Part of the solution: Management systems in healthcare

The rate of change in the business of healthcare has been extraordinarily fast in the past two decades.

The shift to electronic medical records, mergers that create giant hospital systems, nationwide plans to insure more (or less) people—all of these systemic transformations have been rolled out with promises that healthcare will be improved for all.

Those promises have not been followed by reporting on results. In fact, the claims have raised fundamental questions. Can changes in operations management, driven by healthcare administrators, really improve the care that patients receive from physicians, nurses, and therapists? Can non-medical managers and executives actually affect patient outcomes with management alone?

This is the question I have been trying to answer.

Three years ago, when I was president of hospitals for a large cradle-to-grave health system in Wisconsin, I wrote a book about my hospital’s experience implementing a daily management system.1 This system, in conjunction with the improvement tools and principles we employed, had a profound effect on patient outcomes, patient satisfaction, and employee engagement. Throughout the hospitals, we improved patient safety, reduced medical and surgical errors, and increased the percentage of caregivers who said they would recommend our hospital as a good place to work.

As interest in the daily management system grew, we taught it to other health systems in the U.S. and Canada and early results showed very promising returns. The daily management system gave administrators and caregivers a method to find the root cause of problems together, every day. Instead of rushing around putting out fires, managers began their days resource planning with front-line staff and addressing issues before they became problems. Quality metrics rose and costs dropped.

We all know, however, that new programs and reorganization can bring transient improvements, brought on by fresh energy and hope. I wanted to know if the results of those early experiments were a fluke. So, after I left the Wisconsin hospital and began a new role coaching healthcare executives around the world, I kept checking back with those early adopters to see how time was testing the system. As new hospitals and health systems adopted daily management, I began asking for their results, as well.

At this point, we have reporting from six very different healthcare organizations in the U.S., Canada, and Britain that have been using the daily management system for five years or more. These range from a small acute-care hospital in Iowa to a Behavioral Health hospital and clinic that is part of America’s largest municipal health system in New York City.

Using the daily management system, the Behavioral Health hospital in Brooklyn reduced the amount of time a patient had to wait for an appointment from 28 days to four. A large hospital in England, part of the National Health Service, reduced preventable mortality by 18%. A small hospital in Iowa took down incidence of patient harm by 40%.

Each of these organizations focused on different quality, satisfaction, and cost metrics that were important to the circumstances. In some hospitals, the 30-day readmission rate was selected as a critical metric to determine quality. In others, it was infection rates or preventable mortality. So, the results presented here are not apples-to-apples. Instead, the unique metrics for each health system show that leaders were selecting and focusing on the critical few issues most important for their specific needs.

What is important here is that each of these organizations has been able to significantly improve their selected metrics within three critical areas: patient safety/quality, patient satisfaction, and employee engagement, while stabilizing or
reducing costs. And the improvements have stuck over time.

Before we delve into the individual results, let’s look at an outline of the management system. While each system was tailored to the needs of the organization, every health system was also practicing the use of standardized work in order to improve upon it, searching for and eradicating waste, and solving problems using the scientific method.

These methods have been widely adopted in healthcare around the world and are most often seen in focused, team-based problem-solving efforts called rapid improvement events or kaizen2. What has been missing is a way to manage both improvement projects and day-to-day operations in a way that supports on-going progress. The daily management system was designed to address that gap while linking strategic needs to the front-line work. This is not a layer of tasks on top of a manager’s work. Instead, it is a framework for accomplishing all the tasks of floor supervisors, area managers, and executives—including, to some extent, those in the c-suite.

The overall system includes strategy deployment, break-through improvement work, and daily management, linking all elements together so that each informs the other. A daily management system is the element that organizes the work of most people in a hospital or health system and it has three constants: daily check-ins, daily problem solving, and performance reviews.

Check-ins are brief one-on-one meetings between supervisors and their team members at the start of every shift in order to assess needs, determine where issues might occur, and seek improvements. This is a mentoring session as much as it is resource planning and takes place in the work area, not the boss’ office. Supervisors then have similar meetings with their bosses (area managers), who meet with their bosses (division leaders), who all have variations of the same questions, which are guided in part by the organization’s strategic needs.

Daily problem solving usually takes place within daily unit huddles, where a manager leads the group to identify and then address problems, using standard steps based on the scientific method. Separate team-based problem-solving efforts are used to address larger issues that involve more than one department. Both use root-cause analysis, follow plan-do-study-act cycles, and are intended to teach problem solving as well as find solutions.

Performance Reviews are a set of cascading meetings conducted monthly to assess progress toward improvement goals. These sessions begin with area managers working with their advisory teams, who act as mentors and a sounding board. Next, executives at the vice-president or director level meet with their direct-report managers to assess needs and offer help. Then executives meet with the CEO to ensure the work is in alignment with the critical few improvement drivers (or True North) in areas of quality, safety, cost, and employee engagement.

