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Next Generation Quality - Bob Luttman
Next Generation Quality - Bob Luttman

Bob Luttman
Bob Luttman is Principal Consultant with Robert Luttman & Associates, a healthcare management consulting practice specializing in clinical pathways, quality and performance measurement, process improvement, and total quality
management.

His monograph, How to Design Clinical Pathways Variance Systems for Continuous Improvement, was published by the Center for Case Management. This book details Bob's pioneering thinking on variance management systems,
work recognized around the world for its inventiveness.

Before founding RLA , Bob was Director of Management Engineering at Brigham & Women's Hospital, a Harvard affiliated Boston teaching hospital. In that capacity he developed and managed a well regarded internal management and quality consulting group. He was also instrumental in developing the clinical pathways program, quality measurement, clinical and operations improvements, and quality management.

Among his accomplishments at Brigham & Women's was re-engineering the inpatient Pharmacy process to utilize state-of-the-art medication dispensing machines that reduced annual costs $250,000 and reduced narcotic count and other medication errors.

While at Brigham & Women's Bob also helped develop a leading edge clinical pathways and variance management system that greatly improved the utility of clinical pathways and their impact on clinical process improvements. This system was part of an overall cost savings program that attained, among other savings, a 7% reduction in Cardiac Surgery charges over a two year
period.

Bob has also worked to apply quality improvement in community and preventive health settings as well, serving as adviser to a community based team reducing injuries in elderly pedestrians in a suburban Boston community.

As a leading healthcare and quality management consultant Bob has written and presented extensively on a variety of topics including Statistical Process Control (SPC) in healthcare and organizational performance assessment. He is actively involved in regional and national organizations, currently serving as the Healthcare Chair of the Boston Section of the American Society for Quality Control. In the past he has served as President and Board Member of the New England Healthcare and Information Systems Society. Bob is also a Certified Examiner for the Massachusetts Quality Award, based on the Malcolm Baldrige National Quality Award.

Bob has a BS in Industrial and Operations Engineering from the University of Michigan.

Robert J. Luttman, Principal
Robert Luttman & Associates
53 Colonial Road
Medfield, MA 02052
(508) 359-9630
rluttman@robertluttman.com
www.robertluttman.com


Question 1 - The quality management / improvement initiative has gone through different stages since it became mainstream. Can you give us a brief overview on where healthcare organizations are in this evolution? by HBInterview on September 18, 2000

Answer 1 - Nothing like starting with a simple question. The Total Quality Management initiatives that many of us were a part of in the late 80's and early 90's were overcome by mergers, cost and revenue concerns, and changes in regulatory and legal requirements. Much of the work goes on, but with less publicity and overt visibility.

In some ways this was good, we won! Organizations changed and the tools and techniques of quality merged into the corporate culture and work processes. I see a lot more flowcharts out there than I did a few years ago.

Overall, however, I think healthcare is stuck, for awhile anyway, between what I call the "quality assurance" phase and the "next generation" phase where "quality" is pervasive and systematic. And where ORGANIZATIONAL excellence is the goal.

Many organizations have begun to use the Malcolm Baldrige Award Criteria (see www.quality.nist.gov for more, and www.massexcellence.com for a list of healthcare organizations that have won quality awards) as an organization model. This model is the broadest and most comprehensive one available, and the basis of what I call next generation quality.

We are getting there, slowly but surely. After we are a big complicated industry, with complicated customers.

Bob

p.s. The rumor, and you didn't hear this from me ;-) , is that the Baldrige award will have its first healthcare winner this year. Announced in November, we look at this as a trigger for future growth in healthcare quality efforts. by Bob Luttman on September 18, 2000
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Question 2 - Can you describe variance management systems and their role in the quality improvement process? And, are pathways the primary source of variance data? by HBInterview on September 18, 2000

Answer 2 - Another easy one! But I actually wrote the book on variance systems.

Variance management systems are - POTENTIALLY - the greatest and best source of data for performance improvement we have ever had in healthcare. I say
potentially because most people do not do variance systems (I take a straw poll every time I make a presentation and rarely get more than a handful of people who do). Or, they do not do them well.

Variance data connects processes with outcomes, real-time process data from real patients AS THEY GO THROUGH YOUR PROCESSES. Now you can see what happened, and when, and connect that to the patient's outcomes. What's more - here's the segue to pathways - they connect the PLANNED process (the pathway) with the ACTUAL process the patient endured.

