified in Emergency Medicine.

We also have Greg Stock.  Mr. Stock has served for over 20 years as CEO of Thibodaux Regional Medical Center in Louisiana.  He holds bachelors and masters degrees from Brigham Young University.  He has served as CEO in three different HCA hospitals and in Northwest Hospital System in Arkansas.  His career has been characterized by success stories of financial turnarounds, programmatic growth, and growth in relationships with key stakeholders.

And along with our presenters, Dr. Burton and Mr. Stock, we also have a team of analysts similar to what you saw this morning, who will be running the polls and sharing insights.  These gentlemen are seated over here.  We have Brian, John, Patrick, and Joe.

Now, please join me in welcoming Dr. Burton.


[David A. Burton, MD]

Thank you very much.  It’s a pleasure to be with you here and to talk about some tactical and implementation strategies.  I want to start out just by sharing with you a flow diagram which I’ve been working on now for about 20 years and it keeps changing, and it is an attempt to capture on one slide how the healthcare delivery system works.  At the top, you can see that patients enter the delivery system through two routes, one may be through an abnormality on a screening test; the other may be because they have symptoms.  That prompts a diagnostic workup and starting with symptoms and signs, physical exam, and then leading to laboratory and imaging studies, and that leads us to a provisional diagnosis, which is the basis then of triaging to a treatment venue.

And we show here three treatment venues, the clinic care space over on the left, the acute medical, so general med-surg and  ICU in the middle, and then invasive, consisting of both medical interventional, as well as surgery.  As we flow down through the clinic care, there are two broad categories.  One is that we have illnesses that are non-recurrent, like a sore throat.  And then we have chronic diseases.  And as we go on down, we have referral in some cases to invasive surgical clinics or to chronic medical subspecialist.  In the center stream, we have acute medical, general med-surg, acute beds, and acute medical ICU and within those, the bedside care.  Over to the right, we have the two invasive medical streams going to procedures, post procedure care, and then either discharged back to home or some post-acute care or being admitted.

Now, there are decisions points along the way where we have an opportunity to intervene and change both the quality and the cost of care.  The first two categories are based on care process models and the care process model is a conceptual flow diagram which tracks the scientific flow of the care.  The orange boxes that you see here are points of decision with regard to whether to order care or not.  So in the diagnostic workup, there are tests that are contributory or diagnostic and there are tests that are wasteful.  In the triage criteria, sending someone who is sick enough that they should be admitted to clinic care management may result in fact in a crash and an admission to an ICU bed.  On the other hand, sending someone to be admitted who could be cared for in a clinic setting is likewise wasteful.  As we traverse down the clinic care space, we have treatment and monitoring algorithms.  So, how frequently should the patient be seen, how often should key indicators be measured as far as lab or imaging studies.  And then if we are not getting to our target, what are the indications that suggest that we should refer either to an invasive subspecialist or to a chronic disease specialist.  And the chronic disease specialist, likewise, have analogous treatment in monitoring algorithms for the sickest of the patients.

As we look at the next and one final one there over to the right, there are indications for intervention.  So just because someone is referred to an invasive subspecialist does not mean that every one of them should get a procedure.  There are indications for additional diagnostic testing like a cardiac cath, for example, and then based on the findings, whether or not an intervention is justified.

Once we have decided that it’s appropriate to do something, we get to the blue boxes.  And the blue boxes are the physician aspect of per case care.  So this is ordering things within the case.  The biggest category here really is the category of the order sets, what do I include in an order set and how many different varieties of order sets, how standardized am I there.

And then within those orders are some major categories, such as substance selection.  So that would include what antibiotics do I use, what other pharmaceuticals.  It also includes indications for utilization of blood products.  There are pre-op and post-op orders and all of those things are subject to standardization with reduction of waste.

Then finally when the care that is ordered within a case is translated into bedside care, we use different tools.  So now we’re looking at workflow tools like value stream maps and A3’s and that’s what is depicted here by the green boxes, where the primary fundamental knowledge resides in nurses, technologists, therapists, and so on, and they are responsible for the efficiency and the safety with which the care is delivered.  So those are the three dimensions, if you will, of the anatomy of healthcare delivery.  There is out on our website a much more detailed whitepaper about that if you have interest in it.

If we look at this from a different perspective, there are three forms of utilization management within population health management.  The first is, as we said a minute ago, deciding whether or not to do something.  And because they are population utilization management criteria, they are typically measured in per thousand members or per thousand patients, but more typically members.  The second category is we’ve decided that there is something that needs to be done, and now rather than focusing on population indications, I am focused on an individual patient and I’m at a per case level and there I’m looking at cost per case, OR minutes, L&D minutes, things like that.  And finally I get over into the implementation of the care that is ordered and that gets us into the green boxes with complementary metrics as far as the staffing and the costs are concerned.

