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Lean-Led Design Featured Podcast

Lean Healthcare Exchange 21 May 2012, 11:19 pm CEST

Don’t miss the podcast featured today on LeanBlog.org by Mark Graban. Mark shares his interview with Naida Grunden and Charles Hagood on Lean-Led Hospital Design.

Podcast #148 – Naida Grunden & Charles Hagood on “Lean-Led Design”

The podcast explores what lean-led hospital design entails, including getting staff involved, how to tie processes and space together, and how to collaborate with architects and construction companies to build space and processes that best serve the patients and healthcare professionals.

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Hospital malpractice defense tactic unfair, critics say

News 21 May 2012, 8:22 pm CEST

The recent malpractice case at UPMC Presbyterian highlights a common legal tactic that protects physicians under the corporate shield of the health organization--remove the physicians' names from the case, the Pittsburgh Post-Gazette reported.

The family of Samuel Sweet, a patient who died in 2009 while being treated at UPMC, was awarded a $1.37 million settlement. Although the family originally named four doctors as defendants in the case (Amit Kaura, Penny Sappington, Raghavan Murugan and Matthew Rosengart) for allegedly failing to treat his brain hemorrhage, the settlement only included UPMC Presbyterian hospital as the sole defendant. Although it's difficult to determine how many cases remove physicians from settlement cases, the practice could be a nationwide problem, according to Sydney Wolfe, director of the Health Research Group, a policy group within the Public Citizen advocacy organization in Washington, D.C.

"[I]t happens quite a bit," Wolfe told the Post-Gazette. "And we suspect that frequently [dismissing the doctors as defendants] is not on the merits."

Critics view the legal maneuver by hospitals as unfair protection. Removing doctors as defendants in malpractice cases thereby allows them to evade the National Practitioner Data Bank reporting.

The Data Bank guidelines, however, states "if the practitioner is dismissed from the lawsuit in consideration of the payment being made in settlement of the lawsuit, the payment can only be construed as a payment for the benefit of the health care practitioner and must be reported to the NPDB."

Director of the Data Bank Cindy Grubbs said it is aware that dismissing doctors before a settlement is a way to avoid reporting the payment on their record, "but we have no way of knowing how often it occurs." For more information: - see the Post-Gazette article on the settlement and the article on the case

Rethink the healthcare product to cut costs

News 21 May 2012, 7:52 pm CEST

Expand the scope of healthcare to include basic life necessities and bring care to where people live to lower healthcare costs, concludes a new report from Harvard doctors published in the Stanford Social Innovation Review.

The report takes a cue from resource-limited regions and recommends the U.S. healthcare industry change how it views what the healthcare product is and the providers who deliver it, according to WBUR's CommonHealth blog.

For instance, in Brazil, providers send low-income children home from the hospital with resources for ongoing nutrition, sanitation and psychological support, the authors note. They found that connecting patients with essential nonclinical resources like food and housing can help reduce readmission and associated costs.

However in the United States, Medicaid prohibits reimbursement for healthcare efforts related to social services, food stamps, energy assistance or housing, the report notes.

The report also recommends broadening the healthcare workforce so that doctors, nurses and social workers can spend more time doing what they're trained to do. Task shifting--or task sharing--promotes the efficient use of resources.

In resource-limited environments like Haiti, community health workers help healthcare systems by providing high-quality, low-cost services to patients in remote rural areas, and identifying undiagnosed illnesses and social needs before they become more serious and expensive to treat.

But some U.S. healthcare organizations already have started to broaden the definitions of healthcare and healthcare providers. Earlier this month, the Centers for Medicare & Medicaid expanded its definition of the medical staff, allowing hospitals to give nonphysician practitioners privileges like other medical staff members. Nonphysician practitioners could free up physicians to work on more medically complex patients, the agency said.

