Lean Progress at the University of Michigan

Paul Levy

First posted 12/12/11 on Not Running a Hospital

I just listened to an extraordinarily well done webinar from MIT, presented by Dr. John E. Billi, associate dean for clinical affairs at the University of Michigan Medical School and associate vice president for medical affairs at the University of Michigan. John leads the Michigan Quality System, the University of Michigan Health System’s business strategy to transform clinical, academic, and administrative functions through development and deployment of a uniform quality improvement philosophy.

As noted in the webinar summary, the University of Michigan Health System (UMHS) has been on the lean journey for the past six years, creating the Michigan Quality System. UMHS has 20,000 faculty, staff, and trainees. The goal is to create 20,000 problem solvers who are finding and fixing root causes of problems they face daily. Dr. Billi described UMHS’ initial approach, results of early experiments, what leaders learned, and how they adjusted. The discussion covered the transition from scattered projects led by coaches to an integrated approach that incorporates people development and process improvement.

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Let’s Wake Up About ACOs

Paul Levy

Posted 11/30/11 on Not Running a Hospital

Comments by two folks recently should reawaken our concern about how to hold accountable care organizations accountable and whether creation of ACOs will lead to market dominance that will not bring value to patients.

Back in 2009, I noted: 

Here in Massachusetts, there is only one such entity that approaches the definition of an ACO, Partners Healthcare System. But there is no sign that it has used its size and scale to deliver care at a lower cost. Indeed, there is evidence that it has used its market power to extract higher rates from insurance companies. Likewise, there are no data to show that quality, safety, and efficacy in the delivery of care throughout the Partners system is better than other community hospitals or academic medical centers.

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An Appreciation: Monique Doyle Spencer

Paul Levy

Posted 11/27/11 on Not Running a Hospital

Brian’s Note: When I read this poignant piece about one woman’s brave perspective on fighting cancer, I showed it to my wife Elaine, who is dealing with late stage primary peritoneal (ovarian) cancer. She commented, “Ah! Someone else who doesn’t want to be categorized as a ‘victim’ or ‘survivor’!” It clearly struck a chord.

Monique Doyle Spencer (seen here in July 2010) died peacefully and surrounded by her family last night after a long stint with metastatic breast cancer.  By any measure, she was an extraordinary person, full of ideas, strongly held views, and with a marvelous sense of humor.  I was privileged to be her friend.

I came to know Monique during one of her stays in our hospital.  She mentioned that she had been writing a book about her experience with cancer, but that no one would publish it because it was funny.  Without a pause, I said that we would publish it as a book from our hospital, and the result was The Courage Muscle, A Chicken’s Guide to Living with Breast Cancer.  Those title words were chosen carefully because her whole being was about living.
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Mr. Ness, Everyone Knows Where The Booze Is

Paul Levy

Posted 11/13/11 on Not Running a Hospital

A quality-driven physician colleague writes with frustration about two problems in his academic medical center.  I often hear similar comments from nurses and doctors, and so I present the examples for your consideration.

This hospital has a poor record with regard to hand hygiene (in the 30% range), and my colleague suggested at an infection control meeting suggested that the rates be publicly posted in the hospital to provide an impetus for improvement.  “I suggested that instead of being embarrassed, maybe we should OWN the data.” This, of course, is a standard and accepted approach in quality improvement.  S/he was told that the “the lawyers will not let us do this.”  S/he wonders, “Who, exactly, is our primary concern?”

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Bravo To Brent James

Paul Levy

Posted 11/07/11 on Not Running a Hospital

Dr. Brent James last week was awarded Columbia Business School’s W. Edwards Deming Center for Quality, Productivity and Competitiveness. As described in the press release:

The Deming Cup grew from the center’s drive to highlight the achievements of business practitioners who adhere to and promote excellence in operations – the Deming Center’s area of focus. This award is given annually to an individual who has made outstanding contributions in the area of operations and has established a culture of continuous improvement within their respective organization.

Dr. James was recognized for his pioneering work in applying quality improvement techniques that were originally developed by W. Edwards Deming and others, in order to help create and implement a “system” model at Intermountain, in which physicians study process and outcomes data to determine the types of care that are most effective.

Imagine that, improving clinical care is consistent with efficiency in the health care system.  This has to be another lie, just like that stuff about Pronovost saving lives and reducing costs by reducing the rate of central line associated bloodstream infections.  Or assertions by that trio of fraud, Spear, Toussaint, and Kaplan.

This stuff can’t be true.  If it were everybody would be doing it.  Right?

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Harold Miller Offers Advice on Hospital Readmissions

Paul Levy

Posted 10/24/11 on Not Running a Hospital

If you had asked me to predict which topic on this blog would generate acrimony and criticism, I would have been hard-pressed to guess that it would have been hospital readmissions.  Recall that I expressed objections to the use of financial penalties to persuade hospitals and doctors to reduce this phenomenon.  Also, I cited a paper that showed that the data do not exist to fairly and accurately implement such a penalty scheme.  I followed this with a post citing an article suggesting that such penalties might especially adversely affect lower income hospitals.  Then, I suggested the kinds of questions that should be answered as we consider any type of public policy change.

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Twenty Questions for Public Policy Proposals

Paul Levy

Posted 10/23/11 on Not Running a Hospital

As I re-read the comments I have received regarding my critique of plans to impose financial penalties for variations in readmission rates, I realized that my correspondents and I were talking past one another.  I was presenting views based on how to design public policy, while they were stressing (understandable) concerns about the quality and cost of medical care.  They were viewing high readmission rates as something that deserved the hammer of a financial penalty, while I was viewing the issue as one of many public policy issues surrounding the health care environment, where unintended consequences of policy intervention are something to be considered.