Now as we visit today we’re going to talk about three types of waste.  The first is ordering waste.  And so they are the waste that comes in the form of ordering tests or care or substances or supplies that don’t add value.  The second is workflow waste and that reflects variation in the efficiency of delivering the test, the care, and the procedures that were ordered.  And in the process of delivering that care is where defects occur or patient injury.  And so those are the patient injuries incurred as we deliver the test, the care, and the procedures that were ordered.

So with that, we’d like to have you answer the first poll questions.  In your experience, which forms of waste do you feel have the greatest opportunity for cost savings in your organization?  Go ahead and go on to session 6 and answer the three possibilities there.

[Male Facilitator]

Thanks Dr. Burton.  So again, please navigate in your mobile application to session 6.  This is question #1.  I’ll read it one more time.  Which forms of waste do you feel have the greatest opportunity for cost savings in your organization?  So we’ll give you a few more seconds to log in those answers and then we’ll see the results.

Okay.  We will now show the results.  So once again, we have the question, what forms of waste you felt the greatest opportunity for cost savings, and the answers, Dr. Burton, were A – 35%, B – 48%, and C – 60%.

[David A. Burton, MD]

This is a pretty astute audience.  So we’ve got a great… We’ll get quite quantitative with you in a moment.  Now, I’d like to turn the time over to Greg.  And just with the introduction that at Greg’s facility I think he would be the first to say we don’t have optimal physician engagement.  And we wanted Greg to share with you what he has been able to accomplish by engaging and empowering the nurses, the therapists, the technologists and creating a learning environment in his organization, even though it doesn’t have optimal full-blown physician engagement.  And what we hope that would do is remind folks of the notion that unless and until you have physician engagement and can do the population aspect of this, you’re stymied.  You can’t do a lot.  And I think you’ll see from Greg’s presentation there is an awful lot with regard to workflow and patient safety that is actionable with what you already have within your grasp.

So, Greg…

[Greg Stock]

Hello everybody.  Good afternoon.  Can you hear me okay in the back?  It’s a pleasure to be here.  I actually grew up in Arizona from the mountains on a ranch and ended up down the swamps and valleys of South Louisiana.  A bunch of occasions they are with me here today.  I’ve been down there, as Dr. Burton said, for quite a while now, over 20 years.  I actually left there once and came back.  We have a couple of our physicians here, Dr. Money, as we would call him probably as the infectious disease, Dr. Patten, Pulmonary Critical Care, and we appreciate having them here.  So Thibodaux Regional is a Parish hospital, equivalent of a county hospital, 185 beds, 180 plus million in net revenue, 1,100 employees, 150 doctors on the active medical staff and 250 on the total medical staff.  We do about 40,000 in ER visits, 11,000 surgical cases a year.  We have a heart program.  We do bypass, valves, and so forth.  We have three neurosurgeons that only work at our shop, the spine center, orthopedic center, vaccines and some other things.  Five oncologists.  We have a pretty nice cancer center, I think, for a community hospital and by and large we take care of quite a few people and we serve a 5-Parish area.  There are four other hospitals within 15 miles of us and New Orleans is an hour away and Baton Rouge is an hour away.  You have heard of the Landry’s, the swamp people.  We have people related at them.  That’s the rest of the story.

Okay.  So, when I came back to Thibodaux from Arkansas in Northwest Arkansas, the question was, what do we do now?  I spent several months working on this and came up with some of the stuff, a little bit of the stuff you’ll see here.  But it begins with a vision.  What is your vision?  And can people relate to the vision and is it compelling enough that they will actually get in line and go to work and do a thousand things that you can never think of doing yourself because they believe in the vision and they act of their own volition, and they kept thinking about what’s the heart and core of that and concluded it’s the patient.  It is the patient.  So we had lots of discussions in our hospital about this question, why are we here, why are we here.

And out of that, this was 2000, a long time ago, out of that came this and my discussion with the executive team, this term patient-centered excellence, patient-centered excellence.  So that connotates a couple of things – one is that the patient is the center of it; and second is how well are we going to do this?  Are we just going to be there or are we going to achieve excellence?  And from then, you can begin began to discuss what is excellence, tell me what it is.  I asked the nursing director.  “Okay, Brenda (she’s a great person, she’s retiring this month), tell me what excellence is?”  And it’s not just clinical, it’s everything because I don’t think you can sort of compartmentalize that.  We don’t want to.  I don’t think you do either.  So I’ve turned to CFO and said, “Steve, tell me what excellence is in the financial performance of this hospital.”  You know, those were interesting discussions and conversations.  They’ve got alignment on the executive team level.  Then we went through the whole hospital, if you will, doing the same thing.  Part of that excellence is a term that I heard somebody say somewhere and I’ve kind of kept it as “the one-eyed man is king in the land of the blind.”  Do you get what I’m saying?  “The one-eyed man is king in the land of the blind.”  This is not to denigrate all unbelievably great people in our business but who are we comparing ourselves to?  Are you with me?