For more: - check out WBUR the article - read the report

State calls for curbing high hospital prices with anti-trust laws

News 21 May 2012, 7:19 pm CEST

In an effort to curb price disparities among hospitals--that is, costs that range up to five times as much as other hospitals of comparable quality--Massachusetts Gov. Deval Patrick said the Attorney General is empowered to file anti-trust charges against hospitals, WBUR, an NPR station, reported. Hospitals with market clout can inflate prices, thereby driving up healthcare costs. Spokesperson for Attorney General Martha Coakley, Brad Puffer, said in a statement, "While it is true that our office has law enforcement tools at our disposal, law enforcement is just one of many mechanisms that must be used to ensure a competitive marketplace." He hinted at stronger enforcement: "We believe a better mechanism should be in place--one that better tracks data about market consolidation to identify problems early and then is able to act on that data short of involvement by law enforcement." Article

Focus on branding to attract healthcare consumers

News 21 May 2012, 7:03 pm CEST

As patients assume more active roles in healthcare decisions, hospital executives should make branding a top priority, according to the new issue of healthcare marketing report Protocol from Smith & Jones. With an active brand strategy, hospitals can align physicians and staff with the hospital's mission and identity, as well as make communications consistent.

"Until recently, it wasn't necessary to advertise healthcare services," Smith & Jones President and CEO Mark Shipley said today in a statement. "Hospitals are now forced to brand and market their services to retain even their local consumers' care spending."

Meanwhile, patients are choosing health insurers based on brand reputation, reported The Financial. That should signal a warning to hospitals that they need to strengthen their brands to attract patients in today's competitive healthcare environment.

"More than ever before, consumers are paying increased attention to their healthcare options and selecting products and services they prefer to consume. As a result, positive brand recognition has become and will increasingly be critically important," Debra Richman, senior vice president of healthcare business development & strategy at Harris Interactive, said in the article.

To develop a strong brand, hospital executives must gauge the brand from the patient's point of view to figure out what they like or dislike about the brand, according to a March blog post from StrategicPlanningMD. It also noted that a great hospital brand appeals to emotions with a powerful experience that goes beyond quality metrics and connects to patients.

Some of those strategies can be seen in Washington state, where EvergreenHealthcare has rebranded itself as EvergreenHealth to better emphasize its highly personalized care and dedication to patients and the community, the hospital district announced earlier this month.

For more: - read the Protocol announcement - here's the StrategicPlanningMD blog post - here's the Evergreen announcement - read the Financial article

ICU mortality rates biased

News 21 May 2012, 6:08 pm CEST

Although in-hospital mortality rates measure quality in intensive care units, new research finds that the performance metric may be biased, unfairly penalizing large, academic hospitals due to "discharge bias."

"Hospitals differ in the number of patients they transfer to other hospitals or post-acute care facilities," lead study author Lora Reineck, post-doctoral fellow at the University of Pittsburgh School of Medicine, said in a research announcement. "These differences can affect in-hospital mortality measurement if some hospitals discharge patients more frequently or earlier than others, since in these cases the mortality burden is shifted to other facilities." Researchers found that smaller hospitals, as well as facilities that serve fewer commercial HMO patients, appeared to perform better and rank higher. Nearly 30 percent of hospitals jumped in rank by at least one quartile, and 27 percent dropped in rank by at least one quartile because of discharge bias.

The research could point to holes in the pay-for-performance system, which rewards hospitals based on quality metrics, including the National Quality Forum-endorsed ICU mortality measure. "If discharge practices vary between different types of hospitals, use of in-hospital mortality as a performance measure in quality improvement may lead to health disparities," the study states. The researchers further called for state and national programs that can account for discharge bias to fairly assess performance.

Meanwhile, another study from the University of Pittsburgh, published in the New England Journal of Medicine, found that using night-time intensivist physician staffing in ICUs with a low-intensity daytime staffing model reduces mortality. More hospitals are hiring intensivists, doctors that are particularly trained for critically ill patients, to work around the clock. However, researchers found that intensivists improve patient outcomes only in some circumstances.