This connection:

Planned Process -> Actual Process -> Outcomes

is the mother lode of improvement INFORMATION. Is the pathway effective? Are we too agressive in care? Not aggressive enough? Should we get the patient out of bed on day one or day two? Of the patients who were dissatisfied with their care, what were their major variances? What was the LOS of patients readmitted within 7 days?

More importantly, done right, variance systems focus attention on the "viutal few" high value improvement opportunities, not the "trivial many".

A good variance system starts with the pathway, in fact it should collect the data ON the pathway. What are the key interventions and outcomes on the pathway? What are the key transition points (what I call gateways) in the
process, such as transfer from ICU to a stepdown unit?

Identify these variances and focus data collection and analysis efforts on them. This will allow you to build a topdown analysis process that starts with the vital few. The other approach, trying to find the needle of opportunity in the haystack of data, rarely works. I call it "drinking from a firehose".

I have much more variance information on my web site at www.robertluttman.com.

Bob
by Bob Luttman on September 18, 2000
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Question 3 - What are some common mistakes organizations make when implementing quality improvement initiatives? by HBInterview on September 18, 2000

Answer 3 - Fragmentation.

I have known organizations with multiple, and conflicting, improvement and/or "quality" programs and teams. Training, structure, process, etc are highly variable. In short, something only just this side of chaos. This often a waste of time, money, and energy. Now, I know that doesn't happen in your organization, does it?

The most important thing I have learned working with the Baldrige criteria for clients and award applicants is the value of a broader and more integrated structure for "quality" than we have now. Some of it is common sense (at least to an old engineer like me), such as action plans that have some connection to a strategy. Getting everybody focused on the same goals, and the various improvement efforts aligned with those goals.

Another issue is organizing the design, management, and improvement of processes (clinical and otherwise) around a team based effort. Organizing the care delivery process around a set of teams that focus on a patient population. These multi-disciplinary teams develop the pathways, assess the balanced scorecards for improvement opportunities, and initiate and oversee improvement efforts. Some function as a key link with referring physicians and other community based providers and patient groups.

Into these groups flows the data and resources to understand and improve the processes of care. To start, because good data flows throughout the organization, different levels of the organization have different priorities and resources for improvement. But, at the bedside it is the providers that need the most up-to-date and focused information.

Some organizations drown themselves in data or don't organize and relate the data. Balanced scorecards that are integrated up and down the organization are essential. Information is data in context, and if your patient satisfaction data is not integrated with variance data important context is missed.

Related to that is the narrow focus of most quality initiatives. A broader focus pulls in patient satisfaction, employee satisfaction, outcomes, clinical and operational performance, financials, regulatory compliance to assure that that context exists and permeates the organization.

Training in teams, and the tools and techniques of performance have suffered in the last few years as budgets have been cut, and the "we've already done that" issue arises.

Having the TIME for team meetings in an era of reduced staffing is another issue. Healthcare oftens uses the "Noah's ark" approach to creating teams: put on two of everybody so - hopefully - one of them can make a meeting.

Finally, quality is somebody else's job. "We have a quality assurance / management department for that". "The Joint was just here last month, I don't have to worry about this for awhile". Continuous improvement requires
continuous effort, not quarterly chart reviews. by Bob Luttman on September 18, 2000
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Question 4 - The Malcolm Baldrige award is very highly regarded in several industries although is not as well known in healthcare. How did the criteria have to be modified for healthcare? Why should an organization pursue this criteria as opposed to other accreditation standards already established in healthcare? by HBInterview on September 19, 2000

Answer 4 - I'll take the easy one first, how the criteria were modified for healthcare. For more information download the criteria from www.quality.nist.gov. The Baldrige people recognized that education (which is heavily using the criteria) and healthcare have unique attributes.

The primary one in healthcare is the "customer" and "supplier" relationship, especially the role of the physician. Also, since many organizations are non-profit (voluntarily) the financial measures are going to be different. Also, legal restrictions on staffing mean that some of the cross-functional team aspects of the business criteria needed modification. The terminology is also adagpted to healthcare.

The case study a couple of years ago for examiner training was a fictitious home health agency. The study scores pretty well, the agency would be competitive in the award process, and makes interesting reading for those interested in the Baldrige in healthcare. You can still download the Geminii Home Health case study from the NIST web site.

Now, the hard question: how to use it and how it relates to "other accreditation standards". I always make somebody mad when I get into this discussion, so let me say that we need those standards.