I have members of young CEO.  That’s a big mistake.  I’d look at these numbers and if we were a little north to south of the national average, I was good with it.  Some of you had done that?  And you start looking at the data and understand the difference.  It’s an eye-opener.  And really, what is the potential we have if we’re willing to challenge ourselves.  So that was part of that.  The last part of it was believing that we could, and there are people that don’t believe you can, especially in a community hospital that you can for what you do perform at the highest level.  And we began to instill that in everybody right away that, yes, we think we can.  We think we can.

Okay.  So, I went to John Deere and spent a week at John Deere’s headquarters about that time and with their process improvement people.  They know some stuff about healthcare.  They had a graphic up there in those bean fields and cornfields.  You know, in a way that was a sailing ship.  I thought it seemed a little ironic to me but we have plenty of water where we live and ships and boats and things are part of our culture.  So anyway, after 18 iterations, we put this together and we can tell our whole story out from this one graphic, but this is the second question.  So the first question again is why are we here and we dwell on that and we try to connect the values of people’s values, we try to touch their hearts actually and their values, their inner core, their self, why we do this.  It’s the right thing to do.

Second is where are we going?  Where are we going?  And you can see these winds have changed.  That was 2000 when that was put together.  The winds have changed its course.  They’re blowing really hard today and you can see along on the side there what’s happening to some facilities.  A number of those hospitals I just mentioned are no longer what they were originally.  They are operated by somebody else, mostly because they’ve got into financial trouble.  But we tried to stay rigid on what is a great hospital.  So we can actually drill down from that.  Great hospital has great clinical care.  Great hospital has great emotional care, if you want to call it that, the patient experience.  A great hospital has great technology and has great processes, and we can just bang away at that with staff and help them, help all of us I should say, understand what it is to be in a great hospital and do employer orientation.  I did this a couple of days ago.  I asked the people and there were 25 of them there, “Tell me what’s a great hospital?  What would it be like to be in a great hospital?”  It’s interesting to hear what they had to say.  It’s a lot about how people would speak to you, how you’d be treated with respected and those kind of things.  Safety usually comes out of that discussion.  A great hospital is one where I feel safe, I trust the caregivers and the people, and it feels safe to me.

So the third question, I’ll move on from that, is how to do we get there?  How do we get there?  So to enable ourselves to achieve this excellence, because excellence is tough, is really difficult.  What are we going to do?  We have to have something with some power to overcome both internal opposition and external.  When we did this, we forgot about who we were competing with.  We cut that conversation off.  It’s about what we have control over ourselves.  There’s enough there, plenty enough there, to move the log and try and wait down the road without worrying about them.

As you can see on that second sail there, there’s some things there, Six Sigma, Lean.  DIGs are a version of GEs worked out.  And in 2000 we implemented Six Sigma and we really went after it.  There was a lot that come up in that and that was Six Sigma is data driven and it’s great where people could sit around the table and say, what do you think it is?  Or what do you think the problem is?  Here’s this data and accountability and everything that goes with that.  And really culturally, part of the cultural transformation that took place then was significant.

And then Lean, a year later.  GE wasn’t implementing Lean.  We went outside of healthcare to learn Lean.  We went to Florida and trained two of our people and implemented Lean and since that time I think it’s really helped us.  We’re a leaner hospital.  When you work on processes for a decade, hopefully you’re making those a lot better.  Little ones, big ones, in between.  We have plenty of examples of that.

So, those were the cultural part of the transformation.  It was big.  We wrote these behavioral standards.  So if you have respect, which is a value, how do people know that, and how do you hold people accountable for that.  We had a few people that weren’t and we let them go.  I mean we wrote those standards in October of 1999 and January 1, 2000, and we said, from here on, you have to walk the talk or you can’t work here.  And some of those people were good people in a way but they just, they couldn’t handle that part of it and, you know, they’re working for our competitors, which is okay with us.

Alright.  So, today we’re here with these three things that seems like patient experience, clinical quality and cost-effective care, the Triple Aim that’s well known by everybody now.  And you know, in terms of where do you go, this is a pretty good place to go I think because you can’t figure out, at least I can, exactly what’s going to be in our market 24 months from now.  Just don’t know.  I have ideas and it’s constantly changing but I know this, if we can excel in these three areas, I feel like then we can play and we can adapt to whatever else is out there and we can survive.  We might even be able to thrive in that sense.  And that’s what we’ve been up to and what we’ve been doing now for a while.   So let’s just talk about a few of those things.  On the patient experience, of course these are HCAHPS scores and we’re on that left hand column.  The next column is probably our biggest competitor.  They’re about 12 miles away, 350 beds.  Ochsner system is all around us really.  The Lake, and we have somebody from the Lake here.

