The Mölnlycke O.R. blog
Healthcare and the legacy of the 1920s car industry, part 2
Driving the focus to the patient journey
In the first instalment of this series, I described the present production system in healthcare and its 1920s Detroit car-industry legacy. In this second part I will describe the new production philosophy, which is now replacing the old system all over the healthcare world.
The new production philosophy is based on two fundamental ideas. The first idea is the principle of flow. Instead of focusing on the highest possible utilization of every silo or resource in healthcare, we focus on the patient’s journey through the healthcare system. The goal is high flow efficiency, measured as the fraction of the patient’s time when something value-adding is actually happening to her. Normally, flow efficiency is less than one percent in healthcare. Diagnosing breast cancer in Sweden typically takes, from the patient’s first visit to a healthcare provider to the finished diagnosis, between six and eight weeks. Yet, the content of the investigation takes just two to three hours. This is a major discrepancy and certainly does not win accolades from the patient taking this journey.
There are now examples in several places in Sweden where the breast cancer investigation process has radically changed to reflect the efficiency that is actually possible – reducing delivery of diagnosis to the three hours the investigation can actually take. While this approach is still only done in a minority of cases, this illustrates how the process could be.
What makes the principle of flow extra pleasing is the fact that it is not only better for the patient – it also saves work and money for the hospital. This positive effect is caused by several different factors. One of them is Little’s law, stating that the longer the investigation, the more patients are under investigation at a certain time. At Lund University hospital, the ADHD team shortened the time for an ADHD-investigation from four months to three weeks, thus decreasing the number of patients under investigation from 30 to 5. This made it possible to visualize every patient’s journey and did wonders for the ability to plan the work. The team increased its capacity by a mindboggling 70 percent, thereby reducing stress and frustration.
Another negative factor caused by inefficient flows is failure demand, a term coined by John Seddon. If you cannot give the patient or a referring doctor what she needs, unnecessary demand will occur. A laboratory in Sweden received hundreds of telephone calls from angry physicians every week, asking for results they were waiting for. On each occasion the receiving employee, not infrequently a pathologist, had to spend considerable time looking for the sample among the thousands they had in progress (due to Little’s law).
Flow is really a matter of meeting the demand, just-in-time, for each and every demand in the patient journey. Another word for this is pull, which also tells us that it is the person having the demand that is setting the standard for when just-in-time is. When a certain demand occurs, the patient or her doctor should be able to pull the needed service at their convenience instead of having to wait in a queue.
Imagine a future emergency department. From the department’s point of view, the necessary surrounding services are like supermarkets. If you need an X-ray investigation, the patient can pull it instantly from the “shelf” and the X-ray department refills the shelf with a new, open investigation slot. If the patient needs a bed, she pulls an empty bed from the ward, and the ward replenishes with an empty bed on standby. It is however counterintuitive for all of us living in the economy-of-scale era to believe that this is a more cost-effective system, considering that the X-ray department and the ward need more resources. You need to see it to believe it.
There is a pleasing, humane aspect of the principle of flow, which is perfectly suited to healthcare. It is based on the value Respect for People, and so is in fact the second fundamental idea of the new production philosophy – the idea of self-improving systems based on the improvement work of every employee.
In traditional healthcare, the rate of development is considered to be roughly one improvement per employee and year. This low pace is one of the causes of the appallingly high defect rate in healthcare that I described in my previous blog instalment, causing both unnecessary suffering and cost. The defects are however no one’s fault. There is simply no effective just-in-time system in place for employees to challenge the quality problems they face every day. The best sectors (which for now are found outside healthcare) have achieved quality systems that produce something in the neighbourhood of a hundred improvements per employee and year. To make this possible, you need to abandon the hierarchical Taylorism described in my last post and change to a system where every employee is involved every day in the improvement of every process.
This includes giving up the concept of management-led improvement projects, performed outside of daily operations. You need to create two structures, or processes, that are integral to the ordinary work day, to make it possible for employees to make plans and standards, check the outcome, find defects, analyze them and improve, every day. The trick is to start with very small defects.
I will in the final article of this series describe how these systems can be created, and how a leader’s job will have to change to make it possible.