"[W]e found that ICUs with high-intensity daytime staffing did not share the same benefit from nighttime intensivists," Jeremy Kahn, associate professor of critical care medicine and health policy and management at the University of Pittsburgh, said in the research announcement.

The 24-hour staffing, however, may be reason enough to adopt the model if that means the small number of very sick patients, such as those in severe shock or cardiac arrest, can avoid death. For more information: - see the research announcement and abstract on mortality rates - here's the research announcement and abstract on intensivists Related Articles: Top management strategies for better hospital survival rates Pay for performance fails to improve quality Pay for performance fails to improve mortality rates More hospital spending tied to lower mortality, readmissions

Embrace specialized teams, comanagement to improve surgery

News 21 May 2012, 6:01 pm CEST

After the results of a data-sharing project found wide variations for knee surgery readmissions, length of stay and operating times, several U.S. health systems are adjusting clinical processes, reported the Associated Press. For example, Dartmouth-Hitchcock Medical Center in New Hampshire now is looking to implement a specialized operating room team and a comanagement model, among other identified best practices.

The Health Affairs report has demonstrated that the one institution consistently matching surgeons with the same specialized team of technicians and nurses had the shortest surgery times. With longer operative times linked to more inpatient complications, Dartmouth-Hitchcock is embracing the team-based approach for total knee replacement surgeries going forward, the article noted.

The medical center also decreased length of stay by almost half a day after telling patients what to expect before, during and after surgery, Ivan Tomek, a Dartmouth-Hitchcock surgeon, told the AP.

The health system with the lowest in-hospital complication rate identified coordinated management of medically complex patients as another best practice, according to the report. So Dartmouth-Hitchcock has started to get the anesthesia, internal medicine, and orthopedic surgery departments all involved in managing patients with additional medical issues that could affect surgery, according to the article.

Meanwhile, research last week suggested hospitals use checklists before discharging surgical patients to avoid infections or moving surgical patients to units with empty beds rather than sending them home prematurely.

To learn more: - read the AP article - here's the research announcement and full report

OSHA Inspections: Protecting Employees or Killing Jobs?

HBS Working Knowledge 21 May 2012, 3:39 pm CEST

Published:	May 21, 2012
Author:	Michael Blanding

With an election looming and the economy continuing to struggle, the effectiveness of government regulation has become a political football. While advocates hold regulations up as necessary to protect public health and safety, critics see them as arbitrary and costly to business, reducing wages and killing jobs at a time when the United States can ill afford to lose them. Few regulatory agencies have a more direct effect on businesses than the Occupational Safety and Health Administration (OSHA), the federal agency responsible for enforcing regulations to keep workplaces healthy and accident-free.

"Needless rules and onerous regulations are often roadblocks to economic growth and job creation," groused one congressman during a House subcommittee hearing on OSHA last year, sharing the private frustrations of many employers. The debate over the agency has gone on for years, in part because there has been little evidence to prove the case for either side. In order to get the biggest bang for taxpayers' bucks, OSHA typically inspects companies most likely to have problems, often following accidents and complaints, stacking the deck with companies that are worse than average.

"Where there is smoke, there is usually fire, so the fact that government inspectors find safety problems is not surprising," says Michael W. Toffel, an associate professor and the Marvin Bower Fellow at Harvard Business School.

At the same time, when problems are resolved, there's no way of telling whether the inspections themselves helped fix them, because the law of averages implies that a company with a bad year would usually improve the following year even without an inspection. "When they do find a problem, it's not entirely obvious that it wouldn't resolve itself anyway," he says.

Toffel has long studied the effectiveness of regulations, focusing on voluntary measures. When he and colleague David I. Levine heard of a program at California OSHA to conduct randomized inspections of workplaces, they realized they had the perfect real-world experiment to settle the debate over workplace inspections.

