Friday, July 26, 2013

Focus and Leverage Part 238

In today's posting I want to share an article written by Anna Gorman of the LA Times.  This article is excellent in that it discusses the impact of the Affordable Care Act and how payments are tied to patient satisfaction.  I want to thank Anna for allowing me to publish her well-written article and I hope you enjoy it as much as I did.

Healthcare overhaul leads hospitals to focus on patient satisfaction

Under healthcare overhaul, federal payments to hospitals are tied to patient satisfaction. Customer service efforts are underway.

By Anna Gorman

July 20, 20135:45 p.m.

SAN FRANCISCO — For years, the check-in process in the urgent care center of this city's large, downtown hospital was reminiscent of a visit to the DMV. The ailing and sick walked in, pulled a number, took a seat and waited to be called. Many grew impatient and exasperated.

Now, patients at San Francisco General Hospital are greeted by a smiling face and a helping hand to guide them along the path to getting care. It's one of a series of customer-friendly touches being added at the 156-year-old institution by a newly named “chief patient experience officer.”

“Saying ‘number 32' versus ‘Mr. Jones' is dramatically different,” said Baljeet Sangha, who holds the new position. “We have to remind ourselves these are people.”

Under the national healthcare overhaul, patient experiences matter. Federal payments are being tied to surveys that gauge patient attitudes about such things as a hospital's noise and cleanliness, communication and pain management.

If patients are happy, hospitals get more money. If they aren't, hospitals get less. That's prodding hospital executives to make changes to improve the patient experience. Televisions are being upgraded, cafeteria fare improved and patient call signals answered more promptly, officials say.

“The goal is not to turn hospitals into hotels,” said Patrick Conway, chief medical officer for the federal Centers for Medicare & Medicaid Services, “but to ensure that every patient and family has the best possible experience when they are hospitalized.”

Positive patient experiences can affect medical outcomes and a hospital's bottom line, Conway said. If nurses clearly communicate discharge instructions, for example, patients better understand what they need to do to stay healthy and avoid costly readmissions.

Competition is partly responsible for the transformation. People have access to hospital patient satisfaction and quality scores, empowering them to make informed choices about where to seek care. Public hospitals, particularly, risk losing large numbers of newly insured patients.

“It's not good enough to be the safest or the highest quality,” said Bridget Duffy, chief medical officer at Vocera Communications and an expert on patient experience. “You have to connect with people on an emotional level to get them to be loyal.”

One example: The first questions patients are asked shouldn't be whether they are insured and have an advance directive for end-of-life treatment, said Duffy, who works with San Francisco General and dozens of other hospitals. “It just takes one person to destroy great outcomes,” she said. “It's often the apathetic, rude person at check-in.”

Bay Area facilities were among the pioneers in the movement to make hospitals more patient-friendly, in large part because of Duffy's work.

To help make patients feel more welcome, San Francisco General created the position of director of first impressions. An oversized stoplight dubbed the “yacker tracker” was installed next to a nurses' station that switches to red when noise levels rise too high. Yoga classes for patients and staff have been added and new signs posted to make it easier for people to find where they're going.

At a recent management meeting at the hospital, patients shared their stories, saying they were pleased with their care but frustrated by customer service.

David McClure, 65, said doctors have saved his life twice — after a stroke and cancer. But he has encountered “abrupt, curt and insulting” employees, he said. Vivian Lusky, 43, said her stays at the hospital have been “bittersweet.” The doctors are amazing, she said, but staff members don't always communicate well and wait times are too long.

Chief Medical Officer Todd May said inviting such candid patient feedback is difficult but can lead to better care. “You have to have the courage to do this at the risk of hearing the good, bad and ugly,” he said.

The federal government began publicly reporting the results of hospital patient surveys in 2008. Reimbursements were linked to responses beginning last year. The surveys include questions such as: After you pressed the call button, how often did you get help as soon as you wanted it? Before giving you any new medicine, how often did hospital staff tell you what the medicine was for?

