Posted by: knightbird | March 11, 2015

Stanford Identification of 10 Best Practices

Whenever I read “Best Practices” reports, I check to see if Lean is mentioned as a source of best practices. I guess I automatically do a root cause analysis as a maker about whether to accept the report. I know that there is always some validity in reading documents from respected research institutions like Stanford, but this one left me frustrated. A recitation of outcomes does not explain how the best practices came to be. Let me explain by examining one of the examples.

Banner Health Clinic Internal Medicine of Phoenix was identified as a high performer of the 10 best practices. Banner has also been a Lean Healthcare practitioner since at least 2009, or 6 years. Here is the list of the 10 best practices that emerged:

  1. Easily accessible
  2. Tests and treatments chosen wisely
  3. Feedback encouraged
  4. Tests and procedures not outsourced
  5. Referrals made with care and monitoring
  6. Follow-up appointments and meds checked
  7. Providers work at the top of their licenses
  8. Collaboration prevalent
  9. Pay based on performance
  10. Invests in people rather than space and equipment

An effective implementation of Lean Healthcare produces all of the results listed, and then some. Lean Healthcare’s “Respect for People” pillar is in full view. But you cannot just say to staff to become more easily accessible, for example. But through Lean Healthcare, you can examine the facts about your practice and through respecting your patient, improve patient flow like Virginia Mason Medical Center did, as a system and not one area of focus.

There are a number of value streams that impact the 10 practices that have to be coordinated in order to become great at what you do. Patient Flow is important, and that is one value stream that VMMC improved considerably. A team consisting of an MD, an RN and an MA work collaboratively to facilitate patient flow. Using only one exam room, an MD sees about 26 patients per day on average. A patient checks in and is roomed by the MA almost immediately. We were told that if the waiting room has more than 5 patients, the clinic manager is alerted and the source of the wait found and corrected. The MA has prepped the MD, and after their work is complete, the MD enters the room.

VMMC developed a unique system for “mining” their information streams in order to consolidate patient visit needs. If a patient needs a mammogram, the system notes the need and it is brought to the attention of the patient. VMMC’s information system is so good that it projected that 3 lives would be saved through early detection. Other tests are consolidated into the patient visit, which saves patient time and effort.

While the MD is with the patient, the MA is prepping important work for the MD to do during the short time between patient visits. When the MD exits the room, they chart the visit and address 2 to 3 vital tasks directly related to patient care—lab results, expert consults and patient contact. The RN takes care of education and care coordination requirements.

Item 5 is interesting. VMMC developed a back care system for Starbucks. Before examining the system, it too 6 weeks for a patient to get an appointment, and an MRI was almost always included as a part of the treatment requirements. After assessing the system and gathering the facts, VMMC found that 95% of patients could return to work the same day. They had a same day appointment with a Provider and Physical Therapist. After ruling out a serious case requiring an MRI, the patient received an average of 4 PT sessions.

Other value streams are involved, including labs and testing. Charting and the EHR are important as well. Taking a systems view, instead of a best practices view, can have a profound impact on healthcare.

My point is that all Stanford has focused on is the results for a lot of hard work. The root cause of the best practices needs to be pointed out. All managers will find from this report are the practices and attempt to require them from staff. Command and Control. The real improvements come from training your staff in Lean and helping it become your culture.

Think differently. Think Lean. No excuses.

http://www.petersonhealthcare.org/sites/default/files/images/media_library/Peterson%20Center%20on%20Healthcare_Stanford%20Executive%20Summary.pdf

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