So, these are – the Cleveland Clinic, we put the Cleveland Clinic in there.  Sometimes we compare to the Mayo Clinic and Scottsdale.  They have some of the top numbers from what I’ve seen and we’ll line up with them.  And so, we’ll look for whoever is the best and start trying to figure out how to close the gap between us and them.

Let’s take the third one down real quick.  Patients “Always” receive help as soon as they wanted.  That would be a pretty important item, wouldn’t it?  To me, that’s a reflection of nursing care and other caregivers, direct care right there on the patient.  This is all inpatient, patient force, and probably could be correlated, and some of you may know how to do this, to clinical outcomes.  Do you agree?  Do you agree with that, Dr. Burton?  Response to the patient how quickly the patient’s needs are attended to would correlate to clinical outcomes, might correlate to length of stay.  I don’t know what.  Various things.

So, you know that these numbers are hard to move.  To go from 68 to 70, for example, doesn’t seem like much but from my experience, my viewpoint, very difficult to move it.  The very bottom down there, patients reported YES, they would definitely recommend the hospital, about 83% said yes.  Our competitor, 69%.  Ochsner 70%.  That’s a huge gap and we’re real happy with that because what that means to me in our neighborhood, in our region, people are going out and saying, yes, they would definitely recommend our hospital.  Okay.

So this is – I hope to say this right – this is not about just awards or something but it’s a form of measurement for me.  And so these are some of the awards in the bottom right.  That’s a top 5% for three years in a row in Press Ganey system.  We have nine of those.  So we tried to define excellence is not going there once and then you just follow off the map.  Excellence is you built something that sustains itself at that high level.  That’s what we’re after.  The JD Power awards, we have those distinguished hospital awards, nine of them.  The Healthgrades, that’s top 5% in patient safety.  We have I think three of those and in the patient experience.  This is Malcolm Baldrige stuff down here on the bottom left.  That’s a state quality award.  I kind of like that clinical cancer, that’s accreditation but you know, as I understand at the American College of Surgeons, they review everybody during the course of the year.  They sort of rank these hospitals in a way that, I don’t know if they do it numerically, but there’s a few that are given outstanding achievement award and it’s above everybody else frankly.  That’s American College of Surgeons.  There may be clinical oncology people and you’ll know this better than me but in our last three cycles of being accredited, we received that.  I think there’s one other facility in Louisiana that has.  And so, that means something, I think, to me.  But the other thing with this stuff is that others are getting better.  I guess everybody knows that you can’t sit still.  You have to keep moving and improving and these are numbers today.

Okay.  So I’m just going to move through these.  I think a lot of hospitals can show that they’ve done this sort of thing.  When I saw how we could move it all like that, I felt, you know, I honestly felt bad about it a little bit because the question is why didn’t we do this before?  Alright.  We could have done this.  Why didn’t we get focused and do it before?  So these are pressure ulcers that’s not because the case mix index went down, it actually went up.

This is LeapFrog.  This is just a few weeks ago.  So, they rate hospitals A through D, right?  And we were rated an A and here are these other rated, different ratings.  I think Ochsner’s main campus was a C.  So they can argue those numbers and suggest one of those measurement tools that’s out there.  But here’s a great question.  What’s the difference in that market basket of clinical indicators that are included in this, such as trauma, falls, instruments or whatever left in the body after surgery, and hospital-acquired infections?  That’s just 3 of about 20 or 25 indicators.  What’s the difference in the performance of an A hospital and a B or a C?  And from all I can tell, it’s pretty significant.  Somebody in here know that?  Does anybody know that?  So it may be something like this.  The difference between an A and B hospital for hospital-acquired infections is that an ‘A’ hospital has 33% less chance of getting a hospital-acquired infection.

I have a brother that passed away from a hospital-acquired infection.  It was a difficult situation, very difficult for the family to handle.  And so, when we really consider what it is and how it affects people, it’s kind of a serious subject.  That’s a difference in performance, as best as we can tell.

I’d like to go to cost for a minute or two.  So these are Medicare cost per discharge, Case Mix Adjusted.  This data is about a year old.  So here’s Thibodaux on the left $4,370 per discharge.  Ochsner – the second one actually is Terrebonne General, which is that other hospital 12 miles away.  The third one is Ochsner.  So over time through what Dr. Burton referred to, we’ve been able to lean the hospital out and get our cost down where we’re able to do this going into the eye of the storm.  What’s the difference in $5,600 and $4,370 per discharge times, let’s say $8,000 or $9,000 discharges?  How much does that affect the bottom line of our hospitals?  Not someone somewhere else.  The difference is a million dollars a month to your bottom line.  So we have no special reimbursement.  Our case mix is above average but is not way up there.  Our Medicaid is about 11%, our Medicare is 55% of our business, and so forth.  There’s nothing special about it.  But $12 million a year and for Ochsner, the difference would be $18 million a year.  And just think about that over 5 years how many dollars that is.  A lot of hospitals don’t have a $12 million bottom line, do they?  They wish I’d been in them.  I had been in them looking from the backend, wondering why the trap, the guys didn’t get on the frontend get after it and figure out how to get these things done.