In California hospitals, 74% of patients reported that their nurses always communicated well, 51% reported that the area around their room was always quiet at night, and 70% of patients reported that their room and bathroom were always clean. All three were below the national averages.

The new patient satisfaction incentives are part of a push under healthcare reform to tie hospital payments to performance. Nationwide, about $1 billion in payments will be based on patient satisfaction scores and other clinical quality measures.

The money won't make or break hospitals, but the scores could affect whether patients return, said Jason Wolf, president of the Beryl Institute, which works to improve the patient experience. Wolf said hospitals need to treat patients with respect and address the entire customer experience. “You can't just change one tire on a car and expect the car to run better,” he said. “You have to be aware of all the pieces and parts.”

Los Angeles County hospitals are addressing patient satisfaction by cutting the time it takes to respond to patient call buttons and delivering meals more quickly so they don't get cold. Some hospitals use volunteers as “patient ambassadors” to check on patients throughout the day and relay concerns to nurses. Others make follow-up calls to patients after their release.

Lucile Packard Children's Hospital at Stanford University recently hired its own “patient navigators” to assist patients and families with whatever they need: getting to the pharmacy, connecting with a social worker, scheduling appointments. Chief Operating Officer Anne McCune said the goal is to forge strong relationships with patients and help them through what is often a trying time.

“If somebody walks in with a sick child into a complex medical center, they don't have a healthcare GPS that helps steer them around,” she said. “The patient navigator … is that GPS.”

One of the most effective ways to improve patient satisfaction is by improving conditions for the staff, Duffy said. When nurses and doctors are content, she said, they are more likely to work together and provide better care.

At San Mateo Medical Center, staff members recently organized several social events to foster cooperation. The hospital also started morning “huddles,” at which nurses, doctors, physical therapists and others discuss patients' needs and progress.

The huddles have helped everyone start the day on the same page, said nurse Azucena Zeledon. “We're all helping each other,” she said, “and that helps the camaraderie.”

The hospital has begun its own mini-surveys to identify problems that can be addressed before patients are discharged. “This is so much more effective,” said Chief Executive Susan Ehrlich. “They can address it as it is happening.”

Bob Sproull

Monday, July 15, 2013

Focus and Leverage Part 237

I think most of you would agree that there’s an enormous difference between trying to prevent something from happening versus waiting until it does happen and trying to detect its presence.  In most companies these days, effective quality systems have been put in place in the name of prevention, while detection system have taken more of a back seat and for good reason.  In today’s posting I want to share a personal experience that I had last week and tie in the difference between prevention and detection.  This posting won’t be a long, drawn-out one, but I hope you enjoy it.

Most of my weeks are spent out on the road on consulting assignments which means I’m not at home as often as I’d like to be.  Because I travel so much, I don’t get to interact with the seemingly endless array of contractors, salesmen (and saleswomen), etc. who come to our home.  My poor wife has to deal with them.  Last week was one of those off-weeks where I was at home and I totally enjoyed it.  We have hired some of the contractors who have “invaded” our home and one of them was a company who sprays for “bugs” and termites.  Actually our termite guy doesn’t spray, he just comes by every so often and “inspects” the termite traps, I guess he’s looking in the traps, which contain wood, to see if any of the wood has been eaten.  I guess this guy relies on detection to make his money.  If he sees that wood has been eaten, then I guess he knows that termites are in the area.  This seems like something I could do, but my wife insists on having this company do it.

The bug man, on the other hand, sprays outside and inside our home, so he definitely is in the prevention camp.  We rarely, if ever, see live insects in our house unless they flew in when we left a door open, so his work is very effective…..or at least it was….  When he was here spraying outside I saw him and asked him when he was coming to spray the inside.  He told me that they’ve changed their policy to only spray inside when we see bugs inside of our house.  I told him I didn’t want to wait for bugs to appear before they sprayed.  I told him I believed in prevention rather than detection.  He said he did too, but that was the new policy so he had to follow it.