Baldrige is NOT an accreditation standard, never will be. You could win every quaality award out there, but you will still have to get accreditated by somebody in order to unlock the doors and turn on the lights.

The Baldrige criteria describe an "excellent" organization. They do not prescribe any processes, behaviors, policies, etc. They leave that up to you and your customers and employees. They are much more comprehensive and organizationally focused than most accreditation standards, though cross-pollination has reduced the difference.

The criteria make an excellent model for designing, managing, and improving and organization. They start with Leadership and your Leadership SYSTEM (don't laugh!!), move on to Strategic Planning, Customer Focus and Knowledge, Information and Analysis, Staff Focus and Work Systems, Process Management, and Results. Nearly half of the points (on a 0-1000 scale) are in the Results which include financials, "customer" satisfaction and market share, employee satisfaction and wellness, supplier quality, and internal measures.

The criteria are daunting to read, because they describe excellence. Fortunately, they grade on a curve (500 is good, 600 award winner potential). The breadth of the criteria make it an organizational effort to effectively use them, not something to dump on the quality assurance department or the Chief Compliance Officer.

The key values of the criteria, as I see them, are:

- They are a wholistic approach to quality, they look at the entire organization.
- Integration. Is what you do connected to the strategic plan? Is what you measured connected to the strategic plan? Is your strategic plan connected to what your patients, physicians, the community, and other stakeholders
want/need? How do you know? Do you have relationships (not those kind) with suppliers, or does Purchasing cruise Ebay looking for deals?
- Linking processes and results. Can you show how what you do (process) influences your results? Gee, your LOS is down in Cardiac Surgery and is better than other hospitals in your peer group. What did you do to get there?
- Continuous improvement, which includes continuous review. Are you still doing things the way you did 5 years ago? Why? Have you at least examined the process and decided that was good?
- Values. Most quality standards don't go anywhere near this issue. What are your organizations values? How does senior leadership instill and reinforce those values in the organization? How do your values affect your behaviors?
- Data driven. Show me the data! More importantly, it is about how you design and manage your performance measurement process. How do you use data to identify improvement opportunities? Create and implement solutions? Are measures connected with process, customer requirements, the strategic plan?
- Non-prescriptive. You will notice that I am asking questions, you are telling me about what you do. I am not telling your how you should do it. I (as an examiner) am not going down a list checking boxes, I have no white
glove.

How do you score the criteria, you ask? Do you have a "sound and systematic" approach to addressing these issues? Do you have a process, formal or informal? Is it aligned with strategy and key requirements? Do you measure it? Has it gone through cycles of improvement? Are your results connected with action plans and processes? Do you have 3-5 years of good trend data? How do you compare to competitors? Other organizations? Non-healthcare organizations? How do you know your performance is "world-class"?

Most organizations that use the criteria are looking for an objective review of their organization that will identify important improvement opportunities and gaps in processes and results. Virtually, every state (45) has an award program along with several cities (through the Chamber of Commerce). All have a self-assessment process to provide this feedback. All have an examiner team process where you write a 30-50 page report of what you do and a team of 6-12 examiners reviews it, does a site visit, and writes a feedback report.

It is this feedback report that organizations find most valuable, beyond even winning an award. Those examiners, by the end of the process, will have devoted nearly 100 hours each at a minimum. Times 6-12 examiners is a lot of very cheap consulting.

And the other accreditation standards fit nicely into the criteria. If you are interested I have (somewhere) a JCAHO/Baldrige crosswalk developed by Ned Barber, who wrote the book on Baldrige in healthcare.

This is a very long winded answer and I know your eyes are glazing over, or you stopped reading completely. If you want to know more:

- Call or email me
- visit www.quality.nist.gov
- visit www.massexcellence.com and check out the list of baldrige based awards and their winners (Missouri in particular has had several healthcare winners, Michigan has had Port Huron Hospital as recent winner).

Bob
by Bob Luttman on September 19, 2000
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Quesiton 5 - Would discuss the concept of clinical scorecard processes in a little more detail? Is this practiced in other industries? This is either a new concept or I have been out of the loop for a while. by HBInterview on September 19, 2000

Answer 5 - Well this one is a little easier, my carpal tunnel thanks you.

Just to be difficult I'll start with the last question. This is not a new technique, unless you are from the World's Greatest University (no, not Vanderbilt, the other one).