Okay.  Alright.  So we have no debt.  That’s for us something at one point that we said we turned the tax revenues in 1993 back to the local government.  And so we have no tax revenues, we have no special reimbursement.  That 14 numbers is actually 480.  So that enables us to have the independence to do things and not have to – we can last through some difficult times if we continue to function like this and it allows us to acquire technology and things that when it’s there, we can go get it.  Here’s an old example of that, writing GE a check for $10 million once and another for $8 million and these things weren’t even budgeted but the time was right to acquire them because we had the financial ability we could do it.

Okay.  We had some other people look at their cost scores for Teche, two guys and so forth and so forth and they came back and said, “Greg, you have good news and bad news.”  Okay.  “So the good news you’re the low-cost provider.  Bad news, you’re the low-cost provider.”  And by that it means where else are you going to go?  Where are you going to go with this, in the future where the pressures are tremendous?  They are today, it’s not in the future.  All the cuts, I have 12 different ways that we’ve been cut.  You know, the shift in inpatient to outpatient on these short stays, really that’s a big hit for hospitals.

So, that points so much to this conversation where we are today in that.  I’d like to talk about staff for a minute or two.  They’re such a critical part of it.  So this is Press Ganey measurement of employee satisfaction and engagement, both.  And there’s probably people from this room that use this.  But you know, front the frontline managers all the way to the senior managers, how well do we engage in our staff?  We work hard at this and it’s not easy to do them.  My opinion, it’s felt like patient care.  It’s pretty tough. And yeah, I’m so happy when we have results like this.  We’re getting ready now to do another survey here in November.  But that’s critical for us.

Now, this, I don’t think I have time to mess with this too much but here’s a kind of stuff that differentiates hospitals going forward.  If you’re part of a clinically integrated network and they look at you and say, what are your costs to provide care and your staffing is way higher and your clinical outcomes aren’t so good.  You’re a less desirable partner.  Right?  So here, these revenue numbers, high revenue is actually 182,000 I think this year and there’s this up a little bit higher than ours.  So there’s our actual dollars and percent.  You see that 49% size and benefits as a percent of that revenue?  Let’s take in that second line and calculating what percent it is of their net revenue.  It’s relating your salary cost and benefit cost to the amount of payment you’re receiving.  And so, you can see the difference is pretty significant.  Just on that one, it’s about a $14 million difference between the two hospitals.  This is something that in exchange and even in the data, I hope I’m not going in the wrong direction with this, but we try very hard to keep the heart and soul of our hospital alive.  We don’t want to ever lose that ever.  And from beginning with me and everyone else, I can’t just talk business talk every second to people and expect them to perform out of this world, which is the kind of performance we need.  And so, we pay a lot of attention to how people are treated.  I had a discussion with the senior manager the other day and it was an eyeball-to-eyeball discussion about how he had spoken to some of the staff.  And I don’t think he liked it too well, but I explained to him he’s kind of new to our organization, that’s not how we work here.  You’ll have to work somewhere else if you can’t fix that.  That’s not the way we treat people.  So, our culture, our connectivity, leadership, and so forth, is real critical to us.

This is from Six Sigma, this is the team role, first out on Motorola, that originate at Six Sigma.  And so, people can’t really change unless they become aware that they need to change and usually almost always that’s through data.  The right thing that’s been the center of the sort of the discussion here, which gives you knowledge that you didn’t have before.  I didn’t know that.  You can apply that to employee satisfaction engagement survey.  We had a pharmacist, director of pharmacy and everybody thought he was a great leader until we surveyed his staff.  And then he had to come up, he’s a great guy, you know, and he took that challenge.  He didn’t quit and he went to work and he improved it tremendously.  That data gave him knowledge he didn’t that changed his beliefs about certain things, how he related to the staff and recognized them or didn’t recognize them.  Then he began to value those things differently.  When you come up those steps, there can be a passion that just gets inside of you that is powerful.  And somebody who said that passion is the root of all real change.  Passion is the root of all real change.

So, question #4, how engaged is your medical staff in the healthcare transformation?

[Male Facilitator)

Thank you, Greg.  So we will do question #4.  Again, please go to your mobile application, session 6, question #4, and we will give you a few more seconds and then we’ll show the results.  A few more seconds here.  Okay.