I called our contractor and expressed my displeasure in the new policy and that we had selected them to prevent insects and not to spray them after they appeared.  I went on to explain the difference between prevention and detection, but he didn’t want to hear it until I told him not to come back and that we would be hiring a new bug company.  So you see, even in your personal life prevention versus detection has to be considered.


Bob Sproull

Friday, July 12, 2013

Focus and Leverage Part 236

I have been so busy lately that I have not been able to write a new posting, so today I want to share another video with you from Dr. Goldratt.  Dr. Goldratt wrote an important paper before he passed away entitled Standing on the Shoulders of Giants and he did make a video on it.  Goldratt talks about and praises Ford and Ohno in this video.  I hope you enjoy it.

Bob Sproull

Monday, July 8, 2013

Focus and Leverage Part 235

One of the ways that consulting firms (and any company for that matter) can differentiate themselves from other organizations who supply Continuous Improvement (CI) facilitation and mentorship is the approach to CI that they take.  While most firms utilize a mix of Lean and Six Sigma, I have always believed that these organizations are truly missing the most important ingredient of all… that provides focus and leverage.  It is my contention that if companies realized where to focus their improvement efforts, they would be able to leverage their maximum potential in terms of  Continuous Improvement success.  Regular followers of my blog know that the method I endorse is an improvement methodology that blends not only Lean and Six Sigma, but includes Constraints Management (a.k.a. Theory of Constraints) as well.  So for me, the missing ingredient I cited earlier is Constraints Management.
Constraints Management (CM) is, in its most basic form, a management philosophy which facilitates much more effective managerial decisions.  Effective from a bottom line improvement perspective that is.  In its most basic form, CM encompasses a simple 5-step process for system improvement which will always deliver maximum improvement in the shortest time possible.  One of the reasons so many other improvement methods fail to deliver sustainable bottom line improvements is that efforts are focused at the local level and not at the system level.  What actually ends up happening when the organization’s leverage point is missed are that “pockets” of improvement occur rather than improvements to the system as a whole.  Integrating CM into the mix assures that improvements are made with the system in mind.
In addition to the simple 5-step process, CM also offers a set of logic-based Thinking Processes (TP’s) used to scrutinize, identify and zero-in on the organization’s core problem(s).  The TP’s use both necessity and sufficiency based cause and effect logic to identify and interconnect all of the organization’s negative symptoms, terminating with the true core problem.  The cool thing is, these same TP tools can then be used to develop organization specific out-of-the-box solutions in the fastest and most effective way.
In addition to the TP’s, Constraints Management also offers ready-made solutions for such areas as Production, Finance, Distribution and Supply Chain, Project Management, Marketing and Sales, and Strategic Planning.  Imagine a simple day-to-day financial decision-making method where everyone understands the outcome of their decisions and actions before they are implemented.  Imagine projects that are routinely completed on time, on scope, and on budget with project durations being reduced by 30 to 50 % from what is normal.  Finally, imagine a customized growth plan which many times delivers a net profits in 4 years that is equal to today’s sales revenues!  Constraints Management does not make predetermined assumptions about what’s wrong within the organization, but rather systematically identifies the organization’s true core problem(s) and then develops sound solutions.
One of the keys that I’ve written about several times before is how Constraints Management views the conduit to greater profitability.  Assuming the Goal of the organization is to make more money now and in the future, CM offers a different form of financial accounting known as Throughput Accounting (TA) (also referred to as Throughput-Based Decision-Making).  CM and TA challenge conventional Cost Accounting’s (CA) belief that the path to profitability is through saving money (i.e. through cost cutting).  Instead, CM and TA teach us that the more effective path to profitability is by focusing on making money by improving Throughput.  These two approaches to profitability are dramatically different and have been discussed in earlier postings.  Let’s now look at the basics of Constraints Management and how it can take a company to significantly higher levels of performance just by identifying and focusing on the leverage point.
When CM or TOC was first introduced by Dr. Eliyahu Goldratt, he likened it to a chain.  He explained that in any chain there is always a weakest link that controls the strength of the chain.  It stands to reason then, if you wanted to increase the strength of the chain, you must first identify the weakest link and then focus your strengthening effort on it.  It then follows that strengthening any other link in the chain will simply not improve the chain’s strength.
Although I like the chain analogy, I believe a better understanding is gained by demonstrating the concept of the constraint  through using the flow of water through different diameter pipes as in the following figure.  In it, each section of pipe is depicted with a different diameter. Like improving the strength of the chain depends upon focusing improvements on its weakest link, if you wanted to improve the flow of water through this piping system, you could only do so by increasing the diameter of Section E.     And like strengthening the chain’s weakest link is the only way to improve the strength of the chain, increasing Section E’s diameter is the only way to improve the delivery rate of water through this system.  Increasing the diameter of any other pipe would have absolutely no impact on the flow of what through this system.