I first stumbled across it in my first job out of school. Making aluminum in a small town in the cornfields of the Midwest. A trade magazine, probably something like Molten Metal Monthly, had an article on "key indicators management". Since my job was to produce the monthly management reports I was intrigued. This was when a personal computer was a guy (me) with a calculator, spreadsheets came in a pad of 50, and the "database" was an 800 page stack of green and white paper. The year was 1980 and I was wondering about my career options.

Since we were a dirty smelly factory in a cornfield and Molten Metal Monthly is not on the shelves of our leading universities, it was left to some Harvard professors to popularize the idea.

But I digress.

The idea is a simple one that every quality management professional holds near and dear to their heart: focus on the vital few, not the trivial many. What are the important things to your organization's success? How do you know you are doing well?

Another thing is relationships. Quality is multi-dimensional, cost, clinical indicators, stakeholder satisfaction, process performance are dimensions of performance. Really really good organizations are good across dimensions.

So, a balanced scorecard (the people at Dartmouth who ported this idea into healthcare call them value compasses) is a set of 3-5 indicators in each of 4-5 dimensions of quality.

Financials might include revenue, costs, LOS, uncompensated care days, market share, etc. Clinical depend on what you do, but usually include unplanned events (readmits, ED visits), adverse events, SF (36, 12, 8, 1) scores, etc. Satisfaction would include patient/family, physician, employee, community. Process performance again depends on you, but might include clinical pathway measures, productivity, incident reports, and a variety of others.

Successful scorecards encompass more than clinical quality (there's that broad comprehensive organization-wide thing again). And they work from the top to bottom in the organization. The indicators also need to have some connection to strategy.

Every organization has different "action levels", which is why we have management hierarchies. People at the bedside have different issues and resources than the board, and the people between them and the board. A good balanced scorecard system works from "bedside to boardroom". The indicators are deployed down through the organization. Ideally, even the newest housekeeper on the midnight shift can tell you how they are measured and how those measures contribute to the organization's overall peformance and goals.

That's the really hard part.

What do scorecards tell you? Lots:

- Absolute and relative performance of individual indicators. What is the LOS for Cardiac Surgery, how does it compare to our goal, the competition, and the industry?
- Trend data
- Relationships between indicators or dimensions. Gee, LOS is down and so is patient satisfaction; have we been too aggressive in reducing LOS?

This level of analysis identifies improvement opportunities, or imperatives, and provides some indication of where to look to address the issue.

As the indicators are deployed, different reports are developed for each level. THE MOST TIMELY AND DETAILED DATA GOES TO THE BEDSIDE. Or at least a multi-disciplinary team (see yesterday). They should get a summary report and patient level detail.

So:

- Identify the vital few issues in multiple dimensions
- Create indicators
- Define goals
- Deploy the indicators and goals (with feedback from the organization) throughout the organization
- Create multiple levels of reports to address each action level
- Identify improvement opportunities and address them.

Easy, right?

If you have any questions contact me.

Bob
by Bob Luttman on September 19, 2000
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Question 6 - You mentioned that healthcare is "stuck" between the QA phase and "next generation" quality. How can organizations recognize they are stuck? Who are some practicing "next generation" organizations? by HBInterview on September 19, 2000

Answer 6 - The simplest answer is to use the Baldrige criteria and do a self-assessment. Very inexpensive and it will point out where you stand and what are the major improvement opportunities. Each award program has a self-assessment process, and the tools they use are increasingly sophisticated and effective. I am in the middle of helping a multi-site group practice do one and they are very impressed with what they have learned so far.

You can also go back to the earlier question on the criteria and ask yourself the questions I asked. Pick-up the criteria (they're free) and take a look, how would you rate? What are your strengths and weaknesses.

As for who is doing this, check out winners of the state quality awards. The rumor is the first healthcare national Baldrige winner is this year, that will tell us something. The SSM healthcare system in Missouri has won several Missouri awards, Port Huron Hospital in Michigan, and others.

Plus, I believe that you can tell a next generation organization, no matter what industry. You can tell by the attitude of the employees, the neatness and warmth of the facility, the attention to detail, knowing and focusing on what is important, good working relationships and team work. It doesn't have to be Nordstroms or the Ritz; quality doesn't have to equal high cost. If you know where your money is going, and why, you can do something about it.

Nor does it take paper heavy bureaucratic organizations. Small companies can do this with informal processes.