If leadership has decided to track and improve infection rates, for instance, daily check-ins will include questions about which patients might be at risk for infections, unit huddles might discuss procedures for changing dressings and IV lines, and performance reviews will focus on gaps between the current and target infection rates.

The results. It is this system-wide focus that helped organizations such as King’s County Hospital Behavioral Health make break-through improvements. This system of in-patient and out-patient clinics dedicated to mental health treatment and drug rehab in Brooklyn is part of the New York City Health & Hospitals Corporation, the largest municipal health system in the U.S. With 133 adult beds and 40 beds for children and adolescents, the in-patient unit discharged 4,042 patients in 2016.

Beginning in early 2016, leaders at Behavioral Health chose to focus their daily management system queries on why some patients were staying in-patient longer than 15 days. Illnesses such as schizophrenia, depression, and bipolar disorders almost always require long-term treatment. Patients are admitted to the hospital to overcome crises and stabilize, with therapy continuing outpatient. But too many patients were staying well past the usual 15 days and leaders wanted to understand why. Using problem-solving tools, a team soon found a root cause: providers did not trust that outpatient services were robust enough to help their more fragile patients once they left the hospital. Patients often had a hard time getting regular appointments and miscommunication was too common.

So, the gap between in-patient and outpatient services became a daily focus of check-ins and improvement projects. Over a few months, staff worked to improve communication between providers; to better link treatment plans between in- and out-patient settings; standardize intake forms and overhaul the scheduling system to ensure more patients could be seen. That scheduling system was the first breakthrough.

“By cleaning up the provider templates, standardizing intake times and slots based on a factorial calculation of the demand at different levels, with a no-show probability percentage, to determine true required slots per day, we were able to identify opportunities. The daily management system helped us ensure no available appointments were left unfilled,” said Jordan Vanek, senior director.

In a single month, the average number of days until the third next-available appointment—the measure all outpatient clinics use to assess availability—dropped from a high of 31 to 5. Over the next 12 months as the system settled in, and then they shifted from paper records to centralized electronic records, the average days crept up to 8 and then settled back down to a steady 4.

Leaders also reconfigured staffing to ensure accountability and created oversight triads—with one provider, nurse, and administrator—for each service area. Needs and solutions were identified in team huddles and daily check-ins, and then reinforced and standardized.

“We’ve hardwired anticipating and solving problems for our patients,” says Dr. David Estes, Director of Primary Care. “The metrics that we’re focused on reflect our goals across the system. And now we transmit information both top-down and bottom up.”

Within 16 months, Behavioral Health had reduced by 68% the number of days a patient spent over the 15 days. This amounted to 59,200 fewer bed days over that 16 months and a savings of $2.9 million. At the same time, their 30-day readmission rate dropped from 9% to 6%.

Meanwhile, 480 miles north and west, at St. Mary’s Hospital in Kitchener, Ontario, leaders working with a daily management system selected patient falls and infection rates for their safety and quality metrics. For 12 months, daily check-ins all included questions about falls and infection risks. Unit and area huddles discussed recent cases and gaps in the care process, and then, supported by root cause analysis, a management team chose specific, measureable countermeasures. When standard work procedures were changed, staff members were assigned to teach new procedures and then follow-up regularly to see if the countermeasures were still in place and working.

In 2017, the staff of this 149-bed acute-care hospital was celebrating the results. Patient falls were reduced by 50%. Three different kinds of hospital-acquired infection had been reduced by 51%, 63%, and 64% across the hospital.3

“A key learning for us was to focus on just a handful of improvement measures rather than everything at once,” says CEO Don Shilton. “Our senior team quickly understood that 13 improvement goals were too many. We reduced our focus to seven goals, then to five and finally four, which seems to be an ideal number for us.”

In Western Sussex, England, this acute healthcare trust of one out-patient and two acute-care hospitals focused several quality measures on an internationally recognized metric that is notoriously difficult to budge: hospital standardized mortality ratio, HSMR. This is a mathematical calculation that shows actual deaths versus expected deaths in 65 diagnoses that comprise 80% of all deaths. Moving that number requires a hospital to look hard at its weaknesses in a variety of areas and address common problems.

Just one area the team in Western Sussex looked at were later-than-expected discharges from Intensive Care Units. By investigating problems, applying countermeasures, and then returning to the scene multiple times to make sure they were still in use, staff cut in half the number of delayed discharges from the ICU. Correcting problems like this throughout the system all added up to a remarkable 18% improvement in the HSMR and vaulted Western Sussex into the top 20% of all hospitals in the National Health System.

At the Hospital for Sick Children, affectionately called SickKids, in Ontario, Canada, daily improvement work reduced the number of central-line infections by 45% and slashed the amount of time kids—and parents—had to spend in the Emergency Department by 14%.

Unity Point Health-Trinity Muscatine in Iowa is a smaller facility, with 80 in-patient beds and 450 employees. While the numbers are smaller, the improvements are still significant, especially since leaders here are using the daily management system without the additional team-based breakthrough improvement work used by our other examples.