"When I learned that Cal-OSHA was conducting some of its inspections at random, I felt almost an obligation to analyze that experiment," says Levine, a professor at UC Berkeley's Haas School of Business. "To let these debates on OSHA and other regulatory agencies continue for another generation when this experiment had already been done seemed inexcusable."

Little did the researchers know at the time how difficult it would be to extract the data for analysis. That task fell to Toffel, who was still completing his doctoral studies at Haas when the research began in 2005. "We received all this data from Cal-OSHA on cassettes, the likes of which I have never seen," Toffel laughs. "They were Memorex tapes about three-quarters of an inch tall and six inches square. We had to hire someone to make them machine-readable."

The team brought on Matthew Johnson, then an HBS research associate who is now an economics doctoral student at Boston University, to help with the data analysis.

Thus began the long saga of extracting statistics on inspections and sorting out which were randomly assigned, which followed accidents, and which followed complaints. In addition, Toffel and Levine essentially became deputized by another California regulatory agency to gain access to workers' compensation data. Because the data were collected at the company level, the researchers limited their analysis to firms with only one plant, where the effects of an inspection on injury rates and costs could be clearly identified. Finally, they matched companies by size, industry, and other characteristics to end up with some 800 companies. Half of the companies had been subject to random inspections; half of them were eligible for inspections but not chosen.

Surprising findings

The results of their analysis, published in Science last week, are definitive: inspections worked. Compared with uninspected firms, the companies subject to random inspections showed a 9.4 percent decrease in injury rates. What's more, the findings were consistent for both large and small accidents. "We thought our results might have been driven by fewer big problems, like preventing storage racks from collapsing and other major accidents; or perhaps by a particularly dramatic decline in smaller injuries prevented by workers more regularly wearing personal protective gear," says Toffel, who worked as an environment, health, and safety manager in the private sector before pursuing his doctorate. "But we found it to be an across-the-board effect."

Just as important are the findings about the costs to companies of complying with regulations. Testing every measure they could find—jobs, wages, sales, and credit ratings among them—the researchers found no evidence (within the margin of error) of any cost to businesses that had been inspected. In fact, quite the contrary: the decrease in injuries led to a 26 percent reduction in costs from medical expenses and lost wages, translating to an average of $350,000 per company. While those costs would be felt most immediately by the firms' workers' comp insurance companies, over time that would translate to lower insurance premiums for the employers.

In other words, those who charge that OSHA regulations cost business money have it completely wrong. In fact, the regulations save money. The magnitude of the results surprised even Toffel and Levine, who expected perhaps a small savings if any. But the strength of the findings, they say, should persuade even skeptical antiregulatory critics.

"If people are skeptical of OSHA, it's likely based on anecdotes," Toffel says. "The difference in our study is we are looking at hundreds of companies over a long period of time, and we find that those anecdotes are not typical. If they know of a company that has been shut down, that is not typical." In fact, the inspected firms were just as likely to be in business at the end of the study period as the control firms.

Of course, a single study cannot settle the debate over regulation, or even the debate over OSHA. This study is limited to one regulatory agency in one state; other states and other agencies could show different results. One thing the research does show, though, is the value of randomized inspections as a way to help gauge regulations' effectiveness. What's more, say Toffel and Levine, the potential benefits from randomizing isn't limited to government inspections, but can also extend to the private sector in the form of randomizing the deployment of new safety, environmental, and quality programs.

But randomizing, of necessity, involves a trade-off. Focusing on short-term cost-effectiveness often leads managers to implement new programs at sites or at times when they think they will do the most good. But such targeted interventions make it impossible to evaluate the program's overall effectiveness, as one could with randomized deployment.

"There is a perceived cost in doing a portion of the work in a randomized fashion," Toffel says. "But if you want to learn, it requires an investment and some patience. You have to be willing to delay or forgo deploying a new program at some of the neediest sites in order to evaluate whether the program is effective." Or as Levine puts it: "It's costly to learn, but it's more costly to be ignorant."

