Rebuilding the ordinary into the extraordinary.

Costs keep going up.

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In an information-transparent world, our quality problems are increasingly embarrassing.

External factors, such as the peak of oil production, projected global water problems, and the continuing threat of terrorism, promise a bumpy, even chaotic, and certainly inflationary environment.

Factors that directly affect health care, such as the increasing probability of a major viral pandemic, and the likelihood that new drugs and technologies will move much of what we do in health care--diagnostics and therapeutics--upstream, from the hospital to the clinic, to the doctor's office, and even to the school, the workplace, and the home, point in the same direction: We must expect the unexpected.

What is the smart strategy for such an unpredictable environment?

What we need is a strategy that lowers costs and increases quality. It must do this while it secures both customer and workforce loyalty, or it won't work. At the same time, the strategy must make the organization more nimble, more flexible, more prepared for change.

Such a strategy has to have three parts:

1. Build the extraordinary

2. Rebuild the ordinary

3. Rebuild the culture

Building the extraordinary

The first part of the strategy is to adopt new technologies, to let a thousand flowers bloom, let health care reshape itself around the technologies in large and small ways, much as other industries have done.

Slow, uncreative, dinosaurian health care has lagged behind other industries. Here are two examples, one small, one large, of health care using new technologies in new ways.

Insta-Doc on the laptop: You're at a hotel in Barcelona, it's the middle of the night, you can't sleep, you're breaking out in weird spots. Is it just poison oak? Bedbugs? Or some dread disease? Open the laptop, fire up the webcam, and in moment you are shining the desk lamp on the spots, showing them to a doctor in Kansas City.

He asks you a few questions, asks you to move the webcam for a better look, and pronounces it poison oak--itchy, but nothing to worry about. Put a hot compress on it and try to get back to sleep.

Your credit card is charged $50 and you deem it a bargain. This is futuristic, but not the future: You can do it now on myMD.com, by webcam, webchat, or phone, in the language of your choice, 24/7/365.

Is your organization offering anything like this to its customers?

Does your organization do e-mail consultation? The practice is spreading.

For years, consumers have said in surveys that they want to be able to e-mail their doctors. The sticking point: no compensation. Now that is changing in the U.S.

Many insurers, including Blue Cross/Blue Shield in California, New York, Florida, Massachusetts, New Hampshire, Colorado and Tennessee have begun paying physicians half an office visit (or similar amounts) for every e-mail exchange.

Kaiser Permanente is experimenting with it in the Pacific Northwest, Hawaii and Colorado. A bill introduced in the U.S. House in February would authorize Medicare to make "bonus payments" for doctors to answer e-mail.

Studies at the University of California at Davis showed that physician e-mail reduced call volume enormously, reduced overhead, improved physician productivity and increased access to physicians for all patients, whether they used e-mail or not.

And e-mail (unlike phone calls) provide a documented record of advice, which can sometimes be a shield against malpractice claims. (1)

The basic processes of health care are archaic in the extreme and will be redesigned around new technologies. Health care systems that lead this redesign will not only enjoy competitive advantages over systems that delay, they will also experience lower cost structures, higher quality and better patient and staff satisfaction.

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The change is likely to be fairly rapid. What is an experiment now will likely be commonplace within a few years.

Rebuilding the ordinary

New technologies can change the shape of health care. But so can careful, ongoing attention to the basic processes of health care--simple things like patient transport, the use of space, making appointments, stocking carts.

For decades, as other industries struggled to redefine and redesign every process, to emerge sleeker, leaner, more efficient and effective, health care resisted. Health care was special, different, you can't automate it, standardize it, capture it in rules. Can't be done.

Well, it turns out it can be done. Scores of health care organizations have begun to redesign every process, large and small, using a set of principles identified as "lean" thinking.

One variety comes directly from the Toyota Production System (TPS). Virginia Mason in Seattle, with guidance from Boeing, turned the TPS into VMPS--the Virginia Mason Production System.

"It was increasingly clear that the status quo management methods in health care were not working. Our workforce is demoralized, which shows up in the nursing shortage and in physicians retiring early. Our patients perceive that they are not getting the quality, the safety, or the service that they require," says Gary Kaplan, MD, and CEO of Virginia Mason. "We have very thin margins, and our costs are rising ... The industry has tolerated a safety record and quality results that would not be tolerated any other industry. Health care has traditionally tolerated a 2 to 3 percent error rate. We believe it is possible to have zero-defect medicine." (2)

The process to change can be grueling. Teams trained in the system look at particular processes, examining each step to see, first, whether the work is even necessary. Does it add value?