'Nuff said. Please let me know if you have any questions. You can email me at rluttman@robertluttman.com

Bob

p.s. Much of what I talk about in these answers is better described graphically. That's a little hard to do in a text box. My web site has Short Takes pages that describe some of these ideas and have pictures. I also have a Powerpoint version of the short version of a workshop I do on Next Generation Quality on the web site, in the download area of the case management subsite. Or email me. by Bob Luttman on September 19, 2000
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Question 7 - Data, data, data. While essential, it is almost a four letter word to some that try to get a handle on it. How sophisticed does your data analysis
need to be to establish valid or significant results? And, how do you approach the data collection without incurring huge expenses or installing a new information system? by HBInterview on September 19, 2000

Answer 7 - "Client" has six letters. Just kidding. Now that I have angered the JCAHO people I'll take on the IS people. Since I married a healthcare CIO I am very good at making them angry.

Let me say two things: we have all the data we need, and data analysis is a lot easier than we make it seem.

On the data side. In some cases we capture too much data, burying the important stuff in a sea of noise. Just flip through a medical record someday and look at the amount of data in there. And how easy it to get it out again and use it. Or look at those multi-page satisfaction surveys patients are dying to fill out.

Another problem is that we throw away a lot of good data, I have done some perfectly good studies using data from log books.

Another problem is that much of the data that goes into information systems - and there is some very good data hiding in there- requires a programmer or data analyst to get it back out. And that's a waiting line you don't want to get into.Or we can't connect the databases to uncover the relationships between, say process and outcomes.

Finally, for a variety of reasons, our data collection and analysis is rooted in retrospective reviews, not concurrent.

It is easier and more effective to do continuous, on-going, concurrent data collection and analysis, especially using statistical process control tools such as control charts. THESE TOOLS WERE DESIGNED FOR FACTORY WORKERS AND
MANAGERS TO USE, AND USE EFFECTIVELY.

Think about these scenarios:

- graphing patient LOS as they are discharged from a unit.
- getting - or requesting - a quarterly report showing patient LOS

Which one is easier to use? More importantly, which one leads to more effective and timely performance improvements?

Which is easier to do, surveying patients as they go through the system, or once a year? That's a big pile of envelopes to open and key in. I've run patient satisfaction programs, believe me it's easier to open a few every day than hundreds in a couple weeks. Responses rates are higher too. I know one hospital that does a simple sat survey when they make their routine post-discharge followup call.

So, enough ranting. Some solutions:

- keep it simple, what do you need to know?
- Continuously collecting small samples over time is easier and more actionable that collecting one large sample
- make it transparent, use data people are already collecting or incorporate the data collection into people's daily routine. And use the paperwork they already use, adding paper never made anybody happy.
- dig out those computer databases and make them accessible. New technology around data warehouses are nice.
- train people in the simple analysis tools and help them use them. When I walk on to a nursing unit and see a control chart - in pencil - hanging on a wall, and people using it to manage patient care, I will die happy.
- similarly, get people the tools. Create spreadsheet templates to do control charts or histograms or whatever. Then all the people need to do is enter the data (which they are transparently collecting everyday, right?), click print, and go get a cup of coffee. The gateway variance system I created is a spreadsheet,modeled on one a case manager had developed for herself (I just made it look better and more graphical).

It is easier in the long run to embed the knowledge of people like me and your IS people to set these kinds of easy tools than wait in line behind Y2K, HIPAA, and whatever acronym is coming at the IS people next.

Keep it simple, do it everyday, make it graphical, and use good tools.

Bob

p.s. 30 - 40 is usually a reasonably good sample size, especially if you are looking at only a couple of variables. by Bob Luttman on September 20, 2000
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Question 8 - In your presentation "Next Generation Quality" you note that a good variance system tells everything. Are there legal liabilities and does this
prohibit some organizations from implementing organization wide variance systems? by HBInterview on September 19, 2000

Answer 8 - I am not a lawyer and this is not legal advice. These days there is legal risk in everything. The short answer is that a good variance system reduces legal risk because it tells your story your way.

My sense is that the information is in the medical record anyway, and that any good plaintiff's lawyer can find it.

Christopher Nolin - a Boston lawyer (the really mean ones) - has written a monograph on this topic:

Nolin, C.E., Lang, C.G.An Analysis of the Use and Effect of CareMap® Tools in Medical Litigation. South Natick, MA: Center for Case Management, 1992.