About the author

Boston-based writer Michael Blanding is a fellow at the Edmond J. Safra Center for Ethics at Harvard University and author of The Coke Machine: The Dirty Truth Behind the World's Favorite Soft Drink.

MO Hospitals Review Highlights Value of Disaster Preparedness

HealthLeadersMedia.com - Daily News & Analysis 21 May 2012, 2:01 pm CEST

A year after a tornado destroyed the healthcare delivery infrastructure in Joplin, a report from the Missouri Hospital Association suggests that hospitals' ability to overcome depended in no small part upon the emergency preparedness plans they'd been developing for the last decade.

Podcast #148 – Naida Grunden & Charles Hagood on “Lean-Led Design”

Lean Blog 21 May 2012, 11:00 am CEST

MP3 File (run time 21:03)

Episode #148 is a conversation with a returning guest, Naida Grunden (previous episode) and her co-author Charles Hagood (of Healthcare Performance Partners), talking about their new book Lean-Led Hospital Design: Creating the Efficient Hospital of the Future. It’s an outstanding book and I was happy to endorse it, as did John Toussaint, MD and many others.

In the podcast, we talk about what lean-led hospital design entails, including getting staff involved, how to tie processes and space together, and how to collaborate with architects and construction companies to build space and processes that best serve the patients and healthcare professionals.

For a link to this episode, refer people to www.leanblog.org/148/.

For earlier episodes, visit the main Podcast page, which includes information on how to subscribe via RSS or via Apple iTunes.

You can use the player (use the VCR-type controls) at the top of the post to listen to a streaming version of the podcast (or click here for the streaming audio and RSS subscription). The streaming link is faster for one-time listening (hardly any delay to start listening). Or you can use the download link to put it on your iPod or other MP3 player.

A new way to listen to free streaming episodes of the podcast: Download the free Stitcher app and use promo code LEANBLOG for a chance to win $100.

If you have feedback on the podcast, or any questions for me or my guests, you can email me at leanpodcast@gmail.com or you can call and leave a voicemail by calling the “Lean Line” at (817) 776-LEAN (817-776-5326) or contact me via Skype id “mgraban”. Please give your location and your first name. Any comments (email or voicemail) might be used in follow ups to the podcast.

About LeanBlog.org: Mark Graban is a consultant, author, and speaker in the “lean healthcare” methodology. Mark is author of the Shingo Award-winning book Lean Hospitals and the upcoming book Healthcare Kaizen. He is also the Chief Improvement Officer for the technology startup KaiNexus.

Measuring Hospital Efficiency

Healthcare Economist 21 May 2012, 7:50 am CEST

Medicare recently released the Medicare Spending per Beneficiary (MSPB) measure on Hospital Compare. This measure includes all payments to doctors, hospitals or other facilities for services provided to a patient during the three days before the hospital stay, during the stay, and during the 30 days after discharge from the hospital. Kaiser Health news provides an analysis of this measure and also provides an interactive graph of state level efficiency and a list of hospital MSPB scores.

The Kaiser Health News article notes that:

“Patients treated at most or all hospitals in Las Vegas, Fort Lauderdale, Newark, Miami, Los Angeles and Orange County, Calif., tended to cost more than the national median, which is $17,988. Patients treated at most or all hospitals in Anchorage, Des Moines, Honolulu, Minneapolis and Portland, Ore., tended to cost Medicare less.”

The article also recaps the opinions of a number of industry and policy thought leaders.

Jennifer Faerberg, director of health care affairs at the Association of American Medical Colleges stated that differences in the MSPB measure across hospitals is primary due to how well hospitals can control post-acute costs. This is generally true. The MSPB measure controls for the type of admission (i.e., MS-DRG) of the index admission. Thus, differences in the MSPB measure are due principally to differences in post-acute spending and the frequency with which the patient is readmitted to the hospital within the 30 days after the initial hospitalization.