In 2016, staff reduced incidence of patient harm by 40% and recorded 21% fewer patient falls, and 59% fewer medication errors.

And at Providence Little Company of Mary in Torrance, California, where they focused on reducing patient harm, providers and staff worked together to cut the rate of Central Line Associated Blood Stream Infections, CLABSI, by 50%. And they reduced hospital-acquired pressure ulcers—bedsores—by 92%.

“This reinforced my belief that great leadership can be even better when people connect regularly and discuss day-to-day problems and performance using data,” says CEO Mary Kingston. “They begin to aspire to greater things and it becomes contagious.”

Of course, health systems are not judged on quality of patient care alone. We cannot simply impose medical interventions on people. People must also be satisfied with the care received. And employees must be satisfied too, if we are going to keep a stable staff. These measures are far more alike than quality metrics. So, in most cases, we can simply report annual response rates to two questions. For patients: would you recommend this hospital to friends and family? To care providers and staff: would you recommend this hospital as a good place to work.

Would you recommend this hospital to friends and family?
Most health systems ask this fundamental question of all patients and then use the data to target areas for improvement. Leaders at Little Company of Mary, for instance, found that low patient satisfaction scores were strongly correlated with longer wait times in the emergency department. This, coupled with a staff of E.D. providers that were very open to change, made for a natural improvement focus point. Physicians banded together to change the triage system and reduce waiting between their department and radiology. This increased patient satisfaction scores in the ED by 8%. (Most people don't think you can improve this score by more than 1-2% in a year.)

At Sick Kids in Canada, administrators used patient satisfaction scores to guide improvement work in pediatric surgery. During daily check-ins and huddles, they all looked for ways to reduce waiting and errors. Parent surveys guided their efforts. However, the quantitative results of those surveys was not available.

Kings County Behavioral Health. Patient satisfaction was rising here but, under financial distress in 2017, NYCHHC disbanded the existing improvement team and so data was unavailable.

The staff at St. Mary’s General Hospital in Ontario improved their patient satisfaction score by 8% in 2016.

Western Sussex, in Britain, reported that patient satisfaction was up 1% from 2014 to 2015.

UnityPoint-Trinity Muscatine improved patient satisfaction 5% from 2014 to 2015.

Would you recommend this organization as a good place to work?
This is the question that most health system, particularly in the U.S., use to assess the satisfaction of staff doctors, nurses, and support staff. Here are the 2015 results.

Providence Little Company of Mary: California, improved 8%

Hospital for Sick Children: Ontario, Canada, improved 12%

Kings County Hospital Behavioral Health NYC HHC: New York, not available

St. Mary’s General: Ontario, Canada, improved 8%

Western Sussex: Britain, improved 7%

UnityPoint-Trinity Muscatine: Iowa, improved 1%

These wildly different health systems attacked their own problems from a variety of directions and found at least one common outcome: steady progress toward a goal over time. There were few wild swings along the Y axis. Instead, they chipped away at problems in unit huddles, found root causes, and made changes. It added up.

Dramatic solutions followed by crashing trend lines is not a common feature of a daily management system. The daily nature of it—the check-ins, huddles, performance reviews—creates a cadence that helps hospitals focus just as much on sustaining past improvement as it does on achieving dramatic results.

Breakthrough improvement projects still give these health systems big bumps in quality improvements and waste reduction. We need focused projects with big goals in order to create changes such as the Muscatine, IA team that reduced incidents of patient harm by 40% in a single year, or the health system in Torrance, CA that slashed central-line infections by 50%. Once breakthroughs have been made, we need the management system to keep improvements in place.

As anyone can see from the story of Kings County Behavioral Health above, however, even a daily management system and improvement projects are not enough. When a performance improvement team can be dissolved by fiat, leaving the future uncertain, it is clear that we need to work on leadership behaviors that support a unified management system. And then, we cannot stop at executive leadership. We need active engagement by the board of directors in order to ensure that searches for new leadership include questions about whether a new leader understands improvement work and will support a disciplined daily management system.

This five-year study has proved that a daily management system can create better patient outcomes and happier staff and patients. Like all systemic changes, however, we have also seen that improvements will be transitory unless leaders make long-term commitment to supporting the work. As the study continues, we will be looking closely at how such initiatives fail as well as succeed.

About the Author
As CEO of Catalysis, Kim Barnas actively teaches and supports healthcare executive teams around the world. Her current focus expands the management system to the executive leadership team, with a principle based approach to leadership. She is the author of “Beyond Heroes, A Lean Management System for Healthcare,” published in 2014.

1 Kim Barnas, Beyond Heroes: A Lean Management System for Healthcare. (ThedaCare Center for Healthcare Quality: 2014)
2 Kaizen is from the Japanese symbols meaning “change” and “good.” It is translated as “change for the better” and usually refers to an improvement project in which a cross-functional team studies and then improves an area or process. It was popularized by the Toyota Production System.
3 It is also worth noting that St. Mary's has the lowest HSMR score—or, hospital standardized mortality ratio—in all of Canada: 67.

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