To quote from my variance book, which relied on and referenced Mr. Nolin's work:

"Overall, a good variance system is a legal asset. As Nolin demonstrates, "where variation from a map is patient driven, the map record provides positive features that can discourage frivolous claims ". This occurs because the map is an explicit process design and variations from the process are clearly indicated., along with the reason for the variation, and the subsequent care process. The best defense is good documentation.

In the more troubling case of provider driven variation the variance data creates the potential danger that the data will benefit the plaintiff. Again, good, and more importantly contemporaneous, documentation is important. As Nolin explains," a map rewards the provider who is able to give cogent, complete explanations for his or her actions ".

This is not to say that CareMaps® documents and variance systems eliminate all legal risk. Nolin outlines two scenarios where legal risk is still high:

o When providers vary from the pathway by mistake.

o Where internal or external system problems or limitations caused the variation.

Where providers deviate by mistake the risk is clearly high unless the risk is an acceptable one . What the variance system can provide is more meaningful data to the quality assurance process to help eradicate substandard care and providers. The need for clear variance documentation at the time the variance occurs is extremely important.

The same holds for variances due to system limitations. Nolin states that variance information for these types of variances often passes through the quality assurance system and is not contained in the medical record. This could, conceivably, make this data privileged and unavailable to the plaintiff. He suggests that the decision needs to occur on a case by case basis.

It appears, pending the development of case law or changes in statute, that clinical pathways and their accompanying variance systems are a legal asset to a well run institution with high quality providers. The improved, consolidated, and contemporaneous documentation that a good variance system provides are beneficial to the defense and may reduce legal risk significantly when variation is patient or family related. "

My belief is that telling my story my way is more effective than the other guy telling it his way.

Ask your law department what they think.

Bob
by Bob Luttman on September 20, 2000
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Question 9 The ability to enlist everyone within the organization appears to be key to its success. However, this is easier said than done. With these turbulent times in healthcare, how can organizations enable employees to "take ownership" in their every day responsibilities? What approaches or initiatives have you seen that were particularly successful? by HBInterview on September 19, 2000

Answer 9 - As Dr. Don Berwick, CEO of the Institute for Healthcare Improvement, says "nobody washes a rented car". I will take care of that car, fill up the gas, and scoop up all the coffee cups and road maps. But my responsibility, and therefore my effort, is limited. Not that I wash my own car a lot.

If you want people to take ownership you have to actually give them ownership. This is frustating for many managers. They will say, "we've empowered our staff but they won't change!!!!" Often the "empowerment" was "you're empowered, go forth and do good".

Empowerment is not anarchy. It is not taking away "barriers" it is working with people to define meaningful barriers and helping people work within them. Nordstrom's gives its staff a budgeted amount of money to spend on customer service, they can spend it however they want to provide good customer service.

Knowledge is power. If I know what I can do, and not get in trouble, I will not fear to do it.

Another thing is organization. Most organizations are hierarchical. What we need is more of a network organization with the "power" at the bottom of the
organization. Again, it's how you create and structure this that is important.

Reorganizing around multi-disciplinary teams that manage care for patient populations is a first. Getting them the data, training, and resources that they need to effectively do this is another.

Data, data, data as the previous question said. If I know what the "problem" is I can probably fix it. Or at least try.

Give people time to fix a problem. Imagine this:

You show up for work at 8am on a Monday to find a voice mail from your boss asking why this or that indicator looks bad and what you are going to do about it. In your mailbox, just delivered, is the report she's looking at too. She came in at 7. Do you feel empowered?

Look at the organizations you do business with. Look at how their employees handle "problems" or just the routine work. Do they seem to have the information they need, or do they have to call Mable in Shipping? Can they actually make a decision, or do they have to call the boss, and he's at lunch?

Then look at your staff and ask the same questions.

Simple answer:
- Processes, clearly defined and understood, so staff know what they are supposed to do. And what the "guardrails" on their decison making are.
- Data
- Tools, resources, and the time to manage and improve things.
- Support, especially when they mess up.
- Look in the mirror. Have you truly "empowered" your staff?
- Organize for empowerment.

Bob
by Bob Luttman on September 20, 2000
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Question 10 - You can hardly contemplate data and information without thinking of the internet. In what ways will the internet assist quality improvement efforts, if any? Are any organizations currently using the internet to assist in data gathering and analysis techniques? by HBInterview on September 20, 2000

Answer 10 - The best thing the Internet will do is facilitate data sharing, and process sharing. Integrating processes and care across the continuum. Healthcare will catch up in terms of electronic data exchange, it saves too much money, time, errors, and aggravation.