I also like to move this piping system analogy to a simple process example.  The figure below is a simple 4-step process, not unlike any process within most other companies. In this process, raw materials enter at Step 1 and are then processed through the remaining 3 steps until a finished good exits.  Each step has its own cycle time listed in each step’s box, so if you were trying to locate the system constraint, or the process step that is limiting how much product can be produced with this process,  your conclusion in this case would be based upon time.

If you wanted to increase the process throughput, the only way to do this is to reduce the cycle time at Step 3 which has the longest cycle time.  In other words, Step 3 is constraining this process.   Like the chain with its weakest link and the piping system with its smallest diameter pipe, reducing the cycle time of any other step in this process would not deliver any more finished products.  It should logically follow that in any system, you must focus your improvement efforts on that part of the process that is preventing you from achieving more of what you want.

One mistake that many companies often make is attempting to maximize the speed of every step in their process in order to drive manpower efficiencies or equipment utilizations higher.  While this may seem like the right things to do, is it really?  Let’s look at a different 4-step process and consider what would happen if we were to run each step at maximum capacity.  That is, Step 1 produces 1 part every day, Step 2 produces 1 part every 6 days and so on.  The figure below demonstrates the eventual outcome within this process if all four of these steps were forced to run at their maximum capacity.

Because Step 3, with a cycle time of 8 days, controls the throughput of this process and because it can only process incoming materials from Step 2 at this rate, a backlog of work would appear in front of it.  Also, because Step 2 is much slower than Step 1, a queue would also appear in front of it.  The decision to run faster than the slowest operation to drive overall efficiencies higher simply does not make much sense, nor do the metrics efficiency and utilization.  Having said this, it should also be clear that the only place these metrics do make sense is a measure of constraint performance.  One thing we know about the constraint is that it should never sit idle, so we strive for maximum efficiency (or equipment utilization).

The heart and soul of Constraints Management is actually a 5-step process with two prerequisites for applications as follows:
-  Identify the System Goal (e.g. Make more money now and in the future
-  Determine a Means to Measure Goal Attainment (e.g. Throuhput, ROI, etc.)
The actual 5 Focusing Steps of Constraints Management are:
1.  Identify the system constraint (i.e. Section E of the piping system and Step 3 of our 4-Step process).

2.  Decide how to exploit the system constraint or how can I get the most out of the system constraint (e.g. apply Lean Six Sigma to it).

3.  Subordinate everything else to the above decision (i.e. never permit any step in the process to outrun the system constraint).

4.  If necessary, elevate the system constraint (i.e. if in the previous 3 steps the system constraint has not been broken, you may have to spend some money).

5.  If the system constraint is broken, return to Step 1, but don’t let inertia create a new system constraint (i.e. This is TOC’s Process Of On-Going Improvement (POOGI).  The concept of inertia means reviewing all policies put in place to break the original constraint so as not to create a constraint caused by an outdated policy).

This is Constraints Management in its most basic form, but as I have written about on numerous posts, CM is much, much more.  In my next posting, I’ll write about another CM’s tool.

Bob Sproull