Some policy experts were critical of the MSPB measure:

Nancy Foster, a vice president at the American Hospital Association, said the data do not answer key questions: Did the patients that got more services fare better than others? Could the patients that cost Medicare less actually have benefitted from more care? ”What we don’t know is if those additional investments yield differences in outcomes,” Foster said.

Foster makes a good point; the MSPB measure should not be analyzed in isolation. CMS does not only measures hospital efficiency, but also includes a number of hospital quality measures.

Elliott Fisher, one of the main researchers from the Dartmouth Atlas, questioned the practical usefulness of the new information. “As a hospital administrator I would go, how does this help me?” he said. “We just don’t know whether a lot of specialists are running through the hospital doing everything they can to every patient who is horizontal, or whether they’re discharging every patient to a rehab facility. Those are two very different causes of high costs.”

However, CMS did distribute a “hospital specific report” that detailed where the average spending went (e.g., inpatient, skilled nursing facility, home health physician) in the periods before, during and after the index hospital admission. Each of these quantities is compared to the state and national average spending levels for each type of service.

Disclaimer: The Healthcare Economist worked with CMS and a team at Acumen to develop the MSPB measure.

US hospital wins grant to upgrade rehabilitation equipment

Hospital Management-Updates 21 May 2012, 1:00 am CEST

St. Joseph's Hospital in New York, US, has received a $50,000 grant from the Community Foundation of Elmira-Corning and the Finger Lakes to support the purchase of rehabilitation equipment.

MicroAire Surgical Instruments-Orthopaedic Surgical Power Instruments

Hospital Management-Updates 21 May 2012, 1:00 am CEST

MicroAire Surgical Instruments is one the leading manufacturers of orthopaedic power surgical instruments, and replacement burs and blades.MicroAire offers a complete line of orthopaedic power instru...

ArjoHuntleigh-Patient Handling and Hygiene Systems, Therapeutic Surfaces, Wound Healing, Hospital Beds, DVT Prevention and Infection Control

Hospital Management-Updates 21 May 2012, 1:00 am CEST

ArjoHuntleigh contributes to finding the right answer to these problems by providing solutions that improve the working environment for staff and increase quality of life for the elderly, and disable...

ArjoHuntleigh-Patient Handling and Hygiene Systems, Therapeutic Surfaces, Wound Healing, Hospital Beds, DVT Prevention and Infection Control

Hospital Management-Updates 21 May 2012, 1:00 am CEST

US hospital wins grant to upgrade rehabilitation equipment

Hospital Management-Updates 21 May 2012, 1:00 am CEST

St. Joseph's Hospital in New York, US, has received a $50,000 grant from the Community Foundation of Elmira-Corning and the Finger Lakes to support the purchase of rehabilitation equipment.

MicroAire Surgical Instruments-Orthopaedic Surgical Power Instruments

Hospital Management-Updates 21 May 2012, 1:00 am CEST

Florida medical centre embarks on $29.5m expansion

Hospital Management-Updates 21 May 2012, 1:00 am CEST

The Gulf Coast Medical Center in the US state of Florida has launched a $29.5m expansion programme to add 62 beds to its existing 176-bed facility.

Florida medical centre embarks on $29.5m expansion

Hospital Management-Updates 21 May 2012, 1:00 am CEST

The Gulf Coast Medical Center in the US state of Florida has launched a $29.5m expansion programme to add 62 beds to its existing 176-bed facility.

ICD-10 Coding Uncovers Higher Rate of Fatal Falls Among Seniors

HealthLeadersMedia.com - Daily News & Analysis 1 Jan 1970, 1:00 am CET

A report from the Johns Hopkins Center for Injury Research and Policy concludes that an increase in death rate attributed to falls is not because more seniors are suffering more serious falls, but because of updates in ICD-10 coding for death classification.