Another thing, happening already, is access to databases. Many states and companies are Internet enabling their benchmarking databases, some of them open to the public. I know their are data quality issues, but if you understand them you can work within them.

The next step is creating best practices databases. Some efforts are underway, for example I am web master for a Baldrige web site that we are expanding to include best practices from winners of state and local quality awards.

Ways are emerging for patients to communicate data over the Internet with their providers, improving care and shortening communication loops.

More is happening internally, over intranets and Lotus Notes systems, to share data, hold virtual meetings, create repositories for notes, data, minutes, etc.

I have, in my own practice, done "remote" data analysis: clients send or upload data, I analyze it and send or upload the analysis back. Conference calls, chat, email, or discussion boards can answer questions. If I wanted to get really fancy I could create slide shows in Quicktime with voice or text narration and links to web sites or data.

The internet offers simple, effective, standardized, useable, cheap, publically available tools for sharing data, information, and knowledge. What is already available is good, what's coming is even better.

Bob
by Bob Luttman on September 21, 2000
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Question 11 - It seems healthcare struggles with implimenting quality improvement systems in their organizations. Any insights as to why this is? by HBInterview on September 20, 2000

Answer 11 - The way healthcare is organized has a lot to do with it. We are a very fractured industry. Licensing issues create boundaries between departments,
sometimes even within departments. This is also reflected in organizational structures which tend to be vertical. Look at the physician / hospital relationship. We operate more like a shopping mall (several little businesses sharing space) than Wal-Mart (one big happy family all working for the same boss).

These and other issues make the "silo" problem more acute in healthcare than in other industries. Attempts to breakdown these barriers often happen mostly at the top. Doctors are still doctors, nurses are still nurses, and physical therapists are still physical therapists.

This makes it difficult to create a broad system for quality.

Regulatory and accreditation systems are not as broad and as comprehensive as, say, the Baldrige criteria. Righfully so, their primary focus is on the quality of clinical care.

But, for the long term success of an organization, things like strategic planning and leadership are important. Vision, values, empowerment, interdepartmental knowledge and work systems are important to maintaining a dedicated, motivated, and talented staff.

Thining in broader terms about "quality" helps identify and address high value interventions. It is this process of getting the organization to think like ONE organization that we also need to address.

I know that's a lot of preaching for a Thursday.

Bob
by Bob Luttman on September 21, 2000
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Question 12 - Are you aware of any community healthcare models that use quality improvement methods to pull the community entities together? by HBInterview on September 20, 2000

Answer 12 - YES. And to plug somebody besides me, I'll give you some links to go and find out more.

The Institute for Healthcare Improvement, the people who started the quality management movement in healthcare years ago (yes, it's their fault. I tried to stop them!) have run scores of "breakthrough collaboratives". The collaboratives bring together 10 or so teams from around the country to focus on a specific issue (e.g.; c-section rates, motor vehicle accidents, medication errors, etc). These teams, in turn, include whoever is necessary to address the problem.

For example, I worked with them on motor vehicle accident injuries (if you know Boston you know we can get a large MVA sample size). Our team was sponsored by the Town of Brookline to look at elderly pedestrian injuries. It included people from the health department (now worrying about Wet Nile virus and dead crows), traffic department, police department, fire department, elderly affairs, one of the local teaching hospitals, and had access to traffic safety experts that IHI had recruited for the project.

Among the solutions, the hospital funded the presence of a police officer during evening rush hour at a busy and dangerous intersection. When you consider the cost of caring for an elderly pedestrian injury in your emergency, this makes sense in economic terms as well as preventive medicine terms.

Visit www.ihi.org for more information.

Many of the hospitals organizing multi-disciplinary teams do, or should, include representatives of the community. A chronic disease team cannot function without strong community involvement. These teams, then, provide the focus and infrastructure for addressing the cares and concerns of their particular patient population.

Bob
by Bob Luttman on September 21, 2000
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Question 13 - Let's assume for a moment that you have convinced me to develop my company into a "Next Generation Quality" organization. How do you get started? Should you start by employing consultants, taking classes or just doing it? by HBInterview on September 22, 2000

Answer 13 - Hire a consultant, the number is 508.359.9630.

JUST KIDDING.

I think there are several ways to get started, and inexpensive ones at that.