Then they find ways to standardize the work, eliminate hand-offs, reduce the opportunity for error, and eliminate waste (which includes waiting time, doing things before they need to be done, unnecessary inventory and many other kinds of process waste).

The results can be stunning and satisfying. Park Nicollet, in Minneapolis, Minn., eliminated 34 miles per day of employee walking.

By rearranging the way appointments were made, they reduced patient wait time by 1,400 hours per day, freeing up over 100 parking spaces, and eliminating the need for a new parking structure.

In the first year alone, Park Nicollet recouped over $8 million from process improvement. (3)

At Swedish Medical Center in Seattle, a team reduced the time it took to clean fusion pumps from 21 hours to 34 minutes, and the cost from $12.65 to 67 cents.

Similarly, it reduced the lead time necessary to stock a surgical cart from 20 hours to 10 minutes and eliminated all rework due to surgical schedule changes.

The pharmacy at Overlake Hospital in Bellevue, Washington, reduced the time it took to get a unit dose by 71 percent, and the orders in process by 70 percent. (4)

Virginia Mason re-examined the usage of space in its main building and found ways to fit a new gastrointestinal center into it, saving the cost of a planned $1.2 million building.

It also reduced its lab turnaround by 85 percent and eliminated the need for two unfilled CT radiation tech positions by redesigning the patient flow.

Altogether, Kaplan gives the Virginia Mason Production System much of the credit for turning the center's financial performance around, from $2 million per year in losses in the late 1990s to better than $20 million net operating income in recent years.

Both Kaplan and Park Nicollet CEO David Wessner believe they have just begun a process that may take a decade or more of rebuilding every process, whether clinical, physical plant, or administrative, in their systems.

But, as Kaplan says, "We are impatient." (5)

Rebuild the culture

But you can't just set a typical hospital workforce to work rebuilding its processes. People are more or less comfortable where they are, doing things the way they are used to.

Change is threatening and uncertain, the status quo is not. There is no "burning platfrom" driving them to do things differently.

So you must begin, and continue, the "long conversation" about the future, putting people throughout the organization in charge of changing it. They must be given real tasks for concrete change.

And you must give them new ways to communicate across boundaries of department, specialty and profession. This can be in face-to-face meetings, but these are episodic and expensive. They can be supplemented by e-mail, but e-mail is either broadcast or one-to-one. It does not approximate a group discussion.

E-mail and meetings can be bolstered by an online conversation. A number of systems (including Ascension, Christus, Partners, MD Anderson, Catholic Healthcare Initiatives, and Bon Secours) use project-oriented online communities to shift their cultures and change their processes. That is the goal, as well, of the new Healthcare Futures Exchange, now in testing phase. (6)

The goal is knowledge management (turning the sea of information into actionable knowledge), sense-making (turning the mind of the organization to making real sense out of all that information), and competency transfer (spreading useful knowledge from one part of your organization to another, or from elsewhere to your organization).

Health care is facing enormous changes. New technologies and powerful new pharmaceuticals are poised to shift the ground of everything we do. Global pandemics threaten to rearrange our entire business. Digitization and automation will reshape every job, every department, every physical plant. Pressures for higher quality and greater patient safety mount, from within the industry and from its patients, customers, payers and regulators.

The way out of this crushing confluence of factors is simply that health care must reinvent itself, building "the next health care" in situ even as we stumble forward through the problems of today.

The answers lie in those very new technologies, in digitization and automation, and in the grueling process improvement work now common in other industries. To make this happen in health care, we have to invent new ways to talk to each other: knowledge management, "sense-making" and competency transfer, the "long conversation" that rebuilds our organization from within.

References

1. Freudenhaim, M. "Digital Rx: Take Two Aspirin and Call Me In The Morning," NY Times, March 2 2005

2. Interview.

3. Interview with CEO David Wessner.

4. McAuliffe, J., Moench, T., Wellman, J. "The Lean Enterprise Meets Health care," Hospitals and Health Networks, January 15, 2004.

5. Interview.

6. Interviews with officials of the systems named, and Janet Guptill, president of KM At Work, Inc.

Joe Flower is a nationally known health care futurist and CEO of Imagine What If, Inc., which is building the new online world for health care executives, the Healthcare Futures Exchange. He can be reached at [e-mail]