So here are the results to the question, how engaged is your medical staff, the answer B was 19%, C the largest at 45%, moderately engaged, and then the other three were lower down, Greg.  Back to you.

[Greg Stock]

So Kotter wrote these books, a couple of them I’d recommend to you if you haven’t read them, you probably have about leadership and transformation.  One time on the radio I heard this woman interviewing Willie Nelson and she began by asking him “what’s the key to your success?”  And he said, “We play good music.”  And I think that’s a challenge for us as we really have to perform and we have to do a great job of what we’re doing.  And the last thing is somewhere in all of this, we’ve all got to get upstream where we can help prevent a lot of the cost and quality issues, debts, all sorts of things.  And so, we are pursuing a wellness center, we have a 230,000 sq. ft. wellness center that’s under construction.  Thank you.

[David A. Burton, MD]

Thank you, Greg, and I think you agree with me that’s an impressive record in terms of not having physicians in a situation where they’re in abreast with debt and pulling on the orders together with the hospital.  And I’m sorry, not to be adversarial but it is in the burning platform and yet look at what has been accomplished.

If we look at a diagram again in a little more detail and look at population ordering waste reduction, these are the orange boxes that we looked at earlier.  I’m going to let you read these at your leisure.  You’ll have a link to all of this, but this is just some of the examples at the primary care level of ordering variation within a population, the different things where there are potential elements of waste that you can ring out by getting down the specifics.  And one experience that we had over and over again in my experience at Intermountain was that the data were really important and the data feedback was important because it got your engagement.  Data feedback alone does not change behavior but it does get physicians and other clinicians to the level of asking the question, so what would you like me to do differently?

This is a dashboard around primary care.  It’s our community care dashboard.  It’s very flexible.  You can put in what elements you want to put in, whatever you’ve decided you’re working on.  In this case, you can see some diabetic measures and some cardiac measures and then some preventive and you can compare yourself then to whatever benchmark you want to, national or regional or whatever.

The second area is admission, ordering variation within a population.  One of the best studied one, this is the CURB-65 criteria.  So there are 5 indicators and a score for those and then decision making or guidance, if you will, for whether this is a patient where will you save to treat in a clinic care setting, whether they need to be admitted to a general med-surg acute care bed, or whether they need to be in the ICU.

And here is an example of some population ordering waste.  This is taking the simplest, most straightforward, least likely to need a C-section patient group, the NTSV and then looking at various parameters.  In this case, the graph is displaying those patients who had a C-section but there was no attempt at induction.  So you can begin to look at the ways that is there, where if they had to had Oxytocin, some high percentage of them would have gone to a spontaneous delivery with a shorter length of stay, shorter L&D hours, without the cost incurred in the OR.

Then if we look at the per case ordering waste, the blue boxes, now we get into what do we order within a case, and standing order sets are both a good thing and a bad thing.  If you have things on the standing order sets that are not helpful, don’t add value, they get ordered every time regardless.  If you get them standardized to where they are defaulted to those things that are either diagnostic or contributory, then they begin to add value.  Similarly with therapeutics, with your pharmaceuticals and your other substances, getting down to generic where it is equivalent getting down to appropriate utilization of the different blood products and then working on collaborating with the operations people, as far as the clinical supply chain is concerned, especially on the expensive items.  The biggest cost element in a joint replacement is the prosthetic.  And so, getting standardized and using your volume leverage to get those cost down begins to eliminate some wastes.

How do you do that?  Well it starts with order sets, you get evidence-based order sets, the extent you can in an expert consensus, and you look at the Pareto list of the cases where you’re going to make the most difference.  You look at indications, under what circumstances do we order particularly imaging tests.  So if I’m working in clinic care, I would like to know when somebody comes in with back pain, do I jump directly to an MRI or do I try some more conservative things and a lot of those folks would get better without having to have an expensive MRI and similarly in the other areas.

This is an example from one of our clients where a simple change to an ordering standard order sheet made a significant change.  The objective, the aim here was to get standardized around an appropriate antibiotic before surgery for appendectomy patients.  And so, the order sheet was changed and you can see the dramatic increase, and in some cases, desirable by products that weren’t the focus of the intervention.  Down at the bottom in the bottom left graph you can see that the percentage of time that the preferred antibiotic based on the evidence got on board.  In the top left graph, you can see not only did the standardization to that improved the appropriateness of the antibiotic but also the average time to when that was administered which was helpful in later reducing the length of stay.