To help explain how I view these kind of issues, I am going to share a list of twenty questions modified slightly from those Larry Bacow used to share with his students while a professor at MIT (before heading off to be President of Tufts University.)  Even though the list is over twenty years old, and Larry might modify them even more at this point, it is still a remarkably useful framework within which to view a wide range of issues.  Some are not germane to health care, but many are. 

These kinds of questions underlie a lot of the commentary you see from me here on this blog.  Please understand that these questions, although demanding some degree of analytical rigor, are not designed to stymie public policy advances, but to focus public policy interventions in the hope of more effectively solving problems.

1.  In identifying the problem, or proposing the program, what does one hope to change?  Examples:  The overall distribution of income; the income of particular groups; incentives; resources; bargaining power; political power; competitive advantage or opportunities; a condition that afflicts some particular target population; a source of social conflict or friction; some legal, customary, or social arrangement or the legitimacy of certain actions or arrangements; values, tastes and interest; the range of choice available to some group; other.

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Did I Say Unintended Consequences?

Paul Levy

Posted 10/20/11 on Not Running A Hospital

I raised lots of hackles in my recent post about penalizing hospitals for readmissions, generally and in the face of poor data to support such penalties.  Some commentors have said, in essence, “What can be the harm?  We’ll move the needle the right way, even if the methodology is not so precise.”

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What Happens in Atlantic City…Gets Reported Here

Paul Levy

Posted 10/13/11 on Not Running a Hospital 

I just returned from giving a keynote address at the Annual Institute of the New Jersey and Metropolitan Philadelphia Chapters of the Healthcare Financial Management Association.  Regular readers of this blog will not be surprised at the themes I covered (transparency, front-line driven process improvement, the virtuous cycle between reducing harm and financial efficiency), and I need not elaborate on them here.

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As Predicted

Paul Levy

First posted 10/06/11 on Not Running a Hospital

A propos of the story below, see this comment from a piece by Paul Ginsburg in the New England Journal of Medicine.

The unchecked market power of some providers promises to become increasingly problematic for private payers. And if market approaches prove insufficient to solve a problem of this magnitude, regulatory intervention becomes more likely.


Why is this is a big deal?

Here’s what I predicted last April, with regard to the negotiation between the state’s largest insurer and the state’s largest provider group:

Look for the following “victory” announcement in the coming months:

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Reflections on Narcissus and AMCs

Paul Levy

First posted 9/27/11 on Not Running a Hospital

Narcissus was so entranced by a reflection of his own image that he was paralyzed into inaction by looking at it, leading to an unfortunate end.  There is a lesson here for the country’s academic medical centers (AMCs).  These “crown jewels of American medicine” are lobbying to be exempt from certain federal budget cuts.  As noted in a paid op-ed page advertisement in the New York Times,* they cite their special status as “urban medical centers treat[ing] patient populations with high rates of chronic disease, coexisting conditions, and more advanced stages of illness.”  They note that “physicians and scientists at teaching institutions are the foundation of biomedical research and innovation in medicine [where] they invent and improve surgical devices and . . . inform drug discovery and development.”  Finally, they remind us of their essential role in training the next generation of physicians.

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Throwing Money the Wrong Way

Paul Levy

First posted 9/21/11 on [Not] Running a Hospital

I have talked a bit about using financial incentives to encourage doctors to do a better, more efficient, and/or safer job in practicing medicine.  I have been skeptical of this approach because I do not believe that doctors find such measures to be highly motivational.  In my former hospital, we stayed away from financial incentives and even discussion of finances when we were instituting changes in work practices that improved quality and safety and the work environment.  Instead, issues were framed in terms of the underlying values of doctors.

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Doctoring Financial Incentives

Paul Levy

First posted 9/12/11 on Not Running A Hospital

Mixed results are reported in a recent paper entitled, “The effect of financial incentives on the quality of health care provided by primary care physicians.”  In the paper, Australian researchers collected and analyzed data from studies of incentive programs in the US, the UK and Germany.

As noted in this summary article by Reuters:

In those studies, researchers looked to see if financial incentives made a difference in how often doctors screened for different diseases, referred patients to follow-up care or achieved a certain health outcome — such as helping a patient quit smoking. Overall, the effects were mixed.

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Labor, Delivery, Disclosure, Malpractice

Paul Levy

First posted 9/4/11 on Not Running A Hospital

Let’s talk about a different kind of labor on Labor Day weekend, the kind that delivers babies, and an order issued this past week by the U.S. Court of Appeals for the Seventh Circuit in Chicago.  The case is styled Arroyo vs United States, and I want to focus on the concurring decision by Judge Richard Posner.

The appeal involved a question of whether a malpractice lawsuit was filed by the Arroyos after the statute of limitations had run out.  The statute exists to prevent “stale” lawsuits, those filed years after a reasonable period of time.  It makes sense to have such a statute of limitations, in that defending a case gets progressively difficult as years go by:  Memories fade and potential witnesses become unavailable.

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What’s Going On At Parkland Memorial Hospital in Dallas?

Paul Levy

First posted 8/29/11 on Not Running a Hospital

series of stories at the Dallas Morning News raised some serious questions about the quality of care at Parkland Memorial Hospital.  I draw no judgments about those issues.  But what comes across in these stories is something equally interesting:  A hospital that has chosen to take a hard line, dare I say stonewall, with the local press on issues of community concern.  In an era of increasing transparency, this approach is an anachronism.

Those of us a certain generation remember Parkland Memorial as the site of President Kennedy’s trauma treatment and death in 1963, providing it an important symbol of high level care in our national consciousness.  But it is also a major teaching facility of the UT Southwestern Medical Center and is prominent in its own right for many reasons.

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