Rebuilding the ordinary into the extraordinary

Physician Executive, May-June, 2005 by Joe Flower

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)