If we then look at the workflow aspect of this, this is the green boxes in our diagram, and here we turn to a conceptual flow diagram like a care process model but we’re looking at a traditional value stream map.  And for those of you who aren’t familiar with value stream maps, the boxes are the standardized steps in the flow of the care.  The red upside down triangles are delays between the steps and you actually improve the workflow by working on both of them, standardizing the things inside the boxes, the value-added steps, and reducing the delays between the boxes.  The yellow storm clouds are the anecdotal impressions of the clinicians making up this workflow diagram as to where the opportunities most likely lay.  And you can see I’ve highlighted there in the red box what this particular team decided to work on, which was the cycle time, from the time the patient was wheeled out of the room until the next patient was wheeled into the room.

And so, as you know, flow diagrams are hierarchical and so inside every one of those boxes, there’s another flow diagram.  This is the drilldown of the process of that cycle from one case to the next case.  And what was found a little bit to the (07:00 6.4) and surprise of the team was that the lesion, if you will, wasn’t notifying the environmental services crew that the room was ready to clean.

Now, we have nearly a poll question and you’ve got it right, mostly right.  This is a preliminary study that we did on workflow and per case and what we found in this, a little bit surprising to us, was that if you look at the variation and the opportunity, therefore in the ordering waste, so what was ordered within the case as far as diagnostic test and substances and so on, that constituted about 40% of the total opportunity and 60% of it was represented in the efficiency or the variation in the efficiency with which the care was provided.  And the surprise to me frankly was that from a dollar and cent standpoint, the defects, the patient injuries, did not contribute substantially.  Now, having said that, you definitely don’t want to be in the news about your patient injuries.  They just start infrequent enough compared to the every case workflow opportunities.  So when you add all the dollars up, they aren’t as significant as far as the dollar opportunity and they fall more over into the reputation of the hospital, the hour of safety.  And for another reason, it’s important to work on these and we’ll get to that in just a second.

So with that, how confident are you that your organization has the ability to achieve cost savings through waste reduction?  How actionable do you think that proposition is in your facility?

[Male Facilitator]

Thank you, Dr. Burton.  So again, if you can navigate in your applications to poll question #3, how confident are you that your organization has the ability to achieve cost savings through waste reduction?  We will give you another few seconds to answer in the mobile app.  I’m seeing that people are pulling up their phones and then we’ll show the results momentarily.

Alright.  Let’s show those results.

[David A. Burton, MD]

That’s pretty encouraging.  Somewhat confident and moderately confident is not bad.  This is an area where we have a lot of room to grow and one of the big challenges in workflow analysis is it’s still very manual.  And the problem is that when you do Lean or Toyota Production System kinds of improvement projects, Six Sigma, a lot of it is manual.  And so, you can sustain about 3 or 4 projects.  The problem is when you move on to 4 and 5, you lose the gains in one.  So one of the things we’re working very aggressively on is to try to automate the acquisition of the time stamp data.  Because if we can get more accurate time stamps, there are fields, as you know, in your EMR to capture the time stamps.  The problem is the yellow sticky note and the paper towel syndrome is still alive and well.  And so, things get written down but the time stamp is when you actually entered into the computer.  So we’re looking at passive systems such as iBeacon and RTLS to try to figure out a better way to capture those time stamps so that we can automate and begin to harvest the workflow opportunities.

So if we look at that aspect of things and look at the defect aspect, this is straight out of the CMS website.  This is the inclusion and exclusion criteria for the hospital-acquired conditions.  Noticeably absent from those is ventilator-associated pneumonia.  It’s difficult but it’s also very important.  This is a Pareto analysis of the major types of patient injury and this is done on the very large data set from the OSHPD in California, the Office of Statewide Health Planning and Development, and you can see that this is much more concentrated than your population data are.  One process accounts for 52% of the waste from patient injury.  Here is the detailed, I’m not sure whether you can read it at the back there, but #1, that big one is CLABSI, vascular catheter-associated infections.  And then we go to pressure ulcers and then to iatrogenic pneumothorax which just began to be included in 2011, and then falls and trauma, and finally catheter-associated urinary tract infections.  So the CMS folks got one of them right and didn’t necessarily pick the next best one and I guess even a blind squirrel finds an acorn occasionally.

This is just a flow diagram and our time doesn’t permit to go through this in detail but this is kind of a combination of a care process model and a workflow diagram all in one but these are the steps in laying out patient injury as a process so that you can look at preventing process failures rather than incident reporting and looking at people failures.  Now, why work on this from a pure financial standpoint?  Well, CMS is established not on incentives but penalties and the measurement domain #2 includes the CLABSI and the CAUTI and it’s weighted 65%.  So it would be heave us all to get good at preventing CLABSI and CAUTI.

And here are the penalties as far as the things that we’re talking about.  And the purple is the hospital-acquired conditions and the green is the readmission reduction which is a formal workflow waste.  So with that, let me turn it over to questions and answers.

[Female Facilitator]

Thank you.  So thank you, Dr. Burton and Mr. Stock for your excellent presentation.  I’m going to start, before we do the Q&A, to turn it over to Patrick to see what insights the analyst team have gleaned from the responses in this session.  So, Patrick…or is it Joe?  Joe.  Okay.