One good way to get started is to contact your local quality award program. They offer classes on the Baldrige criteria (examiner training and experience is a tremendous way to learn this stuff, I did it that way), and a variety of assessment programs which get you lots of good consulting cheap. Some even have consultant and trainer networks.

Another way is to think about the organizations you do business with in your professional or personal life. Which ones are really really good; odds are they use a next generation quality philosophy, perhaps without even knowing it. Do some process benchmarking with them, take a team and go visit, have them visit you and critique your processes and people. After all, if they are local, they are probably your customer.

Get your staff trained in quality methods, your local section of the American Society for Quality usually provides a whole curriculum of quality related courses. Some will set-up in-house training. Check out www.asq.org.

The Society for Health Systems (note: I am their president-elect) can help through the web site or finding help. Checkout www.iienet.org; we are working on networking community over the web that will greatly increase our
ability to help you.

Sit down and think about your organization. Look at your processes. Define the following:

- Suppliers
- Inputs
- The Process
- Outputs
- Customers

to begin developing deep process knowledge.

Create multi-disciplinary teams for specific patient populations. Create a balanced scorecard: define your performance dimensions, create 3-4 indicators within each one, deploy them down through the organization, work with the teams to create local indicators within the scorecard.

Take a look at your "quality" program. Is it integrated with day-to-day operations and decision making? Are all the "improvement" initiatives integrated? Are improvements linked to the strategic plan? Do you have a methodology for continuous improvement (check out the IHI for a very good improvement methodology: rapid cycle improvement)?

Because this is a broader view of quality, it will involve more people. In the short run that means more work, over the long haul it is less work and more effective.

Bob
by Bob Luttman on September 22, 2000
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Question 14 - I want to take a moment and thank you Bob for the time you have spent with us this week. As we end the week, will you give us some of your thoughts about where Quality Management will be in the next 10 - 20 years?
Are there any innovative movements on the horizon? by HBInterview on September 22, 2000

Answer 14 - You are welcome. I would like to thank the Healthbond people for giving me this podium and the chance to speak with you all. My fingers are a little
shorter than they were on Monday, but is was fun.

If any of you have questions, comments, suggestions, whatever please feel free to contact me:

508.359.9630
rluttman@robertluttman.com

I always like to discuss this stuff, its important and I always learn things when I talk to people. Healthcare is a big and diverse industry, nobody knows it all.

My website has more information on some of the things we've talked about as well.

There are somethings coming down the road:

- computer simulation and modeling. Healthcare systems are complex and could benefit from more sophisticated and rigorous analysis tools.

- Statistical process control is emerging as a realtime management and improvement tool.

- Some process management tools that have worked well in other industries could bendfit healthcare. One important one is called "lean manufacturing" or lean process. A step beyond just-in-time, it looks at processes to eradicate waits and delays. I am sure you don't have that problem, but think about it anyway. Some the lean manufacturing thinking is based on "The Goal" by Goldratt (for more on his books see: http://www.robertluttman.com/toc_books.html

- Some of the customer service and relationship management tools and techniques will move into healthcare. Some organizations have already established call centers to handle a variety of patient service and follow-up activities. A step beyond dial-a-nurse, they can be effective for follow-up, surveys, and other things.

- The internet will give us the tools not only to collect and share data, but to collaborate, communicate, and to change the processes of healthcare.

Quality is about change. If you are happy with the way you're doing, then next generation quality is not for you. Just get through your next accreditation step.

But, as Don Berwick says, "not every change is an improvement, but every improvement requires a change"

Or, to be more blunt:"insanity is doing the same thing over and over again, and expecting a different result"

Time are a changin'. PPS, APS, HIPPA, and a whole bushel of other acronyms are - forever- changing the way healthcare works.

Healthcare costs are starting back-up, some people feel that the cost savings from HMO's have maxed out. More cost reduction pressures are bound to begin again. We've merged, integrated, downsized, and mandatory overtimed
ourselves and staffs.

We need to be creative and take a fresh look at ourselves. Other industries have gone through equally challenging times (trust me, I grew up in Detroit)
and have produced organizations that have gone on to success in a new world. Take a look at them and learn how they did it.

Some resources;

www.iienet.org
www.asq.org
www.ihi.org
www.himss.org
www.robertluttman.com
www.massexcellence.com
www.quality.nist.gov

And don't just look at the healthcare stuff either.

And remember:

Process = Quality = Cost = Outcomes

Thanks,
Bob
by Bob Luttman on September 22, 2000

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