We’ve actually had two insights that we saw in terms of likes.  Stock’s comment about “a one-eyed man is the king of the blind world” was very popular from likes’ perspective.  And then the other one we noticed was that in the smaller hospitals, and it’s just basically plotting bed sizes versus how you answered the first question, defect waste is more important in the smaller hospitals but less important in the larger hospitals.

[Female Facilitator]

Okay.  Thank you.  Dr. Burton or Mr. Stock, any comments on the insight of the differences in terms of hospital sizes?  You want to comment on that?

[Greg Stock]

That was a good joke.

[Female Facilitator]

Okay.  Alright.  So at this point, thank you very much, Joe and team.  So now we’ll answer submitted and live questions.  So if you have a live question, please raise your hand and we’ll have somebody come up with the mic.  And we have one right here.


Hello.  Yeah.  I’m from Johns Hopkins.  Question is like, do you guys think only HCAHPS is the only thing which can actually capture the patient experience or patient satisfaction?  What are the other measures out there and like you guys are working on to have an alternative, like I mean I’m not asking for an alternative but then I’m saying like do you think HCAHP is the only source out there?  Like why is it…

[Greg Stock]

Alright.  Let me just…  I think you ask, are we using any other measurements or ways to…


Yeah.  Is it only HCAHPS.  Like do you think HCAHPS alone can capture the true essence of patient experience or patient satisfaction?

[Greg Stock]

Can everybody hear me?  Okay.  Alright.  Great.  So we’ve been using Press Ganey for quite a while.  Before we used Press Ganey, we used Gallup.  I like Gallup and we talked about going back and looking into that further.  The thing that I was interested, you know, was Gallup didn’t rank hospitals then.  Does anybody use Gallup now?  So we didn’t know how good we were.  We were working on it actively but we couldn’t tell by comparison there’s some kind of benchmark.  A reliable benchmark is obviously a big deal in any kind of data that you’re comparing yourself to something that’s real.  And so, I felt at that time that’s what we should do.  We ran over to Pensacola a long time ago.  Grant Steuter invited us over there to present at Baptist.  We went there and the Press Ganey guys were there.  I’ve never met them before.  And after two or three months, we negotiated an agreement with them and they were very helpful.  I’m not doing an advertisement for them here but yeah, the federal way of doing it is you don’t get too much, I guess there is some, but feedback from them but all those other things that we do, like the follow-up phone calls, I got staff back here that can give you a long list of things that we do to truly try to understand what the patient is saying.  In that respect, we’re looking for how we can get more information.  We’re interested in that and we call that working in smarter part.  We want to know, we want to improve and get better.  And so, we don’t want to keep relying on just the same old things.

[Female Facilitator]

Okay.  Did you want to add anything?  Any other questions from the audience?  And if not, I’ll take one that was submitted.

Okay.  Question for you, Dr. Burton.  You mentioned that the anatomy of healthcare model was something that evolved over about 20 years.  Can you speak at a high level about the evolution and some of the significant changes that you made to the model?

[David A. Burton, MD]

Sure.  One of the most recent was adding the green boxes.  So, a friend of mine, Dan at Stanford, had asked me to come and speak to their leadership and the question that he asked was, “So, when do you use traditional quality improvement methodologies and when do you use Lean?”  Stanford has a very strong tradition of performance improvement, Lean, etc.  I met with the CEO there, came out of that background.  They have a whole department of performance improvement.  And so, one side of the house is leaning toward everything should be done through Lean and Six Sigma.  So we added the green box in order to say when you hand off between the physician ordering the care and the nurse, the therapist, the technologist implementing those orders, is where the transition occurs from your traditional care process models of quality improvement to your traditional Lean TPS workflow improvement.  So that’s’ a major area.

Another area is that we had separate flows at one point for interventional medical.  So things like the GI lab, the cath lab, interventional radiology, versus ambulatory surgery and inpatient surgery, and as we laid out the more detailed flows of those and said, who is the captain of the ship and what are we doing at each step, what we found was the only difference between interventional medical and the surgical side was the depth of the anesthesia.  And so, we went back and said now that’s a single stream.  So it’s that sort of thing of just as we drove detail in and try to write down what we thought we know, it surfaced the issues that said we can simplify this, we can make it more meaningful, and so it’s going through a lot of iterations.

[Female Facilitator]

Okay.  Thank you.  So most of you I think were probably in the general session.  So you know the little polling that we had about staying on time.  And I’m going to contribute to those of you who think we’re going to stay on time.  Unfortunately, our time is up right now.  I do want to thank again Dr. Burton and Mr. Stock and our analysts, as well as you for attending today.

So again, thank you very much.